Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accolade Healthcare Danville during CMS and state inspections, most recent first.
A resident with diabetes, asthma, and osteoarthritis, along with other residents with significant neurologic, mobility, and diabetic conditions, reported long waits for call light response and incontinence care. Staff were observed turning off call lights before meeting resident needs, and grievance records documented complaints about extended wait times and untimely care. Residents stated the delays made them feel degraded, dirty, insignificant, angry, anxious, and worthless.
A resident was subjected to ongoing verbal abuse, degrading and intimidating interactions, and dismissive responses from a CNA despite prior complaints and a care plan meeting in which the resident requested that the CNA not provide care. The resident’s POA reported the resident became hysterically upset after the interaction, and staff were overheard telling the resident the incident was an accident and that the resident was overreacting. Documentation later noted increased sadness, tearfulness, emotional distress, and psychiatric monitoring needs.
Failure to timely report alleged abuse and injury: A resident alleged that a CNA forcefully pulled a wheelchair from beside the bed and struck the resident’s foot, causing pain and bruising, and also alleged prior verbal mistreatment. The POA reported the incident to the facility, and staff interviews showed the CNA admitted the wheelchair struck the resident’s foot, but the ADON did not report the allegation to the Administrator that day. Administration, the physician, the ombudsman, and police were not notified until several days later, and the resident later had continued pain, tenderness, and bruising with x-rays ordered.
A facility failed to thoroughly investigate abuse allegations and protect a resident from continued emotionally distressing interactions with a CNA. The resident and POA reported prior degrading treatment, and despite a care plan meeting where the resident said the CNA should not provide care, the CNA continued to enter the room and provide care. The resident later reported the CNA raised a voice, acted disrespectfully, and forcefully pulled a wheelchair into the resident’s foot; the CNA admitted yanking the wheelchair and striking the resident’s foot, and an LPN overheard stern speech and a comment meant to upset the resident. The ADON was notified but did not notify the Administrator, and formal reporting and suspension were delayed until after the POA returned to the facility.
Failure to assess a resident for self-medication safety. A cognitively intact resident with multiple diagnoses, including repeated falls and reduced mobility, had no documented self-medication assessment and no care plan address for self-administration. During observation, a capsule was left at bedside in a medication cup, and the resident took it without being able to identify it. The RN later confirmed it was gabapentin and acknowledged meds should not be left at bedside without a specific MD order; the DON verified the resident was not on a self-medication program and had no order to self-administer.
A resident who was cognitively intact, totally dependent for mobility and incontinence care, and had an open abdominal wound, severe obesity, reduced mobility, chronic C. diff, and a hx of MRSA was left uncleaned after returning from an appt; feces odor was noted, and her catheter bag was found lying on her abdomen more than an hour later. In a separate episode, a CNA failed to perform hand hygiene or change gloves before applying barrier cream during incontinence care for another resident after cleaning urine and stool, and both the CNA and ADON verified the lapse.
A resident who required maximum assistance for mobility and transfers was left unsupported during a therapy session when a PTA proceeded without a second staff member, contrary to the care plan and facility policy. The resident fell forward off the bed, sustaining a head laceration that required emergency treatment and staples. Staff interviews confirmed the resident's dependency and the need for two-person assistance, which was not provided at the time of the incident.
Three residents had discrepancies between their documented and observed range of motion (ROM) abilities due to inaccurate MDS coding. In several cases, staff interviews and direct observation showed that residents had more or less impairment than what was recorded in their MDS assessments, with one staff member admitting to misunderstanding the criteria for impaired ROM.
Four dependent residents did not receive required assistance with activities of daily living, including nail care, shaving, and feeding. Two residents had long, dirty fingernails despite needing staff help, one was not shaved as required by facility policy, and another was left without feeding assistance for an extended period. These deficiencies were confirmed through observation, interviews, and record review.
Three residents with pressure ulcers did not receive required interventions such as specialized mattresses, regular repositioning, or pressure relieving boots, and initial wound assessments were not completed in a timely manner. Staff and family confirmed lapses in care, and documentation was missing or delayed, contrary to facility policy.
Three residents experienced medication administration errors when nurses failed to follow physician-ordered protocols, including administering insulin after a meal instead of before, giving Metoprolol Tartrate despite a low heart rate, and not checking vital signs before administering Carvedilol. These actions resulted in a medication error rate of 12%, surpassing the acceptable threshold.
Surveyors found that medications, including insulin and a controlled substance, were not consistently labeled with opened dates or properly documented in controlled medication records. A controlled medication brought from home lacked a required count sheet, and medications were not always stored in locked compartments as per policy. Additionally, a resident was found with medications left at the bedside for self-administration without a physician order or care plan documentation, and the LPN did not observe the resident taking the medications, contrary to facility policy.
Two residents with respiratory symptoms were not placed on contact or droplet precautions, and no signage or PPE was provided outside their rooms. Both were observed coughing, with one unable to maintain respiratory hygiene, and both participated in communal activities without precautions. Additionally, a nurse failed to disinfect a blood glucose meter after use, leaving it on the medication cart and potentially contaminating the area.
A resident with Down syndrome and limited ROM was observed with contracted hands and lacked documented interventions or goals for ROM or contracture management in the care plan. Although a restorative program was recommended and staff were educated, there was no evidence of a formal program or documentation that ROM interventions were being provided, with staff indicating these tasks were expected to occur during ADLs without supporting records.
A nurse did not check the gastric residual volume before administering medications and water flushes through a g-tube for a resident, despite facility policy and the care plan requiring this step. The nurse only checked tube placement and confirmed the omission, while the ADON verified that gastric residual should be checked at the time of medication administration.
A resident with severe cognitive impairment and total care needs was found with a new femur fracture of unknown origin. Despite facility policy requiring reporting of unexplained injuries, the incident was not reported to the state agency because staff believed the injury was pathological and not suspicious for abuse.
A resident with a care plan requiring a bed alarm for fall prevention was found with the alarm sensor pad unplugged and the alarm module placed across the room, rendering the intervention nonfunctional. The resident was nonverbal at the time, and a nurse confirmed the alarm was not set up as required by the care plan.
The facility failed to implement and document appropriate pressure ulcer prevention and care for three residents, leading to the development and deterioration of pressure ulcers. A resident developed a stage two pressure ulcer that worsened to an unstageable ulcer due to lack of a turning schedule and nutritional evaluation. Another resident had discrepancies in wound assessments, and a third resident did not receive a recommended low air loss mattress. These failures contributed to declining skin integrity and facility-acquired pressure ulcers.
