Allure Of Sterling

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to notify a resident’s physician after the resident sustained a head injury during a mechanical lift transfer. The resident had multiple medical diagnoses, including ulcerative colitis, prior fractures, chronic pain, muscle weakness, lack of coordination, osteoarthritis, and other conditions, and was assessed as cognitively intact, wheelchair-bound, and dependent on staff for transfers, requiring a mechanical lift with two staff assistance. During a transfer with a mechanical sling lift performed by a newer CNA, the lift hit the resident on the top of the head as she was being lowered into her wheelchair. The resident reported that her head was bleeding, it hurt a lot, and she cried when it happened. On observation days later, the resident had about a one‑inch dark, purplish scab on the top of her head. The initial incident report documented that the top of the resident’s scalp was scraped by the mechanical lift, with pressure applied to the scalp, neuro checks initiated, wound care provided, a skin check completed, an abrasion to the top of the scalp, and a pain level of 10. Despite the documented injury and pain, the facility did not ensure that the resident’s physician was actually notified of the incident. The incident report, completed by an RN, indicated that the physician was notified, but subsequent interviews with multiple LPNs and the wound nurse revealed that none of them notified the physician or knew who had done so. The wound nurse stated she did not update the physician, and the LPNs who were said to have taken over care denied notifying the physician or being aware of who did. The medical director, who was the resident’s physician at the time, did not recall being notified about the mechanical lift striking the resident’s head. The DON stated she was not sure which nurse would have notified the physician and only commented that the wound did not look like it needed treatment such as stitches. This combination of inconsistent documentation, lack of clear responsibility, and staff statements established that the physician was not notified of the resident’s head injury as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to perform and document a thorough assessment and to initiate treatment for a head injury sustained by a resident during a mechanical lift transfer. The resident had multiple medical diagnoses, including ulcerative colitis, fracture of the right clavicle, chronic pain, muscle weakness, impaired balance, and limited mobility, and required a mechanical lift with two staff for transfers. During a transfer, the mechanical sling lift struck the top of the resident’s head, causing an abrasion that the resident later described as never having been measured or treated, and which remained as a dark, purplish scab approximately an inch long more than a month later. Following the incident, several nurses, including an RN, LPNs, the wound nurse, and the DON, viewed the injury but did not complete or document a comprehensive wound assessment in the electronic medical record. The wound nurse acknowledged she did not perform a full assessment, only looked at the wound, recommended the physician be called, measured the wound on paper without entering it into the record, and did not initiate any treatment. The RN reported she only looked at the injury briefly, obtained vital signs, and then allowed other nurses to take over, without documenting an assessment. Two LPNs stated they either did not assess the wound or only viewed it superficially and did not document any assessment. The DON stated she observed an approximately one‑inch abrasion on the scalp that was already scabbed and not bleeding, and told staff it did not appear to need treatment, but she did not complete or ensure a documented, detailed assessment. The initial incident report, completed by the RN, noted that the scalp was scraped by the mechanical lift, that pressure was applied, neuro checks were initiated, wound care was provided, and that the resident’s pain level was 10, but it did not include a full description or measurements of the wound. Subsequent documentation in the electronic medical record lacked a Weekly Skin Assessment on the day of the incident and later only referenced an abrasion to the top of the scalp without size or appearance details. The DON confirmed that the only later note described the abrasion as closed with no drainage, redness, swelling, or pain, and acknowledged this was not an acceptable assessment and that no treatment had been initiated despite the resident still having a scab over a month later.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a safe mechanical sling lift transfer for a resident who required two-person assistance. The resident had multiple medical diagnoses, including fracture of the right clavicle, pain in the right shoulder, low back pain, right knee pain, muscle weakness, lack of coordination, and unilateral primary osteoarthritis of the left hip. Her facility assessment documented that she was cognitively intact, used a wheelchair for mobility, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfers. Her ADL care plan, initiated on 9/2/25, specified that she had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and limited mobility, and required a mechanical lift with two staff assistance for transfers. On the day of the incident, the CNA assigned to the resident attempted to transfer her from bed to wheelchair using a mechanical sling lift without obtaining the required second staff member. The CNA reported that she tried to find help but did not see any other CNAs available, and proceeded to perform the transfer alone. The resident had previously told the CNA that she was terrified of the mechanical lift. During