Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Alden Debes Rehab & Hcc during CMS and state inspections, most recent first.
Multiple residents did not receive their scheduled evening medications when the nurse assigned to a wing failed to report for the 6 PM–10 PM shift and facility leadership was not notified until the next day. Residents with conditions including diabetes, neuropathy, insomnia, depression, epilepsy, hypertension, hyperlipidemia, glaucoma, and pain missed ordered 8 PM doses such as insulin, pregabalin, trazodone, melatonin, antiepileptics, antihypertensives, and eye drops. Several cognitively intact residents reported not receiving their usual medications, with some describing insomnia, increased pain, and fatigue afterward. The DON, administrator, and an NP confirmed that residents are expected to be under continuous nursing care with medications administered as ordered, consistent with facility policy and the facility assessment requiring 24/7 licensed nurse coverage for medication administration.
A group of residents did not receive their scheduled evening medications when the agency nurse assigned to their wing failed to report for the 6 PM–10 PM shift, and no licensed nurse was covering the unit. MARs showed multiple missed doses, including insulin, psychotropic medications, cardiac medications, pain medications, and eye drops. Several residents reported they did not get their evening meds because there was no nurse present. CNAs on the wing stated they were told the nurse was running late, became busy with care, and either assumed the nurse eventually arrived or that others knew there was no nurse; they did not notify other staff or administration. The DON and Administrator both stated they were not informed of the nurse’s absence until the next day, and an LPN on another wing reported he did not learn of the situation until later that night, leaving the residents without a licensed nurse to administer their evening medications.
A resident with multiple comorbidities, functional limitations, and dependence on staff for ADLs was given numerous morning medications by an RN, who placed the pills and liquids on the bedside table and left without observing ingestion, then documented them as administered. The resident reported that nurses commonly leave medications at the bedside without supervision and that she has dropped or spilled pills, including when they were left while she was sleeping. Review of the medical record showed there was no MD order authorizing self-administration, and staff confirmed that self-administration requires a physician’s order per facility policy.
A resident’s scheduled morning medications, including insulin and multiple oral agents, were not administered within the facility’s required 1-hour window, resulting in an 80% medication error rate during an observed med pass. An RN checked the resident’s blood sugar and gave long-acting insulin, then brought 19 additional pre-poured medications into the room, administered only Flonase, left the rest on the bedside table, and documented them as given despite the eMAR showing them as overdue. Review of the MAR confirmed numerous 8:00 AM orders for once- and twice-daily medications, and staff acknowledged that medications highlighted red are overdue and that late twice-daily doses disrupt ordered spacing, contrary to the facility’s medication administration policy.
A nurse prepared 19 medications for a resident and left them in cups on top of an unlocked medication cart in the hallway while entering the resident’s room with only insulin to check blood sugar and administer the injection. The cart, positioned past the doorway and out of the nurse’s line of sight, left the prepared medications unattended and accessible. Another nurse confirmed this practice was not acceptable and that prepared medications should have been secured in the locked cart, contrary to facility policy requiring medications to be stored in locked compartments accessible only to authorized staff.
A resident with multiple chronic conditions, open surgical wounds, an indwelling catheter, and a colostomy was on contact isolation for an MRSA wound infection, with posted signage and facility policy requiring hand hygiene and use of gown and gloves upon room entry. An RN twice entered the resident’s room wearing only gloves to check blood sugar and administer insulin and other medications, and the RN’s sweater contacted the resident’s bedding on both occasions. A CNA later entered the same room without any PPE and touched the bedside table and bed rail while interacting with the resident. The resident reported that staff do not always wear a gown and gloves when entering the room, and the IP nurse confirmed that appropriate PPE should have been used to comply with contact precautions.
A resident on contact isolation for a blood infection reported being told by staff that she could not leave her room to shower and went about 11 days without a shower, during which she felt she smelled bad. CNAs stated that residents are to receive showers twice weekly and that residents on contact isolation can leave their rooms to shower, but one CNA acknowledged not assisting this resident with showering. An RN confirmed the resident’s isolation was later discontinued and she then received a shower, and that the resident had not been showered before that time. The resident’s care plan documented an ADL performance deficit with interventions for assistance with bathing and hygiene, and the facility’s bath/shower report showed she did not receive showers twice weekly as required by facility policy.
A resident with multiple comorbidities and mild cognitive impairment, care-planned as a fall risk and on a restorative bed mobility program requiring side rails for support, fell from bed during incontinence care when side rails and floor mats were not in place and the resident was instead holding onto the bedside table. While a CNA was turning the resident and reaching for supplies, the resident reported feeling weak, let go of the bedside table, and rolled off the bed, sustaining bruising and abrasions to the head, face, elbow, finger, and knee. Post-fall observation and staff interviews confirmed that required safety interventions, including side rails for bed mobility and floor mats, were not in use at the time of the incident, despite facility policy to assess hazards and implement appropriate fall-prevention measures.
A resident’s x-ray results were reported to the facility but were not promptly communicated to the nurse practitioner. An LPN checked the EMR once during the night and saw the results as pending, did not recheck later in the shift, and did not notify the NP. An RN later documented that results were relayed and the NP ordered hospital transfer, but the NP reported they were not notified by staff and only became aware of the results upon independently reviewing the EMR. The DON stated nurses are expected to check for x-ray results at shift start and end and immediately notify the NP when results are available.
Two residents with severe dementia were involved in an incident where one was observed placing his hand inside the other's diaper area in the activity room. The event was witnessed by another resident and an activity aide, who intervened and alerted staff. Both residents were unable to recall the incident due to cognitive impairment, and a body assessment found no injuries. The facility's failure to prevent this contact resulted in a deficiency related to abuse prevention.
A resident with ESRD, chronic pain, arthritis, and multiple other diagnoses was not informed when her oxycodone/acetaminophen was discontinued. She said no one discussed the change with her and she repeatedly asked to speak with the NP, while staff said they were unaware of the change or that it was part of the resident’s plan. The NP stated she probably should have discussed stopping the opioid with the resident before discontinuing it and had simply discontinued it to see how it went.
A resident with multiple serious chronic conditions, including ESRD, heart disease, atrial fibrillation, anxiety, hypertension, and a chronic wound requiring fluconazole, missed several prescribed meds because they were not available to administer. MARs and progress notes showed repeated gaps for cetirizine, clonazepam, diltiazem HCL ER, fluconazole, Lyrica, and amlodipine, with staff documenting that the meds were on order, waiting for delivery, or unavailable. Interviews confirmed the pharmacy stopped sending the resident’s medications because of an unpaid bill, and the DON, ADON, NP, and Administrator acknowledged the resident went without needed meds.
A resident with atrial fibrillation, heart disease, CKD, ESRD, and HTN missed ordered doses of Diltiazem HCL ER and Amlodipine because the pharmacy did not deliver the medications due to an unpaid balance. Staff reported the meds were repeatedly reordered but unavailable, and the DON and Administrator acknowledged the resident went without needed medications for an unknown period despite active physician orders.
