Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aliya Of Crestwood during CMS and state inspections, most recent first.
Failure to Monitor and Document Ileostomy Output: A resident with ostomy status developed abdominal pain and had no output in the ostomy pouch, but staff did not consistently empty, measure, or document the ileostomy output. An LPN noted severe pain and no fluids in the pouch, while the resident’s family later took the resident to the hospital, where the resident was diagnosed with a small bowel obstruction. The resident’s care plan did not reflect independent ostomy care or education about reporting pouch output.
A resident with repeated falls, cognitive impairment, incontinence, and impaired mobility was found unresponsive on the floor after an unwitnessed fall, with staff giving conflicting accounts of last checks, rounding, and call light use. CPR was delayed until after the resident was discovered, EMS found the resident pulseless, and hospital records documented severe traumatic injuries and death. The report also noted a separate failure to provide a working call light for another resident.
Insufficient staffing and delayed call light response led to a resident being found on the floor unresponsive after an unwitnessed fall. The resident had multiple fall-risk diagnoses, and his roommate reported hearing the fall around 4 AM and waiting about 2 hours for staff to respond after using the call light. Staff statements and the facility’s staffing assessment showed night shift coverage did not meet the identified RN/CNA ratios, and multiple nurses and CNAs reported that the workload was too heavy, medications were often late, and more staff were needed.
QAPI process not followed after resident death. A resident with bowel/bladder incontinence, impaired mobility, and wheelchair dependence was found on the floor, sent to the ER, and later died after hospital findings showed acute bilateral PE, cardiogenic shock/STEMI, and multiple injuries. Leadership gave conflicting accounts of the QAPI meeting, with no formal action plan, no audits, and no meeting minutes or related QAPI documentation provided to surveyors.
QAPI Failed to Identify Systemic Call Light and Staffing Deficiencies. The facility’s QAPI process did not identify a broken call light system, including failed audible alerts and no reliable nurse’s station notification, despite staff, leadership, and residents describing long waits and nonfunctioning alarms. QAPI also did not identify insufficient staffing, even though staffing levels were below averages, the facility assessment ratios were not being met, and staff and residents reported delayed meds, delayed care, and heavy assignments. The report also states QAPI failed to address repeated systemic issues with quality of care and incident review.
Failure to protect PHI during med pass: an LPN removed meds from individual sleeves that displayed residents’ names, medications, and dosing, then discarded the sleeves in the cart trash where the information remained visible. The LPN also left one resident’s EHR open and unlocked on the MAR while leaving the cart to get another medication. The DON confirmed the sleeves contained PHI and stated they should be disposed of in a shredder or other unreadable method.
A full code resident with multiple chronic conditions and high fall risk was found unresponsive on the floor with a head laceration and no pulse. Staff gave conflicting accounts of the response, and interviews showed poor BLS knowledge, including improper pulse assessment, uncertainty about assessing respirations, and incorrect CPR training knowledge. The ambulance record stated staff had begun CPR minutes before EMS arrival, and the resident was transported to the hospital after prolonged CPR and later died.
An LPN used the same unsanitized BP cuff/machine for multiple residents, placed it directly on the med cart without a barrier, and did not perform hand hygiene before or after BP checks or medication administration. The LPN also used an outdated isolation sign on a resident’s door despite no active isolation order. The DON confirmed reusable equipment should be sanitized between residents and hand hygiene should be performed before and after med pass tasks.
Improper Administration of Subcutaneous Epoetin Alfa Injection: An LPN administered Epoetin Alfa to a resident with CKD-related anemia at an approximately 15-degree angle into the abdomen, rather than following accepted SQ technique. The LPN was unsure of the correct angle, while the DON stated SQ injections should be given at a 90-degree angle with a skin pinch and the MD affirmed the medication is intended for SQ use. The facility’s SQ medication procedure directed a 45-degree angle, which the report stated did not meet current standards of practice.
A resident with multiple diagnoses, including cognitive communication deficit and low back pain, experienced repeated late medication administrations by several LPNs. MAR review showed delayed doses of insulin, metoprolol, gabapentin, apixaban, and lantus, with some doses given more than 2 hours late. LPNs said the delays were related to busy shifts, understaffing, call lights, and Wi-Fi/charting problems, while the DON stated medications should be given on time and charted immediately.
Nonfunctioning Call Light System and Resident Call Lights: The facility failed to maintain a working call system in resident bathrooms and bathing areas, and two residents had call lights that were not operating properly. Staff reported the system often had no audible alarm at the nurses’ station and required physically checking hall lights. One resident said the call light had been broken for weeks and reported repeated unanswered calls for help, while another resident with significant medical issues said the call light worked only intermittently and was observed with a disconnected electrical box missing a battery.
A resident with dementia and severe cognitive impairment received olanzapine/Zyprexa without documented schizophrenia or other qualifying indication, and the chart lacked target symptoms, behavior history, and non-pharmacologic interventions. MDSs and progress notes showed no agitation, hallucinations, or delusions, while the DON observed lip smacking and jaw movements consistent with tardive dyskinesia. The psych provider’s documentation was inconsistent, and the antipsychotic was continued despite no clear rationale.
Failure to Assess and Order Self-Administration of Medications: A resident with HTN, adult failure to thrive, and cognitive communication deficit had a BIMS score indicating severe cognitive impairment, yet staff did not assess him as able to self-administer meds, did not have a physician order, and did not care plan the process before leaving a med cup with 6 pills at his bedside. The resident said he did not know who placed the meds there, and the RN acknowledged she left them at the bedside even though the resident was not on self-administration.
Food was served dry, cold, overcooked, and unappetizing, with multiple cognitively intact residents reporting bland, tough, and poorly seasoned meals. Residents said concerns had been raised repeatedly through the resident council without change. During meal observation, the baked fish, peas, and rice did not match the recipe’s appetizing presentation, and a test tray reviewed by the Dietary Manager, Administrator, and RD showed desiccated fish and dry peas; the fish portion weighed 1.5 oz instead of the 3 oz recipe portion.
Dietary staff failed to follow policy for beard nets, glove use, and freezer labeling. The Dietary Director and a Dietary Aide were observed with beard guards under their chins until the surveyor entered, a staff member preparing food used the same gloves while handling multiple foods and touching multiple kitchen surfaces, and frozen vegetables were found in the freezer with no label or open date.
Staff failed to use required PPE during high-contact care for a resident on EBP, as a PTA and the DON entered the room wearing gloves only while assisting with a transfer, catheter bag positioning, and other hands-on care. The resident had an indwelling urinary catheter, diabetes, hypertension, and acute respiratory failure. The facility also observed soiled linen sent to laundry without being bagged and a laundry aide reusing an isolation gown in the dirty utility room, despite the director stating gowns are single use and PPE is required when handling dirty linen.
Damaged Dryer Lint Trap: Surveyors observed dryer #2 with a damaged lint screen and a large amount of lint. The HSK/Laundry Aide said lint traps were cleaned every two hours, while the Laundry Aide said the damaged trap had been reported to the Maintenance Director earlier. The Maintenance Director initially said he had just been informed, then later stated the dryer was taken out of service after the surveyor identified the issue.
The facility failed to ensure medications were administered and documented according to professional standards and facility policy. For multiple residents, audit reports showed that numerous scheduled morning medications were documented as given several hours after their scheduled times, while the RN responsible stated that medications were likely given on time but signed out later, contrary to the requirement to document immediately after administration. In a separate case, a newly admitted resident with COPD, anxiety, and other conditions did not receive ordered medications, including anxiolytics and respiratory treatments, during the entire first day after admission, despite the medication list and prescriptions being provided at admission and emergency stock containing some of the ordered drugs. Admission paperwork was delayed in reaching nursing staff, the MAR showed no administration entries for several ordered medications that day, and the facility could not produce a policy for ordering medications for new admissions.
Two residents at risk for falls experienced deficient safety measures when one cognitively intact, bed‑bound resident with spastic quadriplegia fell from a low air loss bed during ADL care after a CNA turned him onto a urine‑soaked, slippery mattress and tucked clean linens without first drying the surface, and another dependent resident with hemiplegia, morbid obesity, and prior documented falls was repeatedly observed in bed without the thick floor mat specified in the care plan, instead having no mat or only a thin mat despite being unable to adjust the bed independently. Additionally, surveyors twice observed unsecured, partially filled oxygen cylinders lying on the floor of a unit storage room while other cylinders were properly racked, and staff, including an LPN and the DON, acknowledged that oxygen tanks are required to be secured in racks to prevent tipping and combustion.
Expired medications were found in multiple medication carts during observation and interview. An LPN on the Hall A-1 cart, an LPN on the Hall D/B cart, and an LPN on the locked unit cart each confirmed that expired medications were still stored in the carts, including Zinc Oxide, Vitamin B, Famotidine, Loratadine, Vitamin A, Aspirin, and liquid Pink-Bismuth. The DON stated that expired medications are not supposed to be in the medication cart, and the facility policy required outdated drugs to be immediately withdrawn from stock.
Hospice staff were not oriented to or trained on facility policies and procedures for residents receiving hospice care. A hospice CNA transported a resident with dementia, anxiety, and a recent brain bleed in a wheelchair when the resident leaned forward and fell, resulting in a forehead laceration and hospital transfer. Interviews with the DON, hospice RN/Executive Director, Administrator, and CNA confirmed the hospice team did not receive facility training and relied on informal instruction from other hospice staff.
A shower room call light on B Wing Unit 2 was found nonfunctional when the pull string was tested, and the device came out of the wall and fell to the floor. A resident reported the shower room in the hall had not worked since admission and that residents had to use the other shower room. The Maintenance Director said he had not been notified before, and the DON said she was unaware the call light was not working; facility policy required defective call lights to be reported promptly.
Two residents experienced care issues when one newly admitted resident did not receive multiple ordered medications, including psychotropic and respiratory drugs, from the afternoon of admission until the following morning despite available orders and an emergency medication supply, and another resident’s witnessed fall from bed to the floor, observed by several CNAs and reportedly assessed on the floor by an LPN, was not documented as a fall in the record and did not result in an updated fall care plan, even though the resident later self‑reported the fall and head pain to nursing staff.
Uncovered Foley Drainage Bag and Care Plan Not Followed: A resident with severe cognitive impairment, neurogenic bladder, CKD, and an indwelling Foley had a care plan directing staff to keep the drainage bag covered to promote privacy. Surveyors observed the urinary drainage bag hanging uncovered from the bed frame with urine present in the bag, and an LPN acknowledged it was not covered. The DON stated that Foley bags should be covered to maintain dignity.
Failure to obtain informed consent for antipsychotic use: A resident with dementia, severe cognitive impairment, and multiple chronic conditions received olanzapine via G-tube for schizophrenia/dementia with psychosis, but the psychotropic consent form did not document the indication or diagnosis. The EHR included the black box warning for increased mortality with dementia-related psychosis, and the pharmacist confirmed the drug was being used off-label for dementia-related psychosis without documentation showing the resident’s representative was informed of the risks and benefits.