the transfer, after the resident was lifted off the bed and while the CNA was trying to align the resident with the wheelchair and adjust the sling, the mechanical lift tipped, causing the resident to “plop” into the wheelchair and the lift to strike the top of her head. The resident cried, screamed that it hurt, and had bleeding at the site of impact. Multiple staff, including LPNs and the DON, later observed the injury. The resident was noted to have active bleeding on the top of her head immediately after the incident, with blood in her hair and on her shirt, and staff applied pressure and performed wound care. A wound nurse later described the wound as bleeding but not heavily, with a dime-sized amount of blood on gauze and the area being very sensitive and painful to touch for the first three weeks. On observation over a month later, the resident still had a scab on the top of her head measuring 1.9 cm by 0.2 cm. The facility’s written Safe Resident Handling/Transfers policy required that mechanical lifting equipment be used based on resident needs and explicitly stated that two staff members must be utilized when transferring residents with a mechanical lift and that transfers must be performed according to the resident’s individual plan of care, which was not followed in this incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards, resulting in a resident sustaining a significant right-hand laceration. The resident had multiple diagnoses, including heart disease, long-term use of anticoagulants, diabetes mellitus, major depressive disorder, anxiety disorder, morbid obesity, a need for assistance with personal care, a history of falling, muscle wasting, and fragile skin. Her care plan identified potential and actual impairment to skin integrity related to these conditions and documented that she required assistance or an escort to activity functions. Despite these identified needs, the resident was placed at the nurses’ station and later attempted to return to her room independently. On the date of the incident, nursing notes document that staff were called to the hallway and found the resident bleeding on the floor and from her hand. Assessment revealed a large skin tear and laceration on the right hand extending from the middle finger knuckles up between the second and middle finger to the wrist, with some areas too deep to approximate with steri-strips. The resident was transported to a local emergency room, where hospital records described a significant multilayer laceration exposing extensor tendons over the second and third metacarpals, measuring approximately 12 cm by 6 cm. The resident required 19 sutures, a nonstick dressing, and a splint to promote healing and prevent disruption of the sutures, and was started on antibiotics and narcotic pain medication. The facility’s root cause analysis and interviews show that the resident became entangled in a food tray cart while attempting to move herself from the nurses’ station back to her room without staff assistance. Another resident using a motorized wheelchair attempted to help by moving the food cart when he accidentally bumped his wheelchair controller, causing the chair to move and the first resident’s hand to become caught under the wheelchair controller, resulting in the laceration. Both the injured resident and the assisting resident reported that there were no staff present in the hallway at the time. The DON stated that staff usually push the injured resident back to her room after meals and that staff had placed her at the nurses’ station but were called away, and no staff observed that she was stuck in the tray cart. This sequence of events demonstrates that the resident was not adequately supervised in accordance with her assessed needs and the facility’s policy on accidents and supervision.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a registered nurse (RN) was scheduled and on duty for at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own Nursing Services and Sufficient Staff policy. The CMS-671 form dated 12/16/25 documented that 84 residents resided in the facility at the time of the survey. Review of the December 2025 nursing schedule for the period 12/1/25 through 12/16/25 showed there was no RN coverage on 12/6/25 and 12/13/25, and the facility was unable to provide any documentation that an RN worked on either of those days. During an interview on 12/18/25 at 12:19 PM, the Director of Nurses confirmed that there was no RN coverage on those two Saturdays and acknowledged the requirement to have an RN in the facility for at least eight consecutive hours each day.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post daily nursing staff information and to maintain at least 18 months of daily staffing postings as required. Surveyors noted that the CMS 671 form dated 12/16/25 documented 84 residents in the building, but on 12/18/25 at 10:20 AM the posted direct care staff daily report was still dated 12/16/25. During the survey, the Regional Nurse Consultant stated there were no daily staffing reports available after 7/31/25, indicating a gap of over four months without maintained postings, and explained that the prior DON had kept copies of the daily posted reports but the current DON did not. The Administrator acknowledged the importance of posting daily staffing numbers to know who is working and to ensure appropriate staffing for the day. The facility’s undated Nursing Services and Sufficient Staff policy states that the facility will supply services by sufficient numbers of licensed nurses and nurse aides on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. This failure to post and maintain daily staffing information had the potential to affect all 84 residents residing in the facility, as identified in the CMS 671 form.