Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Care Aledo during CMS and state inspections, most recent first.
The facility failed to label opened refrigerated and frozen food items with expiration dates, keep a kitchen freezer free of spills, and document required meal food temperatures. During a kitchen tour, surveyors found an unlabeled, undated package of frozen precooked pork ribs and a large liquid spill in the freezer, both confirmed by the DM. Review of food temperature logs also showed missing supper meal temperatures on two dates, which the DM verified.
Infection control failures involved missed infection tracking, missing PPE in isolation rooms, and staff not following isolation and hand hygiene requirements. A resident with an indwelling catheter and another with wounds were not properly managed under EBP, a resident with Candida auris was placed on contact isolation but CNAs provided care without gowns, and during incontinence care for a resident who was always incontinent, a CNA touched the resident and belongings with soiled gloves before removing them and performing hand hygiene.
Infection preventionist duties were not adequately carried out to support infection surveillance and control. Staff entered a resident’s Contact isolation room without gowns, PPE was not available in an EBP room, and a CNA performed incontinence care on a resident while continuing to touch the resident and room items with soiled gloves without hand hygiene. The LPN/ICP stated the facility was not tracking resident or employee infections, was not placing wounds in EBP, and could only devote about 12 hours a week to infection control.
Dirty and damaged room conditions were found for multiple residents. A cognitively intact resident had tattered bedspreads with holes, a heavily stained toilet, and an over-bed table covered in dried food and dirt, while staff said the toilet had been stained for years and the table may not have been cleaned over the weekend. Other resident rooms had loose baseboard trim, peeling window paint, and large holes in the wall, and the MDS and staff observations confirmed the conditions.
Failure to Prevent Resident-to-Resident Physical Abuse: Two residents with dementia-related behavioral concerns were involved in an altercation when one resident became angry and grabbed the other by the neck, leaving a red mark and fingernail indentation. Staff separated the residents and documented the incident as resident-to-resident abuse; the affected resident had dementia/Alzheimer’s disease and a history of wandering and aggressive behaviors, while the other resident had dementia, schizoaffective disorder, bipolar disorder, and poor impulse control.
A resident with dementia, Parkinson's disease, agitation, and anxiety was prescribed multiple psychotropic meds, including PRN and scheduled injectable Haldol, but the record did not document behaviors or a diagnosis to support the scheduled antipsychotic use. The care plan did not identify target behaviors for Haldol, nursing notes did not justify the order, the first psychotropic observation was delayed, and staff and family reported the resident mainly yelled out and had no other current behaviors. The DON confirmed the resident had duplicative psychotropic meds and that the PRN Haldol order continued beyond the 14-day limit without justification or a new order.
Failure to assess ROM limitations and provide restorative ROM programs for two residents. One resident with CVA-related hemiplegia/hemiparesis had severe cognitive impairment, flaccid right arm and leg, and no restorative ROM program despite MDS-documented ROM impairment and total ADL dependence. Another resident with dementia and Parkinson's disease was fully dependent, non-ambulatory, and had no documented ROM program or plan to prevent decreased ROM/contracture; staff stated no ROM programming was in place and assessments were based mainly on diagnoses.
Failure to maintain fall precautions and assess elopement risk: A resident with a history of falls was observed in bed with the call light out of reach on two occasions, despite a care plan directing staff to keep it within reach. Another resident with dementia, altered mental status, and wandering behaviors was identified as an elopement risk/wanderer in the care plan, but no elopement/wandering risk assessment was found in the chart, and the DON confirmed none had been completed.
Failure to Assess, Consent, and Care Plan for Side Rail Use: The facility failed to complete side rail assessments, try alternatives, obtain informed consent, or develop care plans addressing side rail-related risks for two residents. One resident with severe cognitive impairment was observed in bed with a half side rail raised and no documentation of assessment, consent, or care planning; another resident with paraplegia had side rails in use, including one broken rail on the floor, with no documented alternatives tried and no care plan addressing the risks.
Medication Given Without Current Order: An agency nurse administered valproic acid to a resident despite no current physician order and despite discharge instructions stating not to give the medication because it caused the resident’s confusion. The resident had recently been hospitalized for drug-induced encephalopathy and hyperammonemia due to valproic acid, and the DON later confirmed the medication was not to be given.
An LPN was observed storing three residents’ opened Lantus insulin pens in a medication cart drawer without the date opened. The facility’s policy required opened meds with shortened expiration dates to be dated, and the DON stated multi-dose insulin vials and pens should be labeled when opened and are only good for 28 to 30 days after opening.
Missing Bed Rail Maintenance Inspections: Maintenance inspections and assessments were not completed for three residents with side rail use. Two residents were observed in bed with half side rails raised against beds positioned by the wall, and one resident had a broken half side rail lying on the floor behind the bed. EHRs for all three residents lacked maintenance assessments of the side rails, and the Maintenance Director stated no side rail inspections or assessments had been done within the last year.
A resident entered the dining room and made a provocative statement while walking past three other residents, leading to a loud altercation in which all parties yelled profanities and one resident directed derogatory language and threats such as “I’ll beat your ass” and “nobody wants your man” toward another. Staff, including a housekeeper and an LPN, witnessed the resident moving toward another in a threatening manner and intervened to separate them. Subsequent interviews with multiple residents described a pattern of this resident frequently yelling, talking loudly, and making threats, including threats to have another resident beaten up and to shoot him. One resident reported not feeling safe due to being housed next to the aggressive resident with a shared bathroom, and an LPN identified the incident as verbal abuse under the facility’s own abuse policy.
A resident with dementia, known wandering behavior, and a history of falls was allowed to remain near unit doors despite prior incidents of being struck by those doors. While a dietary cook was bringing in a lunch cart, the resident was standing behind the double doors and was hit when the doors were opened, resulting in a fall and subsequent right femur fracture with hip dislocation. After the fall, the cook and a CNA manually lifted the resident from the floor into a wheelchair without a gait belt or mechanical lift and before an RN/LPN assessment, contrary to the facility’s transfer policy requiring mechanical lifts for residents needing a two-person assist or who cannot be safely transferred by normal technique.
