Hillcrest Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Lake Beach, Illinois.
- Location
- 1740 North Circuit Drive, Round Lake Beach, Illinois 60073
- CMS Provider Number
- 146130
- Inspections on file
- 23
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Hillcrest Retirement Village during CMS and state inspections, most recent first.
A resident reported that a CNA used a condescending tone of voice while providing care, which the resident perceived as discourteous. The administrator confirmed the resident’s complaint and documentation showed the CNA had previously received a disciplinary warning for discourteous behavior toward the resident. This reflects a failure to provide care and communication that support the resident’s dignity and right to a respectful, dignified existence.
A resident with dementia, depression, hallucinations, CKD, and multiple other comorbidities experienced a fall associated with catheter removal, but staff failed to document the fall event itself, including date, time, and location, in the EMR or risk management system. Although the resident’s care plan already identified a high fall risk related to hallucinations, psychotropic use, and self-lowering behaviors, it was not reviewed or revised after the fall. An LPN described the expected process for post-fall assessment and incident reporting, and the DON stated that care plans are to be updated after falls and that she is responsible for those updates, but she was unaware the fall had occurred. The facility’s fall policy requires incident documentation and immediate interventions for witnessed and unwitnessed falls, which were not completed in this case.
Surveyors found that kitchen staff did not maintain quaternary ammonium (quat) sanitizing solution at the required 200–400 ppm concentration or change it every 2 hours as required by facility policy, with test strips repeatedly reading 0 ppm despite staff acknowledging it should be effective for sanitizing food prep areas. During the same kitchen tour, surveyors observed a bag of hot dog buns on the bread cart that was dated beyond the facility’s 6‑day discard timeframe, contrary to the facility’s labeling and dating policy intended to control foodborne illness for all residents.
Surveyors found that multiple residents with G-tubes, indwelling urinary catheters, and chronic wounds had active orders for Enhanced Barrier Precautions (EBP), but their rooms lacked EBP signage and PPE availability at the doorway. One resident receiving enteral nutrition via gastrostomy tube, another with a long-term urinary catheter, and a third with a stage 4 pressure wound all had no posted EBP indicators or PPE outside their rooms. Additional residents sharing a room, one with G-tube bolus feedings and another with sacral wound treatments, also had no EBP signs posted. The facility’s infection prevention nurse and written EBP policy both specified that residents with these devices and chronic wounds should be on EBP and clearly identifiable as such.
A resident repeatedly reported feeling uncomfortable and upset due to her roommate’s jealous and inappropriate behaviors, especially when she had visitors, and stated she did not want to return to her room. Observations showed the roommate crying, calling out for the resident, and hovering over her while the resident attempted to rest, without staff intervention or redirection. The resident’s spouse reported that these behaviors were significantly affecting his wife, including multiple distressed phone calls, and voiced concerns to the DON and social services, who were aware of the situation but had only discussed, not implemented, a room change or other boundaries.
A resident with severe cognitive impairment and limited physical mobility, who required substantial/maximal assistance with personal hygiene per the MDS and care plan, was observed in a common area with prominent whiskers on her chin. CNAs and the Administrator stated that residents receive showers at least twice weekly and that shaving is included on shower days for both men and women. Despite a facility policy requiring staff to assist with grooming facial hair to maintain proper hygiene, the resident did not receive appropriate shaving assistance, resulting in visible facial hair.
Two residents at risk for pressure injuries did not receive ordered pressure-relieving interventions. One resident had an order for an air mattress to be on at all times, but surveyors twice observed the resident in bed with the air mattress pump unplugged and off, despite documentation of pressure-injury risk and a care plan listing an air mattress as an intervention. Another resident, dependent on staff for care and identified as at risk for pressure, was transferred to bed and provided incontinence care by CNAs without application of ordered protective boots, even though a sign above the bed and the care plan directed that cradle/protective boots be on at all times in bed. The facility’s pressure injury policy requires implementation of interventions for all residents assessed as at risk.
