La Bella Of Danville
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Illinois.
- Location
- 1701 North Bowman, Danville, Illinois 61832
- CMS Provider Number
- 145753
- Inspections on file
- 66
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 12 (3 serious)
Citation history
Health deficiencies cited at La Bella Of Danville during CMS and state inspections, most recent first.
A resident with a history of falls, recent femur fracture, moderate cognitive impairment, and dependence for ADLs fell while attempting to transfer independently from bed to a wheelchair while wearing slippers, despite a care plan requiring assisted ambulation and fall-prevention measures. A CNA found the resident on the floor, assisted her up, and took her to the nurse’s station without obtaining an RN/LPN assessment and did not report the fall, even though the resident complained of wrist pain. An X‑ray later showed an acute distal radius and ulnar styloid fracture, and the resident returned from the hospital with a soft cast and an order for urgent orthopedic follow‑up. The facility failed to ensure the orthopedic referral was completed: the orthopedic office could not reach the facility using an incorrect phone number, no appointment was scheduled, the transportation aide received no appointment request, and there was no EMR documentation of follow‑up, leaving the resident in a loose, misshapen soft cast until a delayed ortho visit resulted in application of a hard cast.
Two residents’ medical records were not maintained in a complete and accurate manner. For one resident with multiple complex conditions and total dependence for ADLs, the EHR documented that the resident left for a procedure but contained no follow-up notes on the resident’s return, new devices, status, or orders, and several 72-hour readmission entries were left blank until a later NP note about a new infection. For another resident with a history of falls and a left femur fracture, the care plan and fall log reflected multiple falls and fall-prevention interventions, but the EMR lacked any documentation of a fall that resulted in injury or a related physical assessment, even though a subsequent progress note described bruising, swelling, and physician notification.
A resident’s hospice order for concentrated oral morphine was incorrectly transcribed from 0.25 mL PRN to 30 mL PRN on the physician order sheet and MAR, and an RN administered approximately 25–30 mL (about 500 mg) without questioning the unusually large dose or verifying accuracy. The RN also failed to document the controlled substance on the narcotic count sheet. Following administration, the resident became very drowsy, difficult to arouse, and developed shallow, slow respirations with periods of apnea, requiring Narcan and subsequent transfer to the ED. The resident later recalled receiving a much larger-than-usual dose in a medicine cup instead of the usual dropper and reported memory loss for much of the day. A pharmacist and hospice MD confirmed that the dose given was a high morphine dose with potential for severe respiratory depression or death, and the facility’s medication error report noted the error had a high potential for serious adverse reactions.
The facility did not maintain required RN coverage for at least eight consecutive hours on a day during the review period, despite its facility assessment and staffing plan specifying that one RN should be present on each shift in accordance with CMS minimum staffing rules. Review of daily nurse staffing sheets showed a day with no RN coverage for the required duration, and this was confirmed by a regional nurse consultant. During this time, 146 residents were documented as residing in the facility.
The facility failed to prevent sexual abuse by a resident with known sexually inappropriate behaviors and a documented criminal history, resulting in nonconsensual sexual contact with two cognitively impaired residents who lacked capacity to consent. One resident with dementia and multiple comorbidities was found in bed with her incontinence garment unfastened and a resident’s finger inside her vagina, shortly after staff had left her properly covered and fastened; she was observed to be tearful. Another resident with Alzheimer’s disease and prior documented abuse by the same perpetrator was later seen in the dining room when a visitor witnessed the same resident poking his finger into her genital area and intervened. The perpetrating resident’s care plan already identified wandering, inappropriate touching of residents and staff, and high-risk heterosexual behavior, yet he was still able to access and sexually touch these residents, contrary to the facility’s abuse-prevention policies.
A facility failed to protect residents from further sexual abuse after an initial allegation when staff did not immediately and effectively separate an alleged male perpetrator from other residents. A visiting family member reported seeing the man in a wheelchair intentionally touch a female resident’s genital area in the dining room and informed a CNA. The CNA told the man to go to his room but then left to remove her coat, leaving him unsupervised. During this time, a housekeeper found him in another female resident’s room, touching her genital area while she lay in bed with her incontinent brief unfastened and bed sheet pulled aside; an LPN removed him and observed his finger inside the resident’s vagina. Facility policy required immediate protection of alleged victims and separation of the alleged perpetrator, and leadership later confirmed that staff were expected to remove and monitor the perpetrator immediately, but this did not occur, resulting in a second sexual assault and an immediate jeopardy finding.
Staff failed to report a new allegation of sexual abuse to the facility Administrator/abuse coordinator as required by policy. A family member observed a resident in a wheelchair intentionally touching another resident’s private area in the dining room and reported this to a CNA, who had previously received abuse reporting training. The Administrator later confirmed he had not been informed of this allegation until notified by surveyors, despite a facility policy requiring immediate reporting of all abuse allegations and a documented history of prior sexual abuse incidents involving the same two residents.
The facility failed to maintain required licensed nurse coverage on multiple shifts, including the absence of an RN for at least 8 consecutive hours on several days and a complete lack of RN and LPN coverage on one overnight shift in one building while LPNs were present in another building. The facility’s own assessment specified that each shift should include an RN and that night shift should include multiple LPNs, yet staffing records and leadership interviews confirmed these requirements were not met for the building housing 54 residents.
The facility did not maintain required RN coverage for at least eight consecutive hours per day, seven days a week, despite its own assessment indicating that staffing should include one RN per shift. Review of nurse staffing records showed multiple days without adequate RN presence, and this was confirmed by the ADON, who reported that nursing management was only on-call on weekends if needed. Resident council minutes over several months documented ongoing concerns about short staffing, during a time when 138 residents were in the facility.
The facility did not submit required final investigation reports to the State Agency within five working days for three cases involving allegations of abuse and misappropriation of property. Although initial reports were made and investigations were started, the process was not completed as mandated by policy and regulation, due to residents recanting allegations or leaving the facility before investigations were finished.
The facility did not thoroughly investigate or document three separate allegations involving physical abuse and misappropriation of property. In each case, either the investigation was not completed or supporting documentation was missing, including situations where a resident recanted an abuse allegation against an LPN, another resident denied abuse by a CNA, and a third resident left AMA after reporting missing money.
A resident with severe cognitive impairment and a history of physical aggression struck another cognitively impaired resident, causing injury. Multiple prior incidents of aggression by the same resident were documented, but there was no consistent evidence that these behaviors were reported to a provider or addressed before the altercation occurred, resulting in a failure to protect residents from abuse.
A resident with dementia, known for a friendly and helpful demeanor and a history of working as a CNA, was not provided with a care plan that reflected their specific activity interests or behavioral patterns. This omission contributed to an incident where the resident startled another, resulting in a physical altercation and injury. Staff interviews confirmed the resident's activity preferences and behaviors, but these were not documented or addressed in the care plan.
Multiple residents with severe cognitive impairment and histories of aggression were involved in physical and verbal altercations, including one incident where a resident sustained a skin tear after being grabbed and another where a resident was struck in the face and subjected to a racial slur. Staff witnessed these events, and care plans documented the residents' behavioral risks, but the facility did not prevent the abuse.
A resident with a wound infection did not receive five consecutive doses of an ordered IV antibiotic, with the first dose delayed by over a day. Facility staff also failed to notify the prescribing provider about the missed doses, contrary to facility expectations.
A resident with severe cognitive impairment and a history of stroke experienced multiple falls from a wheelchair due to inadequate supervision and inconsistent implementation of care plan interventions. Staff provided conflicting accounts regarding who witnessed and responded to the falls, highlighting a lack of clear communication and supervision.
Two residents were involved in an alleged abuse incident, with one resident reportedly touching and kissing another who was severely cognitively impaired. Although the incident was reported internally and investigated by the administrator, it was not reported to the State Agency as required by facility policy.
A resident with a left above-the-knee amputation did not receive a physician-ordered referral to a prosthetic clinic. Although staff were aware of the order and discussed it among the interdisciplinary team, no appointment was made, and the resident did not receive the required service.
The facility did not employ a clinically qualified Director of Food and Nutrition Services, with the person in charge lacking required credentials and only holding a ServSafe certification. The dietician was present only one day per week. Additionally, the facility failed to maintain sanitary dishwashing areas and did not prevent flying insects in food service areas, leading to cross-contamination of dishes used by all residents.