A facility failed to reposition a dependent resident as required by their care plan. The resident was observed sitting in a reclining geriatric chair for several hours without repositioning. A CNA confirmed the resident was not laid down until the early afternoon, despite being up since late morning. The resident's spouse had previously raised concerns about the lack of repositioning. The care plan required repositioning every two hours and as needed.
A resident experienced significant weight loss over several months, but the facility failed to document and assess this adequately. The resident's care plan did not reflect the weight loss, and there was no timely evaluation by a dietitian or physician. Observations showed low meal intake, and the facility did not follow its policies for weight monitoring and nutritional assessment.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with pressure ulcers, as required by their policy. Observations revealed a lack of EBP signage and PPE carts near residents' rooms, and staff were not wearing gowns during high-contact care activities. The ADON confirmed the absence of EBP orders and signage for affected residents, and the DON acknowledged missing EBP documentation for a resident. This indicates a failure to follow infection prevention measures.
A resident with Peripheral Vascular Disease and Type 2 Diabetes Mellitus developed a bruise on the left foot after a mechanical lift transfer. The facility failed to monitor and document the bruise, leading to an infection and hospitalization. Initial assessments were incomplete, and the wound nurse was not informed due to being on vacation. The facility's policies for monitoring and physician notification were not followed, resulting in the resident's condition worsening.
A resident with moderate cognitive impairment and physical limitations did not receive adequate fingernail care, as their nails were observed to be long and dirty. Despite the resident's request for nail care, a CNA did not provide it during routine hygiene assistance. The facility's policy requires regular nail care to maintain cleanliness and prevent infection, but this was not followed.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in the development and improper management of pressure ulcers. One resident, who was incontinent and required assistance, was not repositioned as per the care plan, leading to a stage two pressure ulcer. Another resident with a stage three pressure ulcer on the heel was not positioned correctly to offload pressure, despite care plan instructions. The facility did not follow its skin and wound management guidelines, failing to document and report the wounds to the physician.
The facility failed to implement effective fall interventions for three residents, resulting in significant injuries. One resident sustained a head laceration and arterial bleed, another had bilateral wrist fractures, and a third experienced multiple falls with skin tears. The interventions in place were insufficient to prevent these incidents.
The facility failed to timely notify the physician of newly developed, draining wounds for a resident. The resident had no wounds documented upon readmission from the hospital, but later developed three open areas with green pus. The physician was not notified until the following day when antibiotics were ordered, contrary to the facility's policy and guidelines.
The facility failed to culture a resident's draining wound before administering antibiotics, did not assess a surgical incision upon admission, and inaccurately transcribed wound treatment orders for three residents. Additionally, the facility did not monitor and record fluid intake for a resident, contrary to their care plan and facility policies.
The facility failed to assess and measure a pressure ulcer upon admission for a resident. The resident's unstageable coccyx wound was not documented with measurements or descriptions until the following day. The wound nurse confirmed that wounds should be assessed and measured upon admission, as per the facility's guidelines, which were not followed in this case.
The facility failed to employ a qualified Director of Food and Nutrition Services, with the current Dietary Manager lacking necessary education and qualifications. Observations revealed unsanitary conditions in the kitchen, including rust, grease, and food debris on equipment. The Administrator confirmed the DM's lack of qualifications.
The facility failed to maintain kitchen equipment in a clean and sanitary condition, potentially affecting all 96 residents. The Dietary Manager confirmed that the commercial mixer had rust, grease, and food debris buildup, while the can opener had grease, metal fragments, rust, and a peeling silver laminate coating, along with a sticky substance in the shaft holder sleeve.
The facility failed to have required members, including the Infection Preventionist and Medical Director, attend QAA meetings, potentially affecting all 96 residents. The Medical Director provided only verbal reviews, and the Infection Preventionist was absent on specific dates, contrary to the facility's QAA Committee requirements.
The facility failed to ensure residents' dignity and timely care, as evidenced by prolonged periods of incontinence without timely assistance and delayed responses to call lights. Residents and their family members reported multiple instances of inadequate care, with staff often being unresponsive or preoccupied with personal activities. This compromised the residents' well-being and dignity.
The facility failed to accurately encode a resident's health status on the MDS regarding dialysis. A resident, who goes to an outside facility for dialysis treatment three times per week, had their dialysis treatments omitted from their MDS. The Administrator/Registered Nurse acknowledged the inaccuracy.
A resident with multiple medical conditions did not receive PRN dressing changes for a left knee wound as per physician's orders. Observations on two consecutive days showed the dressing was saturated, and RNs confirmed it should have been changed more frequently.
A resident with multiple diagnoses and high fall risk experienced several unwitnessed falls due to inadequate implementation of fall interventions. Despite requiring supervision and assistance, the resident's care plan was not consistently followed, leading to injuries and hospital evaluation. The facility's staff often failed to respond promptly to call lights, and essential safety measures like bed alarms were found non-functional.
A resident with multiple medical conditions, including MRSA, did not receive physician-ordered IV antibiotics on two consecutive days due to issues with their PICC line. Despite attempts to replace the PICC line, delays occurred, leading to missed doses and a delay in treatment.
The facility failed to maintain accurate medical records for a dialysis resident, as required assessments for the dialysis port were not documented due to an error in the electronic medical record entry by the physician.
A facility failed to follow infection control protocols during high-contact wound care activities for a resident with multiple diagnoses, including recent amputation and pressure ulcers. Staff did not wear gowns as required by the facility's enhanced barrier precautions policy, leading to a noted deficiency.
Delayed Call Light Response and Untimely Incontinence Care
Penalty
Summary
The facility failed to answer call lights in a timely manner for four residents, affecting their dignity and self-determination. The report states that the facility’s Call Light Answering policy required staff to answer residents’ call lights and/or see to their requests and needs, but multiple residents reported prolonged waits for assistance and incontinence care. The surveyor also observed that an auxiliary aide would enter residents’ rooms, turn off the call light, and then notify staff of the resident’s needs after the light was turned off. A resident with diabetes, asthma, and osteoarthritis reported an extended wait for incontinence care after activating the call light when urinary incontinence occurred, stating that multiple staff entered the room, turned off the call light, and left without providing care. The resident said this caused feelings of being degraded and disrespected and reported itching and redness in the peritoneal area from remaining in urine-soaked briefs. Another resident with a history of intracranial hemorrhage, hemiplegia/hemiparesis, and diabetes reported that call light waits could last up to an hour, that the resident was sometimes left in urine-soaked clothing for a whole shift, and that this contributed to anger, anxiety, sleep loss, and increased use of PRN anti-anxiety medication. A third resident with spinal stenosis, cerebral infarction, cardiomegaly, gastroparesis, and diabetes reported long waits for call lights and stated staff sometimes shut off the call light without providing care, making the resident feel insignificant and dirty. A fourth resident with diabetic foot ulcer, vitamin D deficiency, hyperlipidemia, and diabetes reported needing staff help to transfer and sometimes waiting 25 to 30 minutes or longer for the call light to be answered, stating that long waits for incontinence care made the resident feel worthless and unimportant. Grievance records also documented concerns about long call light wait times and untimely incontinence care, including a complaint that staff turned off the call light before care was provided.