A resident with an indwelling urinary catheter and a history of frequent UTIs was observed in a wheelchair with a leg drainage bag attached high on the thigh, positioned above bladder level and without slack in the tubing, preventing gravity-assisted drainage. A CNA acknowledged that catheter drainage bags should be kept below the waist to prevent UTIs/infections. The resident’s care plan and the facility’s catheter care policy both required that the catheter drainage bag and tubing be maintained below the level of the bladder to discourage backflow of urine, but this was not followed.
A resident with moderate dementia and anxiety exhibited escalating behaviors including yelling, crying, delusions, pacing, and intense preoccupation with a roommate, yet staff did not consistently intervene or document specific behavioral interventions during observed episodes. On one day, the resident loudly yelled and became agitated after a CNA delivered a meal tray; an RN attempted redirection but the resident remained distressed, and later that day two CNAs provided care to the roommate while the resident continued crying and calling out without staff engagement. Staff interviews and social services notes confirmed ongoing anxiety, hallucinations, and obsessive focus on the roommate, with acknowledged increases in behaviors after an antidepressant dose reduction, but progress notes lacked documentation of the observed behavioral incidents or targeted interventions, contrary to the facility’s dementia care policy requiring person-centered, non-pharmacological approaches and individualized care plan implementation.
A resident with COPD, whose principal diagnosis was COPD, had an order for an ipratropium-albuterol inhaler to be given four times daily, but two scheduled doses were not administered when the inhaler was not available at the time of medication pass. The MAR documented the missed doses and referenced notes indicating the medication was unavailable, and the resident reported missing two doses of the inhaler. An LPN later stated the inhaler was not in the med cart when she attempted to give it and was later found at the end of the resident’s bed, although it should have been stored in the cart. The DON confirmed the inhaler had been misplaced, despite the care plan and facility policy requiring medications to be administered as ordered.
Surveyors found that controlled medications and insulin were not managed according to facility policy. In one medication room, an LPN left the medication refrigerator unlocked while it contained a new box of Methadone Oral Concentrate, a Schedule II controlled substance, despite facility policy requiring locked storage. In a separate case, a resident with diabetes had a Humalog KwikPen labeled with an expiration date that had already passed, and an RN acknowledged it should have been discarded, while the facility’s insulin pen policy required disposal after 28 days.
A resident with documented oral/dental health problems did not receive routine or preventative dental care during more than two years in the facility. The resident’s spouse reported that no dental services had been provided and that he was only notified in writing much later that a dentist could see the resident if she was enrolled in a dental program. The Administrator confirmed the resident had never seen a dentist there and explained that, although eligible, she was not enrolled in the dental program. The DON stated there was no dental policy in place and acknowledged the resident was not offered enrollment in the dental plan at admission, noting she was Medicaid pending and was not informed about the program after Medicaid coverage began.
A resident with mobility issues and requiring mechanical lift assistance was found with a displaced left hip fracture after being put to bed early due to not feeling well. Despite staff reports of no falls or complaints of pain, the resident was discovered in pain with a hip deformity and cheek redness, suggesting a fall. The facility's investigation classified the injury as of unknown origin, highlighting a deficiency in supervision and monitoring.
A facility failed to supervise residents with a history of falls, resulting in injuries. One resident sustained a hip fracture due to lack of close supervision, while another suffered a head wound from improper transfer by a single CNA, against policy. A third resident's care plan was not updated after multiple falls, violating the facility's policy on monitoring and modification.
A facility failed to properly sanitize a blender pitcher used for pureed diets, affecting four residents. The dietary staff did not ensure the presence of sanitizer in the three-compartment sink, compromising the sanitization process. The dietary director confirmed the absence of sanitizer and corrected the issue, but not before the blender was used for meal preparation.
The facility failed to implement enhanced barrier precautions (EBP) for six residents with specific medical needs, such as urinary catheters, a urostomy, wounds, and a PEG tube. Observations revealed the absence of EBP signage and PPE stations outside residents' rooms. The Infection Control Nurse was unaware of the mandatory nature of EBP and admitted the facility lacked a policy on it.