A resident with dementia fell when a dietary staff member opened double doors into the hallway where the resident was standing, causing a change of plane and resulting in the resident landing on the floor with right-sided discomfort. The dietary staff and a CNA then lifted the resident from the floor, stood her up, and placed her in a wheelchair without using a gait belt and before any nurse could perform a post-fall assessment. The LPN later found the resident already in the wheelchair and stated the resident had been moved before she could assess for possible injuries. The DON reported that facility practice requires a nurse to assess a resident after a fall, including ROM, pain, and vital signs, and that residents should not be moved prior to this assessment, consistent with the facility’s fall prevention policy.
Failure to Protect Residents from Abuse: An RN verbally abused one resident by cursing and delaying toileting help, then later verbally abused another resident by yelling and cursing when he needed the restroom. The facility also had multiple resident-to-resident physical abuse incidents, including hitting, punching, and an open-hand strike, and an agency CNA was reported to have been rough during cares and hurt a resident’s wrist. The report states these events were not properly prevented and resulted in Immediate Jeopardy.
A resident was left waiting for toileting help after asking an RN for bedpan assistance, and the RN reportedly used profanity and said staff were busy with other residents. After no help arrived for hours, the resident urinated into an emesis basin and later told an LPN she felt humiliated. The AIT stated the RN should have assisted the resident when requested and called the situation unacceptable and a violation of resident rights.
Failure to Properly Investigate and Respond to Abuse Allegations: Facility leadership did not consistently identify or handle two allegations of verbal abuse involving the same RN as abuse. One resident reported the RN cursed at her and refused toileting help, and another resident reported the RN yelled, used profanity, and pushed him in his wheelchair while he needed the restroom. Both events were classified as misconduct rather than abuse, and no changes were made to prevent repeat occurrences.
Failure to provide timely toileting assistance occurred for two residents who were dependent on staff for ADL support. One resident with MDD and acute pain requested a bedpan and was told staff were busy; help was delayed for hours, and the resident used a container as a bedpan. Another resident with cerebral ischemia, DM2, and a fractured femur asked to use the restroom, but the RN delayed assistance, pushed the resident’s wheelchair away from the dining room, and left him waiting until he had urinated on himself. The AIT confirmed the RN should have assisted both residents with toileting.
A resident with multiple chronic conditions was not assessed for fall risk as required by facility policy, with no documented fall risk assessments completed for several consecutive quarters. This lapse was confirmed by both the DON and a regional RN after the resident sustained a hip fracture from a fall.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Multiple residents with cognitive impairment and behavioral issues were not adequately protected from physical abuse by peers, resulting in altercations and injuries. In one case, a resident was left suspended in a mechanical lift by a staff member, who was observed yelling and using the lift to control the resident's movements. Staff interviews and facility documentation confirmed that supervision and intervention were insufficient, and that the actions taken did not meet expected standards of care.
The facility failed to maintain cleanliness on the tops of stationary kitchen equipment next to food preparation areas. During a kitchen tour, it was observed that the tops of the upright refrigerator and freezer were covered with dirt and debris. The Dietary Manager confirmed that these surfaces should have been cleaned, acknowledging the role of ventilation and air movement in the accumulation of dirt. This deficiency could potentially affect all 38 residents in the facility.
The facility failed to keep the lids of outdoor trash dumpsters closed and secure, allowing potential access by pests and animals. This was observed during a kitchen tour with the Dietary Manager, who confirmed the lids should be closed. The deficiency could affect all 38 residents in the facility.
The facility failed to use standardized diagnosing tools for infections, as required by their Antibiotic/Antimicrobial Stewardship Program. Infection control logs lacked set standards for diagnosing infections, affecting all 38 residents. An LPN/Infection Preventionist acknowledged the absence of tools like McGeer's or Loeb's and planned to implement them. The Medical Director and DON were responsible for setting standards, but this was not adhered to, leading to the deficiency.
The facility failed to justify the use of psychotropic medications for several residents and did not attempt a Gradual Dose Reduction (GDR) for a resident, despite policy requirements. One resident was on Quetiapine without documented behaviors necessitating its use, while another resident's care plan lacked specific behaviors justifying antipsychotic medication. Additionally, a resident on Venlafaxine and Aripiprazole had no documented harmful behaviors, yet no GDR was attempted. The facility's Director of Nursing confirmed the lack of documentation for GDR attempts.
A resident requiring a mechanical lift for transfers was incorrectly transferred using a stand pivot method, leading to a near fall and a broken toe. The facility failed to assess the resident's transfer needs properly, resulting in an injury due to inadequate supervision and accident prevention.
A facility failed to assess and identify triggers for a resident with PTSD, as required by their Behavioral Health Services Program policy. The resident, who also has dementia and psychotic disorder, was not provided with a care plan identifying specific environmental factors triggering their behaviors. Despite the need to gain the resident's trust for background stories, no comprehensive PTSD assessment was completed, and the care plan lacked individualized interventions.
The facility failed to prevent physical abuse between two residents in the Memory Care Unit. On two occasions, one resident approached and struck another, leading to altercations. Staff intervened promptly, and no injuries were noted. Both residents had severe cognitive impairments.
The facility failed to prevent resident-to-resident abuse between two residents in the Memory Care Unit. Despite multiple altercations, effective interventions were not implemented. R2's room was moved, but this did not prevent further interactions with R1. R1 was placed on 15-minute checks instead of 1:1 monitoring, and R1's transfer to a non-secure unit was unsuccessful. No interventions were in place after R1's return to the Memory Care Unit, leaving R2 vulnerable.
A facility failed to notify a physician and obtain treatment orders for a resident with burns and did not investigate or implement fall interventions for two high-risk residents. One resident had untreated burns from spilled hot tea, and both residents experienced multiple falls without proper follow-up or new interventions. The facility lacked a system to track and monitor falls, contributing to inadequate care.