Inaccurate resident assessments and MDS coding were found for two residents. One resident’s restorative assessment incorrectly documented the resident as alert and oriented and having no falls, despite cognitive impairment and a recent fall with subdural hematoma. Another resident’s MDS failed to code routine antipsychotic use even though the MAR showed daily olanzapine and the MDS nurse confirmed the medication was being given for dementia-related psychosis.
Care plan did not accurately reflect a resident’s splint status or psychotropic indication. The resident’s record showed dementia with psychosis and severe cognitive impairment, but the care plan listed bilateral hand splints despite the L hand being too contracted for a splint and described olanzapine as treatment for schizophrenia with agitation/aggression, even though staff confirmed the medication was being used for dementia-related psychosis and the resident had no schizophrenia diagnosis or history of those target behaviors.
Incorrect Low Air Loss Mattress Setting: A resident with a history of pressure injuries and documented risk for pressure ulcers had a low air loss mattress ordered and in use, but staff observed the mattress set far above the resident’s actual weight. An LPN and the wound nurse confirmed the mattress should be set to the resident’s weight, and the DON stated the setting is important to avoid further skin breakdown and discomfort.
A resident with COPD, HTN, and OSA had an order for O2 at 2 L/min via NC PRN for SOB, but was observed in bed without the NC in place while the O2 concentrator was off. The NC was hanging on the side of the bed and not contained, and the resident stated she did not know who turned off the concentrator. The DON stated the NC should be stored in a clean plastic bag when not in use for infection control.
Failure to Daily Monitor and Log Resident Personal Refrigerator Temperatures: The facility did not consistently check and document the temperature of a resident’s personal refrigerator. A resident with diagnoses including depression, psychosis, and HTN had a fridge log with missing temperatures and initials on multiple days, despite a care plan noting the resident preferred a personal fridge and staff would assist with cleanliness. The facility policy required daily temperature logs and refrigerator temperatures between 33 and 40 degrees.
Incomplete Daily Staffing Posting: The facility failed to ensure the daily nurse staffing posting was current and included required information. A staffing sheet observed at the front desk was dated incorrectly and did not list the facility name or census. The receptionist said it had not yet been changed over, and the Administrator confirmed the posting was using the wrong form and lacked the required details.
The facility failed to complete an accurate facility assessment that reflected actual CNA staffing needs across shifts, including nights, where staffing was about 1:18 despite the assessment listing 1:12-1:13 for each shift. The assessment also omitted the facility’s recruitment and retention efforts and contingency staffing plans, even though the administrator and regional director confirmed those strategies existed outside the assessment.
A resident with epilepsy was admitted on multiple anti-seizure medications, but the evening doses of three ordered drugs were not administered because two were not available and one, although present in the dispensing system, was not given. The nurse did not document the missed doses on the MAR or notify the NP that the medications were unavailable and not administered, despite facility policy requiring notification and documentation when orders cannot be followed. The next morning, the resident experienced a seizure and was sent to the hospital.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a deficiency.
Multiple residents experienced significant medication errors due to staff failing to administer the correct dose or to provide scheduled medications on time. In one case, a resident was only given part of a prescribed antidepressant dose, while others missed doses of critical medications such as anticoagulants and hypoglycemics. These errors were confirmed through medication records and staff interviews, indicating a failure to follow established medication administration procedures.
Staff failed to follow medication administration procedures, resulting in a medication error rate above 5%. Errors included administering the wrong dose of Escitalopram, giving an enteric-coated Aspirin instead of the prescribed chewable form, and dispensing Calcium Carbonate and Lactobacillus without proper dose verification. Nurses did not consistently check orders or ensure the correct medication and dose before administration.
A resident who was cognitively intact but dependent on staff for toileting and repositioning was left soiled and saturated with urine for extended periods on multiple occasions. Staff confirmed that incontinence care was not provided in a timely manner, with call lights left unanswered and care intervals exceeding facility policy. The resident expressed distress and concern for safety due to these lapses.
Three high-risk residents with significant cognitive and physical impairments experienced multiple falls, including one resulting in a facial fracture and intracranial hemorrhage, due to staff failing to provide adequate supervision, not following care plan interventions such as two-person assistance and proper chair positioning, and not effectively modifying fall prevention strategies after repeated incidents.
A facility failed to provide a written notice and explanation for a room change to a resident's representative, as required by their policy. The resident's sister and POA reported not being informed about the room change, and the facility could not produce documentation of the notice. The policy mandates written notification and an explanation for room transfers.
A facility failed to report an allegation of abuse involving a resident with dementia. A visitor informed an RN that a CNA allegedly slapped the resident on the knee, but the RN did not report this to the DON or Administrator. Consequently, the DON was unaware of the incident until several days later. The facility's policy requires immediate reporting of such allegations, which was not followed, leading to a deficiency.
The facility failed to maintain the roof's integrity, leading to ceiling cracks and water collection in two residents' rooms. Additionally, there was a significant accumulation of dust in ventilatory outlets throughout the facility, with no cleaning schedule in place. The maintenance staff acknowledged the roof issue had persisted for three years, and the medical director highlighted the potential health risks of excessive dust for residents.
The facility failed to follow its policies for food storage, cleaning, and hand hygiene, affecting all residents receiving food. Observations revealed a foul odor in the cooler, unlabeled food items, and improper hand hygiene practices. The Registered Dietitian confirmed the importance of labeling food and maintaining hygiene, which was not adhered to, compromising food safety.
The facility failed to store and label insulin pens according to its pharmacy policy. Unopened insulin pens for two residents were not refrigerated, and an opened pen for another resident lacked an open and expiration date. LPNs acknowledged the oversight, and the DON stressed the importance of proper labeling for drug safety.
A facility failed to notify a resident's family about a newly acquired sacral wound in a timely manner, despite the resident being at high risk for skin breakdown. The wound care nurse noted the resident's decline in condition and the development of moisture-associated skin damage, but documentation of timely family notification was lacking. The facility's policy requires educating the resident's representative about pressure ulcer prevention and treatment.
A facility failed to follow its skin care prevention policy and develop a care plan for a resident at risk of skin breakdown. The resident, who was readmitted from a hospital stay, developed a facility-acquired MASD sacral wound due to fragile skin, loose stools, and moisture in briefs. Despite being dependent on all ADLs and unable to reposition themselves, the resident's care plan did not address the risk for skin integrity alteration or actual skin impairment.
A facility failed to follow its tube feeding policy by not checking a resident's G-tube for residual before administering medications and bolus feeding. An RN was observed administering medications and feeding without checking the G-tube for residual or placement, contrary to the facility's policy and the resident's physician order. Interviews with LPNs and the ADON confirmed the expectation to check for residual before such procedures.
A facility failed to follow its enteral tube medication administration policy and physician orders for a resident with a gastrostomy tube. An RN did not flush the tube with water between medications and omitted a scheduled dose of omeprazole, failing to inform the resident. The resident, with a history of gastric ulcer and esophageal obstruction, later reported stomach discomfort. The medication administration record inaccurately documented the administration of omeprazole.
A resident with multiple health conditions, including osteoarthritis and obesity, fell out of bed due to inadequate assistance during bed mobility. The CNA provided care alone, despite the resident's care plan requiring three-person assistance. This resulted in the resident sustaining a rib fracture, shoulder contusion, and knee sprain.
The facility failed to respond promptly to call lights, affecting four residents. A family member reported a 45-minute wait for assistance, while another resident waited three hours. Observations showed staff passing by an illuminated call light without responding. The facility's policy requires prompt response, which was not followed.
Failure to Monitor and Document Ileostomy Output
Penalty
Summary
The facility failed to follow the resident’s plan of care and accepted standards of practice for ostomy care by not monitoring, measuring, and documenting ileostomy output for one resident with ostomy status. The resident’s record showed diagnoses of colostomy status, and the care plan identified a potential risk for complications related to an altered elimination device, with interventions to check the device, monitor for complications, and provide ostomy care. The care plan did not reflect that the resident would independently care for the ileostomy, nor did it show education about independently caring for the site or informing staff of pouch output. On the day of the event, staff and family described the resident developing abdominal pain and having no output in the ostomy pouch. A CNA stated she did not empty the pouch during her shift and said the resident emptied her own bag. An LPN later stated she did not empty the pouch during her shift, assessed the resident’s abdomen, found no fluids in the ostomy bag, and heard the resident report no bowel movement for 2 to 3 days and severe pain. The LPN documented abdominal pain and refusal of treatment, but also stated she did not document the abdominal assessment or the finding of no fluids in the pouch. The resident’s family member reported that the resident complained of abdominal pain, was taken to the nurse station, and later went to the hospital by private vehicle after continued distress. The nurse practitioner stated staff should have monitored and documented ileostomy output and should have been informed of all details, including the severe pain and lack of pouch output. The physician stated the facility should have been monitoring and documenting ileostomy output. The resident was admitted to the hospital and diagnosed with a small bowel obstruction.
Failure to Supervise High-Fall-Risk Resident and Provide Timely Emergency Response
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences and goals, and failed to follow its own policies and protocols for two residents. One resident, R4, had a history of encephalopathy, generalized weakness, cognitive communication deficit, chronic kidney disease, seizures, repeated falls, impaired mobility, and incontinence. Records show R4 was assessed as high risk for falls, required assistance with ADLs and transfers, and had a care plan that included frequent rounding, call light access, proper footwear, and placement in a room with optimal visual access from the nurses’ station. Staff also documented that R4 was confused, impulsive, and frequently attempted to get up without assistance. On the night of the incident, staff last documented seeing R4 asleep in bed around 5:20 a.m., but the roommate reported hearing a fall around 4:00 to 4:30 a.m. and said no staff came for about two hours. When staff found R4, he was on the floor, unresponsive, with blood under his head and a laceration to the forehead. The ambulance record states staff reported beginning CPR only 5 to 10 minutes before EMS arrival, and the crew found R4 pulseless in asystole with blown, non-reactive pupils. Hospital records show R4 was admitted after an unwitnessed fall and cardiac arrest, required prolonged CPR, and later died from injuries associated with the fall, including hypoxic ischemic encephalopathy, a scalp/periorbital hematoma, an acute L1 fracture, an acute C7 fracture, and rib fractures. The record review and staff interviews also showed gaps in supervision and documentation. Staff gave conflicting accounts of when R4 was last seen and when the call light was activated, and there was no narrative incident note in the chart describing the fall. The RN stated R4’s room could not be directly seen from the nurses’ station and that R4 required increased supervision beyond what was being provided. The DON and other staff acknowledged that the room placement did not allow direct observation and that the facility did not have a system to ensure rounding was completed or documented timely. The report also identified a separate failure involving R25, for whom the facility failed to provide a working call light.