Failure to Protect Resident from Verbal Abuse and Dismissive Staff Interactions
Penalty
Summary
The facility failed to protect a resident from verbal abuse, degrading interactions, intimidation, and emotionally distressing treatment by a CNA. The resident’s POA reported that the resident called crying hysterically after an interaction with the CNA, and stated there had been prior allegations that the same CNA had degraded the resident about two weeks earlier. A care plan meeting had been held with the resident, POA, and facility staff, including the DON, where the resident reported feeling degraded and emotionally mistreated and requested that the CNA not provide care, but the CNA continued to enter the resident’s room and provide care. On the evening of the incident, the CNA entered the resident’s room despite the prior request, stood over the resident, became argumentative during care, and raised the voice while directing the resident to roll over. The resident described the interaction as humiliating, intimidating, and emotionally overwhelming, and stated staff appeared not to believe the allegations and made the resident feel like a liar. The POA overheard staff tell the resident the incident was an accident, that the CNA would never do that, and that the resident was overreacting. The CNA also acknowledged making a comment about being glad staff had recorded the interaction, and an LPN stated that comment appeared intended to upset the resident further. Subsequent documentation noted increased sadness, frustration, emotional distress, tearfulness, and psychiatric monitoring needs after the conflict with staff.
Failure to Timely Report Alleged Abuse and Injury
Penalty
Summary
The facility failed to timely report allegations of abuse, neglect, injury of unknown source, and mistreatment involving one resident after staff became aware that a CNA allegedly forcefully pulled a wheelchair from beside the bed and struck the resident’s left foot during care. The resident reported that the CNA had also previously degraded and verbally mistreated the resident. The resident’s POA stated the resident called crying and emotionally distressed after the incident, and the POA later sent a text message to the Social Services Director describing that the wheelchair had been rammed into the resident’s leg and that the CNA said the wheelchair was stuck under the bed and was pulled out, running over the resident’s foot. Record review and staff interviews showed the CNA admitted yanking the wheelchair from under the bed and accidentally striking the resident’s foot, and the LPN stated the CNA reported the incident on the day it occurred and that the ADON was notified. The ADON acknowledged receiving notification on the day of the incident but did not report the allegation to the Administrator that day. Documentation showed administration, the physician, the ombudsman, and local police were not notified until several days later, after the POA came to the facility. Additional records noted the resident had bruising, pain, and tenderness to the left toe and foot, with x-rays ordered due to continued pain, and the NP confirmed physician notification should have occurred when the allegation and injury were first reported.
Failure to Investigate Abuse Allegations and Protect a Resident from Continued CNA Contact
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and failed to implement timely interventions to protect a resident from further potential abuse and emotionally distressing interactions involving a CNA. The resident’s POA reported that there had been prior allegations that the CNA was degrading and disrespecting the resident about two weeks before the incident on 5/2/2026, and stated a care plan meeting had been held with the resident, the POA, and facility staff, including the DON, to discuss concerns about the CNA’s treatment. The resident stated the resident did not want the CNA providing care because of feeling degraded and emotionally mistreated, yet the CNA continued to enter the resident’s room and provide care. The resident and POA reported that on 5/2/2026 the resident became emotionally distressed after another interaction with the CNA, including allegations that the CNA became upset during care and forcefully pulled a wheelchair into the resident’s foot. The resident stated the CNA repeatedly raised the CNA’s voice, acted disrespectfully, and was argumentative and intimidating. The CNA admitted yanking the wheelchair from beside the bed and striking the resident’s foot, and also acknowledged making a comment about recording the interaction. An LPN confirmed overhearing the CNA speaking sternly to the resident and believed the recording comment was intended to visibly upset the resident. The ADON stated being notified of the incident on 5/2/2026 but did not notify the Administrator at that time, and the facility did not suspend the CNA or begin formal reporting until 5/5/2026 after the POA came to the facility. The record also showed no evidence of immediate protective interventions after the earlier care plan meeting, no documented effort to keep the CNA away from the resident, no monitoring of staff interactions, and no thorough investigation after the earlier allegations of degrading behavior.
Failure to assess resident for self-medication safety
Penalty
Summary
The facility failed to assess one resident for safety to self-medicate. The resident’s care plan, updated 10/2/25, listed diagnoses including an open wound to the abdominal wall, polyneuropathy, spondylosis, severe obesity, reduced mobility, repeated falls, chronic Clostridium difficile, history of MRSA, and history of total knee replacement. The resident’s MDS documented that the resident was cognitively intact and totally dependent on staff for mobility and incontinence care, but there was no documentation of a self-medication assessment in the electronic medical record and the care plan did not address self-medication. During observation on 11/19/25, a brown capsule was found in a medication cup on the resident’s over-the-bed table. The resident could not verbalize what the pill was and stated, “They just leave my medicine and I take it.” The resident swallowed the capsule and disposed of the cup. The RN caring for the resident later verified the capsule was gabapentin and stated the resident was “totally with it mentally,” and that the nurse thought the resident would take it. The RN also verified awareness that residents should be watched swallowing medication and that medication should not be left at bedside without a specific physician’s order. The DON verified the resident was not to receive medication without the nurse watching the resident take it, was not on a self-medication program, and had no physician’s order to self-administer medication.
Delayed Incontinence and Catheter Care; Improper Hand Hygiene During Pericare
Penalty
Summary
The facility failed to provide timely incontinence care and catheter care for one resident who was cognitively intact, totally dependent on staff for mobility and incontinence care, and had diagnoses including an open wound to the abdominal wall, severe obesity, reduced mobility, chronic Clostridium difficile, and a history of MRSA. After returning from a doctor’s appointment, the resident told the CNA she needed to go to bed to be cleaned because she had diarrhea, and there was an odor of feces around her. More than an hour later, she was still in bed with the sling-type mechanical lift sling under her, and her catheter bag was lying on her abdomen. The resident stated she had not been cleaned since returning from the appointment, and the CNA said staff were busy with lunch and she had to get help. The DON verified the resident should have been cleaned sooner, especially given the open abdominal wound. The facility also failed to use appropriate hand hygiene during incontinence care for another resident. During care after the resident was incontinent of bladder and bowel, a CNA cleaned urine from the perineal area, then turned the resident on her side and cleansed feces from the anal area with assistance from the ADON. The CNA then failed to perform hand hygiene or change gloves before applying barrier cream to the resident’s abdominal fold. The CNA and ADON both verified that hand hygiene and glove change should have been completed before applying the cream. The facility policy states that incontinence care will be provided after each incontinence episode and kept clean, dry, free of irritation and odor.