A facility failed to ensure morning medications were given on time for several residents. An agency RN was observed with multiple late meds on the MAR, did not have one ordered BP medication available, and administered one resident's oral meds late after the resident requested applesauce and declined inhalers. MAR review showed other residents' 8 AM meds were also given late, and there was no documentation that the provider was notified when meds were delayed or unavailable.
A resident with heart bypass, morbid obesity, and type 2 DM, who was cognitively intact, had a basin of emesis left on her over-bed table for hours. Staff entered the room and tried to get her to eat lunch but did not clean the basin, and an LPN said she knew the resident had been sick but found her asleep. The resident later said staff should have removed the vomit instead of leaving it in front of her until a male nurse cleaned it up.
Unclear indications and target behaviors for antipsychotic use: The facility failed to document clearly defined target behaviors and appropriate indications for quetiapine in two residents with dementia. One resident with bipolar disorder and dementia displayed loud, demanding, argumentative behavior and delusions, but progress notes did not describe the behaviors prompting psych eval, and the BH director stated the current delusions may be related to dementia rather than bipolar disorder. Another resident with dementia, Alzheimer’s disease, and delusional disorder had quetiapine ordered for delusions, but the care plan lacked specific delusion details, target behaviors, and non-drug interventions, even though tracking showed fixed false beliefs and the psych note did not specify current symptoms requiring the medication.
A resident with CHF, CKD, dementia, and a history of falls was assessed as able to use a side rail and had requested one for bed mobility, but staff did not provide bed rails. During incontinence care, the resident repeatedly reached for something to hold onto, grabbed the bedside table, and stated she needed something to grab so she could turn over. Staff and the DON acknowledged the resident would benefit from one side rail.
Failure to provide ordered nausea medication and wound/skin care. A cognitively intact resident with recurrent emesis was observed with a basin containing vomit, but the PRN anti-nausea medication ordered after an NP assessment was not documented as given and was not offered by an LPN despite the resident reporting she had vomited after breakfast and that the medication helps her. Another resident with cognitive impairment and skin integrity issues had an order for a foam dressing to the buttock, but staff did not apply the ordered dressing during incontinence care, and an LPN later provided skin care using soap, water, and barrier cream instead of the ordered NS cleansing and foam pad.
The facility failed to complete ordered weights for two residents with weight loss. One resident with dysphagia, DM, cancer, and GERD had a documented 20-pound loss and an order to be weighed 3 times a week, but the order was not entered on the MAR/TAR and no weights were completed. Another resident had an order for weights after a significant drop in weight, but no follow-up weights were found in the record. Staff described a disconnect between ordering, documenting, and communicating the weights.
Medication administration was not completed per physician orders and the facility had a 32.1% med error rate. An agency RN passed a resident’s morning meds late, did not initially have one ordered BP med available, and had to locate the resident before giving nine oral meds; the resident also declined inhalers at the time. The DON stated 0800 meds given after 9:00 AM were late and should be documented and reported.
A resident reported to family that a CNA had hit him, and the family informed facility management. Despite the facility's policy requiring immediate removal of staff accused of mistreatment, the CNA continued to work with the resident the next day. The DON did not return a call from the family seeking assurance that the CNA would not care for the resident, and the Operations Manager did not clarify the allegation or ensure proper action was taken.
A resident's family reported to the Operations Manager that a CNA was rough and allegedly hit the resident, but this allegation was not immediately communicated to the Abuse Coordinator or reported to the State Agency as required. The initial report was sent approximately 48 hours after the allegation, contrary to the facility's policy for immediate reporting.
The facility failed to ensure that call lights were within reach for three residents at risk for falls. One resident had the call light clipped to the opposite side of the bed, another had it clipped behind the bed, and a third had it coiled and clipped to the wall. All residents had care plans indicating a risk for falls due to weakness, with interventions to keep call lights accessible.
A resident with Parkinson's Disease suffered a third-degree burn after being handed a cup of hot coffee from an unregulated single-serving coffee maker. The coffee spilled onto her leg, causing a severe burn due to the high temperature. The facility failed to monitor the coffee temperature, leading to the incident.
Two residents in a facility experienced an incident of resident-to-resident abuse. One resident, with a history of schizoaffective disorder and aggressive behavior, physically assaulted another resident, who has schizophrenia and cognitive deficits. Despite the known risks and previous aggressive incidents involving the aggressor, the facility failed to prevent the assault, highlighting a deficiency in protecting residents from abuse.
A facility failed to document the notification of a Physician or NP when a resident's blood glucose levels were outside ordered parameters. The resident, with a history of diabetes and other complex conditions, had frequent instances of hypoglycemia and hyperglycemia. Despite the facility's policy, there was no documentation of notifications on several occasions, as confirmed by the DON and NP.
A resident with a right hand contracture and multiple medical conditions, including diabetes, was found with a long, thick nail causing pain. The resident reported inadequate hand cleaning, and a CNA noted the difficulty in cutting the nail, stating that nurses were responsible. The DON acknowledged the resident's frequent refusal of care and the lack of recent attention to the nail issue. The facility's policy for nail care, especially for diabetic residents, was not followed, as documented in the Treatment Administration Record.
A resident with venous stasis ulcers did not receive consistent application of dressings as ordered, leading to a deficiency in care. Despite physician orders for daily application of a support bandage, observations showed the resident's dressings were not applied, and staff interviews confirmed noncompliance and lack of documentation. The facility's policy on skin alterations was not followed, resulting in inadequate wound care management.
A resident with hemiparesis and hemiplegia did not receive necessary ROM therapy, leading to a decline in mobility. The resident's care plan required ROM exercises, but these were discontinued without explanation. The DON incorrectly assumed dressing the resident sufficed for ROM therapy. Incomplete assessments and task sheets further highlighted the facility's failure to provide adequate care.
A resident, dependent on staff for transfers, was injured during a mechanical lift transfer when only one CNA was present, contrary to the facility's policy requiring two staff members. The resident sustained a bruise to the eye when the lift's arm hit her. The incident was reported by the resident and confirmed by a nurse, highlighting a failure to adhere to safety protocols.
A facility failed to have physician orders for a suprapubic catheter and its care for a resident with a neurogenic bladder. The resident returned from the hospital without rewritten catheter orders until months later. The Director of Nursing admitted the orders should have been on the TAR to remind staff of the care needed. The resident's POS lacked catheter orders, and the MARs for April and May did not include catheter treatments. The facility's catheter care policy did not specify when to change the catheter, except when dislodged.
A resident with significant weight loss was not adequately assisted or encouraged with meals, leading to continued nutritional decline. Observations showed the resident often ate alone without necessary supervision, and meal documentation inaccurately reported food intake. Despite care plans and physician orders for fortified foods and supplements, these were not effectively administered, contributing to the resident's weight loss.
Two residents received incontinence care that did not adhere to infection control practices. A CNA placed soiled linens on a chair and did not change gloves before assisting a resident with other tasks. Another CNA placed soiled items on the floor before bagging them. These actions were against the facility's policies, which require soiled linens to be transported in closed bags and not placed on the floor to prevent cross-contamination.