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to offer bedtime snacks to residents in accordance with their needs, preferences, and requests, as required by facility policy. During a group meeting with residents and the facility ombudsman, residents reported that they do not receive bedtime snacks unless they specifically ask for them, and that staff do not routinely offer or pass snacks room to room. Residents stated that bedtime snacks had been offered in the past but this practice stopped after staff were allegedly taking snacks for themselves, and that this change occurred a long time ago. Residents also reported that if they want a snack after dinner, they must bring something back from lunch and keep it in their rooms until evening. Record review showed there were 84 residents in the facility, and assessment review for residents present at the group meeting revealed no cognitive impairment among them. The Dietary Manager reported that kitchen staff take a snack cart to the resident units daily and place it in the nutrition room on the LTC unit, and that CNAs are responsible for passing the snacks rather than dietary staff. Observation showed the nutrition room had a number-coded locking system, preventing residents from accessing snacks without staff assistance. The DON stated that CNAs should be offering bedtime snacks during the water pass because it is important for residents to have substance between the evening and morning meals. The facility’s undated “Offering/Serving Bedtime Snacks” policy states that nursing staff will offer bedtime snacks to all residents daily in accordance with their needs, preferences, and requests, which was not occurring as described by residents and staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified deficiencies in the facility’s infection prevention and control practices related to wound care and use of personal protective equipment (PPE) for multiple residents. For one resident with a stage 4 sacral pressure injury and a separate pressure injury to the coccyx, the wound care nurse cleansed and treated both wounds using the same gauze pad and the same sequence of products, and then covered both wounds with a single bordered foam dressing. The nurse confirmed that the sacral and coccyx wounds were considered two separate wounds that were measured and assessed individually, yet she routinely cleansed and treated both areas at the same time. The Assistant Director of Nursing and Infection Preventionist later stated that when a resident has multiple wounds, each wound should be cleansed, treated, and covered individually, starting with the cleanest to the dirtiest wound to avoid cross contamination and prevent infection. The facility’s wound treatment management policy stated that wound treatments would be provided in accordance with physician orders and current standards of practice. Additional deficiencies were observed in wound care and PPE use for another resident receiving multiple dressing changes. An LPN performed a dressing change on a leg wound wearing gloves but no gown, removed the soiled dressing, cleansed the wound, applied skin prep, and completed the treatment without changing gloves at any point. He then acknowledged he should have worn a gown. For the same resident’s subsequent wounds on the upper back and lower buttocks, the LPN donned a gown and gloves but again failed to change gloves between removing soiled dressings, cleansing wounds, applying skin prep, repositioning the resident, handling supplies, and repacking a wound. The facility’s PPE policy required changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and wearing gowns to protect exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Surveyors also found failures to follow enhanced barrier precautions and contact isolation requirements. For a resident on enhanced barrier precautions due to skin integrity issues and a diabetic foot ulcer, the wound nurse performed a dressing change and treatment to the diabetic foot ulcer wearing only gloves and no gown, despite an enhanced barrier precautions sign on the door specifying that gowns and gloves must be worn for high-contact care activities including wound care for any skin opening requiring a dressing. For another resident on contact isolation for an ESBL infection in a right lower extremity wound, a sign on the door instructed staff to wear gowns and gloves before room entry. A CNA entered the room twice to drop off bed sheets without wearing a gown or gloves, and the resident’s right lower leg dressing did not fully cover the toes, leaving a bleeding toe exposed. While one staff member stated gowns and gloves were only necessary for direct care, the Infection Preventionist stated that staff must wear gowns and gloves before entering the room, consistent with the facility’s transmission-based precautions policy requiring gown and glove use for contact precautions when interacting with the resident or potentially contaminated areas in the resident’s environment. The report also documented that the wound nurse who performed the wound care for the resident with sacral and coccyx pressure injuries did not have a current nursing license at the time of the survey. A license verification printout provided by the facility showed that this nurse’s license status was "not renewed," with an expiration date earlier in the year. This issue was cited separately under a different regulatory reference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate grooming assistance for a dependent female resident by not removing coarse facial hair from her chin. On multiple observations over two consecutive days, the resident was seen in her wheelchair, appropriately dressed and appearing clean, but with visible coarse chin hair approximately 1–2 inches in length that