Insufficient Nursing Staffing and Delayed Response to Call Light
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, failed to staff in accordance with the staffing needs identified in its facility assessment, and failed to ensure staff were available to answer a call light when one resident used it to seek help for his roommate. The report states that these failures affected one resident involved in the event and had the potential to affect all 145 residents in the facility. The facility assessment identified staffing ratios of 1 licensed nurse to 20 residents in post-acute units, 1 licensed nurse to 25 residents in long-term care units, and 1 direct care staff member to 9 residents on night shift, but the facility was not staffing to those levels. On the night of the incident, the assignment sheet showed two RNs and two CNAs on floor 2, one CNA on the locked unit on floor 2, and multiple nurses and CNAs on floor 1. R4 had diagnoses including encephalopathy, generalized muscle weakness, muscle wasting/atrophy, cognitive communication deficit, chronic kidney disease, seizures, and repeated falls. His admission evaluation identified him as high risk for falls due to impaired memory/judgment, history of falls, multiple medical conditions, age over 75, and incontinence. His MDS documented cognitive impairment and partial to moderate assistance needs with activities of daily living. R4’s roommate, R6, stated he heard a boom around 4:00 AM and saw R4 on the floor with blood coming from his head. R6 said he pushed the call light and staff did not come for about 2 hours. The ambulance record states staff reported the event was unwitnessed, that R4 was found pulseless on the floor, and that CPR had begun only 5 to 10 minutes before EMS arrival. V9, the RN, said she last physically saw R4 around 5:20 AM, then later found him on the floor and unresponsive. V12, another RN, stated there was not enough staff and said the facility needed another nurse and another CNA for the second floor on night shift. Other staff and residents described delayed call light response, late medication administration, and staffing assignments that exceeded the staffing ratios identified in the facility assessment.
QAPI process not followed after resident death
Penalty
Summary
The facility failed to follow its QAPI plan and failed to make good faith attempts to correct known quality issues after a QAPI meeting was held in response to a resident’s death. The report states that the facility census was 145 residents. The QAPI plan required the governing body and executive leadership to ensure execution of the plan, required QAPI committee minutes to be documented and kept by Administration, and required the committee to use data sources, root cause analysis, and appropriate interventions to address adverse events and negative outcomes. The event involved R4, who was incontinent of bowel and bladder, had impaired mobility, required assistance with ADLs and transfers, and used a wheelchair as the primary source of transportation. R4 was found on the floor on his left side in front of the dresser, with urine-soiled brief and non-skid footwear on. He was last seen asleep in bed by the nurse at about 5:20 a.m. He was sent to the ER and later expired at the hospital. The report states that R4 had a history of CVA and that the collapse was determined to be secondary to acute bilateral pulmonary embolisms and cardiogenic shock/STEMI. The hospital findings included hypoxic ischemic encephalopathy, a laceration to the right forehead requiring staples and sutures, acute bilateral pulmonary emboli with right heart strain, acute L1 vertebral fracture, acute nondisplaced right anterior rib fractures 3-6, and an acute C7-T1 fracture. After the incident, staff and leadership gave conflicting accounts of the QAPI process. V1 stated a QAPI meeting was held the same day and that the committee reviewed interviews, the chart, and risk factors, identifying issues such as R4’s room not being close enough to the nurse’s station and the need for return demonstrations of code status. However, V1 also stated no action plan or formal action was completed, no audits were developed, and no other residents at risk were identified. V2 stated a QAPI meeting occurred with V1 and V40, but V2 also said V40 was not present for later QAPI meetings and that audits were made and staff were in-serviced. V40 stated being aware of the incident and R4’s death, but denied being involved in a QAPI meeting that day. The Medical Director stated he was not aware of the incident until later, said no QAPI meeting had been done for the incident, and reported he had not been involved in the root cause analysis. The surveyor requested QAPI documentation, but only the QAPI plan was provided; no meeting minutes, audit tools, or related documentation were provided to the survey team prior to exit.
QAPI Failed to Identify Systemic Call Light and Staffing Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI committee monitored systemic compliance and identified multiple deficient practices involving quality of care, a malfunctioning call light system, insufficient staffing, and root cause analysis of incident investigation and reporting. The report states that these failures affected all 145 residents in the facility. The facility also had a repeated history of non-compliance involving professional standards of care, quality of care, functioning call lights, and infection control, and the QAPI process did not correct those repeated issues. Survey findings showed the call light system had been in disrepair, including problems with the audible alarm and the nurse’s station notification system. Staff described that the call lights often did not sound, the nurse’s station did not clearly show which call lights were activated, and the television display used for call lights had not worked for more than two months. The maintenance director later identified a bad relay in the main control box and stated the wiring had to be repaired so the call light would illuminate near the nurse’s station and the audible sound could be heard. A cognitively intact resident stated the call light was "no use," reported waiting over an hour for response, and said staff could not hear or see the call lights when activated. The administrator, DON, medical director, and other staff members acknowledged the system problems, but the QAPI committee minutes and call light logs did not document identification of the overall system failure before the survey exit. The facility also had insufficient staffing concerns that were not identified by QAPI. The facility’s Care Compare staffing rating was 1 star, with staffing levels below state and national averages for RN, LPN, and nurse aide hours per resident day, including weekends. The facility assessment listed staffing ratios that were not being met, and the administrator acknowledged that the night shift would require 16 CNAs to meet the stated ratio while only 10 were scheduled. Staff described assignments that were too large, including one nurse responsible for 34 residents, and reported difficulty completing medication passes, blood sugar checks, charting, and timely care. Residents reported long waits for call lights, late medications, and delayed incontinence care, while the administrator and DON both denied that insufficient staffing had been reviewed or identified by QAPI prior to the survey.
Failure to Protect PHI During Medication Pass
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential and failed to dispose of protected health information in a manner that rendered it unreadable, indecipherable, and otherwise unreconstructable. During medication administration observation on 5/20/2026, V35 (LPN) removed medications for multiple residents from the medication cart, opened individual plastic sleeves containing each resident’s name, medication, and dosing information, placed the medications into a cup, and discarded the sleeves into the cart’s garbage receptacle. The discarded sleeves for R14, R18, R17, R19, and R16 were observed in the trash with the residents’ identifying and medication information visible. R14’s face sheet documented diagnoses including type 2 diabetes mellitus, morbid obesity, cardiomegaly, COPD, atopic dermatitis, spinal stenosis, chronic diastolic heart failure, atrial fibrillation, hypothyroidism, fibromyalgia, major depressive disorder, and anxiety disorder. R18’s diagnoses included non-traumatic intracerebral hemorrhage, type 2 diabetes mellitus, morbid obesity, hemiplegia of unaffected side, basal cell carcinoma, atopic dermatitis, chronic pain syndrome, atrial fibrillation, and hypertension. R17’s diagnoses included Ogilvie syndrome, moderate protein calorie malnutrition, anemia, enterocolitis due to clostridium difficile, acute kidney failure, cachexia, hypoxemia, major depressive disorder, anxiety disorder, and unspecified psychosis. R19’s diagnoses included COPD, muscle wasting and atrophy, multiple sclerosis, type 2 diabetes mellitus, quadriplegia, osteoarthritis, and metabolic encephalopathy. R16’s diagnoses included systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, acquired absence of both legs, and osteoarthritis. During the same observation, V35 accessed R16’s electronic health record and then left the medication cart with the record open and unlocked on the MAR while going to obtain another medication from the refrigerator, allowing passerby access to resident PHI. V35 confirmed the record should be closed when not in use and stated that the sleeves are typically tied and placed in the garbage can, adding that all nurses do this. V35 also denied that staff ensure the information on the sleeves is unreadable, indecipherable, or otherwise unreconstructable when disposing of them. The DON later confirmed the sleeves contain PHI and stated they should be disposed of in a shredder or by another method that prevents the resident’s health information from being read or reproduced.
Delayed CPR Response and Inadequate BLS Performance
Penalty
Summary
The facility failed to ensure staff were trained properly on CPR and failed to ensure appropriate emergency response when a full code resident was found unresponsive on the floor. The resident had diagnoses including encephalopathy, generalized muscle weakness, muscle wasting/atrophy, cognitive communication deficit, chronic kidney disease, seizures, and repeated falls. The resident’s assessment identified high fall risk, impaired memory and judgment, and full code status. The resident’s change-in-condition documentation stated that the resident was found unresponsive with a laceration to the left forehead, and blood pressure and pulse were zero. Record review and interviews showed conflicting accounts of the response. The ambulance run sheet documented that staff said they began CPR 5 to 10 minutes before EMS arrival and that the resident was found pulseless after an unwitnessed fall. The roommate stated he heard a fall around 4:00 AM to 4:30 AM and later told the surveyor that staff did not come for about 2 hours. The RN gave differing statements about when the resident was last seen, when the resident was found, and whether CPR was started immediately. One RN interview stated CPR was initiated after the resident was found unresponsive and that 911 was called by the supervisor; another interview stated the RN assessed the resident, could not find a pulse, screamed for help, called an LPN to call a code, and went to get the crash cart. The surveyor’s interviews with the supervisor and other staff showed that staff did not demonstrate correct basic life support knowledge. The supervisor stated the pulse should be checked by palpating the carotid artery, but when asked how to assess respirations, the supervisor could not explain. The supervisor also stated a pulse oximeter was used instead of palpating the carotid artery. The RN stated the last CPR training was about a year earlier. An LPN stated CPR training occurred that day but answered that the compression-to-breath ratio was 20:2 instead of 30:2. The medical director stated that delay in assessing the resident was a big issue and that CPR should start immediately without interruption. The resident was transported to the hospital after prolonged CPR and later died.
Infection Control Failures During Medication Pass
Penalty
Summary
The facility failed to adequately sanitize reusable durable medical equipment between resident use, failed to perform hand hygiene before preparing and administering medications, and failed to have accurate signage posted for isolation precautions. During observation of a medication pass, an LPN removed an automatic wrist blood pressure machine from the medication cart and used it to obtain blood pressures for multiple residents, including residents with diagnoses such as diabetes, obesity, COPD, atrial fibrillation, intracerebral hemorrhage, hemiplegia, malnutrition, anemia, acute kidney failure, cachexia, and multiple sclerosis. The blood pressure cuff/machine was not sanitized before or after use with each resident, and it was placed directly on the top of the medication cart without a barrier, contaminating the preparation area. The medication cart itself was not sanitized after the cuff was placed on it. The same LPN did not complete hand hygiene after obtaining blood pressure readings, after placing medications in a medication cup, or before entering residents’ rooms to administer medications. The LPN withdrew medications from the cart and administered them to residents without hand hygiene before administration. The LPN stated the blood pressure cuff was typically sanitized only after 3-4 residents because residents complained the cuff caused itching or skin breakouts when sanitized between each use. The DON stated nursing staff should sanitize durable, multi-use medical equipment between each resident and perform hand hygiene before and after medication administration and care. For one resident, a contact isolation sign with PPE was posted on the door even though there was no active physician order for contact isolation. The LPN stated the sign was old and should have been removed because the resident had not been on isolation in months. The DON confirmed the resident did not have active isolation orders and stated the sign should have been enhanced barrier precautions. Facility policies on disinfecting reusable equipment, medication administration, and infection control were cited in the record review.