A resident with multiple medical conditions was left in urine for hours after a staff member refused to assist her to the bathroom, causing emotional distress and embarrassment. The incident was reported by a CNA and corroborated by the resident's daughter, leading to the staff member's termination.
Missed Evening Medication Pass for Multiple Residents Due to Unstaffed Nursing Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when an entire wing of residents did not receive their scheduled 8:00 PM medications on 3/28/26. For 20 of 23 residents reviewed, including residents with conditions such as Type 2 diabetes, neuropathy, restless leg syndrome, hyperlipidemia, epilepsy, hypertension, depression, glaucoma, insomnia, and pain, the March 2026 MARs showed that ordered evening medications were not administered. One resident with intact cognition had physician orders for Lantus insulin, melatonin, and pregabalin at 8:00 PM for diabetes, insomnia, and pain, but the MAR showed these were not given on that date. Another cognitively intact resident with orders for nabumetone, Entresto, trazodone, and atorvastatin did not receive any 8:00 PM medications. A resident with epilepsy, hypertension, depression, and glaucoma did not receive ordered doses of Vimpat, metoprolol, mirtazapine, trazodone, and latanoprost eye drops. A facility list also showed that additional residents (R5–R20) did not receive their 8:00 PM medications that evening. Interviews confirmed that residents did not receive their evening medications because the nurse assigned to their wing for the 6 PM–10 PM shift did not show up, and facility leadership was not notified until the following day. One resident reported not receiving insulin, pain, or sleep medications, describing higher blood sugar the next morning, inability to sleep, and leg pain from neuropathy. Another resident reported not receiving evening medications for depression and insomnia and described poor sleep and fatigue the next day. A third resident stated she did not receive her evening medications but noted her pain was not severe that night, while another resident reported not getting any evening medications at all. The DON, administrator, and nurse practitioner each stated that residents are expected to be under the care of a nurse 24/7 and that medications are to be administered as ordered, with the nurse practitioner specifically noting that missing pain and sleep medications could cause increased pain and insomnia, and that missing an antiepileptic dose could increase seizure risk. Facility policies and the facility assessment indicated that medications are to be administered at the correct time by a licensed nurse and that skilled nursing, including medication administration, must be provided 24 hours a day, 7 days a week.
Missed Evening Medications Due to Absence of Licensed Nurse
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to meet residents’ needs when an agency nurse assigned to one wing for the 6 PM–10 PM shift did not report to work, resulting in 20 of 23 sampled residents not receiving their scheduled 8:00 PM medications on 3/28/26. Medication Administration Records (MARs) showed that one resident did not receive prescribed evening doses of Lantus insulin, Melatonin, and Pregabalin; another did not receive Melatonin and Trazodone; a third did not receive Nabumetone, Entresto, Trazodone, and Atorvastatin; and a fourth did not receive Vimpat, Metoprolol Tartrate, Mirtazapine, Trazodone, and Latanoprost eye drops. A facility list dated 3/28/26 showed that residents 5 through 20 on that wing also did not receive their 8:00 PM medications. Multiple residents reported that they did not get their evening medications that night because there was no nurse on the unit. The DON stated that each resident must be assigned to a nurse 24 hours a day, 7 days a week, and confirmed that the residents on that wing did not receive their 8:00 PM medications because the agency nurse scheduled from 6 PM–10 PM never arrived, and that she was not informed of the no‑show until the following day. The Administrator similarly stated that the residents did not receive their medications because the assigned nurse did not show up and that she was not notified until the next day. Two CNAs assigned to the affected wing reported that they were told the nurse was running late, became busy providing care, and either assumed the nurse eventually arrived or assumed others were aware there was no nurse; neither CNA notified any staff or administration that no nurse was present. An LPN assigned to a different wing stated he did not learn that the nurse had not shown up to cover the affected unit until 10 PM, and no one had reported the absence to him, leaving the wing without a licensed nurse to administer scheduled evening medications.
Failure to Supervise Medication Administration and Lack of Order for Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to supervise a resident during medication administration and to ensure that self-administration occurred only with a physician’s order. The resident was assessed as cognitively intact but with range of motion limitations in both upper and lower extremities and was dependent on staff for all other activities of daily living. Her admission record listed multiple diagnoses, including MRSA infection, local skin and subcutaneous tissue infection, disruption of an external surgical wound, chronic kidney disease stage 3A, chronic pain syndrome, major depressive disorder, generalized anxiety disorder, extracorporeal dialysis catheter, colostomy, anemia, bilateral hip osteoarthritis, lower abdominal pain, type II diabetes mellitus, and a healing right femur fracture. During a morning medication pass, an RN administered the resident’s insulin injection and nasal spray, then placed the remainder of her morning medications in cups on the bedside table and left the room without observing her take them. The unsupervised medications included 18 different drugs, such as clonidine, buspirone, amlodipine, ferrous gluconate, liquid protein supplement, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, Miralax in water, and milk of magnesia. The RN documented these medications as administered and moved the medication cart down the hall. Later, the resident reported that most nurses leave her pills on the bedside table without watching her take them, that she does not like this practice because she has dropped pills before, and that pills have spilled when left on the table while she was sleeping and bumped it. She also stated she is clumsy and sometimes drops a pill. Review of the resident’s orders confirmed there was no physician order permitting her to self-administer medications. Facility staff stated that residents allowed to self-administer must have a physician’s order, and the facility’s self-administration policy specified that residents may self-administer only according to a physician’s order and under specified conditions.
High Medication Error Rate Due to Late and Improperly Documented Administration
Penalty
Summary
The deficiency involves the facility’s failure to administer medications at the ordered time, resulting in an 80% medication error rate during a medication pass observation. On 3/3/26 between 8:44 AM and 9:18 AM, an RN was observed checking a resident’s blood sugar and administering long-acting insulin at 9:10 AM, then retrieving 19 additional medications that had been pre-poured for the same resident. At 9:12 AM, the RN administered only Flonase nasal spray and left the remaining medications on the bedside table before exiting the room. The electronic MAR showed the resident’s medications highlighted in pink/red, indicating they were overdue, yet the RN documented them as administered and moved the medication cart further down the hall. Record review of the March 2026 MAR showed multiple medications ordered for administration at 8:00 AM, including Lantus insulin, Flonase, clonidine, buspirone, amlodipine, ferrous gluconate, Pro T Gold, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, polyethylene glycol, and milk of magnesia, many of which were scheduled once or twice daily. Facility staff stated that medications should be administered within one hour before or after the ordered time, and that medications turning red in the system indicate they are overdue. Staff also stated that late administration of twice-daily medications affects spacing between doses and could affect therapeutic levels. The facility’s medication administration policy requires drugs to be administered in accordance with written physician orders and established procedures, which was not followed in this instance.
