La Bella Of Sterling
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling, Illinois.
- Location
- 3601 Sixteenth Avenue, Sterling, Illinois 61081
- CMS Provider Number
- 14E579
- Inspections on file
- 20
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at La Bella Of Sterling during CMS and state inspections, most recent first.
Multiple areas of the facility, including resident rooms, common spaces, and shower rooms, were found to be significantly colder than required, with temperatures as low as 50°F. Residents and staff reported discomfort and wore extra clothing indoors, while maintenance staff cited ongoing issues with old heating units and drafts. Leadership was not promptly informed of the extent of the cold conditions, and the facility's policy to maintain temperatures between 71-81°F was not met.
A resident with multiple medical conditions but no cognitive impairment sustained second-degree burns to the hand and forearm after returning unsupervised to a fire pit during an outdoor activity. Staff were occupied with other tasks and did not maintain supervision of the fire area, leading to the incident. The facility did not have a policy for supervision during outdoor activities.
The facility failed to ensure its activity program was directed by a qualified professional, affecting all residents. The Activity Director, who also serves as Social Services and a CNA, had been in the role for two months and worked every other weekend. During her absence, residents received activity packets. The Regional Director of Operations confirmed that the Activity Director lacked necessary certifications.
The facility failed to ensure the dishwasher sanitation solution was checked at the recommended level, affecting all 43 residents. A cook and a dietary aide used incorrect test strips for the hypochlorite solution, leading to inaccurate readings. The correct strips were later found under the dishwasher, and when used, showed the correct concentration. However, the log book showed inconsistent records, and the dietary manager confirmed the switch from quaternary ammonia to hypochlorite a month ago.
The facility failed to provide adequate behavioral health services for residents with mental illness, affecting four individuals. Residents expressed dissatisfaction with the lack of on-site counseling and in-person psychiatric care, relying instead on limited telehealth services. The facility's social services staff lack the necessary background to address residents' mental health needs, resulting in unmet care requirements.
The facility failed to provide necessary social services to residents with significant mental health needs. One resident expressed boredom and lack of counseling, another had unmet dental and vision needs, a third lacked in-person therapy, and a fourth had not met a psychiatrist in person. The social services staff was inexperienced and inadequately trained.
The facility failed to document consents for two residents who received the PCV 20 vaccine and declinations for two residents who refused it. The Corporate Regional Director of Operations confirmed the absence of necessary documentation in the residents' EMRs, contrary to the facility's policy requiring signed consent forms and documentation of refusals or contraindications.
A resident's room was found with missing sections of the wall and an ant infestation, which had not been addressed despite the resident notifying staff. The Maintenance Supervisor admitted to being aware of the issue but cited limited resources and time as reasons for the delay in repairs. The facility lacked a policy on building maintenance.
The facility failed to provide adequate activities for two residents, leading to dissatisfaction with the age-inappropriate and limited options available. One resident expressed a desire for more group activities and access to newspapers, while another noted staffing shortages prevented outdoor activities. Observations confirmed a lack of organized activities, contrary to the facility's policy.
A facility failed to provide appropriate mental health services for a resident with PTSD and other mental health diagnoses. The resident, who identifies as non-binary or male, did not receive recommended rehabilitative services, structured environments, or psychotherapy. The care plan was incomplete, lacking specific triggers and preferences. Staff were not informed of the resident's preferred pronouns, leading to misgendering. The facility lacked a policy on psych services and did not provide evidence of services received.
The facility failed to administer medications as ordered and properly account for controlled substances, affecting three residents. One resident missed their evening medication due to lack of staff reminder, while another had discrepancies in their narcotic count documentation. A third resident did not receive cogentin due to delayed prior authorization, leading to refusal of haldol. These issues highlight deficiencies in medication administration and documentation practices.
The facility failed to address pharmacy recommendations for three residents, leading to deficiencies in medication regimen reviews. One resident did not have required lab tests completed, another had a medication dosage adjustment unaddressed, and a third had a recommendation to discontinue a medication left incomplete. The DON found a backlog of unaddressed pharmacy forms.