Improper Administration of Subcutaneous Epoetin Alfa Injection
Penalty
Summary
The facility failed to administer a subcutaneous injection in accordance with its procedure and professional standards for one resident receiving Epoetin Alfa for anemia related to chronic kidney disease. The resident had multiple diagnoses including systemic lupus erythematosus, osteomyelitis, type 2 diabetes mellitus, anemia in chronic kidney disease, obesity, sickle cell disease, chronic kidney disease, bilateral leg amputations, and osteoarthritis. The resident’s MDS documented cognitive intactness, and the care plan identified renal failure due to CKD and altered hematological status with interventions to give medications as ordered by the physician. The physician ordered Epoetin Alfa 3000 units subcutaneously every Monday, Wednesday, and Friday. During observation, an LPN drew up the Epoetin Alfa and administered it into the resident’s lower right abdomen after cleansing the site. The LPN held the syringe at approximately a 15-degree angle and injected the medication flush to the resident’s skin. The LPN later recalled giving the injection at a 15-30 degree angle and was unsure what angle subcutaneous injections should be given, stating, "maybe 5-10 degrees?" The DON stated subcutaneous injections need to be administered at a 90-degree angle with a skin pinch, and the Medical Director affirmed Epoetin Alfa is given subcutaneously and staff should inject medications in accordance with professional standards. The facility’s subcutaneous medication administration procedure directed staff to insert the needle at a 45-degree angle, which the report stated did not meet current standards of practice.
Significant Medication Administration Delays
Penalty
Summary
The facility failed to follow its medication administration policy and failed to ensure a resident was free from significant medication errors. The resident had diagnoses including abnormalities of gait, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, and low back pain. The resident’s BIMS score was 15, indicating cognitive intactness, and the resident was later admitted to the hospital with chest pain. Record review of the resident’s MAR showed multiple late medication administrations by several LPNs. On one date, Metoprolol Succinate ER was given 2 hours and 15 minutes late, and Gabapentin and Apixaban were given 1 hour and 16 minutes late. On another date, Metoprolol Succinate ER was given 1 hour and 5 minutes late. Additional MAR review showed late administration of Insulin Aspart Injection, Metoprolol Succinate ER, Gabapentin, Apixaban, and Lantus on several other dates, with delays ranging from 49 minutes to 2 hours and 35 minutes. During interviews, the LPNs stated medications were sometimes passed late because the unit was busy, understaffed, call lights and resident needs took priority, and the Wi-Fi was unreliable, preventing timely computer charting. One LPN said the facility could use more help, another said staffing had been reduced from three nurses to two, and another said the workload was hectic and medications may be a little late. The DON stated that if staff could not chart in the computer, they should use paper charting until the system came back up, that medications should be given on time, and that staff should let others know if they needed help. The facility policy required medications to be administered safely and appropriately at the proper time, and the physician orders policy required time or frequency of administration to be followed.
Nonfunctioning Call Light System and Resident Call Lights
Penalty
Summary
The facility failed to ensure a working call system was available in resident bathrooms and bathing areas, and failed to ensure two residents’ call lights were working properly. Staff interviews showed the call light system was unreliable and often had no audible sound at the nurses’ station, requiring staff to physically look for activated lights. A unit manager and other staff stated there was no panel or other system to notify staff of an activated call light other than a light outside the resident’s door, and staff described long-standing problems with the system, including periods when the television display used for call lights was not functioning. Resident R17 reported that the call light had not been working for about two weeks and said the front desk telephone number had been provided so the resident could call from a cell phone for help. Surveyors tested R17’s call light and the call light for the empty bed in the room and verified neither was operational. R17 stated that after needing brief changes for severe diarrhea, calls to the front were repeatedly answered and hung up, and the resident reported remaining in diarrhea for hours until help arrived. The maintenance director later stated there was a bad relay in the main control box that prevented the signal from turning on the light near the nurses’ station. Resident R25, who had diagnoses including blindness in the right eye, paralytic syndrome, neuromuscular dysfunction, and epilepsy, was observed with a call light and electrical box that were not working, not attached to the wall, and missing a required battery. R25, who was cognitively intact with a BIMS score of 13 and used a motorized wheelchair, stated the call light sometimes worked and sometimes did not. Staff interviews after the observation confirmed that the call lights were easier to hear only after the system began sounding again, and multiple staff described that previously they had to search the halls to see whether any resident’s light was on.
Unnecessary antipsychotic use without adequate indication or target symptoms
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary antipsychotic medication use, failed to ensure the antipsychotic was prescribed with an adequate indication, and failed to document or identify targeted symptoms for the antipsychotic use. The resident had diagnoses including dementia with psychotic disturbance, severe intellectual disabilities, anxiety, depression, epilepsy, dysphagia, tremors, and muscle weakness, but the record did not show schizophrenia, schizoaffective disorder, or another qualifying serious mental illness. The resident’s MDS assessments repeatedly documented no behaviors, hallucinations, or delusions in the lookback periods, and the resident was described in progress notes as calm and cooperative. The resident was observed sitting calmly in a wheelchair when involuntary lip smacking and jaw movements were noted. The DON confirmed the movements appeared to be tardive dyskinesia and acknowledged the resident was receiving an antipsychotic. The resident had been receiving olanzapine/Zyprexa after a hospital stay, but the hospital records did not explain why it was ordered. The facility’s psychotropic medication assessments were inconsistent and incomplete, at times listing schizophrenia as the indication, at other times listing dementia with psychosis, and often failing to identify target symptoms or non-pharmacological interventions. The care plan also listed psychotropic medication use for schizophrenia with agitation or aggression as target behaviors, but the record did not show those behaviors in the resident’s chart. The psychiatric provider documented that the resident had a history of schizophrenia and later schizoaffective disorder, but there was no DSM-V-based documentation supporting those diagnoses in the notes. The provider also stated the resident was non-verbal and could not report the symptoms needed to diagnose schizophrenia, yet the diagnosis was added because it was seen in the chart and reportedly from family history. The provider and DON acknowledged the resident had no documented aggression, agitation, hallucinations, or delusions, and the provider stated the medication had been continued because of concern the resident would worsen. The record also showed the resident developed extrapyramidal symptoms/tardive dyskinesia while receiving olanzapine, and the black box warning for increased mortality in elderly patients with dementia-related psychosis was present in the chart.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident’s ability to safely self-administer medications, failed to obtain a physician’s order for self-administration, and failed to care plan self-administration before allowing it to occur. The resident involved had diagnoses including hypertension, adult failure to thrive, and cognitive communication deficit, and the MDS documented a BIMS score of 6, indicating severe cognitive impairment. The resident’s self-administration assessment documented that he did not want to self-administer medications, had severely impaired decision-making ability, could not name the dosage, frequency, or reason for each medication, and could not tell time or state when medications were due. Despite these findings, a med cup containing 6 pills was observed on the resident’s bedside table while the assessment was being completed. The resident stated he did not know who placed the medications there. The RN later stated she had left the medications at the bedside and was supposed to make sure he took them before leaving the room. The DON stated the resident was not on self-administration of medication, had a low BIMS score, and that self-administration requires a physician order, care planning, and the ability to complete a return demonstration and explain the indication and schedule for each medication. The facility’s policy stated self-administration is determined by the interdisciplinary team and requires nursing evaluation and care planning.
Food Served Dry, Cold, and Unappetizing
Penalty
Summary
The facility failed to prepare food that was palatable, attractive, and served in a manner that conserved nutritive value, flavor, and appearance for the residents who ate from the kitchen. The report states that 139 residents consumed food from the kitchen, and multiple cognitively intact residents complained that the food was cold, overcooked, bland, dry, tough, or otherwise unappetizing. R17 said the vegetables were overcooked and that there was no taste, while R104 reported that much of the food was not edible, some items were unrecognizable, the food was cold, and the meat was like cardboard. R132 described the food as awful, always cold and tough, and said the facility barely gave enough food on the plate. R5 stated that the food was terrible, including a French toast casserole that tasted horrible, and said the food was overcooked and under seasoned. At a resident council meeting, 14 residents unanimously agreed they had concerns about the food, including that it was cold and unseasoned, and said these concerns had already been brought to the facility without change. During observation of the lunch meal, the baked fish, peas, and rice with cheese did not match the appetizing presentation shown on the recipe. R27’s fish appeared dry and whitish, and R27 said it was warm but dry and bland, then asked another resident for barbeque sauce to add moisture. R155’s fish appeared dry and hard, the peas looked dull green, and R155 said the food was terrible, dry, and tasteless. A test tray observed with the Dietary Manager, Administrator, and Registered Dietitian showed the fish appeared desiccated, overbaked, and tough, the peas appeared dry, and the tray was not considered palatable or appetizing by those who observed it. The fish portion on the test tray weighed 1.5 oz even though the recipe indicated a 3 oz portion, and the Dietary Manager stated the fillets had cooked down and were not weighed before serving.
Dietary Staff Failed to Follow Beard Net, Glove, and Food Labeling Requirements
Penalty
Summary
The facility failed to follow its dietary policies related to beard nets, glove use, and freezer labeling. On 04/20/2026 at 10:48 AM, the Dietary Director was observed in the kitchen with a beard and the beard guard positioned under his chin; he pulled it up only when the surveyor entered. Later that same day at 10:51 AM, two packages of frozen peppers and onions were observed in the walk-in freezer with no label or open date, and the Dietary Director stated they should have been labeled and dated separately. On 04/21/2026 at 9:51 AM, the Dietary Director and a Dietary Aide were again observed wearing beard guards under their chins and pulled them up when the surveyor entered the kitchen. At 11:00 AM, a staff member preparing grilled cheese sandwiches and burgers donned gloves, handled bread and cheese, placed items in a pan, turned sandwiches with her hands, then used the same gloves to handle frozen beef patties and touch multiple surfaces and objects in the kitchen. On 04/22/2026 at 10:38 AM, the Dietary Manager stated that beard guards should be put on when entering the kitchen and that gloves should be removed and changed with hand washing between each task to prevent cross contamination.