Surveyors found that the facility did not maintain an effective pest control program in the kitchen, resulting in accumulations of decomposed food, soiled surfaces, and the presence of flies and other pests. Flies were observed landing on clean dishes near contaminated drain areas, and pest control reports documented ongoing issues with flies, cockroaches, and spiders. The kitchen prepares food for all residents in the facility.
A resident who was cognitively intact and dependent on staff for care was required to remain in bed for several hours until a wound physician arrived, despite expressing a desire to get up. Staff confirmed that the resident was not allowed out of bed, leading to distress and emotional upset. The DON acknowledged that this prolonged restriction violated the resident's rights to dignity and choice, as outlined in the facility's policy.
A resident's comprehensive assessment was marked as receiving an antibiotic, but review of medical records and order summaries showed no antibiotic was prescribed or administered during the assessment period. The MDS Coordinator confirmed the error, which was inconsistent with facility policy requiring accuracy in assessment documentation.
A resident with necrosis and peripheral vascular disease did not receive wound care in accordance with updated physician orders, as a wound nurse failed to enter new treatment instructions into the system and continued care under outdated orders. During a dressing change, the nurse also did not change gloves between cleaning the wound and applying a new dressing, contrary to professional standards.
A resident with a suprapubic catheter and multiple medical conditions received catheter care from an LPN who failed to change gloves or perform hand hygiene after cleaning a contaminated insertion site, then applied a new dressing with the same gloves. The resident reported that daily site cleaning was not performed as ordered. The DON confirmed that such contamination could lead to infection, and facility policy requiring glove removal and hand hygiene was not followed.
Two residents with severe cognitive impairment were not offered, administered, or documented for Influenza and Pneumococcal vaccinations as required by facility policy. Review of their medical records showed no evidence of consent, administration, or refusal of these vaccines, and the Infection Preventionist confirmed the lack of documentation.
A resident's bathroom ventilation fan remained inoperable despite repeated requests to staff for repairs. The fan had not worked since the resident's admission, and no corrective action was taken by facility staff.
A resident with a history of falls and assessed as a fall risk experienced a preventable fall resulting in a forehead laceration requiring emergency treatment. The facility failed to implement and monitor resident-centered fall interventions, such as ensuring the bed was in a low position and call light accessibility. Staff were unaware of the resident's care plan, leading to inadequate supervision and intervention.
A resident with severe cognitive impairment and a history of elopement exited a facility through a deactivated alarmed door, walking 0.4 miles in cold weather before being found. The facility failed to update the care plan for elopement risks, ensure functional exit alarms, and conduct a post-elopement assessment, leading to significant safety lapses.
The facility failed to maintain a clean and comfortable environment as a resident's disruptive behavior, involving hacking and spitting up mucous, went unaddressed. This behavior, which included throwing tissues on the floor, was observed to affect the dining experience of other residents, leading to complaints. Despite being aware of the issue, the facility did not take action to manage the behavior, resulting in a deficiency.
Two residents reported dissatisfaction with another resident's disruptive behavior, involving hacking and spitting in the dining room, to the staff, including the Assistant Administrator. Despite the facility's grievance policy requiring prompt investigation and resolution, no grievance was filed, and the issue remained unaddressed, as the Assistant Administrator did not recognize it as a grievance-worthy complaint.
The facility failed to provide necessary medications to three residents, resulting in missed doses due to unavailability. One resident did not receive Duloxetine and Lorazepam as ordered, another missed Alendronate-Cholecalciferol due to billing issues, and a third did not receive Aripiprazole because it was not in the backup supply. The facility's policies for handling unavailable medications were not followed, and there was no documentation of physician notification for the missed doses.
A resident in the facility did not receive insulin on time, leading to significant medication errors. The resident, who is cognitively intact, reported delays in receiving medications, including insulin, which affected blood sugar levels. The MAR showed that Lispro insulin was scheduled at specific times but was often administered hours late. The DON confirmed that medications should be given within an hour of the scheduled time, as per the facility's policy.
A facility failed to administer medications correctly, resulting in a 12% error rate. An LPN did not give a resident their prescribed Ferrous Sulfate, another resident received the wrong dosage of Breo Ellipta and was not instructed to rinse their mouth, and a third resident missed a dose of Aripiprazole due to unavailability. The facility's policy mandates correct administration according to physician orders.
A resident with multiple diagnoses, including wounds, experienced maggot infestation due to the facility's failure to perform wound dressing changes as ordered. The resident's wounds deteriorated, causing significant pain. The DON acknowledged the unacceptable care, and the wound physician raised concerns about infection.
The facility's ineffective pest control program led to a fly infestation affecting all 141 residents. Despite a policy requiring regular pest control, reports from April to August 2024 did not address flies. Observations revealed numerous fly strips in resident rooms, with one room having over 50 flies on a strip. A resident reported using fly strips for months, and an LPN confirmed widespread use among residents. The Maintenance Director dismissed flies as pests, while the pest control representative identified entry points and breeding sites but was unaware of the issue until the survey. The DON confirmed a resident had maggots in wounds, highlighting the infestation's severity.
The facility failed to provide prescribed low concentrated sweets diets to diabetic residents, serving the same meals to all residents regardless of dietary needs. This oversight was confirmed by staff interviews and could lead to health issues such as elevated blood sugar levels and poor wound healing.
A resident was physically abused by another resident, resulting in facial swelling and fear. The incident occurred after an argument over borrowed money, with staff witnessing aggressive behavior and racial remarks. The facility's abuse prevention policy was not effectively enforced.
A facility failed to ensure resident safety by not accurately screening a new resident with a criminal background, leading to an incident where the resident physically assaulted a roommate. The facility's background check process was flawed, and necessary safety interventions were not implemented, resulting in harm to the assaulted resident.
A facility failed to create a comprehensive care plan for a resident identified as an offender, as required by their policy. The resident, with a history of criminal offenses and assessed as a moderate risk, did not have their offender status or risk level documented in their care plan. This oversight was confirmed by the Social Service Director.
A resident's breakfast meal preferences were not honored, as they were served only one fried egg on two consecutive days, despite requesting two fried eggs, two pieces of toast, and two sausages. The Dietary Manager confirmed the resident's request but was unaware of the deviation.
A resident reported an incident where a CNA made a derogatory comment about the resident's weight after the resident was unable to clean himself following an episode of loose stools. The incident was reported to the Activity Director and led to an investigation by the Administrator and DON, resulting in the CNA's suspension.
The facility failed to include the resident, their guardian, and other required staff in a care plan meeting, resulting in incomplete documentation and lack of interdisciplinary input. The Care Plan Coordinator held the meeting alone without ensuring the guardian received an invitation.
A resident dependent on staff for all activities of daily living was found in a soiled state with long toenails and unshaven hair. The facility's policies on bathing and nail care were not followed, and there was no documentation of when the resident last received these services. The Administrator and DON acknowledged the neglect but could not explain the oversight.
The facility failed to protect a resident from sexual abuse and another resident from physical abuse. One resident with Alzheimer's was sexually abused by another resident with a history of inappropriate behavior. In a separate incident, a resident with dementia was physically abused by another resident with aggressive behaviors. Both incidents were witnessed and confirmed by staff.
The facility failed to thoroughly investigate an allegation of sexual abuse between two residents. The incident was witnessed by a dietary aide and a CNA, but the facility did not document interviews with the IDT or other staff and residents who might have had knowledge of the behavior. The administrator confirmed the lack of documentation and interviews.