A resident with psoriatic arthritis and other health issues was not provided with a necessary rheumatology consultation after her initial appointment was canceled due to insurance issues. Despite being in pain and expressing a desire to see a specialist, the facility did not reschedule the appointment, as confirmed by the DON.
Failure to Ensure Respectful and Dignified Communication During Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to a dignified existence, self-determination, communication, and exercise of rights. On 02/17/2026 at 9:50 AM, R1 was observed sitting in her room in an overstuffed reclining chair. Earlier that morning, at 9:31 AM, the Administrator (V1) stated that R1 reported disliking the tone of voice used by a CNA (V3) during care, describing it as condescending. R1 communicated this concern to the Administrator. Record review showed that V3 had received a Disciplinary Warning Notice dated 01/14/2026 for “discourteous behaviors to resident,” confirming that the CNA’s manner of interaction with R1 had been identified as inappropriate. This conduct reflects a failure to provide care and communication that support the resident’s dignity and quality of life.
Failure to Document Fall and Update Care Plan After Incident
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall and to update the resident’s care plan following that fall. Progress notes for the resident showed entries on one day indicating that the resident’s catheter had been dislodged and reinserted in the morning, and later that the catheter was removed during a recent fall, with another note stating the catheter was removed during a fall that evening. However, there was no documentation in the progress notes of the date, time, location, or any additional information related to the fall itself. The DON later confirmed that the nurse did not enter a note in the facility’s risk management system or any incident note in the electronic medical record about the fall, and that she was not aware the fall had occurred. The resident’s care plan, dated prior to the fall, identified the resident as being at risk for falls related to hallucinations, antidepressant use, and behaviors such as intentionally sliding out of a wheelchair to the floor when up longer than desired. Despite this identified fall risk and the documented references to a fall in the catheter-related notes, the care plan was not reviewed or revised after the fall. The DON stated that care plans are to be updated after a fall and that she is responsible for updating them, but acknowledged that the resident’s care plan was not updated because she was unaware of the fall. The facility’s fall policy requires the nurse to complete risk management documentation for witnessed or unwitnessed falls and to complete an incident note under progress notes at the time of the incident, as well as to initiate interventions immediately based on the resident’s specific needs, which did not occur in this case.
Improper Sanitizer Concentration and Failure to Discard Expired Bread
Penalty
Summary
Surveyors identified that the facility failed to maintain appropriate sanitizing solution levels for food contact surfaces in the kitchen. During an observation, the dietary manager tested the quaternary ammonium (quat) sanitizing solution in a bucket and the test strip registered a light orange color corresponding to a 0 ppm level, both after 10 seconds and again after approximately 20–30 seconds. The dietary manager stated the solution should be between 200–400 ppm and that the strip should turn dark blue to be effective for sanitizing food preparation areas. The dietary manager also stated the sanitizing solution was only effective for 2 hours and needed to be replaced. A dietary aide later reported that the sanitizing solution had been mixed at 6:00 AM and should have been replaced at 8:00 AM to remain effective, indicating it had not been changed in accordance with facility policy. Surveyors also found that the facility failed to discard expired bread products in the kitchen. During a kitchen tour, a bag of hot dog buns on the bread cart was observed with a date of 8/8/25. The dietary manager stated that all bread products were dated on the day of delivery and were to be discarded within six days, confirming that the buns should have been discarded by 8/15/25. The facility’s policies on manual sanitizing and on labeling and dating of foods documented that quat sanitizing solution must be maintained at 200–400 ppm and changed every 2 hours, and that food must be labeled with dates received, opened, and discard dates to decrease the risk of foodborne illness and provide the highest quality food. At the time of the survey, the CMS-671 form documented 126 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions for Residents With Devices and Wounds