Unsecured Prepared Medications Left Unattended on Medication Cart
Penalty
Summary
The deficiency involves unsecured medications left unattended on a medication cart after being prepared for administration to a resident. On 3/3/26 at 9:10 AM, an RN (V5) prepared 19 different morning medications for a resident (R1) and placed them in several cups on top of the medication cart. The RN then entered the resident’s room carrying only the resident’s insulin to check blood sugar levels and administer the insulin. The medication cart, with the remaining 19 prepared medications on top, was pushed against the wall past the resident’s doorway and was not within the RN’s line of vision. During this time, another nurse, an LPN/Infection Preventionist (V4), was observed coming up the hall and was asked whether it was acceptable to leave medications on top of the cart when the nurse goes into a room. V4 stated it was not acceptable to leave medications on top of the medication cart unattended and later confirmed that, since the medications had already been prepared, they should have been placed back into the locked medication cart so other residents could not access or grab them. The facility’s policy dated 05/2025 requires resident-specific medications to be stored in a locked cabinet or cart accessible only to authorized staff, with Schedule II controlled medications stored under a double-lock system.
Failure to Use Required PPE for Resident on Contact Isolation
Penalty
Summary
The deficiency involves staff failing to follow the facility’s contact isolation and PPE requirements for a resident on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. The resident had multiple complex medical conditions, including chronic kidney disease, type II diabetes mellitus, chronic wounds, an indwelling urinary catheter, a colostomy, and multiple open surgical wounds to the abdomen and right lower extremity, placing her at increased risk for infection. Her care plan and physician orders specified single-room isolation with contact precautions for MRSA, and the facility’s posted signage outside her room directed all individuals to perform hand hygiene and don gloves and a gown before room entry, discarding them before exit. The facility’s written policy on contact precautions required hand hygiene prior to entering and exiting the room and mandated that all individuals entering the room use PPE appropriately, including gloves and a gown. Despite these requirements, surveyors observed multiple instances of noncompliance. An RN entered the resident’s room wearing only gloves to check blood sugar and administer insulin, during which the RN’s sweater touched the resident’s bedding. After being told by the IP nurse to wear proper PPE when entering the room, the RN re-entered the room again wearing only gloves to administer additional medications, and her sweater again contacted the resident’s bedding. Later, a CNA entered the same resident’s room without any PPE, touched the bedside table and bed rail, and interacted with the resident. The resident reported that staff do not always wear a gown and gloves when entering her room and stated she had an abdominal wound infection for which she was receiving antibiotics. The IP nurse confirmed that the resident was on contact isolation for MRSA of the abdominal wound and that the RN should have performed hand hygiene and donned both gown and gloves before entering the room.
Failure to Provide Required Showers and ADL Assistance During Contact Isolation
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living, specifically bathing, to a resident who was unable to independently meet this need. Surveyors observed the resident in her room without an isolation sign posted and noted she had no shower stall in her bathroom. The resident reported that upon admission she was placed on contact isolation for a blood infection and was repeatedly told by staff she could not leave her room to shower, resulting in her not receiving a shower for approximately 11 days and feeling that she smelled bad. Certified nursing assistants stated that residents are supposed to receive showers twice a week and that residents on contact isolation can leave their rooms to shower, and one CNA acknowledged not assisting this resident with showering while she was in isolation. A registered nurse confirmed that the resident’s contact isolation was discontinued on a specific date and that she received a shower then, and that the resident had reported not receiving a shower prior to that time. The resident’s care plan documented an ADL performance deficit with interventions to assist with bathing and personal hygiene, and also noted contact isolation precautions, while the facility’s bath/shower report showed the resident did not receive showers twice weekly as required by facility policy, which states bathing is to provide cleanliness, comfort, and prevent body odors.
Failure to Implement Care-Planned Fall Prevention Interventions During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure that safety interventions were in place for a resident identified as being at risk for falls. The resident had multiple diagnoses including osteomyelitis, palliative care status, type 2 diabetes, heart disease, chronic kidney disease stage 3, hypertension, mild cognitive impairment, and lymphedema. Her care plan identified her as at risk for falls, with self-care deficits and a need for staff assistance with bed mobility, and included interventions such as using side rails for support and cueing her to grasp the side rail for positioning. A Restorative Nursing assessment documented that she was on a bed mobility program and would roll side to side during care and repositioning using side rails as needed, and that side rails were indicated as an enabler to promote independence. Despite this, staff interviews and observations confirmed that side rails were not in place prior to the fall, and the resident instead held onto the bedside table during care. On the date of the fall, a CNA reported providing incontinence care and rolling the resident to her side while the resident held onto the bedside table because side rails were not in place. The CNA stated that while reaching for a towel with one hand and maintaining one hand on the resident’s body, the resident let go of the bedside table, said she got weak, and rolled off the bed onto the floor on the right side, where the bedside table was located. The nurse on duty reported that when she entered the room after the fall, the floor mats were not on the floor and that she believed the resident hit her head on the bedside table. The fall incident report documented multiple injuries including a lump with swelling on the right forehead, right eye bruising, a chin abrasion, a small cut on the right elbow, a bruise and small cut on the right ring finger, and bruising to the left knee. Subsequent observation showed the resident in a large bariatric bed with a large dark purple/greenish bruise to the right eye/forehead area and a small laceration to the chin, with the bedside table on the right side of the bed and thick bilateral floor mats on the floor. The Restorative Nurse confirmed the resident should have had side rails for bed mobility, acknowledged that her strength varied day to day and that she should have something to hold onto when weak, and was unsure who was responsible for ensuring side rails were in place, despite the facility’s Management of Falls Policy requiring assessment of hazards and implementation of appropriate interventions to minimize fall risks.
Failure to Promptly Notify Practitioner of Radiology Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of radiology results for one resident. The resident’s x-ray was performed on 1/5/26 at 6:37 PM, and the radiology report indicates the results were reported to the facility on 1/6/26 at 1:43 AM. The nurse practitioner ultimately reviewed the results on 1/6/26 at 4:59 PM. The facility’s nursing schedule shows that an RN and an LPN were assigned to the resident’s hall when the x-rays were ordered and when the results were received. The LPN reported checking the resident’s electronic medical record for updated x-ray results around 3:30 AM on 1/6/26 and stated that at that time the results still appeared as pending. The LPN did not check again for updated x-ray results for the remainder of the shift, despite being instructed that nurses should check for results at the end of each shift and notify the nurse practitioner immediately when results are received. The RN later documented in a nurse’s note on 1/6/26 at 5:30 PM that the x-ray results were relayed to the nurse practitioner, who then ordered the resident sent to the local hospital for further evaluation and treatment. However, the nurse practitioner stated that no facility staff notified them that the x-ray results had been uploaded prior to their own review at 4:59 PM on 1/6/26, and that earlier notification would have resulted in the resident being sent to the hospital earlier in the day. The Director of Nursing confirmed that the facility’s expectation is that nurses check for x-ray results at the beginning and end of their shifts and notify the nurse practitioner by call, text, or in person when results are available, to ensure the practitioner receives and reviews them.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents with severe dementia from sexual abuse. One resident with Alzheimer's disease and a severely impaired BIMS score was observed by another resident and an activity aide making physical contact and placing his hand inside the diaper area of another resident, who was also severely cognitively impaired and on hospice care. The incident occurred in the activity room, where the resident was seen with his hand inside the other resident's pants, and staff were alerted by a witness. The staff intervened and separated the residents after the inappropriate contact was observed. Both residents involved were unable to provide details about the incident due to their cognitive impairments. The event was reported to facility management and a body assessment was conducted on the resident who was touched, with no injuries found. The care plan for the resident at risk for abuse noted interventions to keep her safe, but the incident still occurred. The facility's policy affirms residents' rights to be free from abuse, including sexual abuse, but the failure to prevent this incident resulted in a deficiency.