The facility failed to address a gradual dose reduction for a resident on buspirone and did not ensure a stop date for a PRN anti-anxiety medication for another resident. The DON and MDS Coordinator did not follow up on the dose reduction, and the PRN order lacked the required 14-day stop date.
A resident missed five doses of apixaban due to an empty medication card sent by the previous facility and a delay in processing insurance information. The resident, admitted with acute embolism and thrombosis, received their first dose three days after admission, contrary to the facility's policy to prevent significant medication errors.
The facility failed to ensure RN staffing data was accurately entered in the PBJ system, affecting all 42 residents. The Administrator indicated uncertainty about the issue, suggesting it might be due to the corporate office pulling punch codes from the time clock, which outside agency staff do not use, or how the time clock codes the nurses. The person responsible for reporting the PBJ data only works weekends and did not respond to an email inquiry. The PBJ Staffing Data Report for a specified period showed no RN hours and failed to have licensed nursing coverage 24 hours a day, despite the nursing schedule indicating otherwise, demonstrating inaccurate reporting.
The facility failed to administer medications according to manufacturer's directions, monitor residents during medication administration, and provide ordered medications. An LPN did not provide a resident's prescribed medication due to unavailability, did not monitor another resident who threw away a pill, and did not instruct a resident to rinse after using an inhaler. Additionally, the LPN did not follow proper procedures for administering insulin to another resident.
Failure to Maintain Comfortable Temperatures Throughout Facility
Penalty
Summary
The facility failed to maintain comfortable temperatures throughout the building, resulting in multiple areas being significantly colder than the required range. During an initial tour, surveyors observed that the west hallway, group and activity room, nursing station, and main dining area were very cold. Temperature readings taken with the facility's infrared gun showed several locations with wall temperatures as low as 50.0°F to 57.2°F, including resident rooms, common areas, and shower rooms. Residents and staff reported that the building had been cold over the weekend, with some residents wearing jackets indoors and staff layering clothing to stay warm. One resident room's heating unit had not been working properly for about a week, and maintenance staff acknowledged ongoing issues with old heating units and drafts from exhaust fans. Staff interviews revealed that although the cold conditions were noticed by both residents and staff, there was a lack of timely communication to facility leadership. The administrator and DON were not made aware of the extent of the cold temperatures until after the weekend, despite staff and residents experiencing discomfort. The maintenance log indicated that heating issues in at least one resident room had been reported two weeks prior, but the problem persisted. The facility's policy requires immediate action to maintain temperatures between 71-81°F, which was not achieved in several areas during the survey.
Lack of Supervision During Outdoor Fire Activity Results in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident during an outdoor activity involving a fire pit. The resident, who had diagnoses including major depressive disorder, anxiety disorder, COPD, schizoaffective disorder, and tremor but no cognitive impairment, was participating in a marshmallow roasting activity. Staff members were assigned to supervise different areas, but after assisting the resident with roasting a marshmallow, the dietary manager left the resident to assist others. The resident then returned to the fire pit alone, attempted to throw a napkin into what appeared to be an extinguished fire, and the napkin ignited while stuck to her hand, resulting in burns to her left hand and forearm. Other staff present were occupied with setting up a piñata and were not supervising the fire area at the time of the incident. The incident resulted in the resident sustaining second-degree burns, requiring immediate first aid and subsequent evaluation at a local emergency room. Interviews with staff revealed that supervision around the fire was not maintained after the initial activity, and there was confusion regarding who was responsible for monitoring the residents near the fire pit. The facility was unable to provide a policy regarding supervision of residents during outdoor activities.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that its activity program was directed by a qualified professional, which has the potential to affect all residents residing in the facility. The facility's Resident Census and Condition form dated March 10, 2025, indicated a census of 43 residents. On March 11, 2025, the Activity Director, who also serves as Social Services and a CNA, stated that she had been in the role for about two months and worked every other weekend. During her absence, residents were provided with activity packets containing crosswords, sudoku puzzles, and coloring pages. However, it was revealed by the Regional Director of Operations that the Activity Director did not possess any activity director certifications.