Failure to Assess Fall and Follow Orthopedic Follow-Up Orders After Wrist Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and appropriately assess an acute change in condition following a fall, and failure to follow physician orders for post-fracture care. The resident had diagnoses including UTI, left femur fracture surgical aftercare, repeated falls, moderate cognitive impairment, and dependence on staff for ADLs, and was care planned as high risk for falls with a recent femur fracture. The care plan specified ambulation with assistance and a walker, left leg weight bearing as tolerated, and fall-prevention interventions such as a scoop mattress, non-skid strips by the bed, and non-skid socks to replace slippers. Despite this, the resident’s roommate reported that the resident got out of bed unassisted, attempted to walk to a wheelchair located by the bathroom door, and slipped and fell while wearing slippers. Following this fall, the CNA who responded found the resident seated on the floor on her buttocks with both palms on the ground, wearing a t‑shirt, brief, socks, and slippers. The CNA assisted the resident from the floor and transported her to the nurse’s station but did not have a nurse assess the resident at the time of the fall and did not report the fall to nursing staff. The roommate stated the resident complained of wrist pain after the fall, and the DON later confirmed that the CNA got the resident up from the floor without a nurse assessment and failed to communicate the fall, resulting in the wrist injury going unnoticed until the evening of the next day. A subsequent radiology report documented an acute distal radius (Colles’) fracture and ulnar styloid fracture, and the resident returned from the hospital with a soft cast and a referral to orthopedic surgery. The facility also failed to follow through on the physician’s order and referral for orthopedic follow-up. The After Visit Summary from the hospital documented that the resident was to schedule a follow-up appointment with orthopedic surgery as soon as possible. The orthopedic office reported that no appointment was scheduled and that their referral was closed after unsuccessful attempts to contact the facility using an inaccurate phone number. The transportation aide stated there had been no request or information regarding the need for an orthopedic appointment until weeks later, and that the original order was written during off hours when the nurse should have placed the information in the transportation box. The DON stated there was no documentation in the EMR about the resident going to a follow-up appointment and that the facility did not have a policy on following physician orders, despite the RN job description requiring nurses to transcribe and carry out physician orders as written. During observation, the resident was seen with a soft cast that was very loose and misshapen until a later date when a hard cast was finally applied after a delayed orthopedic evaluation.
Incomplete and Missing Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents in accordance with its own policies and accepted professional standards. For one resident with multiple complex diagnoses including CVA, epilepsy, vascular dementia, obstructive uropathy, severe protein malnutrition, anxiety, and autonomic nervous system disorder, the care plan documented total dependence for ADLs, severe cognitive impairment, seizure disorder, aphasia, and risk for skin breakdown. The EHR progress note recorded that this resident was out of the facility for a procedure on 4/9/26, but there was no subsequent documentation of the resident’s return, any new medical devices, status, or new orders associated with the procedure. The progress notes also contained five blank 72-hour readmission entries, and the next documented entry was not until 4/20/26 by a nurse practitioner regarding a new infection. The DON confirmed there were blank entries and no follow-up progress notes documenting the resident’s return from the appointment or clinical changes. For another resident admitted with diagnoses including UTI, left femur fracture surgical aftercare, and repeated falls, the undated care plan documented high fall risk with a recent fracture, multiple fall-prevention interventions, ambulation with assistance and walker with left leg weight bearing as tolerated, dependence on staff for ADLs, risk for skin alterations, and moderate cognitive impairment and weakness. The facility’s fall log showed this resident had falls on 2/6/26 and 3/26/26. However, the resident’s EMR did not contain documentation of the 3/26/26 fall, the incident that caused the injury, or any physical assessment related to that event. A progress note the following day documented bruising and swelling to the left wrist, physician notification, and diagnostic testing, but there was no corresponding incident documentation in the EMR. The DON confirmed the absence of documentation of the 3/26/26 fall, despite facility policies requiring that each medical record accurately represent the resident’s experiences and that incidents and accidents be documented within 24 hours.
Significant Morphine Overdose Due to Transcription Error and Failure to Question High Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an opioid analgesic order was inaccurately transcribed and an abnormally large dose was administered without verification. Hospice orders for the resident dated 3/5/26 specified Morphine Sulfate (concentrate) oral solution 100 mg per 5 mL, with a dose of 0.25 mL by mouth every two hours as needed for moderate pain or air hunger. However, the physician order sheet for March 2026 documented the same medication and concentration but with a dose of 30 mL by mouth every two hours as needed, which represented a 100-fold increase over the prescribed dose. This incorrect dose was also reflected on the resident’s Medication Administration Record (MAR), indicating that the transcription error carried through to the record used for medication administration. On 3/10/26, the RN responsible for the resident’s care administered approximately 25–30 mL of Morphine Sulfate orally, consistent with the incorrectly transcribed order rather than the original hospice order of 0.25 mL. The RN later stated that the order had been transcribed incorrectly into the physician orders and MAR and acknowledged that she should have verified the order and questioned the unusually large dose. She also confirmed that she failed to document the administered dose on the corresponding narcotic count sheet, contrary to facility policy requiring controlled substances to be recorded on the designated usage form and controlled drug record. The facility’s policies required nurses to follow the six rights of medication administration, compare the medication source with the MAR, and refer to drug reference material if unfamiliar with a medication, but these safeguards were not effectively applied in this instance. Following the administration of the overdose, the resident initially went about her normal routine but later became very difficult to arouse. When a hospice CNA arrived around midday to provide care, the resident was sleeping, responded in a very quiet whisper that she was in pain, and was difficult to awaken. The CNA reported the situation to the RN, who then realized she had given the wrong dose earlier that morning and had no additional morphine available. The CNA and hospice staff observed that the resident was very drowsy, hard to wake, and had shallow, slow respirations that required placing a hand on the resident’s chest to count breaths. A hospice RN later documented a respiratory rate of eight breaths per minute, and a hospice LPN that evening noted periods of apnea, a respiratory rate of ten, eye-rolling, and brief unresponsiveness, leading to the decision to transfer the resident to the emergency room for evaluation of the morphine overdose. The resident later reported that the dose she received that morning was much larger than normal, that she usually received the medication in a small dropper under her tongue rather than in a medicine cup, and that she had no memory of events between breakfast and being told she was going to the hospital, describing the day as a blank and stating she was glad to still be alive. The facility’s pharmacist and hospice medical doctor confirmed that the dose administered, approximately 500 mg of oral morphine, was a high dose and that an overdose of concentrated oral morphine could result in shallow breathing, decreased respirations, impaired cognition, and potentially death. The facility’s medication error report documented that there was a transcription error with the morphine order, that the dose was supposed to be 0.25 mL orally every two hours as needed but was transcribed as 30 mL orally every two hours as needed, and that the administering nurse did not question the order and administered 30 mL of morphine sulfate. The report further documented that the error could have endangered the resident and had a high potential for adverse reactions up to and including death. The DON confirmed that the RN did not verify the inaccurate dose or question the abnormally large dose, which led to the administration of approximately 25 mL (500 mg) of oral morphine sulfate and resulted in the morphine overdose for the resident.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty providing services for at least eight consecutive hours a day, seven days a week, as required. The Facility Assessment Tool for the period 07/2025 through 04/2026 documented a staffing plan for licensed nurses that referenced the facility assessment and CMS minimum staffing rule and further specified that staffing should include one RN on each shift. However, review of the Daily Nurse Staffing Sheets from 2/26/2026 through 3/31/2026 showed that there was no RN coverage for at least eight consecutive hours on 3/1/2026. On 4/1/2026 at 11:54 a.m., the Regional Nurse Consultant confirmed that the facility did not have RN coverage for eight consecutive hours on that date. The facility’s Midnight Census Report dated 3/20/2026 documented that 146 residents resided in the facility during this period. This deficiency is based on interview and record review and reflects noncompliance with the requirement to have an RN on duty for at least eight consecutive hours each day, seven days a week, despite the facility’s own assessment and staffing plan indicating that one RN should be present on each shift.