Failure to Provide Adequate Staff Assistance During Therapy Session Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but required maximum assistance with mobility and transfers due to overweight status and functional decline, was left without adequate staff support during a therapy session. The resident's care plan specified that two staff members were needed to assist during therapy sessions. Despite this, a physical therapist assistant (PTA) proceeded with the session alone, attempting to have the resident sit on the side of the bed and then stand, even though the resident was dependent for bed mobility and did not stand independently. During the session, the PTA let go of the resident and walked to the other side of the bed to reposition the resident, leaving the resident unsupported. The resident subsequently fell forward off the bed, hitting the bedside table and sustaining a head laceration that required emergency treatment and 15 staples. Witnesses, including another resident and staff, confirmed that the PTA did not attempt to assist or prevent the fall and that the resident typically required two staff members for all transfers and mobility tasks. Interviews with staff, including a CNA, LPN, DON, and the resident's nurse practitioner, consistently indicated that the resident was dependent on staff for mobility and that the PTA should have waited for additional assistance before proceeding. The facility's safety policy also required two or more persons to assist when necessary for resident safety. The failure to follow the care plan and facility policy directly resulted in the resident's fall and injury.
Inaccurate MDS Coding for Range of Motion Impairments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the documented range of motion (ROM) impairments and the residents' actual physical abilities. For one resident, the MDS indicated limited ROM in the lower extremities and no impairment in the upper extremities, while observation revealed a contracture in the left hand and inability to flex the fingers. Another resident's MDS inconsistently documented one-sided impaired ROM across multiple assessments, despite staff interviews confirming that the resident had upper and lower extremity impaired ROM and was totally dependent on staff for activities of daily living since admission. A third resident's MDS documented one-sided impairment for ROM to upper and lower extremities, but both staff interviews and direct observation showed that the resident could move both arms and legs, assist with feeding, and hold a coffee cup unassisted. The MDS Coordinator acknowledged misunderstanding the definition of impaired ROM when coding previous MDS assessments. The facility's policy requires accurate and thorough assessments per MDS guidelines, but these requirements were not met for the residents involved.
Failure to Assist Dependent Residents with ADLs: Nail Care, Shaving, and Feeding
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for four residents who were dependent on staff for personal hygiene, eating, and grooming. Observations revealed that two residents had long, jagged, and dirty fingernails, with no documentation of refusal of nail care in their care plans. Both residents were noted to have cognitive impairments and required staff assistance for personal hygiene, yet their fingernails remained untrimmed and unclean over consecutive days. The Assistant Director of Nursing confirmed the condition of the residents' fingernails and acknowledged that CNAs are responsible for providing this care. Another resident, who required extensive assistance for bathing and showering, was observed with facial hair stubble and reported not being offered shaving services since admission, despite expressing a preference to be clean-shaven. The resident's care plan indicated a need for staff assistance, and facility policy required shaving on shower days, but records showed the resident was not shaved during a recent shower. Additionally, a resident who was dependent on staff for eating was left unattended with an untouched meal tray for an extended period, with staff confirming that assistance had not been provided until much later. Facility policies for nail care, shaving, and feeding dependent residents were not followed as observed in these cases.
Failure to Prevent and Treat Pressure Ulcers and Complete Timely Wound Assessments
Penalty
Summary
The facility failed to implement necessary interventions to prevent and treat pressure ulcers and did not complete initial wound assessments for three residents with pressure ulcers. For one resident with multiple comorbidities, including diabetes, morbid obesity, and chronic kidney disease, the care plan required a specialized air mattress and repositioning every two hours. However, the resident was observed without the required air mattress on multiple occasions and remained in a wheelchair for extended periods. The resident and a family member confirmed the absence of the air mattress and prolonged time spent in the wheelchair. The Assistant Director of Nursing verified that the resident should have had a special mattress and regular repositioning, which was not provided. Another resident, who was dependent on staff for mobility and incontinent of bowel and bladder, had a history of a stage four coccyx pressure ulcer that had healed but subsequently reopened as a stage three ulcer. The care plan required turning and repositioning every two hours, but the resident was observed sitting in a wheelchair for several hours without being offered to lie down. Staff confirmed the resident was not repositioned as required. Additionally, there was no documented assessment of the reopened wound at the time it was first identified, with the initial assessment only completed two days later. The nurse responsible for the resident's care acknowledged the lack of timely documentation, and the Assistant Director of Nursing confirmed the absence of an initial wound assessment prior to the documented date. A third resident, who was dependent on staff for lower body dressing and turning in bed, had a right heel pressure ulcer and was supposed to use pressure relieving boots while in bed. The resident was observed in bed without the boots, with heels directly on the mattress, and the boots were found in the wheelchair. The CNA assigned to the resident was unaware of the need for pressure relieving boots and only applied them after being prompted. The care plan required the use of these boots, and the Assistant Director of Nursing confirmed this intervention was not followed. Additionally, there was no documented assessment of the resident's right heel pressure ulcer upon readmission, with the first assessment completed several days later. The facility's policies required timely notification and documentation of wounds, which was not adhered to in these cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to properly administer medications as ordered for three residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold. In one instance, a registered nurse administered Novolin Regular Insulin to a resident after the resident had already eaten lunch, rather than prior to the meal as required by the physician's sliding scale order. The nurse confirmed that the blood glucose was checked and insulin was given after the meal, contrary to the prescribed protocol. In another case, a nurse administered Metoprolol Tartrate to a resident despite the resident's heart rate being below the physician-ordered parameter of 90 beats per minute. The nurse acknowledged that the medication should not have been given under these circumstances. Additionally, a third resident received Carvedilol without the nurse checking the required blood pressure and heart rate prior to administration, as specified in the physician's order. The nurse admitted to not obtaining these vital signs before giving the medication. The facility's policy requires checking the MAR, verifying orders, and obtaining any necessary monitoring parameters before administering medications.
Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication labeling, storage, and documentation. During a review of the medication cart, it was observed that an insulin pen for one resident was not labeled with an opened date, and two insulin vials for other residents were labeled with both opened and discard dates. Additionally, a bottle of Clonazepam, a controlled medication, was found without an accompanying controlled count sheet, despite facility policy requiring such documentation for all controlled substances, including those brought from home. The Assistant Director of Nursing confirmed that controlled medications from outside sources should be counted and documented upon arrival. The facility's policies also require that all medications be stored in locked compartments and that multi-dose containers be labeled with opened dates, which was not consistently followed. In a separate incident, a resident was found asleep in bed holding a medication cup containing several pills. The LPN stated that the medications had been given earlier and that the resident typically self-administers them, but there was no physician order or care plan documentation permitting self-administration or bedside storage of medications. The ADON confirmed that nurses are required to observe residents taking their medications and that no residents were currently approved for self-administration. These findings demonstrate failures to adhere to facility policies and accepted professional standards regarding medication labeling, storage, and administration.
Failure to Implement Infection Control Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents exhibiting symptoms of respiratory infection and during blood glucose monitoring. Two residents with respiratory symptoms, including one diagnosed with pneumonia and another with a non-productive cough and fever, were not placed on contact or droplet precautions as required by facility policy and CDC guidelines. Observations revealed that neither resident had transmission-based precaution signage on their doors, nor was personal protective equipment available outside their rooms. Both residents were observed coughing frequently, with one unable to practice respiratory hygiene and seen contaminating bed linens, and both were allowed to interact with other residents in communal areas without precautions in place. Additionally, a registered nurse failed to disinfect a blood glucose meter after use on a resident, contrary to the facility's policy requiring cleaning and disinfection after each use with an EPA-approved cleaner. The blood glucose meter was placed on the medication cart without being sanitized, potentially contaminating the cart. The nurse was unsure of the required disinfection frequency and confirmed the lapse in protocol. The Assistant Director of Nursing later verified that bleach wipes should be used to disinfect blood glucose meters after each use.
Failure to Maintain or Improve Range of Motion and Address Contractures
Penalty
Summary
A deficiency was identified when the facility failed to maintain or improve range of motion (ROM) and address contractures for a resident with Down syndrome and adult failure to thrive, as recommended by the restorative program. Observations showed the resident had contracted hands and limited finger movement, yet the care plan did not document any interventions or goals related to ROM, contractures, or a restorative program. The resident's Minimum Data Set (MDS) indicated limited ROM in the lower extremities, but no impairment in the upper extremities, and the care plan only referenced deficits in activities of daily living (ADLs) without addressing ROM needs. Physical therapy records documented that a restorative program for ROM, transfers, and bed mobility was established and staff were educated on these interventions. However, interviews with facility staff revealed that there was no formal restorative or functional maintenance program in place for the resident, and no documentation existed to show that such interventions were being provided. Staff stated that ROM and related interventions were expected to be completed by CNAs during ADLs, but there was no evidence in the electronic health record or care plan to confirm that these tasks were being performed.
Failure to Check Gastric Residual Volume During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse failed to check the gastric residual volume prior to administering medications and water flushes through a gastrostomy tube for a resident with a g-tube. The facility's policy and the resident's care plan both required monitoring of gastric residual volume before administering nutrition and medications. During observation, the nurse stopped the feeding, disconnected the tubing, and checked tube placement using the air rush technique, but did not check the gastric residual volume at the time of medication administration. The nurse confirmed this omission, stating that the gastric residual had only been checked earlier in the shift. The assistant director of nursing also confirmed that gastric residual volume should be checked at the time of g-tube medication administration.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency within the required two-hour timeframe for one resident. The resident, who had severe cognitive impairment and was dependent on staff for all mobility and care needs, was found with a shortened and rotated right leg. Nursing staff notified the resident's Power of Attorney and a Nurse Practitioner, who assessed the resident and ordered x-rays. The x-ray revealed a new comminuted fracture of the distal femur, and the resident was subsequently hospitalized for surgical repair. There was no evidence or report of a fall or trauma, and the resident was unable to explain the cause of the injury. Despite the facility's policy requiring injuries of unknown source to be reported if the cause is unobserved or unexplained, the injury was not reported to the Illinois Department of Public Health. The Administrator stated that the injury was not reported because the Nurse Practitioner did not suspect abuse due to the absence of bruising and because the physician later determined the fracture was pathological. The timeline from the initial observation to the physician's assessment and diagnosis was immediate, but the required state notification was not made.
Failure to Implement Bed Alarm as Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention as outlined in a resident's care plan. During observation, a resident was found lying in bed with a bed alarm sensor pad in place, but the sensor's cord was not plugged into the alarm module. The alarm module itself was located across the room, approximately eight feet away from the bed, making it nonfunctional. The resident did not respond verbally to greetings or questions at the time of observation. A registered nurse confirmed that the alarm was not connected as required by the care plan, which specified the use of a bed alarm for safety and increased supervision in the resident's room. The care plan interventions had been initiated prior to the observation, but the required equipment was not properly set up, resulting in the failure to provide the intended fall prevention measures.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care for three residents, leading to the development and deterioration of pressure ulcers. Resident R4, who had moderate cognitive impairment and was dependent on staff for mobility, developed a stage two pressure ulcer that worsened to an unstageable ulcer. The facility did not implement a turning and repositioning schedule until after the ulcer had deteriorated, and there was no documentation of pressure relieving interventions prior to the ulcer's development. Additionally, R4's nutritional status was not evaluated by a Registered Dietitian after the ulcer was identified, despite significant weight loss and a low albumin level. Resident R3 had discrepancies in wound assessments, with the facility's electronic software system preventing corrections to staging errors. R3's coccyx wound was initially staged incorrectly, and the left buttock pressure ulcer was documented as being on the right buttock. These documentation errors contributed to inadequate wound management and care planning. Resident R1 was recommended to have a low air loss mattress for wound prevention, but there was no documentation that this intervention was implemented. CNAs who cared for R1 did not recall the presence of an air mattress, and the Director of Nursing confirmed the lack of documentation. These failures in implementing and documenting pressure ulcer prevention measures contributed to the residents' declining skin integrity and the development of facility-acquired pressure ulcers.