Dishwasher Sanitation Solution Not Checked Properly
Penalty
Summary
The facility failed to ensure the dishwasher sanitation solution was checked at the recommended level prior to use, affecting all 43 residents. During an observation, a cook (V7) and a dietary aide (V8) were involved in testing the dishwasher's sanitation level. Initially, quaternary ammonia test strips were used, which turned yellow, indicating an incorrect concentration. Upon realizing the sanitizing solution bucket was nearly empty, V7 replaced it with a full bucket and retested, but the strips still showed an incorrect concentration. It was then discovered that the strips used were not appropriate for the hypochlorite solution currently in use. Further investigation revealed that the correct test strips for hypochlorite were found scattered under the dishwasher. When these strips were used, the concentration registered at 50 ppm, which is the correct level according to the facility's policy. However, the log book showed that V8 had recorded a concentration of 100 ppm earlier, which was inconsistent with the findings. The dietary manager (V6) confirmed that the sanitation level should be 100 ppm and acknowledged the switch from quaternary ammonia to hypochlorite a month ago. The facility's policy requires that the chemical solutions be maintained at the correct concentration and checked at least once per shift, which was not adhered to in this instance.
Inadequate Behavioral Health Services for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care services for residents with mental illness diagnoses, affecting four residents in the sample. Resident 32, diagnosed with major depressive disorder, PTSD, and schizophrenia, expressed dissatisfaction with the lack of on-site counseling services and reported feelings of boredom and depression. The facility's activity director, who recently assumed the role of social services, lacks a behavioral health background and is unsure of the specific services needed by the residents. The resident's care plan includes interventions for depression and self-harm risk but lacks effective implementation of behavioral health services. Resident 41, with diagnoses including major depressive disorder, bipolar disorder, and PTSD, also reported inadequate mental health services at the facility. He was under the impression that he would receive more intensive psychiatric care and has had to find his own therapy. The facility's social services staff, who are new to their roles, are not equipped to provide the necessary psych services, and the resident's care plan does not adequately address his mental health needs. The facility previously had behavioral health aides and an in-person psychiatrist, but these services are no longer available, leaving residents without sufficient support. Residents 22 and 26, both with severe mental health diagnoses, also reported dissatisfaction with the facility's psychiatric services, which are limited to telehealth visits. Both residents expressed a preference for in-person psychiatric care, which the facility does not currently provide. The lack of comprehensive behavioral health services and the absence of a qualified social services staff have resulted in unmet needs for these residents, contributing to their ongoing mental health challenges.
Failure to Provide Adequate Social Services for Residents
Penalty
Summary
The facility failed to provide medically related social services to four residents, each with significant mental health diagnoses, as observed during the survey. One resident, a male with major depressive disorder and PTSD, expressed dissatisfaction with the lack of on-site counseling and life skills activities, feeling bored and uninformed about his discharge plan. Another resident, also with major depressive disorder and other mental health issues, was found with broken glasses and unmet dental needs, feeling overwhelmed due to the absence of counseling support and inadequate social service documentation. A third resident, identifying as male and with a history of suicidal ideation, reported a lack of in-person therapy and group support for trauma and wellness, despite having been recently hospitalized for mental health issues. The fourth resident, with a history of substance abuse and mental health disorders, had not met with a psychiatrist in person, only through telehealth, and expressed a preference for face-to-face interactions. The facility's social services were inadequately staffed, with the current staff lacking the necessary training and experience to meet the residents' needs.
Failure to Document Pneumonia Vaccine Consents and Declinations
Penalty
Summary
The facility failed to ensure proper consent or declination documentation for pneumonia vaccinations for four residents. Specifically, two residents received the PCV 20 vaccine without documented consent in their electronic medical records (EMRs), and two other residents who declined the vaccine did not have their declinations documented. This deficiency was confirmed by the Corporate Regional Director of Operations, who acknowledged the absence of the necessary consents or declinations in the residents' EMRs. The facility's policy requires that a consent form be signed prior to immunization and that any refusal or medical contraindication be documented in the clinical record.