remained unshaved throughout the day. The resident’s Minimum Data Set (MDS) indicated she was dependent on staff for personal hygiene tasks, including shaving, and her care plan documented an ADL self-care performance deficit related to impaired balance, with restorative programming for dressing, grooming, and bed mobility. Her care plan interventions specified that she required staff assistance with bathing and showering. Record review showed that the resident’s shower schedule was twice weekly, on Wednesdays and Sundays, with shower sheets requiring staff to indicate whether facial hair was removed. The facility-produced shower sheets for several dates over the prior three months showed that facial hair was not removed on at least two documented shower days, and there were no shower sheets provided for several other scheduled shower days immediately preceding the survey observations. Progress notes for the prior 30 days contained no documentation of the resident refusing care. The Assistant DON/Infection Preventionist stated that residents are typically groomed or shaved on shower days and that female residents should not have facial or chin hair, adding that any refusal of grooming should be charted. The facility had a policy stating it would assist residents with grooming facial hair to maintain proper hygiene, but the observed and documented care did not reflect consistent implementation of this policy for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s failure to complete weekly measurements and comprehensive assessments of a resident’s diabetic ulcer as required by facility policy and the resident’s care plan. During observation, the resident was seen seated in his room while the wound care nurse removed the dressing from the bottom of his right foot, revealing a large, round, dark-colored area on the ball of the foot below the right great toe with raised edges. The wound care nurse stated the wound was a diabetic ulcer related to a bone deformity and that the resident went out to a podiatrist for wound care, but she did not have any wound notes or assessments for the resident and deferred to the ADON for the location of podiatry notes. The ADON later stated that wound documentation should be scanned into the electronic medical record and that staff should be monitoring and documenting the wound weekly using the wound observation tool, acknowledging that the lack of documentation was likely a mistake. Record review showed that weekly skin assessments over several months documented that the resident was being followed by a physician for a diabetic wound to the right plantar foot and that a treatment order was in place, but these assessments did not include measurements or descriptions of the wound. The podiatrist’s note, which the ADON produced, documented a full-thickness diabetic neuropathic ulcer on the bottom of the resident’s right foot, with specific post-debridement measurements, confirming the presence and severity of the wound. The resident’s diagnoses included type 2 DM with foot ulcer and vascular dementia, and physician orders directed daily betadine application and use of a post-op shoe. The resident’s care plan and the facility’s wound treatment management policy required monitoring and documentation of wound location, size, and characteristics, including measurements and detailed assessment, but the facility’s own documentation lacked these required elements for this resident’s diabetic ulcer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a safe environment and effectively implement fall-prevention interventions for a resident at high risk for falls. During breakfast observation, the resident was seated forward in a dining chair with her buttocks not against the back of the chair, prompting a CNA to instruct her to scoot back due to safety concerns. The resident was wearing slipper socks that were worn on the bottom, with holes forming and very few grip dots remaining. Upon further inspection, staff acknowledged that the grips were worn off and that it would be safer for the resident to have socks with grips. The resident’s fall risk assessment showed a high-risk score of 15, and the care plan identified her as at risk for falls related to deconditioning and dementia, with an intervention specifying nonslip footwear as tolerated. The DON stated that residents with high fall risk scores should have specific interventions on the care plan that are to be followed. The facility did not have a fall prevention policy and instead had only an Incidents and Accidents policy that applied after an incident occurred. The facility also failed to provide a safe mechanical lift transfer consistent with its own policies and the resident’s care plan. The resident, who had diagnoses including dementia, lack of coordination, Alzheimer’s disease, depression, anxiety disorder, hyperlipidemia, hypertension, hypothyroidism, and sepsis, was documented on the MDS as having severe cognitive impairment, requiring substantial/maximal assistance for rolling in bed, and being dependent for transfers. The care plan specified that the resident required assistance by two staff for transfers and used a mechanical lift. During observation, two CNAs brought the resident to her room for incontinence care, with the resident seated in a wheelchair and a mechanical lift sling under her. After attaching the sling to the lift, one CNA went into the bathroom, and the remaining CNA completed the mechanical lift transfer from wheelchair to bed alone, without assistance. The CNA later stated that facility policy requires two staff for mechanical lift transfers for safety, and the DON confirmed that the mechanical lift policy mandates two staff members—one to maneuver the lift and one to watch and guide the resident—when using a mechanical lift.