PPE and Linen Handling Failures During Resident Care and Laundry Activities
Penalty
Summary
The facility failed to ensure staff used appropriate PPE during high-contact care for a resident on Enhanced Barrier Precautions (EBP). On 04/20/2026, a Physical Therapy Assistant entered the resident’s room wearing gloves only and assisted the resident with putting on a knee brace, positioning a walker, hanging the resident’s indwelling catheter bag on the walker, touching the resident’s hand, placing a gait belt, and helping the resident transfer from the bed to a wheelchair without a gown. The Director of Rehab also entered the room wearing gloves only. The Unit 2 Supervisor later stated the staff should have been wearing gown and gloves during the transfer to protect the resident, and the Physical Therapy Assistant stated she was supposed to wear gown and gloves if a resident is on EBP, but said there was no sign posted on the door. The EBP sign was documented as being posted close to the resident’s door frame, and the DON confirmed the resident was on EBP because he had an indwelling urinary catheter. The resident involved had diagnoses including Type 2 Diabetes Mellitus, hypertension, and acute respiratory failure. The resident’s record showed an active order for urinary catheter care and a care plan noting the need for an indwelling catheter related to neurogenic bladder. The resident’s MDS documented a BIMS score of 15, indicating cognitively intact status. The facility’s EBP documentation stated that gowns and gloves are required during high-contact resident care activities, including transferring, for residents with indwelling medical devices. The facility also failed to follow its linen-handling and PPE practices in the laundry area. Soiled linen was observed in the laundry chute and dirty laundry receiving bin without being placed in a plastic bag, and the Housekeeping & Laundry Director stated soiled linen should be sent to the laundry room in a plastic bag to prevent contact and cross contamination. In the dirty utility room, an isolation gown was observed hanging on a hook behind the door, and the Housekeeping & Laundry Director stated isolation gowns are not to be reused. A Laundry Aide then put on that same gown and stated it was the second time that day she had used it and that she usually uses gowns once or twice before changing them, while the Housekeeping/Laundry Director stated staff should use a new gown each time and wear a gown and gloves when working with dirty linen.
Damaged Dryer Lint Trap
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not ensuring dryer lint traps were clean and undamaged. During observation, surveyors and the Housekeeping/Laundry Director saw dryer number two with a damaged lint screen and a large amount of lint. The Housekeeping/Laundry Aide stated lint traps were cleaned every two hours, and the Laundry Aide reported that the damaged lint trap had been told to the Maintenance Director at least a week earlier, while the Laundry Aide later stated it had been reported the day before or the day before that. The Maintenance Director initially stated he had just been informed that day and that no one had reported it before then. The Maintenance Director later stated the dryer was taken out of service after the surveyor identified the damaged lint trap and explained that the lint trap prevents lint from going into the exhaust and outside into the environment.
Failure to Timely Administer and Document Medications and to Provide Medications for a New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were ordered, administered, and documented in accordance with professional standards and facility policy. For 12 residents, medication administration records (MARs) and Medication Admin Audit Reports dated 4/22/26 showed that multiple scheduled morning medications on 4/08/26 were documented as given several hours after their scheduled times. Examples include medications due at 7:00am, 8:00am, and 9:00am being recorded as administered between late morning and late afternoon, with delays ranging from approximately 1.5 hours to over 8 hours. The medications involved included, among others, Docusate Sodium, Hydroxyzine, Levetiracetam, Furosemide, Loratadine, Gabapentin, Aspirin, calcium supplements, Nabumetone, Polyethylene Glycol, Magnesium Oxide, Eliquis, Memantine, Sucralfate, Amlodipine, Losartan, Carvedilol, Plavix, Tizanidine, Famotidine, Pyridoxine, Thiamine, Dapagliflozin, Protonix, Lexapro, Hydralazine, Ferrous Sulfate, Metformin, Baclofen, multivitamins, Cholecalciferol, Enalapril, Coreg, Lasix, Depakote, Duloxetine, and Centrum. On interview, the RN assigned to these residents for the 7:00am–3:00pm shift on 4/08/26 acknowledged responsibility for administering their medications. The RN stated a belief that the medications had been given on time but admitted to signing them out on the MAR later than when they were actually administered, explaining that it was the first day off orientation and the focus had been on getting all medications passed out on time. The RN also acknowledged that the expectation is to sign off medications immediately after administration. The facility’s Medication Administration policy, dated 2/2026, requires staff to verify the right medication, dose, route, resident, and time, to verify that medications are administered at the proper time, and to document each medication on the MAR as it is prepared and given, including remaining with the resident to ensure the medication is swallowed and documenting reasons if a medication is not given as ordered. A separate deficiency involved a newly admitted resident who did not receive ordered medications on the day of admission. This resident, with a history including COPD, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, hypothyroidism, and other conditions, was admitted alert and oriented and able to communicate needs. The resident and her daughter reported that no medications were received from the time of admission in the afternoon until the following morning, including anxiety medication and breathing treatments, and that the resident was upset and awake all night while the nurse reportedly stated she was working on the medications. Review of the MAR showed that several medications, including Mirtazapine scheduled at 2100, Ativan every 8 hours for anxiety, Ipratropium-albuterol for wheezing, Lomotil for diarrhea, and Albuterol inhaler as needed for wheezing, were not signed out as given on the admission date. Staff interviews and document review showed that the admission paperwork, including the medication list and five prescriptions, was brought in by the resident’s daughter and given to the admissions staff, scanned into the system, but not promptly forwarded to the nursing unit. The Admissions Director stated that the documents were scanned and that there was a delay before they were provided to nursing when requested. The DON stated that for new admissions, the nurse is supposed to send the medication list to the pharmacy after verifying medications with the physician and clarifying the expected time of arrival, and if medications do not arrive on time, the nurse is to obtain medications from the emergency box. The emergency medication list included Ativan, Ipratropium-albuterol, and Albuterol inhaler, which were among the resident’s ordered medications. The facility was unable to provide a policy on ordering medications for new admissions, and attempts by the surveyor to contact the afternoon and night shift nurses assigned to the resident on the admission date were unsuccessful.
Failure to Implement Fall-Prevention Measures and Secure Oxygen Cylinders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and individualized fall‑prevention interventions for residents at risk for falls, as well as failure to properly secure oxygen cylinders. One cognitively intact resident with spastic quadriplegia, diabetes, hypertension, and an indwelling urinary catheter was identified as dependent for rolling in bed and at risk for falls, skin complications, and delayed wound healing. During provision of ADL care, a CNA raised the head of the resident’s bed to about 75 degrees and began a bed bath and linen change after discovering the mattress and sheet were wet from a leaking indwelling catheter. The CNA turned the resident onto his left side toward the window and tucked clean linen under him while the low air loss mattress remained wet with urine; the resident then slipped and fell between the bed and the window onto the floor. The CNA later acknowledged that the wet low air loss mattress was slippery and that she should have dried the mattress before turning the resident and tucking linen, and both another CNA and the DON stated it was not expected for a resident to fall during ADL care and that residents should not be rolled on a wet mattress. Another resident with multiple comorbidities including cerebral infarction, hemiplegia, pneumonia, oxygen dependence, kidney disorder, type 2 diabetes, hyperlipidemia, and morbid obesity, and who was on hospice and Enhanced Barrier Precautions, was also affected by deficient fall‑prevention practices. This resident was alert and oriented to person with a low BIMS score, required a Hoyer lift with two‑person assistance, and was unable to raise or lower the bed independently. Observations on multiple occasions showed the resident in bed without the thick floor mat that was care‑planned as a fall‑prevention intervention, despite documentation that the resident had experienced two falls, one in which he was found on the floor after trying to reach the bed remote and reported hitting his head and having bilateral lower extremity pain, and another in which he was again found on the floor on the right side of the bed. Although two thick mattresses were initially observed by the resident’s door and one was reportedly intended for this resident, they were removed, and only a thin floor mat was later observed in the room, contrary to the care plan specifying a mattress. In addition to fall‑related issues, the facility failed to ensure that oxygen cylinders were stored securely in accordance with its own policies and referenced standards. On the C Wing Unit 2 storage room, surveyors twice observed two partially filled oxygen tanks lying unsecured on the floor while seven other tanks were properly secured in racks. A housekeeping aide and an LPN each acknowledged that the unsecured tanks should be in the rack, with the housekeeping aide stating the need to avoid things exploding and the LPN stating the tanks should be in racks so they do not tip over and explode. The DON later confirmed that oxygen tanks should be on a rack so they are secured and protected from combustion, consistent with facility policy requiring oxygen cylinders to be stored in designated areas and protected from mechanical shock and falling objects.
Expired Medications Found in Medication Carts
Penalty
Summary
Expired medications were found in medication storage carts during observation, interview, and record review. On 04/20/2026 at 1:17 PM, the Hall A-1 cart was checked with an LPN and contained one bottle each of Zinc Oxide 50 mg with an expiration date of 11/2025, Vitamin B tablets with an expiration date of 12/12/2025, Famotidine 20 mg with an expiration date of 2/2026, Loratadine 10 mg with an expiration date of 02/2025, and Vitamin A 2400 mcg with an expiration date of 9/2025. The LPN acknowledged the medications were expired and stated that pharmacy usually checks the carts, but was not sure how the medications remained in the cart. On 04/20/2026 at 2:05 PM, the Hall D/B cart was checked with another LPN and contained one bottle of Aspirin 81 mg with an expiration date of 3/2026 and one bottle of liquid Pink-Bismuth with an expiration date of 3/2026 and an open date of 4/8/26; the LPN confirmed the medications were expired and stated she did not know how the liquid Pink-Bismuth had an open date when it was expired. On 04/20/2026 at 2:30 PM, the locked unit medication cart was checked with a third LPN and contained one unopened bottle of liquid Pink-Bismuth with an expiration date of 2/2026; the LPN confirmed it was expired and stated she did not know why it was still in the cart. On 4/22/2026 at 2:07 PM, the DON stated that expired medications are not supposed to be in the medication cart. The medication storage policy revised 2/2026 stated that outdated drugs are to be immediately withdrawn from stock and disposed of according to drug disposal procedures.
Hospice Staff Not Oriented to Facility Policies
Penalty
Summary
The facility failed to ensure that hospice staff received appropriate orientation and demonstrated competency regarding the facility's policies and procedures for residents receiving hospice care. The report states that 14 residents were receiving hospice services at the facility, and that no documentation was available showing hospice staff had been trained or in-serviced on the facility's policies and procedures. Facility leadership, including the DON, hospice RN/Executive Director, and Administrator, stated that hospice staff did not receive training from the facility. The event described involved a resident admitted with diagnoses including traumatic subdural hemorrhage, generalized anxiety disorder, cerebral ischemia, bilateral primary osteoarthritis, contusion of scalp, unspecified fall, and unspecified dementia. The resident's BIMS score was 99, indicating inability to complete the interview, and the MDS documented moderately impaired cognitive skills for daily decision making. The care plan identified the resident as high risk for falls and also noted hospice care with coordination of services between facility caregivers and the hospice company. According to the investigation, a hospice CNA was transporting the resident in a wheelchair to the shower room when the resident became anxious, leaned forward, attempted to stand, and fell out of the wheelchair. The resident sustained a fall requiring 911 to be called and transfer to the hospital, where a right forehead laceration was treated with 6 sutures. Interviews showed the hospice CNA had not received facility training and relied on other hospice staff for instruction, while the hospice RN/Executive Director confirmed hospice staff did not receive training from the facility.