Penalty
Summary
Surveyors identified a failure to implement the facility’s Enhanced Barrier Precautions (EBP) policy for multiple residents who met criteria for these precautions. For one resident with a gastrostomy tube receiving enteral nutrition, there was a current physician order for EBP, but no EBP signage was posted on or near the room entrance and no PPE was available outside the room. Another resident with an indwelling urinary catheter in place for at least three months had current orders for EBP and for monthly catheter changes, yet the room lacked EBP signage and PPE outside the door. A third resident with a stage 4 pressure wound on the left lateral knee, receiving wound treatment and with a current EBP order, also had no EBP sign posted and no PPE located outside the room. Additional residents with qualifying conditions similarly did not have EBP implemented as required. One resident with an indwelling urinary catheter, whose drainage bag was changed to a leg bag during the day and who had current orders for EBP and monthly catheter changes, had no EBP signage or PPE outside the room. Two other residents sharing a room, one with orders for G-tube maintenance and bolus tube feeding and the other with orders for sacral wound treatments and dressings, had no EBP signs posted on or around their shared room. The facility’s own EBP policy stated that residents with medical devices such as catheters and feeding tubes, and residents with chronic wounds, must be on EBP precautions and that residents on EBP isolation must be identifiable as being on that status. The Infection Prevention Nurse confirmed that residents with chronic wounds, G-tubes, or indwelling urinary catheters should be on EBP.
Failure to Accommodate Resident’s Needs and Preferences Regarding Roommate Behaviors
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences regarding her roommate’s behaviors. During an initial tour, one resident in a wheelchair reported she was having problems with her roommate, stating the roommate became jealous when she had visitors and made inappropriate comments, leading her to say she did not want to return to her room. Later the same day, the resident again expressed discomfort, stating that although the facility had discussed moving rooms, she felt she should not have to move because she liked her room and felt uncomfortable when her roommate exhibited behaviors toward her. Further observations showed the roommate lying in bed crying while the resident sat next to her, holding her hand. When CNAs entered to transfer and provide care to the resident, the roommate repeatedly called out for the resident, asking her not to leave, while crying. The resident attempted to rest in her bed, but the roommate continued calling out, and the CNAs did not intervene or redirect the roommate. The resident’s spouse reported to management that the roommate’s behaviors were affecting his wife, including multiple upset phone calls about the roommate issues. The DON acknowledged that the spouse reported the roommate was “driving” the resident “insane” and that a room change had been discussed but not implemented due to concerns the roommate might follow her. Social services also stated that the roommate hovered over the resident, causing her to become upset, and that the spouse wanted more boundaries and limits to protect his wife.
Failure to Assist Dependent Resident With Facial Hair Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) by not ensuring a female resident was shaved and free of facial hair. On one observation, the resident was seen in the dining room with prominent whiskers covering her chin. Certified Nursing Assistants (CNAs) reported that all residents receive showers at least twice a week and that shaving for both men and women is included on shower days, and the Administrator confirmed that shaving occurs on shower days. The resident’s care plan documented an ADL self-care performance deficit and limited physical mobility, and her Minimum Data Set (MDS) indicated severe cognitive impairment and a need for substantial/maximal assistance with personal hygiene, including shaving. The facility’s policy on grooming a resident’s facial hair states that staff are to assist residents with grooming facial hair to maintain proper hygiene, but this was not carried out for this resident as evidenced by the observed facial hair. This deficiency is based on observation, staff interviews, and record review showing that the resident, who required significant assistance with personal hygiene due to cognitive and physical limitations, did not receive the grooming care outlined in her care plan and the facility’s grooming policy.