Failure to Reposition Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received necessary repositioning, as required by their care plan. On multiple observations throughout the morning and early afternoon, the resident was seen sitting upright in a reclining geriatric chair without being repositioned. A Certified Nursing Assistant confirmed that the resident was not laid down until the early afternoon, despite being up since late morning. This lack of repositioning was a concern previously raised by the resident's spouse in a grievance, indicating that the resident was not being repositioned throughout the day as needed. The resident's care plan specifically required total assistance with transfers and repositioning every two hours and as needed, which was not adhered to during the observed period.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately identify and assess significant weight loss in a resident, referred to as R3, and did not ensure that the resident's nutrition and weight loss were evaluated by a physician and dietitian in a timely manner. R3 experienced a total weight loss of 20.61% from May 2024 to February 2025, with significant losses noted over three and six-month periods. Despite this, R3's care plan did not document the significant weight loss, and there was no evidence of evaluation by a dietitian prior to February 4, 2025, or by a physician after November 26, 2024. Observations revealed that R3 consumed only a small portion of meals, with many instances of meal refusals and low intake percentages recorded. The resident's meal intake records showed numerous entries of 0-25% consumption and several refusals, indicating a persistent issue with food intake. Additionally, R3 had pressure ulcers, which were not adequately addressed in relation to the resident's nutritional needs. The facility's policy required weekly weights and dietary recommendations for residents with significant weight loss, but these were not consistently followed. Interviews with facility staff, including the Director of Nursing and the Registered Dietitian, confirmed the lack of timely evaluation and documentation of R3's weight loss. The dietitian noted that significant weight loss should trigger a nutritional evaluation and physician notification, which did not occur until February 2025. The facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutritional assessment contributed to the deficiency in care for R3.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with pressure ulcers, as observed during a survey. The facility's policy requires the use of gloves and gowns during high-contact care activities for residents with wounds or indwelling medical devices to prevent the transfer of Multidrug Resistant Organisms (MDROs). However, the survey found that there was no EBP signage or personal protective equipment (PPE) carts near the rooms of the affected residents, and staff were not wearing the required gowns during care activities. For one resident, R3, who had pressure ulcers on the left buttock and coccyx, there was no EBP signage on the room door, and staff were observed not wearing gowns during repositioning. The Assistant Director of Nursing (ADON) confirmed the absence of signage and stated that the EBP order was not reinstated after the resident's contact isolation ended. Similarly, for another resident, R4, with a coccyx pressure ulcer, there was no EBP signage or PPE cart, and staff were observed not wearing gowns during care activities. The ADON confirmed the lack of signage and EBP orders for R4 prior to the survey. Additionally, for resident R1, there was no documentation of EBP in the electronic medical record, and staff were unsure if EBP was required. Staff members reported using gloves and masks but could not recall wearing gowns or seeing EBP signage. The Director of Nursing confirmed the absence of EBP documentation for R1. These findings indicate a failure to adhere to the facility's EBP policy, resulting in inadequate infection prevention measures for residents with pressure ulcers.
Failure to Monitor and Document Resident's Wound
Penalty
Summary
The facility failed to routinely assess and monitor a bruise/hematoma on a resident's left foot, update the physician, and assess and measure post-surgical wounds upon readmission. The resident, who had diagnoses of Peripheral Vascular Disease and Type 2 Diabetes Mellitus, developed a bruise on the left foot after a mechanical lift transfer. Initial documentation noted the bruise, but subsequent weekly skin assessments failed to document the bruise or any changes, and there was no physician notification or assessment until the resident was hospitalized. Upon hospitalization, the resident was diagnosed with septic shock and a left foot abscess, requiring intravenous antibiotics and surgical intervention to drain the hematoma. The facility's records lacked documentation of assessments or monitoring of the bruise after the initial identification, and the wound nurse was not informed of the bruise due to being on vacation. The facility's policies required significant bruises to be monitored weekly and physician notification for changes in condition, which were not followed in this case. After readmission, the resident had multiple wounds on the left foot, but the initial readmission assessment incorrectly documented these as being on the right foot, and no measurements were taken. The wound nurse later assessed the wounds, but the initial lack of documentation and monitoring contributed to the deficiency. The facility's policies outlined procedures for documenting and monitoring wounds, which were not adhered to, leading to the resident's condition worsening and requiring hospitalization.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident with moderate cognitive impairment and significant physical limitations, including right-sided hemiplegia/hemiparesis following a cerebral infarction and Type 2 Diabetes Mellitus. The resident required substantial assistance for personal hygiene, as documented in their care plan. During an observation, a Certified Nursing Assistant (CNA) provided incontinence care and washed the resident's face and underarms but did not offer or provide nail care, despite the resident's fingernails being long and dirty with a black substance underneath. The resident expressed a desire for their nails to be cleaned and trimmed, stating that staff typically perform this task every three days, but it had not been done for two days. Later, the CNA acknowledged the condition of the resident's nails and stated that nail care is usually performed twice a week during bathing or showers. The CNA confirmed that the resident's nails were long and dirty and mentioned that nurses are responsible for trimming the nails of diabetic residents. The facility's policy on nail care emphasizes maintaining cleanliness, preventing infection, and ensuring comfort, but this was not adhered to in the resident's case.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care and prevention measures for two residents, leading to the development and lack of proper assessment of pressure ulcers. For the first resident, the facility did not adhere to the care plan that required repositioning every two hours and the use of pillows to offload pressure. The resident, who was incontinent and required substantial assistance, was found with a wet brief and two open wounds, one of which was a stage two pressure ulcer. The wounds were not documented or reported to the physician until the surveyor's observation, indicating a lapse in communication and documentation by the nursing staff. The second resident, who had a stage three pressure ulcer on the right heel, was not positioned correctly to offload pressure from the heels. The resident's care plan included interventions to float the heels using a wedge cushion, but the cushion was improperly placed, causing the heels to rest on the mattress. This improper positioning was observed multiple times, and the staff failed to ensure the heels were floated as required by the care plan. The resident's medical history included conditions such as diabetes and peripheral vascular disease, which increased the risk for skin integrity issues. The facility's guidelines and policies for skin and wound management were not followed, as evidenced by the lack of immediate implementation of pressure-relieving interventions and inadequate monitoring of wounds. The wound nurse was not informed of the new wounds, and there was no documentation of physician notification or updated care plans to address the residents' pressure ulcers. This indicates a systemic issue in communication and adherence to established protocols for wound care management.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective fall interventions for three residents, resulting in significant injuries. Resident 1, who had a history of falls and was identified as a high fall risk, fell multiple times despite being placed near the nurse's station for supervision. The interventions, such as redirecting and checking metabolic panels, were ineffective. This resident sustained a head laceration requiring nine sutures and an arterial bleed after falling twice within a short period. The Director of Nursing acknowledged that more effective interventions could have prevented the second fall. Resident 2, also identified as a high fall risk, fell while trying to move her walker and sustained bilateral wrist fractures. The intervention to move her bed was insufficient, and the facility delayed obtaining stat X-rays, which were eventually performed days later. This delay in diagnosis and treatment resulted in the resident requiring bilateral splints and increased assistance with daily activities. Resident 3, with severe cognitive impairment and a high fall risk, fell twice within a week. The first fall occurred due to a broken toilet grab bar, and the second fall resulted in a large skin tear. The intervention to obtain a urine culture was ineffective as it returned negative. Staff members noted that this resident required close supervision and frequent reminders to sit down, indicating that the interventions in place were not adequate to prevent falls.