Penalty

Inspection fine: $118,360

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another cognitively impaired resident. Both individuals resided in the memory care unit and lacked the capacity to consent to sexual activity, as confirmed by medical documentation and staff interviews. The incident occurred when a CNA entered the resident's room and found both residents naked, with one resident standing over the other and engaging in thrusting motions. The CNA intervened and separated the residents, but the event was not immediately reported to the state, and there was confusion and inconsistency in the accounts provided by facility staff and administration regarding the nature of the incident. The administrator conducted an internal investigation but did not report the incident to the state, reasoning that no intercourse had occurred. Documentation of the incident, including risk assessments and family notifications, was incomplete or missing from the resident's chart. Staff interviews revealed that the normal protocol for documenting and assessing such incidents was not followed, and there was a lack of clarity and consistency in communication with the resident's family. Multiple staff members, including the CNA and LPN involved, expressed concerns about the residents' inability to consent and described the event as sexual abuse, yet the facility's response was delayed and inadequately documented. Further interviews with the resident, her family, and other staff indicated that the resident reported being raped and expressed distress about the incident. The medical director and psychiatric nurse practitioner confirmed the resident's inability to consent due to her cognitive status. The facility's staffing levels were also called into question, as only one CNA was present on the unit during certain shifts, limiting the ability to monitor residents effectively. The failure to protect the resident from abuse, promptly report the incident, and properly document and investigate the event constituted a deficiency and resulted in an Immediate Jeopardy finding.

Removal Plan

• R1 and R2 were immediately assessed for injury, changes in condition and psychosocial impact.
• R1 and R2 POAs, Police and MD were notified of the incident.
• R1 was sent to the ER for evaluation.
• R1 and R2 care plans were updated to reflect enhanced safety interventions.
• R1 and R2 had the Abuse, Neglect and Trauma assessment and Trauma Informed Care Assessment / PTSD was completed.
• The Social Services Director interviewed/assessed all residents with BIMS scores of 8 and above for potential abuse.
• All residents with a BIMs score of 7 or less were assessed using the Abuse Screening Adapted for Cognitive Impairment form.
• A hall monitor was added to the memory care unit to ensure no resident enters another resident's room.
• The Hall Monitor is a dedicated staff member and will have no other duties.
• R2 was immediately placed on a 1:1 until hall monitor was established.
• Abuse investigation procedure and documentation process were reviewed.
• DON, ADON, and Administrator re-educated all staff on facility abuse policies.
• DON, ADON, and Administrator educated all staff on the Intimate Resident Behavior, Privacy and Relationships policy updated to reflect residents within the memory care unit do not have the capacity to consent to sexual relationships.
• In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete.
• Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.
• DON, ADON, and Administrator educated staff on the Hall Monitor duties and responsibilities and that the Hall Monitor is a dedicated individual with no other responsibilities.
• Administrator was educated by Regional Nurse on abuse policy which includes thorough investigation immediately upon receiving report or allegation of abuse.
• Emergency QAPI meeting was held where the abuse policy and intimate relations policy were reviewed along with incident and root cause analysis.
• The Social Services Director or designee will continue to interview residents with BIMs score of 8 or higher on a monthly basis to ensure they have not experienced abuse.
• All residents with a BIMs score of 7 or less will be assessed using the Abuse Screening Adapted for Cognitive Impairment form.
• Any reports of abuse will be immediately reported and investigated.
• The finding to be presented to the Quarterly QAA Committee.

Penalty

Inspection fine: $118,360

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of sexual abuse involving residents with cognitive impairments. In one incident, a CNA entered a resident's room and observed two residents, both partially undressed, in a compromising position. The CNA reported the situation to a nurse, and the administrator later conducted an internal investigation. Despite the facility's policy requiring immediate reporting of all abuse allegations to state authorities, the administrator decided not to report the incident, reasoning that no intercourse had occurred. The administrator later acknowledged that the incident should have been reported, as any allegation is required to be reported and then investigated. The residents involved had significant cognitive impairments. One resident had diagnoses including dementia, sleep disorder, general anxiety disorder, and severe cognitive impairment as documented in the Minimum Data Set (MDS). The other resident involved in the incident had moderate cognitive impairment and similar diagnoses. The facility's own policy mandates reporting all alleged violations to the administrator, state agency, and other required agencies within specified timeframes, but there was no documentation that the Illinois Department of Public Health was contacted regarding the initial allegation or the results of the investigation. A review of prior incidents revealed another episode involving two cognitively impaired residents found together in a private room. Staff separated the residents and reported the situation to the nurse, who then informed the previous administrator. However, the administrator instructed staff not to document the incident in the residents' charts, and there was no evidence of an abuse investigation or reporting to authorities. Interviews with staff and review of facility records confirmed that no abuse investigations had been conducted in the last six months, despite these incidents.