A nurse aide was employed full-time and provided direct care without completing a state-approved training and competency evaluation program. Initially hired as a housekeeper, the aide transitioned to a CNA role but did not pass the required skills competency portion. This oversight affected all residents in the facility.
Two residents at a facility, both identified as high risk for falls, experienced multiple falls due to inadequate supervision and failure to implement necessary interventions. One resident, with severe dementia, suffered a head laceration and hematoma after being left unattended without non-skid footwear. Another resident, with a history of weakness and recent fractures, sustained serious injuries including a fractured hip and pelvis after falling in an unsupervised dining room. Staff shortages and failure to adhere to care plans contributed to these incidents.
A resident with a history of fractures was readmitted to the facility and had an open area on the left buttock noted during the initial skin assessment. The facility failed to document the pressure wound, notify the physician, or obtain treatment orders as required by policy. The wound was later discovered by an LPN, who found a heavily soiled bandage and confirmed no prior assessment or treatment orders were completed.
A resident with severe dementia and anxiety did not receive prescribed Alprazolam due to unavailability, leading to increased agitation. The facility's policy requires documentation of omitted doses, but none was provided. The DON confirmed the medication was not ordered or delivered, and alternative sources were not utilized.
A resident with MRSA in her leg wound was not administered a prescribed antibiotic, Linezolid, in a timely manner after returning from the hospital. The medication was delivered late, and the first dose was given 35 hours after the last hospital-administered dose, contrary to the facility's Medication Administration Policy.
A resident's physician-ordered lab tests were not collected on time, leading to a rescheduled appointment with an infectious disease physician. The DON confirmed the tests were delayed due to a lack of awareness and repeated failures by the lab to process the orders, despite multiple follow-up calls by a nurse.
The facility failed to label residents' clothing in a dignified manner, using black markers that bled through and smeared on the fabric, affecting the quality and readability of the labels.
The facility failed to address and resolve multiple resident grievances, including issues with missing laundry, call light response times, maintenance requests, and transportation. The Resident Council President reported that residents do not receive feedback on their complaints, leading to repeated unresolved issues.
The facility failed to post the daily direct care staff hours and resident census, potentially affecting all 44 residents. The DON was unaware of the requirement and had not posted the data since starting in March 2024. Subsequent checks also found no posted data, and no policy on staff posting was provided by the time of the Exit Conference.
The facility failed to maintain clean kitchen equipment, properly date cooked food items, and monitor and record required temperatures and sanitation levels. These deficiencies were observed during a survey, with missing logs and undated food items noted. The kitchen staff confirmed these lapses, potentially affecting all 44 residents.
The facility failed to place appropriate signage for transmission-based precautions for a resident with MRSA and lacked interventions and documentation for Legionella management. The Infection Control Plan and QAPI Agenda did not include a Legionella prevention policy, potentially affecting all residents.
The facility failed to implement an antibiotic stewardship program, including assessing and monitoring residents for infections, ensuring appropriate antibiotic usage, and using recognized surveillance criteria. The DON/ICP did not formally track or document infection control practices or conduct reports, affecting all 44 residents.
The facility failed to designate a qualified infection preventionist responsible for the Infection Prevention and Control Plan. The designated Infection Preventionist, who was also the DON, had not completed the required specialty training. This deficiency has the potential to affect all 44 residents in the facility.
The facility failed to offer and document required immunizations for five residents, as per their policy. The records for these residents lacked documentation for influenza and/or pneumococcal vaccinations, and refusals were not properly recorded.
The facility failed to ensure the memory care unit had warm water and was clean and free of odors for 19 residents. Observations revealed pungent urine odors, sticky floors, and debris in several rooms. Staff confirmed the lack of hot water for about a year, and maintenance issues were not addressed due to high repair costs. The facility's policies on water temperature monitoring and housekeeping were not followed.
An LPN was observed pre-popping medications and storing them in medication cups labeled only with residents' first names, contrary to facility policy. The DON confirmed that medications should be administered immediately after verification.
The facility failed to notify the Ombudsman monthly of a resident transfer to the hospital and did not provide the resident and their representative with a written notice of transfer. The Social Services Director confirmed these omissions.
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. The Social Services Director confirmed that neither the resident nor the resident's representative received the required bed hold policy or written notice of transfer.
The facility failed to monitor a physician's order for self-catheterization and did not update a resident's care plan to reflect self-catheterization needs. The resident, diagnosed with Hereditary Spastic Paraplegia and Neurogenic Bladder, had a physician's order for self-catheterization that was not included in the current Physician Order Sheet, and the care plan lacked documentation addressing these needs. A lab test showed the resident had a UTI with Escherichia Coli. The DON confirmed the missing documentation.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure opened refrigerated and frozen food items were labeled with expiration dates, a kitchen food storage freezer was kept free from spills, and required meal food temperatures were obtained and recorded. During an initial kitchen tour with the Dietary Manager, surveyors observed an unlabeled, undated package of frozen precooked pork ribs in the freezer and a large green/yellow liquid food spill on the bottom of the same freezer. The Dietary Manager confirmed both the unlabeled meat and the spill. Surveyors also reviewed the facility kitchen Food Temperature Logs and found that no required food temperatures were documented for the supper meal on 5/8/26 and 5/9/26, which the Dietary Manager verified. The facility CMS Form 671 dated 5/11/26 documented that 43 residents resided in the facility.