Failure to Prevent Sexual Abuse by Resident With Known Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with known sexually inappropriate behaviors. One resident with Alzheimer’s disease, prior transient ischemic attacks, altered mental status, muscle weakness, difficulty walking, and a documented risk for abuse had previously been identified as an alleged victim of sexual abuse by the same perpetrating resident, who had touched her breasts in past incidents. This prior incident was serious enough to have been cited on a previous CMS Form 2567, and the resident’s care plan had been revised to reflect her status as an alleged victim of abuse. Despite this history and the resident’s inability to formulate relevant responses to questions, the facility did not prevent further sexual contact from occurring. Another resident with dementia, depression, pseudobulbar affect, reduced mobility, anxiety, lack of coordination, bipolar disorder, and a care plan indicating risk of abuse was also involved. This resident’s diagnoses list later included confirmed adult sexual abuse. On the day of the incident, a housekeeper observed that this resident, who resided alone, had a second wheelchair in her room. Upon entering, the housekeeper saw the perpetrating resident with his hand in the resident’s diaper area while the resident lay on the bed without a diaper. A CNA who had provided care 15–20 minutes earlier reported that at that earlier time the resident’s undergarment had been fastened and she was covered with a sheet, but when she returned after the report, the sheet was pulled aside, the undergarment was unfastened exposing the genital area, and the resident was tearful. A nurse who responded to the report stated she observed the perpetrating resident’s finger inside the resident’s vagina. The perpetrating resident had a documented history of sexually inappropriate behavior and criminal offenses. His care plan noted that he wandered aimlessly throughout the facility, inappropriately touched other residents and staff, and made inappropriate comments. His diagnoses included high-risk heterosexual behavior, schizoaffective disorder bipolar type, and moderate vascular dementia with agitation. During an interview, he admitted to touching a woman’s vagina in her room and stated he believed she wanted him to touch her. A family member of another resident reported witnessing this same resident poking his finger into the private area of the first cognitively impaired resident while both were in wheelchairs in the dining room and intervened by moving his wheelchair. Facility leadership, including the DON and Administrator, confirmed that the two victim residents did not have the cognitive capacity to consent to sexual activity. The facility’s own policies defined sexual abuse as any nonconsensual sexual contact of any kind with a resident, including unwanted touching of the perineal area and all types of sexual assault, and committed the facility to implement policies to prevent all types of abuse. Despite these policies and the known history and care plan information, the facility did not prevent the resident with known sexual behaviors from making sexual contact with the two cognitively impaired residents.
Removal Plan
- R5 was placed on one-to-one continuous supervision.
- R5 was assessed by an emergency room provider, Social Services V4, and a psychotherapy provider.
- R4 received a head-to-toe nursing assessment by Registered Nurse V22.
- R6 received physician notification and medical evaluation by Nurse Practitioner V9.
- R5 received physician notification and medical evaluation by Nurse Practitioner V9.
- R5 received a psychosocial assessment and emotional support by Social Services V4.
- R4 received a psychosocial assessment and emotional support by Social Services V4.
- R6 received a psychosocial assessment and emotional support by Social Services V4.
- Families/responsible parties for R5 and R6 were notified by Social Services V4.
- R4's family/responsible party was notified by Social Services V4.
- Law enforcement and state reporting requirements were completed for R5 and R6 by Administrator V1.
- Law enforcement and state reporting requirements were completed for R4 and R5 by Administrator V1.
- R6 was transferred to the hospital for evaluation and relocated to the south building upon return.
- A facility-wide resident assessment for abuse risk was conducted by Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3.
- All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, Assistant Director of Nursing V3, and Social Services V4.
- The Abuse Prevention Policy was reviewed by Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 to ensure inclusion of defined staff response steps and immediate Director of Nursing and Administrator notification.
Failure to Separate Alleged Perpetrator After Initial Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to separate an alleged perpetrator of sexual abuse from other residents after an initial allegation, resulting in a second sexual assault. A family member visiting a resident in the dining room reported witnessing a male resident in a wheelchair intentionally poking his finger into the private area of a female resident who was also in a wheelchair. The family member stated she had to move the male resident’s wheelchair to stop the contact and then informed a CNA when the CNA entered the dining room. The family member reported that, because both residents were in wheelchairs, the contact could not have been accidental and she believed the act was intentional. After receiving the report from the family member, the CNA stated she directed the alleged perpetrator to go down the hall to his room and then left the area to remove her coat. During this time, the male resident was not supervised. While the CNA was away, a housekeeper observed the same male resident in a female resident’s room, with the female resident lying in bed and the male resident touching her in her diaper area; the housekeeper clarified that the female resident was not wearing her diaper. The housekeeper reported this to the CNA and an LPN. When the CNA arrived at the second resident’s room after this report, she observed that the LPN was already removing the male resident from the room and that the female resident’s bed sheet was pulled to the side, her incontinent undergarment was unfastened exposing her genital area, and she was tearful. The LPN who responded to the second incident stated she observed the female resident in bed with her bed sheet pulled to the side, her incontinent undergarment unfastened, and the male resident’s finger inside the female resident’s vagina. The facility’s Abuse, Neglect and Exploitation policy required immediate steps to protect alleged victims, including room and staffing changes to protect residents from an alleged perpetrator, and mandated that staff respond immediately to protect alleged victims. The administrator stated he expected staff to take steps to prevent further abuse, including immediately removing the resident from the incident and not contacting him until the situation was under control, and confirmed that facility policy required staff to remove the perpetrator from the incident. Despite prior abuse prevention in-service training for the involved staff, the male resident was left unsupervised after the first allegation and was able to access and sexually assault another resident, leading to a determination of immediate jeopardy.
Removal Plan
- R5 was placed on one-to-one continuous supervision pending full investigation.
- R5 was assessed by an emergency room physician.
- R5 was assessed by Social Services V4.
- A psychiatric evaluation was requested by Assistant Director of Nursing V3 and completed by Psychotherapist V49.
- R6 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
- R4 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
- Families and responsible parties of R5 and R6 were notified by Social Services V4.
- R4's family/responsible party was notified by Social Services V4.
- Law enforcement and required state agencies were notified per mandatory reporting requirements by Administrator V1.
- A room change was completed to ensure separation of R5 and R6, and R6 was later moved to the south building upon return from emergency room evaluation.
- All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, and Assistant Director of Nursing V3.
- Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 reviewed the Abuse Prevention Policy to ensure inclusion of a clear step-by-step response protocol following any allegation, mandatory immediate separation of the alleged perpetrator, and immediate notification of the Administrator and Director of Nursing.
- A facility-wide risk assessment for abuse involving Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3 was completed.
Failure to Report Allegation of Sexual Abuse to Administrator
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving one resident (R5) allegedly touching another resident (R4) to the Administrator/abuse coordinator as required by facility policy. The Administrator (V1) stated he is the abuse coordinator and that all staff are trained to report all allegations of abuse to him, but he confirmed he had no active investigation regarding an allegation of sexual abuse involving R5 touching R4 until the surveyor informed him on 2/5/26. The facility’s abuse policy dated 10/1/25 requires all alleged violations to be reported to the Administrator immediately, but not more than two hours if the allegation involves abuse or bodily harm. Training records dated 8/29/25 show that the CNA (V13) had received abuse prevention and reporting training. Interview and record review showed that on 2/2/26, a family member (V21) witnessed R5 in a wheelchair intentionally poking a finger into the private area of R4, who was also in a wheelchair, in the dining room. V21 reported this incident to CNA V13 at the time and stated she had to move R5’s wheelchair to prevent further inappropriate contact. Despite this report, V1 did not receive any report of this allegation from staff. The record also documents a prior allegation on 5/7/25 that R5 had touched R4’s breasts, and a previous CMS-2567 dated 4/17/24 citing an incident in which R5 (then R205) was identified as the perpetrator of sexual abuse toward R4 (then R206) by touching her breasts. These prior documented incidents further establish that R5 had a known history of sexually inappropriate contact toward R4, yet the new allegation reported to staff on 2/2/26 was not reported to the Administrator as required.
Insufficient RN and LPN Coverage on Multiple Shifts
Penalty
Summary
The facility failed to ensure sufficient licensed nursing staff were present for each shift in each building, including required RN coverage, affecting the South Building where 54 residents resided. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses (RNs and LPNs) should follow the facility assessment and CMS minimum staffing rule and specified that staffing should include one RN on each shift and three LPNs on the night shift. Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least 8 consecutive hours on four separate days (1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026). On 1/17/2026, the same records documented that there were no RNs or LPNs working the 11 p.m. to 7 a.m. shift in the South Building, while two LPNs were working the night shift in the North Building. The Assistant DON confirmed the lack of RN coverage for at least 8 consecutive hours on the identified dates and stated that nursing management staff are on-call on weekends if needed. The DON reported being notified by the Administrator at 8 p.m. on 1/17/2026 that there was no nursing coverage for the 11 p.m. to 7 a.m. shift in the South Building and stated that the DON personally worked from 3 a.m. to 5 a.m. during that shift.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least eight consecutive hours a day, seven days a week, as required. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses, including RNs, should follow the facility assessment and CMS minimum staffing rule and further specified that staffing should include one RN per shift. However, review of the Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least eight consecutive hours on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026. On 1/21/2026 at 9:16 a.m., the Assistant Director of Nursing confirmed that there was no RN coverage for eight consecutive hours on those dates and stated that nursing management staff are on-call on weekends if needed. Resident Council Meeting Minutes from October, November, and December 2025 documented short staffing and staffing concerns, and the facility’s Midnight Census Report dated 1/15/2026 showed that 138 residents resided in the facility during this period. No specific resident medical histories or conditions were described in the report, but the deficiency was identified as having the potential to affect all 138 residents currently residing in the facility.