Nonfunctional Shower Room Call Light
Penalty
Summary
The facility failed to ensure that a working call system was available in a shower room on B Wing Unit 2. During observation, the call light in that shower room was found to be non-functional when the string was pulled, and the entire call light device came out of the wall and fell to the floor. A housekeeping aide stated the light was not going on and that the issue was bad, then said maintenance would be notified. The deficiency affected 31 residents, including all 14 residents on B Wing Unit 2 and 17 residents on C Wing Unit 2. A resident on B Wing Unit 2 reported that the shower room in the resident’s hall did not work and had not worked since admission, and that residents had to walk to the other shower room because of the problem. The resident’s record showed an admission date of 2/13/26, diagnoses including chest pain, aortocoronary bypass, and hernia, and a BIMS score of 15, indicating cognitive intactness. The Maintenance Director stated no report had been made to fix the B Wing Unit 2 shower room call light and that 4/20/26 was the first and only time he was made aware of the issue. The DON stated she was not aware the shower room call light was not working and said call lights should be answered timely; the facility policy required defective call lights to be reported promptly.
Failure to Provide Timely Admission Medications and to Document Witnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received ordered medications upon admission and the failure to document a witnessed fall in another resident’s electronic health record. Resident R156, with a history including COPD, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, hypothyroidism, noninfective gastroenteritis, and chest pain, was admitted on 4/20/2026 between approximately 1:30 PM and 2:00 PM. The after-visit summary and scanned admission documents listed multiple medications, including gabapentin, ipratropium‑albuterol nebulizer, mirtazapine, albuterol inhaler, amlodipine‑benazepril, diphenoxylate‑atropine (Lomotil), levothyroxine, montelukast, pantoprazole, Trelegy Ellipta, nicotine patches, and thiamine. Despite this, the medication administration record showed that on 4/20/2026, mirtazapine, Ativan 1 mg every 8 hours for anxiety, ipratropium‑albuterol nebulizer, Lomotil, and albuterol inhaler were not signed out as given. On 4/21/2026, R156 and her daughter reported that the resident did not receive any medications from the time of admission the previous afternoon until the morning of 4/21/2026. R156 stated she was upset, was awake all night, and did not receive her anxiety medication or breathing treatment, and that the nurse on duty repeatedly told her she was working on the medications. The daughter stated she had handed the hospital medication list to the social worker on arrival and did not understand why medications were not provided on time. LPN V25 reported that R156 arrived around 2:00 PM, that she took initial vital signs and handed the resident off to the afternoon nurse, and that the medication list was not available at that time. V25 stated some medications were in the cart the following morning and that she was unsure why the 6:00 AM medications had not been given, but she administered them within the allowable time window. The Admissions Director (V44) stated that R156 arrived around 2:00 PM with paperwork including a medication list and five prescriptions, and that these documents were scanned into the system at 4:00 PM. V44 reported that the front desk failed to return the paperwork to the person transporting the resident to the unit and that the documents were given to nursing staff when they requested them. The DON (V2) stated that for new admissions, the nurse is supposed to send the medication list to the pharmacy after verifying medications with the physician and clarifying the expected time of arrival, and that if medications do not arrive on time, nurses are to use the emergency box, which contains Ativan, ipratropium‑albuterol, and albuterol. The facility was unable to provide a policy on ordering medications for new admissions when requested. The deficiency also includes the facility’s failure to document a witnessed fall for Resident R8. R8, who has diagnoses including type 2 diabetes mellitus, hypertension, and spastic quadriplegia, reported that on 3/16/2026 a CNA (later identified as V40) was changing him, placed him on his side facing the window, and that he then ended up on the floor, naked. He stated the CNA left him on the floor for about 35 minutes and later returned with other staff (V17 and V41) to pick him up. R8 reported that he informed an LPN (V16) the next day that he had fallen and that she told him he needed to go to the hospital. Multiple CNAs (V17, V40, and V41) later described seeing R8 on the floor between the bed and the window and stated that LPN V25 came into the room, assessed him on the floor, took vital signs, and then assisted with or directed his transfer back to bed. In contrast, LPN V25 stated that CNA V40 told her that R8 was slipping out of bed but that she (V40) was able to put him back in bed and that he did not touch the floor. V25 reported that she did not see CNAs V17 or V41 in the room, did not assess R8 on the floor, and that when she asked R8, he said he did not fall. The Administrator (V1) stated this was the first time he was hearing about the incident and noted that staff were giving different stories. The DON (V2) stated that all falls should be documented so that the physician and family can be notified and the care plan updated, and that documentation should occur immediately after a fall. R8’s records showed a fall entry dated 3/17/2026 documenting that the resident self‑reported to the nurse on duty that he had fallen the night prior, stating he fell from the bed, hit his head, and that his head was hurting. The note indicated that after investigation and an IDT meeting it was determined that no fall occurred because staff had no knowledge of the incident and that R8 was described as extremely confused and unable to get up unassisted. However, per the later statements of CNAs V17, V40, and V41, they all witnessed R8 on the floor and reported that V25 assessed him there. No progress notes were found for a witnessed fall on 3/16/2026, and the care plan, which already identified R8 as at risk for falls and required MD and family notification for any new fall, was not updated with a new fall or new interventions related to this event.
Uncovered Foley Drainage Bag and Care Plan Not Followed
Penalty
Summary
The facility failed to implement the care plan for one resident with an indwelling Foley catheter and failed to ensure that the resident’s urinary catheter drainage bag was properly covered. The resident, who could not be interviewed due to altered mental status, had diagnoses including neuromuscular dysfunction of the bladder, chronic kidney disease, and cognitive communication deficit. The resident’s BIMS score was 00, indicating severely impaired cognition. The care plan, dated 4/03/26, documented that the resident required an indwelling catheter for neurogenic bladder and was at risk for infection, with an intervention to keep the draining bag covered to promote privacy. The physician ordered catheter care every shift and as needed. On 4/20/26 at 10:44 AM, the surveyor observed the resident’s urinary drainage bag hanging uncovered from the bed frame while walking in the hallway and looking into the room. The surveyor entered the room and observed approximately 525 mL of clear yellow urine in the bag. At 10:48 AM, an LPN observed the uncovered drainage bag and acknowledged that it was not covered, stating that she needed to get the resident a urinary drainage bag cover. The DON later stated that all Foley bags should be covered to maintain dignity. The resident rights pamphlet in the record stated that the facility must treat residents with dignity and respect and provide care in a manner that promotes quality of life, and that residents should receive the services and items included in the plan of care.
Failure to Obtain Informed Consent for Antipsychotic Use
Penalty
Summary
The facility failed to honor a resident’s right to informed consent before starting antipsychotic medication. The resident had multiple diagnoses including unspecified dementia with psychotic disturbance, severe intellectual disabilities, epilepsy, anxiety disorder, major depressive disorder, dysphagia, and muscle weakness. The minimum data set documented that the resident was rarely or never understood and had severe cognitive impairment for daily decision making, and it also indicated there were no behaviors in the lookback period and no serious mental illness, schizophrenia, or schizoaffective disorder. The physician orders showed olanzapine was first ordered for schizophrenia and later changed to olanzapine for dementia with psychosis, with daily administration through the G-tube. The medication administration record showed the resident regularly received olanzapine, and the electronic health record included the black box warning for increased mortality in elderly patients with dementia-related psychosis. The psychotropic consent form for olanzapine did not document the indication or diagnosis related to the medication use, and no further consent forms were provided showing the legal guardian was informed of the risks and benefits after the medication was initiated. The pharmacist confirmed olanzapine is an atypical antipsychotic and stated it is not approved for dementia-related psychosis, though it is sometimes used off-label. The pharmacist also confirmed the resident was receiving olanzapine for dementia-related psychosis and noted there was no documentation showing why the medication was first ordered or that recommendations had been made earlier regarding its appropriateness. The facility policy stated that when a new psychotropic medication is ordered, the resident or representative must be informed of the risks and benefits and informed consent must be obtained, and that the diagnosis should be added to the medical record.
Inaccurate resident assessments and MDS coding
Penalty
Summary
The facility failed to accurately complete assessments and MDS items for two residents reviewed for assessment accuracy. For one resident with altered mental status, the record showed an admission diagnosis history that included traumatic subdural hemorrhage, generalized anxiety disorder, cerebral ischemia, bilateral primary osteoarthritis, contusion of scalp, unspecified fall, and unspecified dementia. The resident’s BIMS score indicated the resident was unable to complete the interview, and the MDS documented moderately impaired cognitive skills for daily decision making. The resident’s Restorative Comprehensive Assessment documented the resident as alert and oriented x3 and having no falls, accidents, or fractures. This was inaccurate because the MDS documented that the resident could not accurately remember the day, month, or year, and hospital records before admission documented a recent hospitalization after a fall with a subdural hematoma. The DON confirmed that the restorative assessment was not completed accurately and stated that accurate restorative assessments are expected and help prevent injuries and increase safety. For the second resident, the MDS documented severe cognitive impairment and that the resident was rarely or never understood, but it did not identify antipsychotic medication use. The medication administration record showed routine daily olanzapine use during the lookback period, and the MDS nurse confirmed the resident was receiving antipsychotic medication for dementia-related psychosis. After reviewing the record, the MDS nurse stated the assessment was not correct and needed modification, and affirmed that the MDS should be coded according to the RAI.
Care Plan Did Not Match Resident’s Splint Needs or Antipsychotic Diagnosis
Penalty
Summary
The facility failed to revise R10’s care plan so it accurately reflected the resident’s inability to use a splint and the correct diagnosis related to antipsychotic medication use. R10’s record showed diagnoses including unspecified dementia with psychotic disturbance, severe intellectual disabilities, epilepsy, anxiety disorder, major depressive disorder, dysphagia, tremors, muscle weakness, and contractures of the right upper arm, but no diagnosis of schizophrenia, schizoaffective disorder, or schizophreniform disorder. The MDS documented that R10 was rarely or never understood, had severe cognitive impairment for daily decision making, was dependent on staff for ADLs, had limited ROM in all extremities, had no behaviors in the lookback period, and did not have serious mental illness. R10’s care plan stated that the resident required bilateral resting hand splints for bilateral hand contractures and that olanzapine was being used to manage mood and behavior related to schizophrenia with targeted agitation or aggression. Physician orders showed olanzapine had been ordered for schizophrenia and later changed to Zyprexa for dementia with psychosis. On review, V3, the restorative nurse, stated therapy had said R10 could not have a splint to the left hand because it was too contracted, and V23, the DON of Rehab, confirmed R10 could not have bilateral hand splints because the left hand was too contracted. The occupational therapy notes documented a right wrist resting hand splint for up to 2 hours and education to restorative staff on right-hand splint use, but there was no documentation of left-hand splint recommendations while R10 was on caseload. Observation showed R10’s left hand was severely contracted, with fingers flaring outward and only about 10 to 15 degrees of movement in the fingers and hand. V48, the MDS nurse, and V2, the DON, both affirmed that R10 was receiving antipsychotic medication for dementia-related psychosis, not schizophrenia, and V2 stated the care plan diagnosis was wrong and that R10 did not have a history of agitation or aggression as target behaviors for the medication.