Infection Control Failures With Isolation, PPE, and Hand Hygiene
Penalty
Summary
The facility failed to ensure resident and employee infections were monitored and tracked, failed to place residents in isolation precautions when required, failed to keep PPE available in isolation rooms, and failed to ensure staff wore PPE during direct resident care and removed gloves and performed hand hygiene during incontinence care. The Infection Prevention and Control Program policy stated the facility would maintain a log of suspected and actual infections on a day-to-day basis, but the Infection Control Preventionist stated the facility was not tracking resident or employee infections and did not have records showing infection patterns, locations, or employee illness tracking. R4 had an indwelling urinary catheter and was on enhanced barrier precautions, but the room contained a sign for EBP and no gowns were available in the room. A licensed practical nurse stated she was unsure where PPE was kept and assumed it would be in the room. The Infection Control Preventionist later confirmed R4 should have gowns and gloves in the room, and also found that R47, a new admission with an intravenous line, should have been on EBP but had no sign or PPE in the room. The same staff member confirmed R18 had ongoing active wounds and pressure ulcers and was not in EBP, stating wounds had not been placed in enhanced barrier precautions. R40 was admitted with diagnoses including intraspinal abscess and granuloma, paraplegia, acute osteomyelitis, respiratory failure with hypoxia, and spinal stenosis, and had an indwelling urinary catheter, multiple wounds, and contact isolation for Candida auris. Although the doorway sign directed staff to wear gloves and gowns before room entry, two CNAs entered, washed hands, and applied gloves but did not wear gowns while giving a bed bath and catheter care. In another event, two CNAs provided incontinence care to R3, who was dependent for toileting and always incontinent of urine, and one CNA touched the resident and the resident’s belongings with soiled gloves after wiping stool and urine, then continued care and handling of items before removing the gloves and performing hand hygiene.
Infection Preventionist Duties and Surveillance Not Adequately Implemented
Penalty
Summary
The facility failed to ensure that the infection preventionist duties were implemented to provide infection surveillance and that infection preventionist hours were adequate to oversee infection control and infection prevention policies and procedures. The Infection Preventionist job description states the role is to oversee the infection prevention and control program for surveillance, investigation, prevention, and control of healthcare-associated infections and other infectious diseases, including tracking and trending infections, infection control rounding and observations, and regulatory compliance. The facility assessment and infection prevention and control program policy also state that infections, antibiotic usage, and antibiotic monitoring are tracked by the Infection Preventionist and interdisciplinary team, and that suspected and actual infections are to be recorded and maintained on a day-to-day basis. On observation, R40’s room had a sign indicating Contact isolation, but two CNAs entered and provided a bed bath and indwelling urinary catheter care without applying a gown. R4’s room had an enhanced barrier precautions sign, but no gowns were available for staff to wear when caring for the resident. During urinary incontinence care for R3, after cleaning the resident’s genitals, a CNA continued touching the resident’s wrist and multiple items in the room with soiled gloves without removing the gloves or performing hand hygiene. A LPN stated she was unsure where PPE was kept for residents in isolation. Record review and interview also showed that R18 had pressure wounds that received treatments, but the room did not contain a sign or PPE to indicate isolation or enhanced barrier precautions. V19, identified as the LPN/Infection Control Preventionist, confirmed that R47 had an intravenous line and should have been in enhanced barrier precautions, but there was no sign or PPE in the room. The infection control binders did not document tracking logs, trending, or monitoring with location tracing for resident and employee illness. V19 stated the facility was not tracking resident or employee infections to identify patterns or locations, did not have employee illness tracking, had not been putting wounds in enhanced barrier precautions, and was only able to devote about 12 hours a week to infection control.
Dirty and Damaged Resident Room Conditions
Penalty
Summary
The facility failed to keep resident rooms and equipment clean and in good repair for three residents reviewed for a safe, clean, and homelike environment. The report states that R40, who was cognitively intact, was observed lying in bed with two tattered bedspreads with multiple holes and frayed edges. R40's toilet bowl had a thick brownish-black stain on the bottom half, and the legs of the over-bed table were covered with thick dried food and dirt debris. R40 stated, "Things are pretty dirty here." A CNA stated the toilet bowl had been stained for years, another CNA said the bedside table legs were "nasty," and the Housekeeper and Housekeeping Supervisor acknowledged the toilet stain and that the over-bed table may not have been cleaned over the weekend. The Maintenance Director also stated the toilet would need to be replaced. The report also documents environmental damage in other resident rooms. In R6's room, three to four feet of rubber baseboard was coming off the wall under the air unit, and the window trim had several spots of chipping paint around the window; the Maintenance Director confirmed the loose trim and peeling around the window. In R23's room, there were two large holes in the wall behind the bed, and the window had peeling paint around the trim; the Maintenance Director confirmed both the holes and the peeling paint. The facility's job descriptions state housekeeping and maintenance are responsible for keeping the facility clean, safe, comfortable, and in good repair, and the daily housekeeping schedule states table trays and legs should be wiped down daily.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse when one resident grabbed another resident by the neck, leaving a small red mark and fingernail indentation. The facility’s abuse policy states that resident-to-resident altercations that include any willful action resulting in physical injury, mental anguish, or pain must be reviewed as potential abuse, and this incident was investigated as resident-to-resident abuse. According to the investigation, one resident was in a wheelchair in a common area near the hallway talking to herself when another resident walked by, became angry, yelled at her, and quickly grabbed her by the neck with his left hand. Staff separated the residents immediately and assessed the resident who was grabbed. The progress note documented red marks and a small fingernail indentation, with no skin breakage, and the resident denied pain or discomfort and was able to turn her neck. The resident who was grabbed had dementia and Alzheimer’s disease with late onset, could not complete a BIMS, and had care plan documentation noting a high risk for abuse/neglect and behaviors including hitting, grabbing, pushing others, cursing, unprovoked anger, wandering, and agitation. The other resident had dementia, paranoid personality disorder, schizoaffective disorder, and bipolar disorder, with care plan documentation noting potential for physical aggression and poor impulse control. Staff interviews confirmed they were instructed to keep the two residents separated and monitor for signs of pain or bruising, and the DON confirmed resident-to-resident abuse occurred.