Failure to Submit Final Investigation Reports for Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to submit the results of investigations into allegations of abuse and misappropriation of resident property to the State Agency within five working days, as required by federal and state regulations. Specifically, for three residents who made allegations—two of physical abuse and one of misappropriation of property—initial reports were sent to the Illinois Department of Public Health, but the final investigation reports were not submitted. The Director of Nursing confirmed that no five-day final reports were sent for these cases. The previous administrator explained that in two cases, the residents recanted their allegations or clarified that no abuse occurred, and in the third case, the resident left the facility against medical advice before the investigation was completed, leading to the omission of the required final reports. Facility policy and federal regulations mandate that all allegations of abuse, neglect, or misappropriation must be promptly investigated and the results reported to the appropriate authorities within specified timeframes. Documentation reviewed showed that initial reports were made for each incident, but the process was not completed as required. The failure to submit final investigation reports occurred despite the facility's written policies outlining the obligation to report and investigate such incidents thoroughly and within the required timeframe.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse and misappropriation of resident property were thoroughly investigated for three residents. The Director of Nursing was unable to locate investigation files for allegations of physical abuse and misappropriation of property involving three residents, and could not confirm that thorough investigations were conducted due to the absence of supporting documentation. The previous administrator acknowledged being informed of the allegations but did not complete final reports or thorough investigations for any of the cases. In one instance, after a resident recanted an allegation of physical abuse against an LPN, no final report or investigation was completed. In another case, after a resident stated that a CNA was not abusive, the investigation was not completed or reported. For the third resident, who alleged misappropriation of property and subsequently left the facility against medical advice, no investigation was completed.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On 6/2/25, a certified nursing assistant (CNA) witnessed one resident physically striking another with a closed fist, resulting in a skin tear and bruising. The resident who was struck had severe cognitive impairment and was unable to provide detailed information about the incident. The aggressor also had severe cognitive impairment, a history of delusions, physical aggression, and was receiving psychiatric services and antipsychotic medication, which had recently been reduced. Prior to the incident, there were multiple documented episodes of physical and verbal aggression by the aggressor toward both staff and other residents, including swinging at residents and physically assaulting staff during care. These behaviors were noted in nursing and medication administration records. Despite these documented behaviors, there was no evidence that the physical aggression incidents were consistently reported to a physician or provider prior to the altercation. Staff interviews revealed uncertainty about whether such behaviors were communicated to psychiatric providers, and documentation of these reports was lacking. The facility's policy states that residents have the right to be free from abuse, including abuse from other residents, but the failure to report and address escalating behaviors contributed to the incident of resident-to-resident abuse.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement person-centered activities and interventions for a resident diagnosed with dementia. Specifically, the care plan for a resident with severe cognitive impairment did not identify individualized activities of interest or account for the resident's history of working as a CNA, friendly personality, or tendency to enter other residents' personal space. Despite staff interviews confirming that the resident enjoyed helping others, participating in crafts, going outside, and engaging in activities such as manicures and music, these preferences and behaviors were not reflected in the care plan prior to a documented incident. An incident occurred in which the resident, known for patting and rubbing other residents in a non-aggressive manner, startled another resident by patting him on the head. This led to the second resident, who was drowsy and leaning forward, reacting by striking the first resident, resulting in a skin tear. Staff confirmed that the resident had a pattern of getting into others' personal space and that not all residents liked to be touched. The lack of individualized, person-centered interventions and failure to address the resident's specific behaviors and preferences in the care plan contributed to the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple altercations involving three residents with severe cognitive impairments and histories of behavioral issues. In one incident, a resident with dementia and violent behavior attempted to touch another resident's watch, resulting in the second resident, who also has dementia and a history of physical aggression, grabbing the first resident's wrist and causing a skin tear. Both residents were identified as being at moderate risk for abuse, and their care plans documented behavioral problems and tendencies toward aggression. In a separate incident, another resident with dementia and a history of aggressive behaviors attempted to move a wheelchair occupied by a resident with dementia and agitation. This led to a physical altercation where the resident in the wheelchair swung her arms, and the other resident responded by striking her in the face. The altercation escalated further when the resident who was struck used a racial slur. These events demonstrate that the facility did not adequately prevent or intervene in resident-to-resident abuse, despite documented risks and behavioral histories.
Failure to Administer Ordered IV Antibiotic and Notify Provider
Penalty
Summary
Facility staff failed to administer five consecutive doses of an ordered intravenous antibiotic (Unasyn, 1.5 grams every eight hours) to a resident with a history of wound infection and a current diagnosis of cutaneous abscess of the buttock. The resident was scheduled to begin antibiotic treatment on the morning of 4/19/2025, but did not receive the first dose until 4:00PM on 4/20/2025, as documented in the medication administration record. Additionally, staff did not notify the resident's wound care medical provider about the missed doses, as confirmed by a handwritten note and staff interview. The facility's assistant administrator reported that staff are expected to contact the prescribing provider within a day's time if unable to provide an ordered medication. These actions and inactions resulted in the resident not receiving timely antibiotic therapy as ordered, and the medical provider was not informed of the missed doses.
Failure to Supervise High-Risk Resident Resulting in Multiple Falls
Penalty
Summary
The facility failed to provide effective supervision to prevent falls for a resident with severe cognitive impairment, a history of stroke, and Alzheimer's disease. The resident, who was dependent on staff for mobility and transfers, experienced multiple falls from their wheelchair in their room. Despite being identified as high risk for falls and having care plan interventions in place, such as placing the resident in bed after meals and frequent checks, the resident continued to experience falls, including unwitnessed incidents. Documentation indicated that staff were to keep the resident in a common area or under monitoring when in the wheelchair, but these interventions were not consistently implemented. There was confusion and inconsistency among staff regarding who witnessed the resident's falls and who assisted after the incidents. Multiple staff members, including the DON, CNAs, and MDS Coordinator, provided conflicting accounts about their presence and actions during the falls. This lack of clear supervision and communication contributed to the resident's repeated falls, demonstrating a failure to ensure the area was free from accident hazards and that adequate supervision was provided.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one of whom was severely cognitively impaired and dependent on staff for most activities of daily living, while the other was cognitively intact and able to self-propel in a wheelchair. According to the facility's abuse summary report, a certified nurse aide reported to the administrator that the cognitively intact resident had put his hand on the inner thighs of the cognitively impaired resident and kissed her on the side of her neck. The aide immediately removed the resident from the area, and the administrator subsequently reviewed camera footage and interviewed staff and other residents present at the time of the incident. Despite the facility's policy requiring that any allegation of abuse be reported to the State Agency unless it can be immediately refuted, the administrator did not report the incident to the State Agency. The administrator acknowledged that an investigation was initiated but confirmed that no report was made to the required authorities, as stipulated by facility policy. This failure to report the allegation constituted a deficiency in the facility's abuse reporting procedures.
Failure to Arrange Physician-Ordered Prosthetic Clinic Referral
Penalty
Summary
The facility failed to follow a physician's order to arrange a referral to a prosthetic clinic for a resident with a pre-existing left above-the-knee amputation. The resident, who was cognitively intact and required supervision with daily activities, had a physician order documented for a prosthetic clinic referral. Nursing progress notes confirmed the order, but there was no documentation of an appointment being made. Multiple staff members, including the Social Service Director, Physical Therapy Assistant, and Transportation Director, were aware of the referral but did not ensure the appointment was scheduled. The Social Service Director informed the Interdisciplinary Team, but no follow-up occurred, and the Transportation Director was told not to make the appointment. The Nurse Practitioner who wrote the order expected it to be carried out, and the facility administrator confirmed that staff are expected to follow provider orders, although there was no formal policy in place. The lack of action resulted in the resident not receiving the necessary referral to the prosthetic clinic as ordered by the physician.