Failure to Timely Notify Physician of Resident's Wounds
Penalty
Summary
The facility failed to timely notify the physician of newly developed, draining wounds for one resident. The resident was readmitted from the hospital and initially had bruising to the groin and abdomen, but no wounds were documented at that time. On a subsequent date, a CNA discovered three new open areas with green pus above the resident's penis. The wounds were cleaned, and a dressing was placed, but there was no documentation that the physician was notified of these wounds on the day they were found. The physician was only notified the following day when antibiotics were ordered. The facility's Registered Nurse/Wound Nurse confirmed that the physician should have been notified immediately and that green pus is a sign of infection. The facility's policy requires the physician to be notified of changes in the resident's condition, including symptoms of infection and pressure sores. The facility's guidelines also state that if the wound nurse is not available, the nurse on duty is responsible for notifying the physician to obtain treatment orders. The failure to notify the physician promptly led to a delay in treatment for the resident's wounds.
Deficiencies in Wound Care and Hydration Monitoring
Penalty
Summary
The facility failed to culture a resident's draining wound prior to initiating antibiotics, assess a resident's surgical incision upon admission, and accurately transcribe wound treatment orders for three residents. One resident was readmitted from the hospital with no documentation of abdominal wounds, but later developed open areas with green pus. Antibiotics were administered without a wound culture, and the wound was not evaluated by the wound physician until much later. Another resident with a surgical above-knee amputation had no initial wound measurements or descriptions documented upon readmission. The wound nurse confirmed that wounds should be assessed and measured upon admission, but this was not done in this case. A third resident had a right heel wound that was not transcribed correctly in the electronic medical record, leading to incorrect administration of wound treatments. The facility also failed to monitor and record fluid intake for one resident. The resident's care plan documented specific fluid needs, but there was no routine recording of fluid intake besides the evening snack intake. The Director of Nursing confirmed that meal intakes documented only the percentage consumed and not the fluid intake amounts. The facility's policy on hydration and prevention of dehydration was not followed, as fluid intake was not monitored and documented as required. These deficiencies highlight significant lapses in wound care management and hydration monitoring. The facility's policies on antibiotic stewardship, skin and wound management, and hydration were not adhered to, leading to inadequate care for the residents involved. The lack of proper documentation, assessment, and follow-up contributed to the deficiencies observed during the survey.
Failure to Assess and Measure Pressure Ulcer Upon Admission
Penalty
Summary
The facility failed to assess and measure a pressure ulcer upon admission for one resident (R2). R2 was readmitted from the hospital and had an unstageable coccyx wound documented in the Nurses Weekly Skin assessment. However, there were no measurements or descriptions of the wound in R2's medical record until the following day. The Wound Summary later documented the wound's characteristics and measurements. During an observation, the wound nurse and wound physician assessed the wound, noting its size and condition. The wound nurse confirmed that wounds should be assessed and measured upon admission, as per the facility's Skin and Wound Management Guidelines, which were not followed in this case.
Unqualified Dietary Manager and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, potentially affecting all 96 residents. The Dietary Manager (DM), who was actively supervising dietary operations, admitted to not having completed the required DM education due to high staff turnover. Observations revealed significant cleanliness issues, including rust, grease, and food debris on a commercial table top mixer, and a buildup of grease, metal fragments, and rust on a commercial can opener. The Administrator confirmed that the DM lacks the necessary qualifications and has been enrolled in an online Dietary Manager course since the previous year.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illness affecting all 96 residents. During an initial tour of the kitchen, the cook identified the commercial-sized table-top mixer and can opener as clean. However, upon further inspection by the Dietary Manager, it was confirmed that the mixer had a buildup of rust, grease, and food debris on the underplate directly over the mixing bowl. Additionally, the can opener had a buildup of grease, metal fragments, rust, and a peeling silver laminate coating, with a brown and black sticky substance present in the can opener shaft holder sleeve. These unsanitary conditions were acknowledged by the Dietary Manager, who stated that they needed to be addressed.
Failure to Ensure Required QAA Meeting Attendance
Penalty
Summary
The facility failed to have the required members attend Quarterly Quality Assurance (QAA) meetings, potentially affecting all 96 residents. The facility's QAA meeting attendance forms from 6/6/23 through 4/20/24 showed that the Infection Preventionist was not present on 6/26/23, and the Medical Director only provided a verbal review on 11/21/23 and 4/20/24. The Administrator confirmed that the Medical Director's verbal review was not sufficient and that the Infection Preventionist's absence was not compliant with the required attendance. The QAA Committee list indicated that specific members, including the Administrator, Director of Nursing, and Medical Director, among others, needed to be present for the meetings, but this requirement was not met during the specified dates.
Failure to Ensure Residents' Dignity and Timely Care
Penalty
Summary
The facility failed to ensure residents' rights to dignified activities of daily living, affecting six residents. Residents reported that call lights were often left unanswered for hours, leading to prolonged periods of incontinence without timely care. One resident mentioned being left in a soiled bed for hours, causing embarrassment and frustration, while another resident's family member confirmed finding their relative in a similar state multiple times. The facility's policy requires staff to provide incontinence care every two hours, but this was not consistently followed, as evidenced by the residents' and family members' testimonies. A registered nurse acknowledged that residents were not changed in a timely manner, attributing it to the residents' refusal, which was contradicted by the residents' statements. The facility's Resident Council Group Meeting Notes also documented complaints about delayed responses to call lights. Additionally, a family member of another resident reported that the facility was often short-staffed, particularly on nights and weekends, leading to inadequate care. This family member observed staff hiding and using their phones instead of attending to residents' needs. Several residents expressed their dissatisfaction with the care provided, noting that they often waited for extended periods before receiving assistance. One resident mentioned feeling weak and at risk of passing out due to being left in a wheelchair for hours. The facility's failure to respond promptly to call lights and provide timely incontinence care compromised the residents' dignity and well-being, as documented by the surveyors' observations and interviews with residents and their family members.