Resident Not Informed of Oxycodone Discontinuation
Penalty
Summary
The facility failed to inform a cognitively intact resident of changes to her plan of care when her oxycodone/acetaminophen was discontinued. The resident’s record showed multiple diagnoses including end stage renal disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, malignant neoplasm of the left kidney, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, chronic pain conditions, osteoarthritis, obesity, hypothyroidism, and a non-pressure chronic ulcer of the right lower leg. During interview, the resident said she did not know why her oxycodone was stopped and stated that no one discussed it with her, despite her repeated requests to speak with the NP. She said she was told only that if someone stops taking a medication for a period of time, it could be discontinued, and that she was now only offered Tylenol. Staff interviews and record review showed the resident’s oxycodone had been discontinued by the NP without documented discussion with the resident. An LPN said she was not aware of any changes to the oxycodone order, and another LPN said the discontinuation was not being discussed as part of the resident’s plan and that the resident had not been told about scheduled Tylenol either. The NP stated she probably should have discussed discontinuing the oxycodone with the resident before stopping it and said she figured she would just discontinue it and see how it goes. The NP’s last two visit notes documented review of the chart, vital signs, and medication list with continuation of orders and plan of care, but did not document any plan to discontinue the oxycodone. The resident’s care plan identified pain related to weakness, dialysis, chronic pain, and arthritis, and noted that she receives opioid medications.
Medications Not Provided When Pharmacy Refused Delivery Due to Unpaid Bill
Penalty
Summary
The facility failed to ensure prescribed medications were acquired and provided for one resident with extensive medical diagnoses, including end stage renal disease, hypertensive heart and chronic kidney disease with heart failure, atrial fibrillation, asthma, anxiety, anemia, insomnia, hypertension, chronic pain, osteoarthritis, obesity, hypothyroidism, and a chronic non-pressure ulcer of the right lower leg. The resident’s care plan identified long-term use of prophylactic antifungal medication, fluconazole, for care and management of chronic healing surgical wounds, to be given per physician’s orders. The resident’s MAR for October showed multiple missed doses because medications were not available to administer. Cetirizine, clonazepam, diltiazem HCL ER, fluconazole, Lyrica, and amlodipine were documented as not given on multiple days due to no supply, being on order, waiting for delivery, or being unavailable. Progress notes repeatedly documented that these medications were not available or were awaiting pharmacy delivery, including notes that the medications were on order, out, or not available for administration. Staff interviews confirmed the medications were not being delivered because the pharmacy would not continue filling the resident’s medications due to an unpaid bill. An LPN, the Social Services Director, the ADON, the DON, an NP, another LPN, and the Administrator all acknowledged that the resident went without medications because the pharmacy was not sending them. The Administrator stated the facility was ethically and legally responsible to provide the resident’s needed medications regardless of payment status, and the facility’s Medication Administration: General Guidelines policy stated that all medications shall be administered as prescribed.
Failure to Administer Prescribed Cardiac Medications
Penalty
Summary
The facility failed to administer prescribed cardiac and blood pressure medications to a resident with multiple serious diagnoses, including end stage renal disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, paroxysmal atrial fibrillation, and hypertension. The resident’s MAR showed missed doses of Diltiazem HCL ER on 10/20/25, 10/21/25, 10/22/25, 10/29/25, and 10/30/25, and missed doses of Amlodipine on 10/26/25 and 10/31/25. The MAR and progress notes documented that these medications were not given because there was no supply available from the pharmacy. Interviews with nursing and administrative staff showed the medications were repeatedly reordered but not delivered because the resident had an outstanding pharmacy balance. Staff stated they could not administer medications they did not have, and the DON said the resident went without medications for an unknown period, possibly a few days. The NP stated the facility should be providing essential medications to residents, and the Administrator acknowledged the facility was ethically and legally responsible to provide the resident’s care and medications regardless of payment status. The facility’s medication administration policy required drugs to be administered in accordance with physician orders.
Late Medication Administration and Missing Ordered Medication
Penalty
Summary
The facility failed to ensure medications were administered timely as ordered and scheduled for 4 of 5 residents reviewed for medication administration. During observation on 7/30/25, an agency RN was observed passing morning medications while multiple residents were already showing as late on the medication administration screen. The RN stated, "I know there's a lot of red on the screen. That's because they're considered late." While preparing medications for one resident, the RN did not have Isosorbide 60 mg that had been ordered the day before and said she would need to check with a supervisor to see if it was available in the automated medication dispensing system. The RN later administered that resident's oral medications at 9:30 AM after the resident requested applesauce and declined inhalers at that time. The resident had diagnoses including COPD, vascular dementia, schizoaffective disorder, hypertension, diabetes, and generalized anxiety disorder. Medication administration records showed that another resident's 8 AM medications were given from 9:53 AM to 9:57 AM, a third resident's 8 AM medications were given between 9:05 AM and 9:14 AM, and a fourth resident's 8 AM medications were given between 10:13 AM and 10:14 AM. Review of progress notes showed no documentation that the provider was notified when medications were administered late or not available. During the resident council meeting, residents stated that medication passes were late when agency staff were working, with 8 AM medications sometimes not given until 10:30 AM or later. The DON stated nurses should follow the 5 rights of medication administration, that the right time includes a one-hour window before and after the scheduled time, and that medications given outside that window should prompt provider notification and a progress note.
Emesis Basin Left at Resident’s Bedside
Penalty
Summary
The facility failed to maintain a resident’s dignity by leaving a basin containing emesis at the resident’s bedside. R2 was admitted on 4/24/23 with diagnoses including heart bypass, morbid obesity, and type 2 diabetes. Her 6/6/25 quarterly MDS showed she was cognitively intact with a BIMS score of 15 out of 15. A 7/25/25 nursing note documented another emesis occurrence and an NP assessment, with an order for nausea medication every 4 hours as needed. On 7/29/25 at 10:26 AM, R2 was observed asleep in bed, pale, and not arousing to a door knock, with a pink basin on the over-bed table containing about one cup of chunky, dark brown emesis with round off-white pieces. At 2:10 PM the same day, the basin still contained the same emesis, and R114 stated staff had entered the room and tried to get R2 to eat lunch but did not clean the emesis from the basin. An LPN stated she was aware R2 had been sick at lunch time but saw her asleep. The next day, R2 stated she had thrown up after getting too hot and said staff should have taken the vomit instead of leaving it in front of her; she reported it had been there since breakfast until a male nurse cleaned it up. The DON stated staff should be rounding hourly and addressing resident needs, including emptying emesis basins.