Penalty

Inspection fine: $118,360

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate an allegation of abuse involving two residents with cognitive impairment in the memory care unit. In June 2025, a CNA discovered one resident in another resident's room and bed, with both residents present but clothed. The CNA immediately separated them and reported the incident to the nurse, who then informed the Administrator. However, the Administrator instructed the nurse not to document the incident in the residents' charts and indicated that Social Services would handle the situation. There was no evidence of a formal investigation, and no abuse investigation was initiated or documented for this incident. Interviews with staff and review of records revealed that key personnel, including the current Administrator and previous Social Services staff, were either unaware of the full details or could not recall the specifics of the event. The residents involved had diagnoses of dementia and demonstrated severe to moderate cognitive impairment, with one resident unable to consent for herself. The facility's policy required immediate investigation and thorough documentation of any suspected abuse, neglect, or exploitation, but this was not followed in this case.

Penalty

Inspection fine: $118,360

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's medical record contained complete and accurate information regarding an incident involving two residents in the memory care unit. According to the documentation, a social service note indicated that the residents were interested in a romantic relationship and were advised to spend time together only in public spaces, with both agreeing to this guidance. However, interviews with staff and the resident's power of attorney revealed that the actual incident involved the two residents being found together in bed, with conflicting accounts about whether they were clothed or unclothed. The note in the medical record did not accurately reflect the details of the incident as described by staff and the resident's family member. Further review showed that the LPN involved was instructed by the previous administrator not to document the incident in the residents' charts, and the previous social services staff could not recall specific details without her notes. The facility's policy requires that all assessments, observations, and care provided be documented accurately, objectively, and completely in the resident's medical record. The lack of accurate and complete documentation in this case resulted in a deficiency, as the medical record did not contain sufficient details about the incident or the residents' responses to care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and accident prevention for a resident at risk for elopement. The resident, admitted with a diabetic foot ulcer and cellulitis, had a documented history of elopement or attempted elopement at home. Despite this, the elopement evaluation did not identify risk factors or suggest interventions. Staff observed the resident attempting to leave the facility and placed a wander guard bracelet on him, but there was no clear documentation of who ordered or applied the device, and no corresponding assessment, care plan, or physician order was completed as required by facility policy. The resident was able to remove the wander guard and exit the facility in his wheelchair without staff knowledge. He traveled to a nearby gas station, crossing a highway with the assistance of bystanders, before being located and returned by staff and family. Interviews confirmed that staff were unaware of the resident's whereabouts until after he had left, and the incident was not immediately reported to the administrator. The resident was found without injury, but the lack of supervision and failure to follow established protocols for elopement risk contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent resident-to-resident physical abuse involving a resident with moderate cognitive impairment and mild intellectual disabilities. According to the comprehensive cognitive assessment, this resident required total assistance with transfers and had limited use of her right arm due to hemiplegia/hemiparesis. Incident investigation reports and interviews revealed that the resident stated her roommate had hit her "all over," although she denied being physically hurt. The roommate, who was independent with mobility and had a history of manipulative and rude behavior toward past roommates, denied hitting the resident but stated that if she did, it was unintentional. Documentation showed that the two residents were roommates until one was moved to another room, with the move attributed to roommate preferences and behavioral concerns. Staff interviews indicated that there were reports and gossip among staff about the alleged physical altercation, with some staff recalling hearing that one resident was on the other's bed and may have hit her. However, there was no documentation in the progress notes regarding the potential physical altercation or the behavioral incidents leading up to the room change. The facility's policy prohibits abuse, neglect, and exploitation, including physical abuse such as hitting, slapping, and punching, but the lack of documentation and follow-up on the reported incident demonstrates a failure to fully investigate and address the alleged abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of abuse involving three residents to the Abuse Coordinator as required by policy. One resident, who was moderately cognitively impaired and diagnosed with mild intellectual disabilities, consistently reported that a female CNA had thrown her against a wall, causing her to hit her head. The resident relayed this allegation to multiple staff members, including a hospice RN and an LPN, but the information was not reported to the Administrator or properly escalated internally. Staff interviews revealed confusion about the identity of the alleged perpetrator and a lack of clarity regarding reporting responsibilities. Internal reporting of the abuse allegation