Inaccurate MDS Encoding for Dialysis Treatment
Penalty
Summary
The facility failed to accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding dialysis. This deficiency was identified during an observation, interview, and record review. A resident, who had a dressing on their left upper arm covering a dialysis port, stated they go to an outside facility for dialysis treatment three times per week. The resident's Physician Order Sheet confirmed the dialysis schedule. However, the resident's MDS, which indicated no cognitive impairment, failed to document the dialysis treatments. The Administrator/Registered Nurse acknowledged the inaccuracy in the MDS encoding.
Failure to Provide PRN Dressing Changes
Penalty
Summary
The facility failed to provide PRN dressing changes for a resident (R7) as per the physician's orders. R7, who has multiple medical diagnoses including pyogenic arthritis, type 2 diabetes mellitus, and a methicillin-susceptible Staphylococcus aureus infection, had orders for daily and PRN dressing changes for a left knee wound. On two consecutive days, observations revealed that R7's left knee dressing was saturated with a light red and brown substance, indicating it had not been changed as needed. Both times, registered nurses acknowledged that the dressing should have been changed earlier due to its saturated state. The facility's Dressing Change Policy, revised in February 2024, states that the purpose of a dressing change is to protect the wound from contamination, absorb drainage, prevent infection, and promote healing. Despite this policy, the facility did not adhere to the PRN dressing change orders, resulting in R7's dressing remaining saturated and potentially compromising the wound's condition. The failure to change the dressing as needed was confirmed by two registered nurses who stated that the dressing should have been changed more frequently than once a day given its saturated state.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to provide and implement fall interventions to prevent falls for a resident (R29). R29 had multiple diagnoses, including malignant neoplasm of the pancreas, secondary malignant neoplasm of the liver, spinal stenosis, and abnormalities of gait and mobility. Despite being at high risk for falls and requiring supervision and assistance with toileting and transfers, R29 experienced several unwitnessed falls. The care plan included interventions such as a bed alarm, non-skid socks, and prompt response to call lights, but these were not consistently implemented or effective in preventing falls. R29's fall investigations revealed multiple incidents where the resident fell due to ambulating without a walker, improper footwear, and attempting to use the bathroom without assistance. The falls resulted in injuries, including a forehead hematoma and dizziness, requiring hospital evaluation. The facility's Director of Nursing (DON) acknowledged that the interventions were not adequately addressed or updated to prevent further falls. Additionally, the resident's call lights were often out of reach, and the bed alarm was found unplugged and non-functional. Interviews with staff and the resident confirmed that R29 frequently waited for long periods for assistance, leading to attempts to ambulate independently. The Occupational Therapist and Physical Therapy Assistant noted that R29's condition worsened due to chemotherapy, requiring more assistance. Despite these needs, the facility did not ensure close supervision or timely response to call lights, contributing to the resident's repeated falls and injuries.
Failure to Administer IV Antibiotics Due to PICC Line Issues
Penalty
Summary
The facility failed to administer two physician-ordered intravenous antibiotic medications on two consecutive days, resulting in a delay in treatment for a resident diagnosed with Pyogenic Arthritis, Type 2 Diabetes Mellitus, Morbid Obesity, and a Methicillin-resistant Staphylococcus Aureus (MRSA) infection. The resident's Medication Administration Record (MAR) indicated that the intravenous antibiotics Vancomycin and Ertapenem were not administered due to issues with the resident's peripherally inserted central catheter (PICC) line, which had infiltrated and caused swelling in the resident's arm. Despite the facility's attempts to contact the entity responsible for PICC line placement, there was a delay in replacing the PICC line, leading to missed doses of the antibiotics on two consecutive days. The resident's nursing notes and interviews with staff confirmed that the PICC line was removed due to infiltration, and there were delays in coordinating the replacement of the PICC line. The Director of Nursing acknowledged that the resident did not receive the required doses of Vancomycin and Ertapenem on the specified dates and stated that the resident should have been sent to the hospital for a new PICC line to ensure the continuation of the ordered IV antibiotics. The failure to administer the antibiotics as prescribed resulted in a significant medication error and a delay in the resident's treatment for the MRSA infection.
Failure to Maintain Accurate Medical Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident undergoing dialysis. The resident, who has no cognitive impairment, had an undated gauze wound dressing on their left upper arm covering a dialysis fistula port. The resident reported that the facility nurses did not assess the dialysis port fistula patency by thrill and bruit. The Physician Order Sheet (POS) documented the need for dialysis three times per week and required checks for signs of infection and patency of the AV shunt. However, the POS had an incomplete order for how often the thrill and bruit checks should be completed. The Treatment Administration Record (TAR) for the month showed no nurse initials indicating that the required assessments were completed, with an X symbol populating the entire record. The Director of Nursing (DON) confirmed that the nurses were supposed to sign off the TAR but did not, due to an error in the electronic medical record entry by the physician. The facility's dialysis protocol policy, revised in August 2022, states that nursing is responsible for providing care for dialysis residents, but this was not adhered to in this case.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during high-contact resident wound care activities. Specifically, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) did not wear gowns while performing wound care on a resident with multiple diagnoses, including Type II Diabetes Mellitus, gangrene, and recent left above-knee amputation. The resident had enhanced barrier precautions in place, which required the use of gowns and gloves during high-contact care activities to prevent the transfer of multi-drug resistant organisms (MDROs). During the observation, the RN and CNA entered the resident's room, donned gloves, but did not put on gowns as required by the facility's infection control policy. The RN proceeded to remove and replace the resident's soiled and bloody dressings on both the left above-knee amputation and a coccyx pressure ulcer without wearing a gown. The RN acknowledged the mistake, attributing it to nervousness due to being observed by a surveyor. The facility's infection control policy mandates the use of gowns and gloves during high-contact care activities, such as wound care, to prevent the spread of MDROs. The RN admitted awareness of the policy and recognized the failure to comply as a significant infection control issue. The policy specifically lists wound care as an activity requiring enhanced barrier precautions, which were not followed in this instance, leading to the deficiency noted in the report.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Danville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Goldwater Care Danville | 1 mi | ★★★★★ | 8 | 1 |
| La Bella Of Danville | 2.4 mi | ★★★★★ | 16 | 3 |
| Hawthorne Inn Of Danville | 3.1 mi | ★★★★★ | 2 | 0 |
| Waters Of Covington, The | 14.2 mi | ★★★★★ | 27 | 2 |
| Williamsport Nursing And Rehabilitation | 21.3 mi | ★★★★★ | 0 | 0 |
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