Failure to Implement Ordered Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions for residents identified as at risk for pressure injuries. For one resident (R5), the Medication Review Report dated 8/26/25 showed an order for an air mattress to be on at all times. Observations on 8/25/25 at 2:06 PM and on 8/26/25 at 1:42 PM found the resident in bed with the air mattress pump hanging at the foot of the bed, with the lights off and the pump unplugged on both occasions. On 8/27/25 at 9:01 AM, an LPN (V13) confirmed that an air mattress pump is a pressure-relieving intervention. R5’s Braden Scale dated 8/18/25 indicated the resident was at risk for pressure injuries, and the care plan revised 8/19/25 documented potential for skin impairment with an air mattress listed as an intervention. The deficiency also includes failure to apply ordered protective boots for another resident (R30) at risk for pressure injuries. On 8/25/25 at 1:35 PM, two CNAs (V10 and V11) transferred R30 to bed with a mechanical lift and provided incontinence care, then positioned the resident’s feet on the mattress without applying the protective boots. A bright-colored sign above the bed displayed a turning schedule and directed that cradle boots be on at all times when the resident was in bed. On 8/26/25 at 12:33 PM, an RN (V8) stated that R30 is at risk for pressure, dependent on staff for care, and should have protective boots applied when in bed. R30’s current care plan documented potential impairment to skin integrity related to fragile skin, with interventions including an air mattress, wheelchair cushion, and protective boots while in bed. The facility’s Pressure Injury Prevention and Management Policy states that interventions will be implemented for all residents assessed and considered at risk.
Improper Positioning of Indwelling Catheter Drainage Bag
Penalty
Summary
Surveyors identified a deficiency in catheter care when a resident with an indwelling urinary catheter and a history of frequent UTIs was observed sitting in the dining room in a wheelchair with a leg drainage bag attached high on the top of the thigh, positioned above the level of the bladder and without slack in the tubing, which did not allow gravity to aid urine drainage. On a subsequent interview, a CNA stated that urinary catheter drainage bags should be kept below the waist to prevent UTIs/infections. The resident’s care plan indicated the presence of an indwelling urinary catheter and the need for the drainage bag and tubing to be maintained below the level of the bladder, and the facility’s catheter care policy likewise stated that drainage bags should be located below the level of the bladder to discourage backflow of urine. Despite these documented requirements, the drainage bag was not maintained below bladder level for this resident.
Failure to Implement and Document Dementia-Related Behavioral Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document individualized interventions and services for a resident with dementia and anxiety who was exhibiting escalating behavioral and emotional distress. The resident had documented diagnoses of unspecified dementia (moderate) with anxiety, anxiety, hypertension, and muscle weakness, and her care plan indicated moderately impaired cognition and dependence on staff for emotional, intellectual, physical, and social stimulation. Despite a dementia care policy requiring person-centered, non-pharmacological approaches and care plan interventions related to each resident’s symptomatology, the resident’s increased anxiety, crying, yelling, delusions, and preoccupation with her roommate were not consistently addressed with observable interventions or documented in the clinical record. On one observed day, the resident was initially sleeping when a CNA delivered her meal tray, after which she began loudly yelling statements such as “Stay out of my life” and “Get out of it.” The CNA left to notify an RN, and the resident continued to yell and appear agitated. The RN attempted redirection but the resident remained distressed; the RN reported that the resident had earlier accused staff of trying to kill her and believed she might have a urinary tract infection. Later that day, the resident was observed crying in bed, repeatedly calling out to her roommate not to leave her, while the roommate attempted to console her. Two CNAs entered to provide care and transfer assistance to the roommate but did not approach or intervene with the crying, anxious resident, who remained tearful and asking for a kiss when the surveyor left the room. On the following day, the resident was observed wandering, pacing, and appearing restless in her room. Multiple staff interviews confirmed that the resident frequently cries, hallucinates, worries, misses her family, and becomes very anxious and nervous, particularly in relation to her roommate, over whom she “hovers” and becomes preoccupied. Staff, including CNAs, an LPN, the DON, and Social Services, acknowledged that the resident has ongoing behavioral symptoms, including delusions and emotional lability, and that her behaviors had increased after a decrease in antidepressant medication at family request. Social Services documentation noted her anxiety and preoccupation with the roommate and with the roommate’s spouse. Despite these ongoing and escalating behaviors, the progress notes contained no documentation on the day of the observed increased behaviors regarding the episodes or any interventions implemented, and the existing care plan interventions remained general (e.g., consults, encouragement of activities, monitoring) without evidence of being actively implemented during the observed episodes of distress.