Unclear indications and target behaviors for antipsychotic use
Penalty
Summary
The facility failed to provide clearly defined target behaviors and an appropriate indication for the use of antipsychotic medications for two residents with dementia. The report states that the facility did not document specific behavioral symptoms, target behaviors, or non-pharmacological interventions for the use of quetiapine in these residents, despite facility policy requiring a supporting diagnosis, clearly defined target behaviors, and a plan of care with treatment goals and non-drug approaches before antipsychotic use. For one resident with diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and unspecified bipolar disorder, the physician order summary showed quetiapine 50 mg in the morning and 25 mg at bedtime for bipolar disorder. The resident was observed in bed on one occasion and later in a wheelchair in the doorway of the room, where he made loud, demanding statements to staff, insisted he was the owner of the building, and was argumentative but redirectable if not contradicted. Progress notes documented referral to a psychiatric hospital and transfer, but did not describe the behavior that prompted the evaluation. The behavior tracking report listed mood disturbances, lack of motivation, lack of self-initiation, and delusions, with interventions noted as not arguing and reality testing, but the behavioral health director stated the resident displayed typical dementia behaviors and needed a medical diagnosis review by psychiatry because it was unclear whether the delusions were related to bipolar disorder or dementia. For the other resident, the physician order summary showed quetiapine 25 mg at bedtime related to delusional disorder, with diagnoses including dementia with behavioral disturbance, Alzheimer’s disease, and delusional disorder. The resident was observed in a wheelchair in the hallway and was pleasant and appropriate during interaction. The care plan referenced quetiapine for mood issues and delusions but did not include details of the delusions, specific symptoms, targeted behaviors, or non-pharmacological interventions. The behavior tracking report documented fixed false beliefs such as believing someone was there to take her home, waiting for the bus, or believing she was being discharged, and the psychiatry note stated the resident had been started on Seroquel for agitation and delusions and had previously been physically aggressive with staff during ADLs, but the note did not specify the current symptoms or delusions requiring the medication beyond yelling and aggression with care.
Failure to Provide Bed Rail Assistance for Bed Mobility
Penalty
Summary
The facility failed to provide bed rails for assistance with bed mobility for one resident who had diagnoses including heart failure, chronic kidney disease, dementia without behaviors, and a history of falls. The resident’s facility assessment showed moderate cognitive impairment and that side rails were not utilized, while the care plan identified an ADL functional performance deficit and included cueing the resident to grasp a side rail and pull self up to a sitting position or to the side of the bed. Side rail assessments dated 4/25/25 and 7/22/25 both documented that the resident was able to use a side rail to assist in bed mobility, that the use of side rails was indicated to promote independence, and that the resident had requested side rails while in bed. During incontinence care on 7/29/25, the resident attempted multiple times to reach for something to grab onto during bed mobility and at one point grabbed the bedside table, stating, "I need something to grab onto so I can turn over. I feel like I'm going to fall if I don't hold something." A CNA stated the resident did not have bed rails and had never had them, and that the resident did help move herself in bed when she had something to grab onto. The restorative nurse and DON stated that side rail assessments were completed by floor nurses and that the resident’s assessment showed she would benefit from one side rail, with the DON stating it would probably be a benefit if the assessment showed she could use one.
Failure to Provide Ordered Nausea Medication and Wound/Skin Care
Penalty
Summary
The facility failed to ensure signs and symptoms of nausea and vomiting were treated as ordered for a resident with diagnoses including heart bypass, morbid obesity, and type 2 diabetes. The resident was cognitively intact with a BIMS score of 15 out of 15. After an episode of emesis, the NP ordered nausea medication 4 mg PO every 4 hours as needed. On 7/29/25, the resident was observed asleep in bed, pale, and not arousing to a door knock, with a pink wash basin on the over-bed table containing about a cup of chunky, dark brown emesis with round off-white pieces. The roommate stated the resident had been sick that morning and was not feeling well. The MAR did not document administration of the nausea medication that day, and the LPN stated she was not aware the resident was sick, later said she had heard the resident was not feeling well at lunch, saw her asleep, and did not offer the medication. The resident stated she had thrown up after breakfast, was not offered nausea medication, and said the medication works well for her. The facility also failed to provide wound/skin care as ordered for another resident with diagnoses including heart failure, chronic kidney disease, dementia without behaviors, and history of falls. The resident’s assessment showed moderate cognitive impairment and risk for pressure ulcers, and the care plan noted MASD to the sacral/perineal/buttock area and a history of skin alterations. A physician’s order directed a foam dressing to the left buttock every night shift and as needed for skin condition. On 7/29/25, a CNA provided incontinence care and removed the soiled brief, but no dressing was applied to the buttocks. On 7/31/25, an LPN cleaned the buttocks with soap and water and applied barrier cream, but did not cleanse with normal saline or apply the ordered foam pad. The TAR showed missed documentation of the abdominal wound dressing changes on 7/9/25, 7/25/25, and 7/26/25, and the DON stated treatments should be done and documented as ordered.
Missed Ordered Weights for Residents With Weight Loss
Penalty
Summary
The facility failed to ensure ordered weights were completed for two residents with weight loss. One resident had diagnoses including dysphagia, diabetes mellitus, prostate cancer, and gastric reflux, and was assessed as having moderately impaired cognitive skills, requiring supervision for eating and oral hygiene. His record showed a mechanically altered diet, then a July 2025 order to weigh him three times a week and chart weight loss after a documented 20-pound loss. However, his last recorded weight was 7/3/25, and the ordered weights were not entered on the MAR or TAR, so they were not completed. Staff stated the weight order should have appeared on the MAR/TAR and that the resident had not been weighed since 7/3/25. A second resident had a physician order for weights three times for one week after weight loss was identified, with documented weights decreasing from 129.4 pounds to 117.6 pounds. No weights after 7/2/25 were found in the medical record. Nursing staff stated the ordered weights were not documented, and an NP stated there was a disconnect between ordering the weights, documenting them, and notifying the RD so current information would be available. The facility policy stated residents are to be weighed to establish baseline weights and identify trends of weight loss or gain.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration was not completed in accordance with physician orders and the facility’s medication timing requirements. During observation, interview, and record review, the facility had 9 medication errors out of 28 opportunities, resulting in a 32.1% medication error rate. This involved 1 of 2 residents observed for medication administration, including R58, whose morning medications were being passed late by an agency RN. On 7/30/25, the surveyor observed the agency RN preparing medications for R58 while the resident was initially standing behind another resident and then walked away before the medications were given. The RN did not have R58’s Isosorbide 60 mg available and stated it had been ordered the day before, so she would need to check whether it was in the automated medication dispensing system. She prepared and later administered nine oral medications, along with two inhalers, but R58 was not immediately available, was found in the bathroom, and then requested applesauce and declined the inhalers at that time. The Medication Administration Audit Report showed R58’s nine 0800 oral medications were administered at 9:30 AM. The DON stated nurses should follow the 5 rights of medication administration, including the right time, and that 0800 medications given after 9:00 AM were considered late.