Failure to Maintain a Homelike Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a resident's room in a comfortable and homelike environment, as observed during a survey. A resident was found in her room with a section of the baseboard wall missing, leaving an open hole approximately one foot in size, and another section with wood exposed and several ants present. The resident reported that she had informed the staff about the issue, but no repairs had been made, and ants were a year-round problem. The Maintenance Supervisor acknowledged the need for repairs, stating that the facility had been neglected over the years and he was the only maintenance staff available, which limited his ability to address the issue promptly. The facility did not provide a policy regarding the maintenance of the building.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide activities that meet the physical, mental, and psychosocial well-being of two residents, R22 and R26. R22, who has diagnoses including bipolar disorder and major depressive disorder, expressed dissatisfaction with the activities offered, describing them as age-inappropriate and lacking in variety. He noted a preference for activities such as dining out, reading newspapers, and participating in group activities, which were not being provided. R22 also mentioned that the facility no longer receives newspapers regularly, which was an activity he valued. R26, who has diagnoses including major depressive disorder and generalized anxiety disorder, also reported dissatisfaction with the current activity offerings. He noted that the previous activity director had quit, and the new director, who also serves as the social services person, was not providing adequate activities. R26 expressed a desire to go outside more frequently and listen to music, but stated that staffing shortages prevented this. Observations confirmed a lack of organized activities, with no staff directing activities and residents left to wander the halls or engage in minimal activities like card games. The facility's policy requires activities to be based on residents' assessments and preferences, which was not being met in these cases.
Failure to Provide Resident-Centered Mental Health Services
Penalty
Summary
The facility failed to implement and provide resident-centered mental health services for a resident diagnosed with PTSD, major depressive disorder, schizoaffective disorder, borderline personality disorder, and suicidal ideations. The resident, who identifies as non-binary or male, was admitted to the facility with a PASRR II recommendation for rehabilitative services, structured environments, and psychotherapy. However, the facility did not provide these services, and the resident reported having only one telehealth session with a psychiatric nurse practitioner, preferring in-person therapy sessions. The resident expressed dissatisfaction with the lack of trauma, wellness, life skills, or behavior management groups at the facility. The resident also reported that staff were not informed of their preferred pronouns and name, leading to misgendering and inappropriate interactions. The care plan for the resident was incomplete, lacking specific triggers, PTSD information, and preferences for being addressed, as well as activities that the resident enjoys, such as journaling and reward-based tasks. Interviews with facility staff revealed a lack of awareness and training regarding the resident's needs and preferences. The activity director/social services staff lacked a behavioral health background and was unsure of the psych services required by the resident. The facility previously had behavioral health aides and an in-person psychiatrist, but these services were no longer available. The facility did not provide evidence of the psych services the resident was receiving, nor did it have a policy regarding psych services, behavior management, or PTSD.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered and controlled medications were properly accounted for, affecting three residents. One resident missed their evening medication because they were not reminded by staff, and the nurse refused to administer the medication outside the scheduled time. The resident's Medication Administration Record (M.A.R.) confirmed that the medications were not administered as ordered. Another resident's Controlled Substance Form showed discrepancies in the narcotic count, with two doses of hydrocodone not signed out or accounted for. The nurse failed to document the administration of these doses, leading to uncertainty about whether the resident received the medication. Additionally, a third resident did not receive their prescribed cogentin due to a delay in obtaining prior authorization, which led to the resident refusing to take their haldol without it. The facility's attempts to secure the authorization were delayed, impacting the resident's medication regimen.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for three residents, leading to deficiencies in medication regimen reviews. For one resident, R18, the pharmacy recommended obtaining specific lab tests, including CBC, BMP, hepatic panel, GGT, ammonia, and A1C, which were not available in the medical record. The Director of Nursing confirmed that these labs were not done, and the MDS/Care Plan Coordinator was unaware of the reason for this oversight. Another resident, R35, had a pharmacy recommendation to increase the dosage of levothyroxine due to a high TSH level and to follow up with a TSH concentration test. This recommendation was not addressed by the resident's physician, and the resident continued to receive the lower dosage. Additionally, for resident R33, a recommendation to discontinue hydroxyzine PRN for anxiety was not completed, as the form was left blank. The Director of Nursing, who had recently joined the facility, found a backlog of unaddressed pharmacy recommendation forms, including the one for R33.