Missed COPD Inhaler Doses Due to Misplaced Medication
Penalty
Summary
The facility failed to provide ordered pharmaceutical services when a resident with chronic obstructive pulmonary disease (COPD), whose principal diagnosis was COPD, did not receive two scheduled doses of an ipratropium-albuterol inhaler. The resident’s medication review showed an order for the inhaler to be administered four times daily for COPD, and the August medication administration record documented that the 3:00 PM and 8:00 PM doses on 8/18/25 were not given, with a code directing to progress notes. The corresponding progress notes stated the medication was not available for those doses. The resident reported missing two doses of the inhaler about a week prior and did not know why. A nurse stated that when she attempted to administer the inhaler at the scheduled time, it was not in the medication cart, resulting in the missed doses, and that the inhaler was later found at the end of the resident’s bed, although it should have been stored in the medication cart. The DON confirmed the inhaler had been misplaced and should have been kept in the medication cart, and the resident’s care plan and the facility’s medication administration policy both required that medications be administered as ordered.
Failure to Secure Controlled Drugs and Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure controlled medications were secured with a dual lock system and failed to discard an outdated insulin pen. During an observation of the 100-200 hall medication room, an LPN opened the medication room and the resident medication refrigerator was found with an open lock hanging on the latch, leaving it unlocked. Inside the unlocked refrigerator was a new box of Methadone Oral Concentrate, a Schedule II controlled substance, for a resident who had a physician’s order for Methadone 10 mg/ml, 4 ml by mouth once daily for pain. The DON confirmed that the medication room refrigerator should be locked. The facility’s Medication Storage Policy stated that all drugs and narcotics must be stored in a locked storage area with limited access by authorized personnel. In a separate incident, a resident’s Humalog KwikPen insulin was observed with a written expiration date that had already passed. An RN stated that the insulin pen should have been thrown away and explained that nurses label insulin with a “use by” date 30 days from when it is opened. The resident’s records showed a diagnosis of diabetes and an active order for Humalog KwikPen to be administered before meals and at bedtime per a sliding scale. The facility’s Insulin Pen Policy specified that insulin pens should be disposed of after 28 days, indicating that the insulin pen in use was outdated according to the facility’s own policy.
Failure to Provide Routine Dental Care and Enrollment in Dental Program
Penalty
Summary
The facility failed to ensure that a resident received routine dental care despite documented oral/dental health problems and over two years of residency. The resident’s husband reported on 8/25/25 that the resident had been in the facility for more than two years and had not received any preventative dental care, and later stated he was notified in writing in early July 2025 that a dentist would come to the facility and see the resident if he enrolled her in the program, but she had not seen a dentist since admission. The admission record dated 8/25/25 shows the resident was admitted on an earlier date, and the current care plan indicates the resident has oral/dental health problems. The Administrator confirmed on 8/27/25 that the resident had not seen a dentist since admission, explaining that although she was eligible for the dental program, she was not enrolled and therefore did not receive dental care. The DON stated on 8/27/25 that the facility had no dental policy and acknowledged that the resident was not offered enrollment in the dental plan upon admission, noting she was Medicaid pending and should have been informed about the program after Medicaid coverage began. These actions and omissions resulted in the resident not receiving routine or preventative dental services during her stay, despite eligibility for a dental program and identified oral/dental health needs.
Resident Safety Lapse Leads to Hip Fracture
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in a displaced left hip fracture. The resident, who had diagnoses including osteoarthritis, dementia, and unspecified abnormalities of gait and mobility, required substantial assistance for mobility and was typically transferred using a mechanical lift. On the evening of the incident, the resident was put to bed early due to not feeling well, and throughout the night, staff reported no falls or complaints of pain. However, during the morning medication pass, the resident was found with an internally rotated left hip and was in immense pain, leading to an emergency hospital transfer. The hospital records confirmed a comminuted fracture in the left hip, suggesting a fall might have occurred, although staff denied any falls. The paramedic noted a hip deformity and redness on the resident's cheek, which appeared bruised, raising suspicions of a fall. Despite an investigation by the facility, the injury was classified as of unknown origin, and abuse was ruled out. The lack of clear documentation or observation of a fall indicates a deficiency in supervision and monitoring, contributing to the resident's injury.