only occurred after the State Agency surveyor brought it to the Administrator's attention. Additionally, two other residents who were previously roommates were involved in an unreported incident where one resident allegedly hit the other. Staff members were aware of rumors or gossip about the incident, and one resident confirmed being hit by her former roommate, though she denied being physically hurt. There was no documentation in the progress notes regarding this potential physical altercation, and no internal report was made until the State Agency surveyor informed facility leadership. The facility's own policy requires immediate reporting of such allegations, but this was not followed in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from further potential abuse after the resident alleged that a night shift CNA had thrown her against the wall while assisting her to bed, causing her to hit the left side of her head. The resident reported the incident to multiple staff members, including a hospice RN, an LPN, and another CNA. Despite these reports, the alleged perpetrator, identified by the resident as a night shift CNA (though the name used was not found on the staff roster), continued to work primarily as the resident's CNA until resigning from the facility. The facility did not suspend the alleged perpetrator pending investigation, nor did they implement protective measures such as increased supervision or staffing changes as outlined in their abuse prevention policy. Multiple staff members failed to report the resident's allegations to facility administration as required. The hospice RN stated she reported the allegation to the ADON, who denied receiving it, and another CNA admitted to not reporting the allegation at all. The facility's policy requires immediate action to protect residents from further harm during abuse investigations, including examining the alleged victim and making staffing changes if necessary. However, these steps were not taken, and the alleged perpetrator remained in contact with the resident until her resignation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's representative after the resident experienced a fall with injury and was subsequently sent to a local hospital. The resident, who had diagnoses including unspecified dementia, malignant neoplasm of the head, face, and neck, and hypertension, was assessed as confused with severe cognitive impairment affecting all areas of judgment. The clinical admission assessment also noted wandering behaviors and incontinence. On the day in question, the resident had two falls: the first occurred while family was present in the building, and the second happened later that night after the resident was put to bed. After the second fall, the resident complained of left hip and knee pain and was sent to the emergency room. The LPN involved stated she believed she had notified the family but could not recall specific details and admitted uncertainty about whether the notification occurred. Interviews with the resident's daughters, who are also the resident's powers of attorney, revealed that they were not informed by the facility about the second fall or the transfer to the hospital. They only learned of the hospital transfer when contacted by the emergency room doctor regarding surgery for a fractured hip. Review of the resident's progress notes and incident reports confirmed that there was no documentation of family notification regarding the fall or hospital transfer. The facility's policy requires prompt notification of the resident's representative in the event of accidents resulting in injury or transfer, but this was not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and assess a pressure injury on a resident, which progressed to a Stage 3 pressure injury before any assessment or intervention was conducted. The resident, a female with multiple diagnoses including mild protein calorie malnutrition, intellectual disabilities, and cognitive communication deficit, was observed leaning to the left in her wheelchair over several days. Despite the presence of a wound on her left mid-back, no assessment was performed until a week later when the wound doctor identified it as a Stage 3 pressure injury. The wound was attributed to the resident's back rubbing against a metal bar on the wheelchair, and no pressure-relieving interventions were implemented until after the wound was assessed. The Director of Nursing confirmed that there was no documentation or care plan interventions initiated after the wound was discovered. The facility's policy requires prompt assessment and treatment of pressure injuries, but this was not followed. The resident's care plan had not been updated since May, and there was no documentation of the wound in the wound doctor's notes. The facility's failure to assess and document the wound promptly, as well as to implement necessary interventions, contributed to the deterioration of the resident's condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor and record both food and dishwasher temperatures, which are critical for ensuring sanitary conditions and preventing foodborne illnesses. The Dietary Manager, identified as V14, acknowledged that the dishwasher is a hot water sanitizer with a booster to reach temperatures up to 200 degrees. However, the dishwasher logs for September 2024 revealed gaps in temperature monitoring, with no records from September 6 to September 11 and on September 17. The facility's policy mandates that water temperatures be measured and recorded before each meal or after the dishwasher is emptied or refilled, but this was not consistently followed. Additionally, the facility did not consistently log food temperatures before serving meals. The Cook, identified as V16, stated that it is their responsibility to check and log food temperatures prior to serving. However, the food temperature log for the week of September 22, 2024, showed missing entries for dinner temperatures over the past two nights. The facility's policy requires that food temperatures be checked before serving and again after half