Failure to Address Gradual Dose Reduction and PRN Stop Date
Penalty
Summary
The facility failed to address a gradual dose reduction for a resident diagnosed with multiple mental health disorders, including schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. The resident had been receiving buspirone 10 mg three times daily since late February 2025, and a consultation report dated January 9, 2025, recommended a gradual dose reduction to 10 mg twice daily. However, this recommendation was not addressed by the physician. The Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator were identified as responsible for ensuring gradual dose reductions, but both acknowledged that the reduction had not been addressed or followed up on. Additionally, the facility failed to ensure that an as-needed (PRN) anti-anxiety medication for another resident had a stop date. The resident had a physician's order for hydroxyzine tablets to be given every six hours as needed for anxiety, but the order lacked a stop date. The DON confirmed that PRN psychotropic medications should have a stop date of 14 days, which was not implemented in this case. A pharmacy recommendation review also noted the need to discontinue the PRN hydroxyzine dose, citing CMS requirements for a 14-day limit on PRN orders for non-antipsychotic psychotropic drugs.
Significant Medication Error Due to Missed Doses of Apixaban
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of apixaban. The resident, who was admitted with multiple diagnoses including acute embolism and thrombosis, was prescribed apixaban to be taken twice daily. However, upon admission, the resident missed five doses of this critical medication. The omission occurred because the previous facility sent an empty medication card, and the necessary medication was not available at the new facility. The issue was compounded by a delay in processing the resident's insurance information, which was only faxed to the pharmacy two days after the resident's admission. The resident's medication orders were entered into the system on the evening of the admission, but the absence of the medication was not realized until two days later. This series of inactions and oversights led to the resident receiving their first dose of apixaban three days after admission, contrary to the facility's policy to prevent significant medication errors.
Inaccurate RN Staffing Data Reporting
Penalty
Summary
The facility failed to ensure RN staffing data was accurately entered in the Payroll-Based Journal (PBJ) system, affecting all 42 residents. The Administrator (V1) indicated uncertainty about the reporting issue, suggesting it might be due to the corporate office pulling punch codes from the time clock, which outside agency staff do not use, or how the time clock codes the nurses. The person responsible for reporting the PBJ data (V17) only works weekends and did not respond to an email inquiry. The PBJ Staffing Data Report for October 1-December 31, 2023, showed no RN hours and failed to have licensed nursing coverage 24 hours a day, despite the nursing schedule indicating otherwise, demonstrating inaccurate reporting.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with manufacturer's directions, failed to monitor residents during medication administration, and failed to provide ordered medications. For Resident 21, the facility did not provide the prescribed Icosapent Ethyl medication for high triglycerides since March 2024 due to an insurance denial. The Director of Nursing (DON) confirmed that the physician was notified of the denial, but there was no documented notification in the resident's progress notes. Additionally, during a medication administration observation, the LPN did not provide the Icosapent Ethyl medication as it was not available, and the resident had not received it for several months. The facility also failed to monitor Resident 21 during medication administration. The LPN dispensed all morning medications into a plastic cup, and the resident inadvertently threw away a small peach-colored pill, which was later identified as hydrochlorothiazide for high blood pressure. The LPN did not notice the resident had failed to take the medication. Furthermore, the LPN did not instruct Resident 21 to rinse and spit after using a combination inhaler for COPD, which is necessary to prevent fungal infections in the mouth. For Resident 26, the LPN did not follow the manufacturer's instructions for administering Lispro Insulin using an insulin pen. The LPN failed to wipe the tip of the pen with an alcohol wipe and did not prime the pen before injection, which could result in an incorrect dose of insulin. The DON confirmed that the LPN should have followed the manufacturer's instructions to ensure the resident received the correct dose and to prevent infection.
Latest citations in Illinois
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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