Incorrect Low Air Loss Mattress Setting
Penalty
Summary
The facility failed to follow its guideline and standard of care in using a pressure-relieving mattress for a resident at risk for pressure injury. The resident had a history of pressure injuries, and the MDS dated 4/16/2026 identified the resident as being at risk for developing pressure ulcers/injuries and noted use of a pressure reducing device for the bed. The resident stated the weight was about 203 pounds, while the low air loss mattress was observed set between 325 and 350 pounds on 4/21/2026 and again set at 325 pounds on 4/22/2026. During the observations, the LPN stated the mattress should be set based on the resident’s weight and that staff check the mattress settings when checking on the resident, but was not sure why it had been set wrong. The wound nurse stated the nurses on the floor set the mattress by checking the resident’s weight in the chart and that the mattress should be set to the resident’s weight; she stated that if it is not set appropriately, the resident is at risk of impaired skin integrity and it could make the resident uncomfortable. The DON stated the mattress setting is based on the resident’s weight and that an incorrect setting can cause further destruction to the skin and discomfort. The physician had ordered a low air loss mattress on 4/14/2026, and the facility guideline stated the resident may be changed to a pressure-relieving mattress at the discretion of the wound care team, nurse, DON, or ADON.
Respiratory Care Not Provided Consistently With Ordered Oxygen Use
Penalty
Summary
Failure to provide necessary respiratory care consistent with professional standards of practice occurred for one resident, R88, who had diagnoses including chronic obstructive pulmonary disease, hypertension, and obstructive sleep apnea. R88’s active order directed oxygen at 2 liters per minute via nasal cannula as needed every shift for shortness of breath, and the resident’s MDS documented a BIMS score of 13 and oxygen therapy while a resident. During observation, a sign at the resident’s door indicated oxygen in use, but R88 was lying in bed without the nasal cannula in place, the nasal cannula was hanging on the side of the bed and was not contained, and the oxygen concentrator was off. R88 stated she did not know who turned off her oxygen concentrator. When the unit supervisor was asked to check the nasal cannula, it was noted that it was not contained and should be contained when not in use for infection control. The DON stated the expectation was to keep the nasal cannula in a plastic bag when not in use to prevent cross contamination and growth of infectious organisms. The facility’s email correspondence with the Administrator also stated that the expectation for containment of the nasal cannula was storage in a clean plastic bag when not in use to maintain proper infection control standards.
Failure to Daily Monitor and Log Resident Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to check and log the temperature of a resident’s personal refrigerator daily. During observation and record review, the resident’s refrigerator temperature log was found to have missing daily signatures and missing temperature entries. On 04/20/2026 at 12:09 PM, the personal refrigerator temperature log for R62 was not signed daily, and the surveyor asked V14, an LPN, to check the log because entries were missing. The facility’s Director of Nursing later stated that staff responsible for checking the resident’s personal refrigerator daily included housekeeping, Kitchen, and Angel Rounds, with Angel Rounds doing most of the checks. R62’s record showed diagnoses including adjustment disorder with depression, psychosis, and hypertension. The resident’s MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The care plan noted that R62 preferred to have a personal fridge in the room and that staff would assist in assuring the fridge remained clean as needed. The April 2026 fridge/freezer log had no temperatures and initials on days 1, 2, 3, 4, 5, 12, 17, and 18. The facility policy stated that daily temperature logs are to be kept on the refrigerator and that resident food refrigerators must be maintained between 33 degrees and 40 degrees.
Incomplete Daily Staffing Posting
Penalty
Summary
The facility failed to ensure the daily nurse staffing posting contained the required information at the start of each shift. On 4/20/2026 at 9:25 AM, the staffing posting observed across from the front desk was dated 4/17/2026 and did not include the facility name or census information. When the surveyor requested a copy, the receptionist stated the posting had not been changed over for that day and that it was updated daily, but had not yet been changed. On 4/22/2026 at 4:12 PM, the Administrator confirmed the posting was updated daily by front desk staff and reviewed the copy, affirming that it did not have the facility name or census. The Administrator stated the updated form should have shown the current date and that the facility writes the census in the corner. The facility policy required the nurse staffing sheet to be posted daily and to include the facility name, current date, and current resident census.
Incomplete Facility Assessment for Staffing and Contingency Planning
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies. The assessment completed in 2/2026 documented an average census of 140 residents and a capacity of 182 residents, and it identified a CNA-to-resident ratio of 1:12 on acute care units and 1:13 on long-term care units for each shift. However, the staffing schedules reviewed for 4/6/2026 through 4/20/2026 showed that the night shift was staffed at approximately a 1:18 CNA-to-resident ratio, and the scheduler stated that staffing needs were based on acuity and that more staff were scheduled in the morning and afternoon because most care needs occurred when residents were awake. The scheduler and administrator both acknowledged that the staffing plan in the assessment did not reflect the actual staffing pattern and needed to be updated. The assessment also did not include a plan to maximize recruitment and retention of direct care staff, and it did not include contingency planning for events that do not require activation of the emergency plan but could affect resident care, such as staffing shortages. The administrator stated the facility had recruitment and retention efforts including employee recognition events, tuition reimbursement for CNA classes, orientation, training programs, and educational opportunities, and described contingency staffing options such as using nursing department managers, calling part-time staff, or using staff from sister facilities. The regional director of operations also described a corporate recruiter, job board use, school partnerships, a staffing coordinator, a float pool, and staff from other facilities, but both the administrator and regional director confirmed these items were not identified in the facility assessment. Survey staff requested a facility assessment policy, and no policy was provided before the survey ended.
Failure to Administer Ordered Anti-Seizure Medications and Notify Practitioner
Penalty
Summary
The deficiency involves the facility’s failure to follow its Medication Administration Policy by not ensuring timely availability and administration of a resident’s ordered anti-seizure medications and not notifying the practitioner when the medications were not available. A resident with epilepsy was discharged from the hospital with orders for three anti-seizure medications: topiramate 200 mg twice daily, phenytoin (Dilantin) 200 mg twice daily, and oxcarbazepine 1,200 mg twice daily, with the next scheduled doses due in the evening. Record review showed that none of these medications were administered that evening as directed by the hospital discharge medication list. The DON stated that due to a holiday pharmacy delivery cut-off, only phenytoin was available in the facility’s medication dispensing system, and that the nurse should have attempted to obtain medications from the dispensing system and, if not available, notify the physician and family. The DON confirmed that the nurse did not notify the nurse practitioner that two of the three anti-seizure medications were not available and that no anti-seizure medications were given that evening. The nurse practitioner reported being notified only of the resident’s admission and not of the unavailability of the anti-seizure medications or the missed evening doses, and stated he was unaware of the pharmacy’s holiday cut-off. Review of the MAR confirmed that the ordered anti-seizure medications were not administered as scheduled on the evening in question, and there was no progress note documenting notification to the practitioner about the missed doses or unavailable medications. The following morning, a progress note documented that the resident’s concerned party insisted on calling 911 because the resident had a seizure, and later documentation showed the resident was admitted to a local hospital with seizure activity. The facility’s Medication Administration Policy required that if medication is not given as ordered, the reason must be documented on the MAR and the health care provider notified, that staff should obtain medications from contingency sources if not present, and that the physician must be notified in a timely manner if an order cannot be followed, with documentation in the medical record. These policy requirements were not followed in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving missed or incorrect medication administration. In one instance, a resident with a physician order for Escitalopram 30mg daily was only dispensed a 20mg tablet by an LPN, despite the order specifying the need for both a 20mg and a 10mg tablet. The medication administration record indicated that 30mg was documented as given, but only 20mg tablets were available and dispensed for several days. This discrepancy was confirmed by both the LPN and the medication records. Additionally, several residents did not receive their scheduled morning medications on time, as indicated by the electronic medication administration record showing overdue doses for medications such as Eliquis, Tizanidine, Lamotrigine, Metformin, Baclofen, and Metoprolol Tartrate. Another resident, who was cognitively intact, reported missing medications during a night shift, including Xarelto, which was confirmed by the medication administration record and the Director of Nursing. Facility policy required verification of the right medication, dose, route, resident, and time, but these procedures were not followed, resulting in significant medication errors for multiple residents.
Medication Error Rate Exceeds 5% Due to Failure to Follow Medication Orders and Procedures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 4 errors out of 37 opportunities, resulting in a 10.81% error rate. Staff did not follow policy and procedures for medication administration, including ensuring that medication orders included a prescribed dose and verifying the correct medication, dose, and form before administration. In one instance, an LPN prepared to administer only 20mg of Escitalopram to a resident whose order required a total daily dose of 30mg, as specified in the physician order sheet and EMAR. The nurse confirmed the discrepancy after being questioned by the surveyor. Another LPN dispensed an enteric-coated Aspirin 81mg tablet to a resident whose order specified a chewable form, and the nurse confirmed the difference between the prescribed and dispensed forms after reviewing the EMAR. Additionally, a third nurse prepared to administer a 500mg Calcium Carbonate tablet to a resident whose order was for 600mg with Vitamin D, and also administered a Lactobacillus capsule without a specified dose in the order. The medication administration policy required verification of the right medication, dose, route, resident, and time, and checking orders in case of discrepancies, but these procedures were not followed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was cognitively intact but dependent on staff for toileting and repositioning was not provided timely incontinence care. The resident was frequently incontinent and required substantial or maximal assistance to roll and reposition in bed. On multiple occasions, the resident reported being left soiled and saturated with urine for extended periods, including one instance of 3.5 hours and another of over two hours. The resident expressed feelings of stress, frustration, and concern for safety due to being left in this condition and having to rely on a single staff member for care instead of the required two-person assist. Certified nursing assistants confirmed that the resident was found soiled and saturated with urine and bed linens on at least two separate occasions, with call lights left unanswered for over an hour. Documentation and staff interviews indicated that the resident was not a heavy wetter, and the amount of urine present suggested a lack of overnight care. Facility policy required incontinence care every two hours and appropriate skin care to prevent breakdown, but these standards were not met for this resident, as evidenced by the resident's own written complaints and staff observations.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents identified as high risk for falls were adequately supervised and that fall prevention interventions were properly implemented and modified after incidents. One resident with dementia, muscle wasting, and a history of falls was dependent on staff for all activities of daily living and required two-person assistance with transfers using a mechanical lift. Despite these needs, the resident was left unattended in a reclining chair while staff turned away to retrieve an item, resulting in the resident attempting to get up, falling forward, and sustaining a facial fracture and intracranial hemorrhage. Documentation and staff interviews revealed uncertainty about whether the chair was properly reclined, which was necessary due to the resident's poor trunk control, and that only one staff member was assisting at the time, contrary to care plan interventions requiring two-person assistance. Another resident with central nervous system cancer, muscle wasting, and morbid obesity, also identified as high risk for falls, experienced multiple unwitnessed falls both in her room and in common areas. Despite repeated incidents, interventions primarily consisted of reminders to staff to monitor and redirect the resident, with no significant modification to the care plan or supervision practices. Staff were educated not to leave the resident unattended, but the resident continued to be found on the floor after attempting to self-transfer, indicating that supervision and monitoring interventions were not effectively implemented. A third resident with dementia and generalized muscle weakness also experienced several falls, including unwitnessed incidents and falls from a reclining chair in common areas. The interventions following these falls were limited to reminders for staff to monitor the resident more frequently, but staff could not define what constituted adequate monitoring. The facility's fall prevention policy required evaluation and modification of care plans after falls, but the records and interviews indicated that interventions were not sufficiently individualized or adjusted in response to repeated incidents, and residents continued to be left unsupervised despite known risks.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to adhere to its policy regarding room changes by not providing a written notice and explanation for a room change to a resident's representative. The deficiency involved one resident, identified as R2, whose sister and Power of Attorney (POA) reported that the facility did not discuss the room change with her, nor did she receive a copy of the room change notice. Despite requests made to the Director of Nursing, Administrator, and Social Worker, the facility was unable to present documentation of the written notice or explanation for the room change. The facility's policy, dated November 1, 2023, requires that residents and their representatives be notified in writing of room transfers, including an explanation of the move, and be given the opportunity to see the new location and meet the new roommate.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting an allegation of abuse involving a resident with dementia. On February 21, 2025, a visitor informed a Registered Nurse (RN) that a Certified Nursing Aide (CNA) allegedly slapped a resident on the knee. Despite this report, the RN did not communicate the allegation to the Director of Nursing (DON) or the Administrator. As a result, the DON was unaware of the incident until February 27, 2025. The facility's abuse prevention policy, dated March 2022, mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a designated individual in their absence. This failure to report the allegation promptly constitutes a deficiency in the facility's compliance with its internal reporting requirements.