Psychotropic Medication Use Not Supported by Documented Behaviors
Penalty
Summary
The facility failed to document a diagnosis and behaviors to support the use of scheduled injectable Haldol for one resident with dementia, Parkinson's disease, agitation, and anxiety. The resident's orders included Depakote, PRN injectable Haldol for agitation/delirium related to dementia with agitation, scheduled injectable Haldol at bedtime for agitation, Trazodone for mood, and Xanax twice daily plus at bedtime for anxiety, restlessness, and agitation. The resident's care plan stated the resident used psychotropic medications related to dementia, but it did not address Haldol or identify the resident's specific target behaviors for psychotropic use. The resident's record did not show behavior documentation supporting the addition of scheduled Haldol. Nursing progress notes before the scheduled Haldol order did not document behaviors, a reason for the new scheduled Haldol, or justification for continuing PRN Haldol. The first psychotropic medication observation after Haldol was started was completed more than a month later and described the resident as having confused mental status, memory impairment, abnormal thinking, agitation, mood swings, and outbursts, while also listing six psychotropic medications for dementia, agitation, restlessness with agitation, and anxiety. The resident was observed by surveyors sitting quietly in a reclined wheelchair, mumbling incoherently, with uncontrolled tremor-like movements, but not displaying disruptive behaviors. Staff and family statements further showed that the resident's behaviors were limited and not consistently documented. The family member stated the resident did not have behaviors anymore and that he was wheelchair bound and fully dependent. CNAs stated the resident mainly yelled out, sometimes randomly or when bumped, and that his behaviors had decreased. The DON confirmed the resident's main behavior was yelling, that dementia and yelling were not psychotic in nature, that the resident had duplicative psychotropic medications for dementia with agitation, and that nursing staff were not using the behavior charting tasks properly. The DON also confirmed the PRN Haldol order exceeded 14 days without justification or a new order.
Failure to Assess ROM Limitations and Provide Restorative ROM Programs
Penalty
Summary
The facility failed to accurately assess residents' limitations in range of motion and failed to develop and implement restorative ROM programs for two residents reviewed for ROM limitations. The facility's Restorative Nursing Program policy stated that it is intended to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible, and that residents with splints/braces, previous ROM programs, or actual or potential ROM limitations and/or pain should be identified and given an individualized restorative program included on the care plan. One resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, aphasia following a cerebral infarction, major depressive disorder, and hypertension. The MDS documented severe cognitive impairment, ROM impairment to one upper extremity and one lower extremity, dependence for ADLs, and no restorative ROM program. On observation, the resident's right arm and right leg were flaccid. A CNA stated she was not aware of the resident receiving therapy or ROM exercises, and the care plan coordinator stated the resident did not have a restorative ROM program and the facility did not currently have a restorative nurse to develop one. Another resident with dementia, Parkinson's disease, TIA, restlessness with agitation, impaired balance, and total dependence for ADLs had an MDS showing a lower extremity impairment, dependence for sitting, rolling, hygiene, dressing, and transferring, and no walking due to condition. The current record did not document a program to address ROM limits or prevent decreased ROM and contracture. The DON stated there was no ROM programming for this resident, and the care plan coordinator stated she usually based ROM impairment assessment only on diagnoses.
Failure to Maintain Fall Precautions and Assess Elopement Risk
Penalty
Summary
The facility failed to ensure fall precaution interventions were in place for a resident with a history of falls. R29’s admission record showed a diagnosis of cerebral infarction, and the most recent fall assessment dated 4/5/26 identified the resident as at risk for falls. The MDS dated 4/17/26 documented that R29 required substantial/maximal staff assistance for all transfers, was always incontinent of bowel and bladder, and had a history of falls. The care plan identified R29 as at risk for falls and directed staff to keep the call light within reach and encourage use for assistance. However, on 5/11/26 at 10:29 AM and again at 1:13 PM, R29 was observed sleeping in bed with the call light out of reach and lying on the floor. At the second observation, a CNA confirmed R29 had a history of falls and that the call light was on the floor. The facility’s fall investigation reports also documented multiple prior falls in R29’s room. The facility also failed to assess and implement interventions for a resident with exit-seeking behaviors. R6’s MDS showed moderately impaired decision-making, poor decisions, and a behavior score indicating wandering one to three days per week. R6’s care plan documented dementia, altered mental status, and that the resident wandered into other residents’ rooms and personal spaces, identifying R6 as an elopement risk/wanderer. Despite this, there was no Elopement/Wandering Risk Assessment in the chart. On 5/12/26, the DON confirmed that no Elopement/Wandering Risk Assessments had been completed for R6.
Failure to Assess, Consent, and Care Plan for Side Rail Use
Penalty
Summary
The facility failed to assess and identify entrapment risks associated with the use of side rails, attempt alternatives before installing side rails, develop a care plan addressing side rail use and related risks, and obtain consent before side rail use for two residents reviewed for side rail use. The facility policy dated 12/25 states that alternatives must be attempted before bed rails are installed, the resident must be assessed for entrapment risks and possible benefits, informed consent must be obtained, and the care plan must address complications related to bed rail use. R21, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, aphasia, major depressive disorder, and hypertension, had an MDS showing severe cognitive impairment. The electronic record did not include a side rail assessment, alternatives tried, consent, or a care plan for side rail use. Surveyors observed R21 in bed with a half side rail raised on the left side while the bed was positioned against the wall, and V16, the Care Plan Coordinator, stated that no entrapment risk assessment, alternatives, consent, or care plan had been completed. R40, who was admitted with intraspinal abscess and granuloma, paraplegia, acute osteomyelitis to the right ankle and foot, respiratory failure with hypoxia, and spinal stenosis, had a siderail assessment noting risks of decline in function, ADLs, mobility, and bowel and bladder function, with a final recommendation that side rails were indicated to promote mobility and independence. However, the record did not document alternatives tried before side rail installation, and the care plan did not address risks associated with side rail use. Surveyors observed R40 in bed with a half side rail raised on the left side and another half side rail lying on the floor behind the head of the bed; R40 stated the rail on the floor had broken off and had not been fixed. V2, the DON, stated that R40 was supposed to have two half side rails for mobility and positioning, that no alternatives had been tried before side rail use, and that there was no care plan with interventions to address the risks associated with the side rails.