Failure to Remove Accused CNA from Resident Contact Following Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not immediately removing a Certified Nurse Assistant (CNA) accused of mistreatment from resident contact. According to the facility's policy, any employee accused of mistreatment must be removed from resident contact immediately until the investigation is reviewed by the administrator or designee. In this case, a resident reported to family members that the CNA had hit him. The family relayed this allegation to the Operations Manager, who did not clarify the nature of the complaint with the resident and only reported that the CNA was 'rough' to the Assistant Administrator. The Assistant Administrator stated she was not informed of the specific allegation of being hit. Despite the report, the accused CNA continued to work as the resident's CNA the following day, as confirmed by timecard records and staff interviews. The Director of Nursing received a message from the resident's family member requesting a call back to ensure the CNA was not assigned to the resident, but did not return the call. As a result, the accused CNA maintained direct contact with the resident after the allegation was made, contrary to the facility's stated policy.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in a timely manner to the State Agency, as required by its own policy. On a Sunday, a resident's stepdaughter and ex-wife informed the Operations Manager that the resident reported being hit by a CNA. The Operations Manager acknowledged receiving this information after 3 PM but did not report the allegation to the Abuse Coordinator. Instead, she only mentioned to the Assistant Administrator that there was an issue involving the resident's family, without specifying the abuse allegation. The Assistant Administrator confirmed that she was not informed of any abuse allegation that day. The Abuse Coordinator, who is also the facility Administrator, stated that he was not notified of the abuse allegation on the day it was reported by the family. The initial incident report was sent to the State Agency approximately 48 hours after the allegation was made, documenting that a family member reported a CNA had hit the resident and that the CNA was suspended pending investigation. The facility's abuse policy requires immediate reporting of such allegations to the Department of Public Health, but this was not followed in this instance.
Failure to Ensure Call Lights Within Reach for Residents at Risk of Falls
Penalty
Summary
The facility failed to ensure that residents at risk for falls had their call lights within reach, as observed in three out of six residents reviewed for safety. On the specified date, one resident was found sitting in a chair with the call light clipped to the opposite side of the bed, making it inaccessible. This resident's care plan indicated a risk for falls due to weakness and included an intervention to keep the call light within reach. Another resident was observed in a wheelchair with the call light clipped behind the bed, out of reach. This resident's care plan also noted a risk for falls due to generalized weakness, with a similar intervention to ensure the call light was accessible. A third resident was found with the call light coiled and clipped to the wall behind the bed, which a CNA later adjusted to be within reach. The facility's policy on fall management emphasizes assessing hazards and ensuring interventions are in place to minimize fall risks, which was not adhered to in these cases.
Resident Suffers Severe Burn from Unregulated Coffee Temperature
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in a resident, R1, suffering a severe burn. R1, who was cognitively intact and used a wheelchair for mobility, was involved in an incident where she was handed a cup of hot coffee by another resident, R2. The coffee, dispensed from a single-serving pod-type coffee maker in the counselor's office, was at a temperature that caused a third-degree burn when it spilled onto R1's left thigh. The incident occurred as R1 was being assisted by R2 to move her wheelchair, and the coffee was dropped during the exchange. R1's medical history included Parkinson's Disease, which contributed to her hand tremors and potentially affected her ability to handle the hot beverage safely. The wound resulting from the spill was extensive, measuring 12 to 14 inches in length and 5 to 6 inches in width, with nearly 100 percent of the wound covered in slough tissue. The wound care assessments confirmed the severity of the burn as third-degree, involving all layers of the skin and requiring significant medical attention. The facility's failure to monitor and regulate the temperature of the coffee from the single-serving coffee maker contributed to the incident. The coffee was found to be dispensed at temperatures significantly higher than the facility's regulated kitchen coffee machines, which were set to avoid burns. The lack of a process to measure and control the temperature of coffee from the single-serving machines on the unit was a critical oversight, leading to the severe injury sustained by R1.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving two residents. One resident, identified as R58, who has a history of schizoaffective disorder and aggressive behaviors, was observed to have physically assaulted another resident, R30, who has schizophrenia and cognitive communication deficits. The incident occurred when R58, who was known to have verbal and physical aggression issues, shoved and punched R30, causing him to fall to the ground. Despite the presence of staff and surveillance cameras, the facility did not prevent this incident from occurring. R58's behavioral history included multiple instances of verbal aggression, inappropriate behavior, and difficulty with redirection, as documented in his progress notes. These behaviors were known to the facility, as R58 had a care plan indicating his potential for verbal and physical aggression. Despite this, R58 was not adequately monitored or managed to prevent the assault on R30. The facility's failure to implement effective interventions and supervision for R58, given his documented history, contributed to the occurrence of the abuse. The facility's abuse policy emphasizes the protection of residents from abuse by anyone, including other residents. However, the policy's implementation was insufficient in this case, as the staff did not identify or mitigate the risk posed by R58's behaviors. The incident highlights a lapse in the facility's responsibility to ensure a safe environment for all residents, particularly those with known behavioral issues that could lead to conflict or harm.
Failure to Document Notification of Out-of-Range Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that nursing staff documented the notification of a resident's Physician or Nurse Practitioner when the resident's blood glucose levels were outside the parameters ordered by the physician. This deficiency was identified for one resident, who was being treated for type II diabetes mellitus and was on insulin medication. The resident's blood glucose levels were frequently outside the ordered parameters, with instances of both hypoglycemia and hyperglycemia recorded over several months. However, there was no documentation in the nurse progress notes indicating that the Physician or Nurse Practitioner was notified of these out-of-range blood glucose levels on multiple occasions. The resident in question had a complex medical history, including diagnoses of schizoaffective disorder, encephalopathy, generalized anxiety disorder, and adult failure to thrive, and was assessed to have moderate cognitive impairment. Despite the facility's policy requiring notification of the Physician if blood glucose results were outside the given parameters, the Director of Nursing acknowledged that while nurses reported the levels to the Nurse Practitioner, they failed to document these notifications. The Nurse Practitioner confirmed the resident's condition as a brittle diabetic, indicating that the resident's blood glucose levels were difficult to manage, with significant fluctuations occurring with changes in insulin dosage.
Failure to Provide Adequate Nail Care for Resident with Contracture
Penalty
Summary
The facility failed to provide adequate care for a resident's right hand contracture and nails, as observed during a survey. The resident, who has a history of type 2 diabetes mellitus, Parkinson's disease, schizoaffective disorder, cellulitis of the right lower limb, spastic hemiplegia, adult failure to thrive, and a history of falling, was found with a contracted right hand and a long, thick nail on the right thumb. The resident reported that staff do not clean her right hand, and the nails were causing pain by cutting into her hand. A CNA acknowledged the difficulty in cutting the thick nail and mentioned that nurses were responsible for cutting the resident's nails, but the resident often refused care. The Director of Nursing (DON) confirmed that the resident frequently refuses care and that staff should re-approach later when care is refused. However, the DON was unaware of any recent discussions about the resident's nails and noted that the order for nurses to cut the resident's nails weekly was discontinued, as it should not have been in place. The Treatment Administration Record indicated that the nails were to be cut weekly by the night shift nurse, but this was not completed as documented. The facility's policy requires all residents to have clean, well-trimmed nails, with diabetic residents' nails to be cut by a nurse, which was not adhered to in this case.