Lack of Qualified Food Service Director and Sanitation Failures
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, as required by federal and state regulations. The individual identified as the full-time manager of the food service, V10, was observed supervising dietary operations but did not possess the necessary credentials such as being a certified dietary manager, a dietician, or having an associate's or higher degree in food service management or hospitality. V10 only completed a one-day ServSafe food service sanitation course, which did not include clinical nutrition instruction, and held a Certified Food Protection Manager certificate, not a Certified Dietary Manager or equivalent. V10 confirmed not meeting the Illinois standards for a food service or dietary manager and reported that the facility dietician only worked one day per week. Additionally, during the survey period, the facility failed to maintain sanitary conditions in the dishwashing areas and did not prevent or exclude flying insects from the food service areas, resulting in direct cross-contamination of resident dishes. The food prepared in the kitchen was available to all 146 residents in the facility, potentially exposing all residents to the effects of these deficiencies.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain an effective pest control program in the kitchen and food service areas, resulting in the presence of flying insects and unsanitary conditions. On multiple occasions, accumulations of decomposed food were found under the kitchen dishwasher drainboards, on surrounding walls, floors, and plumbing surfaces. The dishwasher drain pipe discharged into a floor-level trough that was soiled with food debris and emitted a fetid odor. Containers beneath the dishwasher and three-basin sink were partially filled with dirty water and food debris, and winged insects resembling fruit flies were seen flying around these areas. The disposal basin attached to the dishwasher, which was designed to empty into a food grinder/disposal, was instead draining into a metal pan in the floor trough, further contributing to the accumulation of food debris and the presence of flies. Pest control reports documented ongoing issues, including fly problems, potential harborage, and sightings of German cockroaches and spiders in the kitchen. Despite recommendations to clean the affected areas, conditions persisted, with flies observed landing on food contact surfaces of clean resident dishes stored near the contaminated drain trough and sewer pipe. The kitchen prepares food for all residents in the facility, and at the time of the survey, 146 residents resided in the facility.
Resident Rights Not Honored During Wound Care Scheduling
Penalty
Summary
A resident with multiple medical diagnoses, including muscle wasting, morbid obesity, end stage renal disease, and moderate protein calorie malnutrition, was documented as cognitively intact and dependent on staff for most activities of daily living. The resident's care plan instructed staff to provide opportunities for choice during care. However, on the day in question, the resident expressed a desire to get out of bed but was told by staff that he had to remain in bed until the wound physician arrived, which could be several hours. The resident became visibly upset and teary-eyed, stating he could not get up by himself and staff would not assist him. Staff interviews confirmed that the resident was not allowed to get up until seen by the wound physician, and that he had been crying all morning due to this restriction. Further interviews revealed that the wound nurse instructed staff not to assist the resident out of bed until the physician arrived, and that the resident refused wound care because he wanted to get up. The resident reported that he was not opposed to wound care but objected to being made to stay in bed for extended periods. The DON acknowledged that requiring the resident to remain in bed for hours was a violation of his rights, stating that a short wait would be acceptable but not a prolonged one. The facility's policy affirms residents' rights to a dignified existence and to be treated with respect, which was not upheld in this instance.
Inaccurate Completion of Resident Assessment
Penalty
Summary
A comprehensive assessment for one resident was inaccurately completed when the medication section indicated the resident was taking an antibiotic during the assessment period. However, a review of the resident's February 2025 Order Summary Report and Electronic Medical Record showed no documentation of any antibiotic orders or administration during that time. The MDS Coordinator, who completed the assessment, confirmed that the resident was not prescribed or given any antibiotics during the look-back period. The facility's policy requires all individuals completing any portion of the MDS assessment to attest to the accuracy of the information provided.
Failure to Update Wound Care Orders and Follow Sterile Technique
Penalty
Summary
A deficiency occurred when staff failed to enter new wound dressing change orders and did not provide wound care in accordance with professional standards for a resident diagnosed with Idiopathic Aseptic Necrosis of both feet and Peripheral Vascular Disease. The wound nurse performed a dressing change on the resident's right foot, cleansing the wound with Betadine and then, without changing gloves, applied a new clean dressing. The nurse later confirmed that she should have removed her dirty gloves before handling the clean dressing, as per the facility's wound care policy, which requires the use of sterile technique and glove changes to prevent contamination. Additionally, the wound nurse did not update the resident's wound care orders in the computer system after the wound doctor changed the treatment plan. As a result, wound care continued to be provided and documented under the previous orders, which differed from the new physician's instructions. The nurse acknowledged that the new orders should have been entered into the system on the same day they were received, but this was not done, leading to a failure to provide care according to the most current physician orders.
Failure to Prevent Cross Contamination During Catheter Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during catheter care for a resident with multiple complex medical conditions, including hereditary spastic paraplegia, morbid obesity, neuromuscular dysfunction of the bladder, and a suprapubic catheter. The LPN removed a contaminated split gauze from the resident’s suprapubic catheter insertion site, which had yellow/pink drainage, and cleansed the area by wiping the gauze back and forth multiple times over the same area. Without changing gloves or performing hand hygiene, the LPN then placed a new split gauze over the insertion site using the same contaminated gloves. The resident’s medical records indicated a physician’s order for twice-daily cleansing of the suprapubic catheter site, but the resident reported that staff never clean the site daily, only during monthly catheter changes. The LPN acknowledged contaminating the site by not changing gloves between cleaning and dressing application. The Director of Nursing confirmed that contaminating an open wound could lead to infection. Facility policy required staff to discard gloves and perform hand hygiene after cleansing around the catheter site, which was not followed in this instance.
Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to offer, administer, or obtain consent or declination for Influenza and Pneumococcal vaccinations for two residents out of five reviewed for immunizations. Both residents had been admitted to the facility and were documented as severely cognitively impaired according to their Minimum Data Set (MDS) assessments. Review of their electronic medical records revealed no documentation of consent, administration, or refusal of the required vaccinations since their admission. During an interview, the facility's Registered Nurse/Infection Preventionist confirmed that there was no documentation available to show that the two residents had been offered or had received the Influenza or Pneumococcal vaccines, nor was there evidence of refusal. Facility policy requires that Influenza vaccines be offered to all residents between October 1 and March 31, and that Pneumococcal vaccination status be assessed within five working days of admission, with all actions documented in the resident's medical record. These procedures were not followed for the two residents in question.
Failure to Maintain Functional Bathroom Ventilation Fan
Penalty
Summary
The facility failed to maintain a functional bathroom ventilation fan for one resident. On two separate occasions, it was observed that the bathroom ventilation fan in the resident's room was inoperable, with the fan blades not moving when the switch was turned on. The resident reported that the fan had not worked since admission in June 2024 and expressed a desire for it to be operational. The resident also stated that multiple requests had been made to various staff members over time to repair the fan, but no action had been taken to address the issue.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident by not implementing resident-centered fall interventions and not thoroughly investigating a fall incident. The resident, who had a history of falls and was assessed as a fall risk, experienced a fall resulting in a forehead laceration that required emergency room treatment and sutures. The resident's care plan included interventions such as wearing non-skid socks and ensuring the bed was in a low position, but these were not adequately implemented or monitored. Observations revealed that the resident's bed was positioned against a wall with multiple pillows, which crowded the resident and forced her to sleep close to the edge, increasing the risk of falling. The resident's call light was not within reach, and staff were not aware of the resident's fall risk status or specific care plan interventions. Interviews with staff indicated a lack of awareness and understanding of the resident's care plan and fall interventions, with some staff relying on visual cues like floor mats to identify fall risks rather than documented care plans. The interdisciplinary team reviewed the fall incident but failed to address the root cause effectively. The resident's sleeping patterns and the inappropriate use of pillows were not included in the care plan, leading to confusion among agency staff. The facility's policy on falls required continuous evaluation and identification of fall causes, but this was not adequately followed, resulting in the resident's preventable fall and injury.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident, who was known to exit seek and had a history of elopement. This resident, who was at high risk of falls and was receiving anticoagulation therapy, managed to exit the facility through a deactivated alarmed exit door without staff knowledge or supervision. The resident walked approximately 0.4 miles in extreme cold weather, down a busy street, before being found by a passerby who alerted the facility. Staff were unaware of the resident's absence for approximately one-half to one hour. The resident's medical history included severe dementia with mood disturbance, delirium, restlessness, agitation, hypertension, paroxysmal atrial fibrillation, muscle weakness, and gait abnormalities. Despite these conditions and a documented history of falls, the facility did not update the resident's care plan to address elopement risks in a timely manner. The resident had been observed wandering and exit-seeking prior to the incident, yet no effective interventions were implemented to prevent the elopement. Additionally, after the resident was returned to the facility, staff failed to conduct a full body assessment to check for injuries or hypothermia. The facility also did not ensure that exit door alarms were functional, contributing to the resident's ability to leave the premises unnoticed. These failures highlight significant lapses in supervision and safety measures, which placed the resident at risk of serious harm.