Medication Given Without Current Order
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident, R7, who was reviewed for medication administration. The facility’s Medication Administration policy dated 01/2026 required medications to be given in accordance with a physician’s order and the right resident, right medication, right dosage, right route, and right time. R7 had been readmitted after hospitalization for metabolic encephalopathy, and nursing progress notes dated 4/29/26 documented left-sided weakness, altered mental status, unsteady gait, and generalized weakness, after which the physician was notified and R7 was sent to the local emergency room. R7’s hospital discharge instructions identified drug-induced encephalopathy, specifically acute metabolic encephalopathy due to valproic acid encephalopathy, and hyperammonemia due to valproic acid. The discharge orders stated, “Please do not give (R7) Valproic Acid because it is the cause of his confusion.” The May 4-May 31, 2026 physician order summary did not include a current order for valproic acid, yet on 5/12/2026 at 8:37 A.M. an agency nurse prepared 2 tablets of valproic acid 500 mg delayed release with nine other medications and handed the medication cup to R7, who swallowed all the medications with water. At 9:40 A.M., the DON confirmed that R7 did not have a current physician order for valproic acid and was not to receive it due to the recent metabolic encephalopathy brought on by valproic acid.
Undated insulin pens stored in medication cart
Penalty
Summary
The facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for three residents, R22, R29, and R35, during review of medication storage and labeling practices. The facility’s Medication Storage Policy dated 12/25 states that staff should record the date opened on medication containers when the medication has shortened expiration dates once opened. On 5/11/26 at 9:30 AM, an LPN was observed at the North and Short Hallway medication cart where the residents’ multi-dose insulin injector pens were stored. In the top drawer, R22’s opened 1/3 full Lantus Insulin 100 u/ml injector pen, R29’s opened 1/4 full Lantus Insulin 100 u/ml injector pen, and R35’s opened 1/3 full Lantus Insulin 100 u/ml injector pen were all not labeled with the date when opened. The LPN stated she only worked there as needed and did not know why the insulin pens were not dated, and stated that all insulin pens should be labeled with the date they are opened. The DON later stated that all multi-dose insulin vials and pens should be labeled when opened and are only good for 28 to 30 days after opening.
Missing Bed Rail Maintenance Inspections
Penalty
Summary
Failed to conduct regular maintenance inspections as part of a maintenance program to identify possible bed entrapment areas for three residents reviewed for side rail use. The facility policy dated 12/25 states that bed rails and mattresses must be properly installed and maintained, and that the mattress and bed rails should be inspected regularly for areas of possible entrapment. The Maintenance Director job description dated 5/26 states the Maintenance Director is responsible for maintaining the facility in a safe and comfortable manner and making weekly inspections of maintenance functions. On 5/11/26, R21 was observed lying in bed with a half side rail raised on the left side; the bed was positioned against the left wall, and R21 was confused with mumbled speech. R21's EHR from 5/11/25 through 5/12/26 did not include a maintenance assessment or evaluation of the side rails. On 5/12/26, R35 was observed lying in bed with a half side rail raised on the left side and the bed positioned against the left wall; R35's EHR from admission on 4/25/25 through 5/12/26 did not include a maintenance assessment or evaluation of the side rails. R40's EHR from admission on 3/5/26 through 5/11/26 also did not include a maintenance assessment or evaluation of the side rails. On 5/11/26, R40 was observed with a half side rail raised on the left side, and another half side rail was lying on the floor behind the head of the bed; R40 stated the side rail on the floor had broken off and no one had fixed it. On 5/12/26, the Maintenance Director stated he had not performed maintenance inspections or assessments for any residents' side rails and could not find any side rail inspections or assessments done within the last year, and he had not been told that R40's side rail had broken off.
Failure to Protect Residents From Verbal Abuse During Dining Room Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect four residents from verbal abuse during an altercation in the dining room. According to the facility’s final report and multiple staff and resident interviews, one resident (R1) entered the dining room and made an unclear or provocative statement while walking past three other residents (R2–R4). Witnesses, including a housekeeper and an LPN, reported that R1 and the other residents began yelling profanities and derogatory terms at each other. Statements indicated that R1 called another resident a “bitch” and “ho,” said “nobody wants your man,” and threatened to “beat [her] ass,” while R3 and R4 yelled profanities back. Staff observed R1 moving toward R3 in a threatening manner, requiring physical intervention by staff to keep them separated. The facility’s own abuse policy defines verbal abuse as willful use of disparaging or derogatory language, including threats of harm. Resident interviews conducted after the incident further described a pattern of verbally aggressive and threatening behavior by R1 toward other residents. R2 stated that R1 started the dining room incident, talked loudly, yelled at people, and threatened them frequently. R3 and R4 reported that R1 “flipped out” while they were sitting and “minding their own business,” that R1 went after R3 and had to be stopped by staff, and that there was a history of R1 threatening to have R4 beaten up and to shoot him. R3 stated she did not feel safe because R1’s room was next to hers with a shared adjoining bathroom, and that she did not feel safe even with staff monitoring in the hallway. An LPN interviewed by surveyors characterized the incident as verbal abuse, consistent with the facility’s definition, due to the yelling, cursing, and threats directed at other residents. These events demonstrate that residents were subjected to verbal abuse and were not adequately protected from such abuse by the facility.
Failure to Prevent Door-Related Fall and Unsafe Post-Fall Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dementia, identified as a wanderer with a history of falls and a prior right hip fracture, was adequately supervised and kept away from the dementia unit doors, despite known risks. The resident’s care plan documented risk factors requiring monitoring and interventions such as disguising exits, covering doorknobs and handles, and distracting the resident from wandering. Staff and the resident’s son reported that the resident had previously been struck by the same unit doors without injury, and staff were aware that the resident tended to stand behind the doors. On the date of the incident, a dietary cook entered the code and pushed open the double doors to bring in a lunch cart, did not see the resident standing in the crack between the door and the wall, and the door hit the resident, causing her to fall. An emergency room radiology report later showed a right femur fracture and right hip dislocation. The facility also failed to ensure a safe transfer of the resident after the fall. After the resident was found sitting on the floor by the doors, the dietary cook and a CNA lifted the resident from the floor without using a gait belt or any assistive device and placed her into a wheelchair, even though the resident could only bear weight on one leg. Both staff later acknowledged that they did not use a gait belt, that moving the resident before a nurse assessed her could worsen any injury, and that it was not safe to transfer her in this manner. The facility’s transfer policy stated that mechanical lifting devices should be used for any resident needing a two-person assist or who could not be transferred comfortably and safely by normal transfer technique, and that manual lifting was not permitted except in emergency or unavoidable circumstances.