Inadequate Supervision and Safety Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to adequately supervise and ensure the safety of residents with a history of falls, resulting in significant injuries. One resident, with a history of falls and moderate risk for falling, sustained a right hip fracture. Despite being known for attempting to get up on his own and having impaired cognitive function, the resident was not provided with close supervision as indicated in his care plan. The incident was not witnessed, and there were no documented signs of pain or abnormal behavior prior to the discovery of the injury, indicating a lack of proper monitoring and intervention. Another resident, identified as high risk for falls, suffered a head wound due to improper transfer procedures. The resident was transferred using a mechanical sling lift by a single CNA, contrary to the facility's policy requiring two staff members for such transfers. This lapse in protocol led to the resident falling forward and sustaining a wound on the forehead. The CNA involved acknowledged the deviation from the standard procedure, which was confirmed by the Director of Nursing. A third resident, also at high risk for falls, experienced multiple unwitnessed falls without subsequent revision of their care plan. Despite having a care plan focus on fall risk due to conditions like Parkinson's disease and confusion, the interventions were not updated following the falls. The facility's policy on monitoring and modification of care plans was not adhered to, as there was no evaluation or adjustment of interventions after the incidents, highlighting a systemic issue in addressing fall risks effectively.
Improper Sanitization of Blender Pitcher for Pureed Diets
Penalty
Summary
The facility failed to ensure proper sanitization of a blender pitcher used for preparing pureed diets for residents. On the morning of September 23, 2024, a dietary aide filled the three compartments of the sink, and shortly after, a cook began pureeing couscous for lunch. After finishing, the cook washed the blender pitcher and lid in the three-compartment sink, allowing them to air dry. However, the sanitization process was compromised as the test strip used to check the concentration of the sanitizer solution in the third sink did not register any sanitizer, indicating that the sink lacked the necessary sanitizing solution. The dietary director confirmed the absence of sanitizer in the sink and subsequently refilled it with a pre-diluted sanitizer and water mixture, achieving the correct concentration. This deficiency affected four residents who were on pureed diets, as the blender used for their meals was not properly sanitized according to the facility's policy. The facility's manual sanitizing policy requires utensils and equipment to be sanitized in the third sink by immersion in a chemical sanitizing solution used according to the manufacturer's instructions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who required them due to their medical conditions. During an initial tour, it was observed that residents with urinary catheters and a urostomy did not have EBP signs on their doors. Additionally, a resident with wounds on his toes also lacked appropriate signage. The Infection Control Nurse admitted to being unaware that EBP was mandatory and acknowledged the absence of a facility policy on EBP. Further observations revealed that a resident with an indwelling catheter had their catheter bag visibly exposed, and there was no EBP signage or personal protective equipment (PPE) station outside their room. Another resident receiving nutrition through a PEG tube also lacked EBP signage and a PPE station. These oversights indicate a systemic failure in the facility's infection prevention and control program, as evidenced by the lack of EBP implementation for residents with specific medical needs.
Failure to Schedule Rheumatology Consultation
Penalty
Summary
The facility failed to provide necessary care and services to a resident who required a rheumatology consultation. The resident, a female with multiple diagnoses including age-related osteoporosis, psoriatic arthritis, and protein-calorie malnutrition, was observed to be in pain and expressed a desire to see a rheumatologist. Despite having an appointment scheduled for July 24, 2024, it was canceled because the provider did not accept her insurance, and no follow-up appointment was made. The Director of Nursing confirmed that the resident is alert, oriented, and in discomfort due to her arthritis, and acknowledged that a new appointment was not scheduled after the cancellation.
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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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