Removal Plan
- Confirmed the facility identified residents affected or likely to be affected by completing resident elopement assessments and reassessments and updating care plans.
- Confirmed elopement binder was updated and at the nurses' stations, and the reception desk.
- Confirmed Accidents and Incidents- Investigating and Reporting Policies including documentation of the condition of the affected person, including vital signs was revised and updated.
- Staff training was initiated and is ongoing. In-service training on elopement protocol and retention quiz were not provided prior to start of shift for several staff.
- Confirmed V1, V2 and V28 Assistant Director of Nurses initiated education relating to immediate head to toe assessments following unusual occurrences.
- Confirmed V12, Maintenance Director assessed all doors, exit alarms, and the departure alert system to ensure proper working order and observed during survey. Ad-Hoc QAPI meeting was completed discussing event and evaluating the current elopement program including conducting daily assessments of exits, and routinely scheduled elopement drills to be ongoing. One mock drill was completed during survey.
- Confirmed V1, provided training to the IDT regarding development of care plans to address residents who are newly identified with exit-seeking /wandering behaviors and elopement risk.
- Confirmed Ad-Hoc QAPI meeting, including the Medical Director by phone, to discuss the incident and the corrective actions to prevent similar events.
- Confirmed in interviews, Daily IDT meetings were conducted to discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring appropriate clinical interventions are implemented to prevent an incident of elopement.
- Confirmed QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for several residents, as observed during a survey. On multiple occasions, a resident was seen sitting at a dining room table covered with napkins, tissues, condiments, and personal items, including mucous-filled tissues. This behavior was noted to be disruptive and unpleasant for other residents, leading to complaints. One resident expressed discomfort and a loss of appetite due to another resident's habit of hacking and spitting up mucous, which was also thrown onto the floor. This resident reported having complained to the staff about the issue, but no action was taken to address the behavior. The administrative assistant acknowledged awareness of the disruptive behavior, which continued to occur daily. The care plan for the resident exhibiting the behavior documented the need for supervision and reminders to refrain from such actions during meal times. Despite this, the behavior persisted, affecting the dining experience and comfort of other residents. The facility's inaction in managing the situation and ensuring a clean and comfortable environment for all residents led to the deficiency noted in the report.
Failure to Address Resident Grievances Regarding Disruptive Behavior
Penalty
Summary
The facility failed to honor the residents' right to voice grievances without discrimination or reprisal, as evidenced by the lack of a filed grievance for a known complaint. Two residents expressed dissatisfaction with another resident's behavior, which involved hacking, spitting up mucous, and discarding tissues on the floor in the dining room. These actions were reported to staff, including the Assistant Administrator, but no grievance was filed, and the issue remained unaddressed. The facility's grievance policy, dated April 2017, mandates that grievances be investigated and resolved promptly, with a written response provided within five working days. Despite this policy, the Assistant Administrator acknowledged awareness of the disruptive behavior but did not file a grievance, mistakenly attributing the issue to the resident's behavior rather than recognizing it as a grievance-worthy complaint. This oversight resulted in the residents' complaints not being documented or addressed according to the facility's established procedures.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, resulting in multiple missed doses for three residents. One resident, who was cognitively intact, reported that the facility had run out of their medications, including Duloxetine and Lorazepam, on several occasions. The Medication Administration Records (MARs) and nursing notes documented that these medications were unavailable on specific dates, and there was no evidence that the resident's physician was notified of the missed doses. Another resident, also cognitively intact, stated that their bone medication was unavailable for several weeks. The MARs indicated that Alendronate-Cholecalciferol was not administered as scheduled due to a billing issue and lack of prior authorization. Despite multiple attempts to resolve the issue, the medication remained unavailable, and there was no documentation that the physician was informed of the missed doses until a later date. A third resident did not receive their prescribed Aripiprazole because the medication was not found in the facility's backup supply. The LPN responsible for administering the medication confirmed its unavailability and reordered it from the pharmacy. However, there was no documentation of follow-up with the pharmacy or physician regarding the medication's unavailability. The facility's policies outlined procedures for handling unavailable medications, but these were not followed, contributing to the deficiency.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer insulin timely, resulting in significant medication errors for one resident. The resident, who is cognitively intact, reported not receiving medications on time, including insulin, which led to fluctuations in blood sugar levels. The resident's Medication Administration Record (MAR) indicated that Lispro insulin was scheduled to be administered three times daily at specific times. However, the Medication Administration Audit Report showed multiple instances where the insulin was administered hours later than scheduled. The Director of Nursing confirmed that medication administration times should be documented accurately and that medications should be given within an hour of the scheduled time unless specified otherwise. The facility's policy on administering medications, dated April 2019, also states that medications should be administered according to physician's orders and within one hour of the prescribed time. Despite these guidelines, the facility repeatedly failed to administer insulin within the required timeframe, leading to significant medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered for three residents, resulting in a 12% medication error rate. For one resident, the Licensed Practical Nurse (LPN) did not administer Ferrous Sulfate 325 mg as scheduled during the morning medication pass, despite confirming that the medication administration was complete. The facility's medication pass times indicated that the medication should have been administered between 6:00 AM and 11:00 AM. Another resident received an incorrect dosage of Breo Ellipta inhaler, which was intended for a different resident, and was not instructed to rinse their mouth after administration as required. The inhalers were stored incorrectly, leading to the administration error. Additionally, a third resident did not receive their prescribed Aripiprazole due to the medication being unavailable in the facility, and there was no documentation of the physician being notified of the missed dose. The facility's policy requires medications to be administered according to physician orders, ensuring the right resident, medication, dosage, time, and method.
Failure to Perform Wound Care Leads to Maggot Infestation
Penalty
Summary
The facility failed to complete wound dressing changes as ordered by the wound care physician for a resident, resulting in the resident's wounds becoming infested with maggots. The resident, who was admitted with multiple diagnoses including wounds and dementia, had specific wound care orders that were not followed. The wound care physician had prescribed the application of Triamcinolone cream and compression wraps twice a week, but these were not consistently documented or performed. On one occasion, a nurse admitted to not performing a dressing change due to being busy, despite having charted it as completed. The resident experienced significant pain and deterioration of the wounds, which were found to be infested with maggots on two separate occasions. The room was noted to have a strong smell of urine and fly strips with flies, indicating poor sanitation. The Director of Nursing acknowledged the unacceptable care, and the wound physician expressed concerns about infection due to the maggot infestation. The resident's condition worsened, with new wounds developing and existing wounds declining in size and condition.
Fly Infestation Due to Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest management program, resulting in a significant fly infestation affecting all 141 residents. The facility's pest control policy, dated March 2024, assigns the Environmental Services Director the responsibility for coordinating pest control, which should be conducted regularly and as needed. However, pest control service reports from April to August 2024 did not document flies as an area of concern. Observations on August 19 and 20, 2024, revealed numerous fly strips with flies attached in several resident rooms, including one room with over 50 flies on a strip. A resident reported having to use fly strips for the past 2-3 months due to the fly problem, and an LPN confirmed that many residents were using fly strips to keep flies away. The Maintenance Director acknowledged the presence of fly traps and a fly light at the courtyard door but dismissed flies as pests. The contracted pest control representative was not informed of the fly issue until the survey and identified entry points for flies through air conditioning units and standing water outside the building as breeding sites. The representative recommended fly lights and noted that the fly strips in use were not provided by their company, indicating a lack of communication and coordination in addressing the pest issue. Additionally, the Director of Nursing confirmed that a resident had maggots found in wounds on two occasions in the past week, further highlighting the severity of the infestation.