Resident Moved After Fall Without Prior Nursing Assessment
Penalty
Summary
The facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred. The resident had been admitted with a primary diagnosis of unspecified dementia without behavioral, psychotic, mood disturbance, or anxiety features. An incident report documented that the resident was ambulating in the hallway behind double doors when the doors were opened, causing a change of plane and resulting in the resident falling, with noted discomfort to the right side. The dietary cook reported that she pushed the lunch cart through the double doors after entering a code and did not see the resident positioned by the crack between the door and the wall. When the door opened, the resident fell. Following the fall, the dietary cook went to get a CNA, and together they picked the resident up from the floor, stood her up, and placed her in a wheelchair, without using a gait belt and before a nurse could assess the resident. The CNA confirmed that she stood the resident up and transferred her to a wheelchair without a gait belt and acknowledged that moving the resident before a nurse assessment could worsen any injury. The LPN stated she returned from break to find the resident already in a wheelchair and that the aides had gotten the resident up before she could perform an assessment, noting they should not have moved the resident in case of a possible broken hip. The DON stated that after a fall, the nurse should perform an assessment first, including range of motion, pain level, and vital signs, and that the resident should not be moved prior to this assessment. The facility’s fall prevention policy indicated that transfer conveyances should be used in accordance with the care plan, and the DON noted there was no specific checklist for post-fall assessments.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect in multiple incidents involving verbal abuse, resident-to-resident physical abuse, and employee-to-resident physical abuse. The report states the facility did not recognize an altercation between an employee and a resident as verbal abuse, did not prevent the same employee from having access to other residents, and later that employee verbally abused another resident. The report also states the facility failed to prevent resident-to-resident physical abuse involving three residents and failed to prevent employee-to-resident physical abuse involving another resident. The deficiency was cited as Immediate Jeopardy and the report states it had the potential to affect all 51 residents in the facility. One incident involved a newly admitted resident who reported that an RN cursed at her, told her staff were busy, and did not provide timely toileting assistance after she requested a bedpan. The resident stated she waited for hours and ultimately urinated in an emesis basin because no one came to help. Staff statements confirmed the resident had been upset, that she had not been informed of any request for assistance, and that she had to use a basin because she was not put on a bedpan when asked. The resident was alert and oriented on admission and had diagnoses including major depressive disorder, acute pain in the left hip, and iron deficiency anemia. A second incident involved another resident who needed to use the restroom while in the dining room. Staff statements and the resident’s account state the RN yelled and cursed at him, told him to wait because staff were busy, pushed his wheelchair down the hall, and left him sitting in the hallway near another resident’s room. The resident later urinated on himself and said he was humiliated. The resident’s MDS showed moderate cognitive impairment with frequent incontinence and dependence on staff for toileting. The report also documents resident-to-resident physical abuse on three occasions. In one event, one resident struck another resident in the face after their wheelchairs came into contact near the dining room entrance. In another, a resident threw coffee at another resident, kicked and punched him in the head, and staff later documented that the resident had been in the other resident’s room taking things. In a third event, a resident struck another resident in the back of the head with an open hand after the other resident entered his room. The report further states an agency CNA was rough with cares toward a resident, grabbed her wrist, pulled on it, and hurt her during toileting-related care, and the resident reported pain and said she did not want that CNA to care for her again.
Failure to Preserve Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to maintain a resident’s dignity and respect for R6 when she requested assistance to use the bedpan after waking up and hitting her call light. According to R6’s handwritten statement, the RN on duty told her that staff were busy assisting other residents and, after R6 said she desperately needed to urinate, responded with profanity and said someone would be sent to help. R6 later reported that no one came to assist her for hours, and she ultimately had to position an emesis basin under herself and urinate into it because she could not get timely help with a bedpan. The evening LPN stated she heard R6 crying and found her very upset after R6 reported that she had asked the RN for bedpan assistance earlier in the evening. The LPN stated R6 said the RN told her all staff were busy, swore at her, and said help would come when staff could get to her. The LPN further stated R6 told her that after waiting for a couple of hours without assistance, she used an emesis basin to urinate and felt humiliated by having to do so. The Administrator in Training stated the RN should have assisted R6 when requested and considered R6 being forced to urinate in an emesis basin unacceptable and a violation of resident rights.