of the meals have been served to ensure proper serving temperatures. These lapses in monitoring and recording temperatures for both food and dishwashing processes apply to all 90 residents residing in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safety of residents by not securing hazardous materials and not using proper transfer techniques. On the dementia unit, a shower room door with a keypad lock was found unlocked on multiple occasions, allowing access to hazardous liquids and disposable razors. These items, which included mouthwash, skin and hair cleanser, hand sanitizer, body lotion, baby powder, shaving cream, and a glass and surface cleanser, were labeled with warnings to keep out of reach of children. Staff acknowledged that the door should always be locked to prevent residents, who are known to wander and take items, from accessing these potentially dangerous supplies. Additionally, the facility did not use a gait belt during the transfer of a resident with a history of lack of coordination, hypertension, and obesity, who was at risk for falls due to deconditioning and gait/balance problems. During a toileting and peri care session, the resident was unsteady and required verbal cues to use a walker and transfer to a wheelchair. Despite the presence of a gait belt in the room, staff did not use it, which the Director of Nurses later confirmed was necessary for the resident's safety during transfers. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure privacy for a resident, R13, during physician appointments. R13, who is cognitively intact and has multiple diagnoses including spinal stenosis and difficulty walking, expressed that the transportation coordinator, V5, accompanied her into the doctor's office despite her requests for privacy. R13 stated that she asked V5 to remain in the lobby, but V5 insisted on accompanying her, citing responsibility for R13's safety. V5 claimed that no resident had ever requested privacy during appointments. The facility administrator, V1, acknowledged that residents who are alert and oriented, like R13, have the right to decide whether they want privacy during medical appointments. The facility's policy supports residents' rights to privacy in communications, both within and outside the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by the lack of physician orders and improper handling of oxygen and breathing treatment equipment. One resident, a female with acute respiratory failure and other chronic conditions, was observed receiving oxygen without a current physician order or a care plan for oxygen administration. The facility's policy mandates that oxygen therapy must be administered under a physician's order and that equipment should be changed weekly and stored properly to prevent contamination. However, the resident's oxygen tubing was not dated or stored correctly, indicating a lapse in adherence to these guidelines. Another resident, a female with acute respiratory failure and other health issues, had an oxygen tank attached to her wheelchair with undated tubing that was not stored in a plastic bag, as required. Additionally, the oxygen concentrator in her room had a nasal cannula lying on the floor, also undated and improperly stored. A third resident, with asthma and other chronic conditions, had a breathing treatment machine with tubing that was not dated or stored in a bag. The LPN administering treatments was unaware of the tubing's age or the need for proper storage, further highlighting the facility's failure to follow its own infection control policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer two doses of an ordered antibiotic to a resident, identified as R32, who was reviewed for hospitalization. R32, a male resident with a history of urinary tract infection, multiple sclerosis, neuromuscular dysfunction of the bladder, calculus of the kidney and ureter, and chronic obstructive pulmonary disease, was diagnosed with sepsis likely sourced from a urinary tract infection, osteomyelitis, and infected decubitus ulcers. After a 14-day hospital stay, R32 returned to the facility with a discharge order to receive amoxicillin 500 mg by mouth three times a day for eight days. However, the facility's records showed that the amoxicillin was not administered on the evening of his return or the following morning. The Director of Nursing acknowledged that there was no excuse for the missed doses, as the facility had amoxicillin available in their stock drug convenience box. The facility's Medication Administration Policy requires medications to be administered by a licensed nurse as ordered by the physician and in accordance with professional standards of practice. Despite this policy, the failure to administer the antibiotic as ordered represents a deficiency in the facility's pharmaceutical services, impacting the resident's care and treatment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper use of personal protective equipment (PPE) to prevent cross-contamination for two residents within the sample and one resident outside the sample. Specifically, residents R71 and R72 were under modified droplet precautions due to COVID-19, requiring the use of N-95 masks, eye protection, gowns, and gloves by anyone entering their room. Despite clear signage indicating these requirements, staff members V11 and V13 entered the room wearing only surgical masks, failing to don the necessary PPE. This occurred during multiple interactions, including delivering meals and engaging in close contact with the residents. Additionally, resident R84 was on enhanced barrier precautions due to a wound on his left foot, necessitating the use of gloves and gowns during high-contact care activities such as transfers and toileting. However, staff members V11 and V12 only wore gloves while performing these activities, neglecting to wear gowns as required. The facility's policies clearly outlined the PPE requirements for both COVID-19 precautions and enhanced barrier precautions, yet these were not adhered to by the staff, as confirmed by the Administrator/Infection Control Preventionist.