Failure to Provide Prescribed Diabetic Diets
Penalty
Summary
The facility failed to provide a diet as ordered for five residents with diabetes, resulting in a deficiency. The facility's Physician Order Policy requires that after an order is received and confirmed, it should be completed as directed by the prescriber. However, the facility provided only one meal option for all residents, regardless of their dietary needs. Specifically, residents with orders for a low concentrated sweets diet were not given meals that adhered to these dietary restrictions. Instead, they were served the same meals as other residents, which included items not suitable for a diabetic diet, such as ravioli and sauce for lunch, and a breakfast of biscuit, sausage gravy, and a banana. The deficiency was confirmed through observations and interviews with facility staff. The Dietary Assistant Manager and the Director of Nursing both acknowledged that there were no different menus or portion sizes for diabetic residents. The Registered Dietician was unaware that the staff were not serving a low concentrated sweets diet to diabetic residents, which could lead to health issues such as elevated blood sugar levels, weight gain, and poor circulation and wound healing. The failure to provide the prescribed diet as ordered for diabetic residents was a significant oversight in the facility's dietary management.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident (R1) struck another resident (R2) in the face. This incident occurred after R1 became aggressive upon returning to the facility. Multiple staff members, including CNAs and an LPN, witnessed the altercation and reported that R1 was yelling profanities and making racial remarks towards the staff. The police were called to manage the situation, and R2 was moved to a different room for safety. R2 experienced discomfort and swelling on the left side of the face near the eye as a result of the altercation. The facility's investigation revealed that R1 had borrowed money from R2 and failed to repay it, leading to the confrontation. R2 expressed fear of R1 following the incident and was relieved to be moved to a different room. The facility's Abuse Prevention and Reporting Policy, dated October 2022, explicitly prohibits abuse, neglect, and mistreatment of residents, yet this policy was not effectively enforced in this case, resulting in a failure to protect R2 from physical harm.
Failure to Implement Safety Measures for Resident with Criminal Background
Penalty
Summary
The facility failed to ensure the safety of its residents by not accurately screening and assessing a newly admitted resident, identified as R1, who had a history of felony offenses and was assessed as a moderate risk to others. Upon admission, R1 was placed in a room with another resident, R2, without implementing necessary safety interventions or an individualized plan of care that considered R1's criminal background. This oversight led to an incident where R1 physically assaulted R2, causing facial discomfort, swelling, and psychosocial harm to R2. The facility's policy required a thorough review of criminal history and the development of a care plan tailored to the needs of identified offenders. However, R1's care plan did not document any offender information, and an abuse risk assessment was not completed until after the incident occurred. The facility's background check process was flawed, as the initial check was conducted with an incorrect date of birth, delaying the identification of R1's criminal history. Despite R1's background indicating a need for a private room, the facility placed R1 in shared accommodations, which contributed to the incident. Interviews with facility staff revealed a lack of awareness and preparedness regarding R1's background and the necessary precautions to protect other residents. The Social Service Director acknowledged the error in the background check process and the absence of safety measures for R1. The Regional Director of Operations was unaware of R1's aggravated battery conviction, and the facility administrator denied being informed by R1 of the need for a private room. This series of inactions and miscommunications led to the failure to protect R2 from harm.
Failure to Develop Comprehensive Care Plan for Identified Offender
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as an offender, which is a requirement according to their policy. The policy mandates that upon admission of an identified offender, the facility must create an individualized plan of care that includes security measures to protect other residents. This plan should be developed in consultation with a medical doctor and law enforcement. However, the resident's care plan did not document their status as an identified offender, their risk level, or any specific interventions to address these concerns. The resident in question has a significant criminal history, including several arrests and convictions for offenses such as aggravated battery, burglary, and resisting a peace officer. Despite this history and the moderate risk assessment from the referring facility, the resident's care plan lacked necessary details to ensure the safety of other residents. The Social Service Director confirmed that the resident's offender status and risk level were not included in the care plan, acknowledging that this was an oversight.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to honor a resident's breakfast meal preferences, affecting one of the three residents reviewed for meal preferences in the sample list of nine. On June 9 and June 10, 2024, the resident was served only one fried egg for breakfast, despite having previously requested two fried eggs, two pieces of toast, and two sausages every day. The resident had communicated these preferences to the Dietary Manager about a month prior, and the facility initially complied for a few days. However, the resident reported that the facility subsequently reduced the meal to one slice of toast and, on the past two days, only one fried egg. On June 11, 2024, the resident's breakfast tray included two fried eggs, one slice of toast, oatmeal, and a four-ounce drink. The Dietary Manager confirmed the resident's request and was unaware of the deviation from the requested meal on the previous days.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
The facility failed to ensure a resident's right to be free from verbal abuse by staff. This deficiency was identified when a resident, who is cognitively intact and requires assistance with grooming and toileting, reported an incident where a Certified Nursing Assistant (CNA) made a derogatory comment. The resident had an episode of loose stools and was unable to reach to clean himself. When the CNA handed him wipes and the resident demonstrated his inability to reach, the CNA responded with a comment about the resident's weight, making him feel ashamed and embarrassed. This incident was reported to the Activity Director and subsequently led to an interview with the Administrator, Director of Nursing, and a local police officer. The facility's abuse policy, dated August 2023, emphasizes the right of residents to be free from abuse, neglect, and mistreatment. Despite this policy, the incident occurred, and the CNA involved was suspended pending an abuse investigation. The Administrator confirmed that based on the gathered information, the incident would be considered verbal abuse. This failure to protect the resident from verbal abuse by staff highlights a significant deficiency in the facility's adherence to its own policies and procedures designed to prevent such occurrences.
Failure to Facilitate Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to facilitate interdisciplinary care plan meetings including residents for one of three residents reviewed for care plan meetings. The facility's Care Plan Meeting Procedure requires invitations to be extended to the resident or their representative and for various staff members to participate. However, for one resident, the quarterly care plan meeting was attended only by the Care Plan Coordinator, with no documentation regarding falls, injuries, behaviors, cares, or weight loss. The Care Plan Coordinator admitted to not knowing if the resident's guardian received the invitation and held the meeting alone. The Director of Nursing and the Regional Nurse Consultant acknowledged the issue, noting that the resident, family, and other staff should be present and that communication with the guardian was lacking.
Failure to Provide Basic Hygiene Care
Penalty
Summary
The facility failed to provide adequate bathing, shaving, and nail care for a resident who was dependent on staff for all activities of daily living. The resident, who was severely cognitively impaired, was observed in a soiled state with long toenails and unshaven hair. The facility's policies on bathing and nail care were not followed, and there was no documentation indicating when the resident last received these essential care services. Both the Administrator and the Director of Nursing acknowledged the resident's neglected state but could not explain why the care needs had not been addressed by the CNAs or the Podiatrist.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and another resident's right to be free from physical abuse. In the first incident, a resident with Alzheimer's Disease and severe cognitive impairment was sexually abused by another resident who was moderately cognitively impaired and had a history of inappropriate sexual behavior. The incident occurred in the dining room where the perpetrator grabbed the victim's chest and refused to let go despite the victim's attempts to pull away. This was witnessed by a dietary aide and confirmed by video evidence. The perpetrator later admitted to the act, stating they knew it was wrong but acted on an urge. In the second incident, a resident with dementia and moderate cognitive impairment was physically abused by another resident with severe cognitive impairment and a history of aggressive behaviors. The perpetrator accused the victim of stealing and struck them with a closed fist, leading to a physical altercation where both residents fell to the floor. This incident was witnessed by a nurse practitioner and a certified nurse assistant, both of whom confirmed the aggressive behavior and the physical altercation. The perpetrator was placed on one-on-one supervision following the incident.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents, R205 and R206. The incident occurred in the dining room where R205, in a wheelchair, touched R206's chest over the clothes. The investigation included statements from a dietary aide who witnessed the event and a certified nurse assistant who assisted in separating the residents. However, the facility did not document interviews with the Interdisciplinary Team (IDT) or other staff and residents who might have had knowledge of R205's inappropriate behavior. The administrator confirmed that no other residents were in the dining room during the incident and acknowledged the lack of documented interviews with the IDT and other potential witnesses.
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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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