Facility Fails to Maintain Roof Integrity and Ventilatory Cleanliness
Penalty
Summary
The facility failed to maintain the integrity of its roof, resulting in ceiling cracks and rusty discoloration in two residents' rooms, with water collection buckets placed underneath the cracks. Additionally, there was an abundant collection of black and dark grey powder-like particles on the ceilings, around and in the ventilatory outlets, and on smoke detectors in these rooms. These conditions were observed by the surveyor over two consecutive days, indicating a persistent issue that had not been addressed. The maintenance staff acknowledged the roof leakage and the need for repairs, stating that the issue had persisted for about three years. Furthermore, the facility failed to ensure dust-free ventilatory outlets in all residents' rooms throughout the facility. The housekeeping director admitted that there was no cleaning schedule in place at the time of the survey, although dusting was supposed to be done weekly. The medical director emphasized the importance of a homelike environment for the elderly residents, noting that excessive dust could lead to allergic reactions or exacerbate preexisting respiratory conditions. The facility's housekeeping guidelines were not being followed, as there were no daily cleaning assignments to maintain a clean and orderly environment.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its policies and procedures for dietary food storage, cleaning, and hand hygiene practices, affecting all 123 residents receiving food from the facility. Observations in the main kitchen revealed a strong foul odor in the cooler, with two large boxes of meat covered in a red substance, indicating possible spoilage. Several food items, including a black bean burger, boxes of tomatoes, lettuce, cucumbers, dry cereals, and bagels, were found without labeled dates. Additionally, a large unmarked can of food was stored with other canned goods, and sauces from a previous event were not discarded. In the second kitchen, ham sandwiches and milk cartons were improperly labeled, and salad dressings were spilled, creating unsanitary conditions. A bin of clean serving ladles was found with a sticky brown substance, and a dietary aide was observed not performing hand hygiene after handling soiled dishes. The Registered Dietitian confirmed that dietary staff should not transition from handling soiled to clean dishes without performing hand hygiene and emphasized the importance of labeling food with received and used by dates to prevent serving expired foods. The facility's policies on food storage, kitchen operations, and hand washing were not followed, as evidenced by the presence of odors, unlabeled food items, and improper hand hygiene practices. These deficiencies highlight a failure to maintain a clean and sanitary environment in accordance with state and federal guidelines, potentially compromising food safety for the residents.
Improper Storage and Labeling of Insulin Pens
Penalty
Summary
The facility failed to adhere to its pharmacy policy regarding the storage and labeling of insulin, as observed during a survey. Specifically, unopened insulin pens for two residents were not stored in the medication refrigerator as required by the facility's policy. Additionally, these insulin pens were not labeled with an open date, which is necessary to track their usage and expiration. The surveyor noted that the pharmacy's prescription bags clearly indicated that the insulin should be stored in the refrigerator until opened, yet this was not followed. The Licensed Practical Nurse (LPN) on duty was unaware of when the insulin was received and acknowledged the oversight in storage and labeling. Furthermore, an opened insulin pen for another resident was found without an open and expiration date label. The LPN confirmed the absence of these labels and intended to contact the pharmacy for the expiration date. The Director of Nursing (DON) emphasized the importance of labeling insulin pens with both open and expiration dates to ensure drug safety and effectiveness. The facility's pharmacy policy mandates that unopened insulin should be refrigerated and labeled with an open date once used, but these procedures were not followed, leading to the deficiency.
Failure to Notify Family of Resident's Wound Development
Penalty
Summary
The facility failed to adhere to its skin prevention policy by not notifying a resident's family about a newly acquired wound in a timely manner. The resident, who was at high risk for skin breakdown, developed a moisture-associated skin damage (MASD) sacral wound due to factors such as loose stools, moisture in briefs from sweating, and fragile skin. The wound care nurse acknowledged the resident's high risk and noted a decline in the resident's overall medical condition, which included starting dialysis treatments after a hospital readmission. Despite discussing potential skin impairments with the family on an earlier date, the facility did not document timely notification to the family about the wound's development and changes in the treatment plan. The resident's medical records indicate that a skin assessment was conducted in the presence of a family member, and no skin impairments were noted at that time. However, subsequent evaluations revealed moisture-associated skin damage, and treatment was applied as ordered. It was not until a later date that another family member was informed of the wound status and treatment orders. The facility's skin care prevention policy emphasizes educating the resident's representative about pressure ulcer prevention and treatment, yet there was no documentation of timely communication regarding the wound's deterioration and treatment changes.
Failure to Develop Skin Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to adhere to its skin care prevention policy and develop a person-centered care plan for a resident at risk of skin breakdown. The resident, who was readmitted from a hospital stay in November, experienced an overall decline in medical condition and developed a facility-acquired moisture-associated skin damage (MASD) sacral wound. The wound care nurse identified the resident as being at risk due to fragile skin, loose stools, moisture in briefs from sweating, and loose skin. Despite being dependent on all activities of daily living and unable to reposition themselves, the resident's comprehensive care plan did not include a risk for alteration in skin integrity or a care plan for actual skin impairment. The facility's policy required the nursing department to review all new admissions and re-admissions to implement a prevention plan based on the resident's activity level, comorbidities, mental status, and risk assessment, which was not done in this case.
Failure to Check G-Tube Residual Before Medication and Feeding
Penalty
Summary
The facility failed to adhere to its tube feeding policy by not checking a resident's gastrostomy tube (G-tube) for residual before administering medications and bolus feeding. This deficiency was observed when a registered nurse (RN) administered medications and a bolus feeding to a resident without checking the G-tube for residual or placement. The facility's policy, as well as the resident's physician order sheet, required checking for residual before such procedures. Interviews with licensed practical nurses (LPNs) and the assistant director of nursing (ADON) confirmed that the standard practice is to check for residual before administering medications and feedings. The failure to follow these procedures was noted during a survey, affecting one resident out of three reviewed for gastrostomy tubes in a sample of five.
Failure to Follow Enteral Tube Medication Administration Policy
Penalty
Summary
The facility failed to adhere to its enteral tube medication administration policy and physician orders for a resident, leading to a deficiency. On January 22, 2025, a registered nurse (RN) was observed preparing and administering medications for a resident with a gastrostomy tube. The RN crushed the medications and dissolved them in water but did not flush the gastrostomy tube with 5-10ml of water between each medication, as required by the facility's policy. Additionally, the RN did not administer the resident's scheduled omeprazole medication because it was not present in the medication cart and failed to inform the resident of this omission. The resident, who has a medical history including gastric ulcer, esophageal obstruction, and gastrostomy, later complained of stomach discomfort to a licensed practical nurse (LPN). The resident's physician order sheet indicated that omeprazole 20mg was to be administered via G-tube twice daily, with specific instructions to flush the G-tube with 30ml of water before and after medications, and 5ml between each medication. Despite this, the medication administration record inaccurately documented that the omeprazole was administered. The facility's failure to follow its medication administration policy and physician orders resulted in a deficiency.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the plan of care for a resident requiring assistance with bed mobility, resulting in an avoidable accident. The resident, who was diagnosed with generalized osteoarthritis, repeated falls, neuropathy, morbid obesity, and other conditions, was assessed to need three-person assistance for bed mobility. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to provide care alone, which led to the resident falling out of bed. The incident occurred when the CNA was changing the resident's bed linens. The resident was positioned on her right side, and as the CNA pushed the linen under her, the resident slid out of bed and fell to the floor. The resident, who was cognitively intact, reported pain and was subsequently diagnosed with a non-displaced left rib fracture, a left shoulder contusion, and a sprained left knee at the hospital. Interviews with facility staff revealed that the CNA did not check the resident's care card, which indicated the need for three-person assistance. The Director of Nursing and other staff members confirmed that the resident required significant assistance with bed mobility, and the failure to provide the appropriate level of assistance was identified as the root cause of the fall.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to monitor and respond to its call light system in a timely manner, affecting four residents. A family member of one resident, who was severely cognitively impaired and dependent on assistance for activities of daily living (ADL), reported waiting 45 minutes for staff to respond to a call light. The family member had to seek help at the nurses' station, and the administrator was informed of the delay. The call light system was noted to be visual only, without an audible alert, which may have contributed to the delay in response. Another resident, who was cognitively intact but dependent on ADL care, reported waiting three hours for assistance after pressing the call light. This resident's experience highlights a significant delay in response time, which was corroborated by the resident's account of pressing the call light at 9 AM and not receiving assistance until 12 PM. Additionally, another resident, also cognitively intact and requiring substantial assistance, reported waiting over an hour for help after a CNA turned off the call light and promised to return, but did not do so until the shift change. The surveyor observed a call light illuminated for a resident with mild cognitive impairment and dependent on ADL care, which was not addressed by several staff members passing by. The call light was eventually turned off by a CNA who admitted noticing it five minutes prior but was busy at the time. The facility's policy, which mandates prompt response to call lights, was not adhered to, as evidenced by the documented delays and resident complaints.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,774 citations issued within 25 miles in the last 12 months — including the 19 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crestwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Terrace | 1 mi | ★★★★★ | 3 | 0 |
| Thryve Of Crestwood | 1.1 mi | ★★★★★ | 26 | 0 |
| Elevate Care Palos Heights | 1.4 mi | ★★★★★ | 3 | 0 |
| Avantara Palos Heights | 3.3 mi | ★★★★★ | 3 | 0 |
| Aperion Care Midlothian | 3.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aliya Of Crestwood.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.