Failure to Consistently Apply Dressings for Resident with Venous Stasis Ulcers
Penalty
Summary
The facility failed to ensure that a resident's dressings were consistently applied as ordered, leading to a deficiency in care. The resident, identified as R20, has multiple medical conditions including venous insufficiency and peripheral vascular disease, which require specific wound care management. Despite physician orders to apply a multipurpose support bandage to both lower extremities every morning and remove it at bedtime, observations and interviews revealed that these dressings were not consistently applied. On one occasion, R20 was observed with multiple open sores on her lower left leg, with drainage present, and reported that the dressings were not applied as scheduled. The facility's records showed that the treatment administration record for June 2024 did not document the completion of R20's leg wound dressing and support bandage on a specific date. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that R20 was noncompliant with her dressings, often removing them herself. However, there was a lack of documentation regarding these incidents and the reapplication of dressings. The facility's policy on skin alterations emphasizes the need for individualized care plans and appropriate treatment, which was not adhered to in this case.
Failure to Provide Range of Motion Therapy
Penalty
Summary
The facility failed to provide necessary services to prevent the decline in a resident's Range of Motion (ROM). The resident, who has hemiparesis and hemiplegia affecting her left side following a cerebral infarction, was supposed to receive ROM therapy as part of her care plan. However, the resident reported that the facility was not providing the ROM therapy, leading to a loss of mobility in her left arm. Observations confirmed that the resident's left arm was bent and close to her body, with a rolled-up washcloth in her hand, indicating a lack of proper ROM exercises. The Restorative Nurse acknowledged that the resident was on a restorative ROM program, which was discontinued in February 2024, without a clear reason. The Director of Nursing mistakenly believed that dressing the resident counted as ROM therapy. Additionally, the Restorative Nursing Assessments from February to June 2024 were incomplete, lacking documentation of goals, progress, or changes needed in the restorative plan. The resident's task sheet also did not list ROM under the restorative category, further indicating a lapse in the provision of necessary care to maintain or improve the resident's ROM.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in an injury. The resident, who was cognitively intact and dependent on staff for transfers due to conditions such as morbid obesity, osteoarthritis, and congestive heart failure, was supposed to be transferred with the assistance of two staff members as per her care plan. However, during a transfer from her bed to a recliner, only one CNA was present, and the resident was injured when the arm of the lift hit her in the eye, causing a bruise. The incident was reported by the resident and confirmed by a Registered Nurse who observed the injury. The facility's policy mandates that two caregivers are required to operate the mechanical lift to ensure resident safety. Despite this policy, the CNA attempted the transfer alone, which led to the resident's injury. The Director of Nursing and other staff confirmed that the policy was not followed, and attempts to contact the CNA involved were unsuccessful.
Lack of Physician Orders for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure there were physician's orders for a suprapubic catheter and its care for a resident with a neurogenic bladder, anxiety, agitation, and paranoia. The resident returned from the hospital in March 2023, but the catheter orders were not rewritten until June 26, 2024. The Director of Nursing acknowledged that the orders should have been documented on the Treatment Administration Record (TAR) to remind staff of the necessary care and to document its completion. The resident's Physician Order Sheet (POS) lacked orders for the suprapubic catheter prior to June 26, 2024, and the Medication Administration Records (MAR) for April and May 2024 did not include treatments for the catheter. The facility's Suprapubic Catheter Care Policy and Procedure from February 2011 did not specify when to change the catheter, except when it becomes dislodged, and indicated it should be replaced by a physician or nurse practitioner.
Failure to Assist and Document Nutritional Intake for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss, identified as R93, was adequately assisted and encouraged with meals. Observations revealed that R93 was often left to eat alone without assistance or verbal cueing, despite needing supervision or touching assistance for eating as indicated in the Minimum Data Set (MDS). On multiple occasions, R93's meal trays were not set up, and the resident did not consume significant portions of the meals, including fortified foods intended to supplement her diet. The documentation inaccurately reflected that R93 consumed 75-100% of her fortified potatoes, which was not the case. R93's weight log showed a significant weight loss of 7.5% from March 2024 to June 2024, with a history of gradual weight loss over six months. The resident's care plan and physician orders included fortified foods and supplements to address her nutritional needs, but these were not effectively administered or documented. The Registered Dietician (RD) and Director of Nursing (DON) acknowledged the need for accurate documentation and the importance of offering alternatives and assistance to residents with significant weight loss. The facility's Nutrition Care Significant Weight Loss policy outlines the procedure for addressing significant weight loss, including assessment by a Licensed Dietician and discussion with the interdisciplinary team. However, the facility did not adhere to these procedures, as evidenced by the lack of proper meal assistance and inaccurate documentation of R93's food intake. The failure to provide necessary support and accurate documentation contributed to the resident's continued weight loss and nutritional decline.
Infection Control Deficiencies in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care for two residents. In the first instance, a Certified Nursing Assistant (CNA) was observed providing care to a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia and congestive heart failure. The CNA placed soiled linens on a chair instead of in a plastic bag and did not change gloves after handling the soiled items before assisting the resident with other tasks. This was contrary to the facility's policy, which requires soiled linens to be transported in closed impermeable bags and hand hygiene to be performed after contact with contaminated items. In the second instance, another resident with a history of type 2 diabetes, Parkinson's disease, and cellulitis, among other conditions, was observed during personal hygiene care. The CNA placed soiled items on the floor before eventually placing them in a clear plastic bag. The facility's policy mandates that soiled linen should not be placed on the floor to prevent cross-contamination. The Infection Preventionist confirmed that placing linen on the floor is against infection control practices, as it can lead to germs being spread throughout the facility.
Neglect Resulting in Resident Left in Urine for Hours
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, resulting in a resident lying in urine for hours, causing embarrassment and emotional distress. The resident, an elderly female with multiple diagnoses including acute cystitis, acute kidney failure, and obstructive sleep apnea, reported that on the night of the incident, she used her call light to request assistance to go to the bathroom. However, a staff member responded with a nasty remark and did not assist her, leaving her to wet herself. The resident felt afraid to ask for further help and was embarrassed by the situation. The next morning, a CNA found the resident and her bed saturated with urine and reported the incident to the administrator, describing it as neglectful care. Interviews with staff and the resident's daughter corroborated the resident's account. The daughter reported that the call light was moved out of the resident's reach, and the resident was told to urinate in her undergarment. The facility's investigation confirmed that the staff member involved was not always pleasant and had been let go due to poor performance. The facility's abuse policy defines neglect as the failure to provide necessary goods and services to avoid physical harm or mental anguish, which aligns with the events described in this incident.
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Illustrative
What surveyors actually found near you
We read the 266 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest City Rehab & Nrsg Ctr | 0.4 mi | ★★★★★ | 19 | 0 |
| Alden Park Strathmoor | 0.6 mi | ★★★★★ | 4 | 0 |
| The Citadel At Saint Anne Place | 2.2 mi | ★★★★★ | 8 | 0 |
| Pa Peterson At The Citadel | 3.2 mi | ★★★★★ | 4 | 0 |
| Fairhaven Christian Ret Center | 3.6 mi | ★★★★★ | 5 | 0 |
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