Failure to Properly Investigate and Respond to Abuse Allegations
Penalty
Summary
The facility failed to implement written policies and procedures for investigating allegations of abuse, including identifying abuse, protecting residents during investigations, and taking corrective action after abuse allegations. In one incident, a resident reported that an RN cursed at her, refused toileting assistance, and left her to urinate in an emesis basin because a bedpan was not provided. Facility leadership later stated they considered staff cursing at or in front of a resident to be verbal abuse, but the incident was handled as misconduct and the RN was suspended for 3 days. The RN then continued working at the facility for weeks after the allegation, and no changes were made to prevent future occurrences. A second incident involved the same RN and another resident who needed to use the restroom. The resident stated the RN yelled at him, used profanity, and pushed him in his wheelchair down the hall instead of assisting him with toileting. A CNA statement also described the RN shouting at the resident, using profanity, and pushing the resident down the hall away from his room. Facility leadership again stated they considered the behavior to be verbal abuse, but the incident was classified as misconduct and the RN was placed on final warning rather than being treated as abuse. The record shows the RN remained employed through the facility after the first incident and until after the second incident was investigated. Facility leadership stated the corporate level made the decisions to classify both events as misconduct, and they acknowledged that no changes were made to prevent future occurrences of abuse. The deficiency involved two residents reviewed for abuse and showed that the facility did not consistently identify, investigate, or respond to allegations of verbal abuse in a manner aligned with its abuse prevention policy.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
Failure to provide toileting assistance occurred for two residents who were dependent on staff for ADL support. One resident was admitted with diagnoses of Major Depressive Disorder and Acute Pain and was documented on admission as alert and oriented to person, place, and time, with toileting assistance requiring substantial to maximal assistance. The resident stated that after requesting a bedpan, the RN told her staff were busy with other residents and that she would send someone later, but no one came for hours. The resident reported she eventually used a container as a bedpan herself. An LPN later stated she heard the resident crying, and the resident told her she had asked the RN for bedpan assistance earlier and had not received help for a couple of hours. The Administrator in Training confirmed the RN should have assisted the resident with toileting when requested. A second resident, admitted with diagnoses including Cerebral Ischemia, Type 2 Diabetes Mellitus, and Fractured Femur, had a MDS showing moderately impaired cognition and dependence on staff for toileting, and the care plan stated the resident was dependent upon staff for toileting. The facility’s abuse investigation report documented that when the resident asked the RN to use the restroom while in the dining room, the RN asked if he could wait because staff were busy and she had to stay in the dining room. The resident stated he needed to go and was not waiting. The investigation further documented that the RN pushed the resident’s wheelchair out of the dining room and down the hall, away from his room, and left him near another resident’s room while CNAs were assisting someone else. The resident later stated he was humiliated and that when CNAs assisted him, he had urinated on himself. The Administrator in Training confirmed the RN should have assisted the resident with toileting needs.
Failure to Complete Required Fall Risk Assessments
Penalty
Summary
The facility failed to complete required fall risk assessments for one resident who was admitted with multiple diagnoses, including Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia. The resident experienced a fall resulting in a right hip fracture. According to the facility's Fall Prevention Program policy, a fall risk assessment should be performed at least quarterly, upon admission, after any fall, and with any significant change in condition. However, the resident's medical record did not contain documentation of a fall risk assessment from November 2024 through August 2025. This lack of assessment was confirmed by both the DON and a regional RN, who verified that the required quarterly assessments were not completed during this period.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Inappropriate Use of Mechanical Lift
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by both other residents and a staff member. Several incidents were documented in which residents with cognitive impairments and behavioral issues engaged in physical altercations. In one case, a resident with severe cognitive impairment and behavioral symptoms pushed another resident, resulting in a fall and injury. Staff interviews confirmed that the residents involved had a history of wandering and aggression, and that staffing levels were low, with only one aide and one nurse on the night shift, making supervision and intervention challenging. Another incident involved a resident being physically assaulted by a peer who accused him of theft. The staff responded quickly to separate the residents, and no physical harm was reported in this case. However, the facility's documentation and staff interviews indicated that the resident who initiated the altercation had escalating behaviors, including a subsequent arrest for staff assault, and required psychiatric care and one-to-one observation upon return to the facility. Additionally, a staff member was observed using a mechanical lift to keep a resident suspended above his bed, allegedly to prevent him from getting out of bed. Witnesses reported the staff member yelling at the resident and expressing frustration, while the staff member claimed he was changing bed linens and waiting for assistance. The facility's investigation confirmed that the use of the lift was inappropriate and did not meet the expected standards of care, as the resident was left in the lift as a means of control rather than for a legitimate care purpose.
Unclean Kitchen Equipment Surfaces
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, specifically on the tops of stationary kitchen equipment adjacent to food preparation areas. During an initial kitchen tour, it was observed that the tops of the upright refrigerator and freezer were covered with dirt and debris. These pieces of equipment were located next to food preparation tables, which could potentially affect the sanitary conditions of food preparation. The Dietary Manager confirmed that the tops of the equipment should have been cleaned, acknowledging that ventilation and air movement contributed to the accumulation of dirt and debris. This deficiency has the potential to impact all 38 residents residing in the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the lids of the trash dumpsters located outside were closed and secure, which is necessary to prevent pests and animals from accessing discarded food and trash. This deficiency was observed during an initial kitchen tour conducted with the Dietary Manager. The large, steel trash dumpster was found with its lids open and was not secured by any walls or access doors. The Dietary Manager confirmed that the lids should be kept closed to prohibit access by pests and animals. This oversight has the potential to affect all 38 residents residing in the facility.
Failure to Implement Standardized Infection Diagnosis
Penalty
Summary
The facility failed to implement a standardized method for determining the presence of infections, which is a critical component of their Antibiotic/Antimicrobial Stewardship Program. The policy of the facility, dated 10/24, emphasizes the importance of using standardized diagnosing tools to ensure appropriate antibiotic use, improve patient outcomes, and reduce healthcare costs. However, the facility's infection control logs for December 2024, January, and February 2025 did not reflect any set standards for diagnosing infections. This oversight has the potential to affect all 38 residents currently residing in the facility. During an interview on 3/12/25, the Licensed Practical Nurse/Infection Preventionist acknowledged the absence of standardized diagnosing tools, such as McGeer's or Loeb's criteria, and expressed an intention to implement them immediately. The facility's policy assigns the Medical Director the responsibility of setting antibiotic prescribing standards and reviewing antibiotic use data, while the Director of Nursing and the Infection Control Officer are tasked with setting standards for assessing and monitoring residents' conditions. The lack of adherence to these responsibilities contributed to the deficiency identified by the surveyors.
Failure to Justify Psychotropic Medication Use and Attempt Gradual Dose Reduction
Penalty
Summary
The facility failed to provide appropriate indications for the use of psychotropic medications for four residents, and did not attempt a Gradual Dose Reduction (GDR) for one resident. The facility's policy requires that psychotropic medications be used only when necessary and that GDRs be attempted at least twice yearly unless contraindicated. However, the facility did not document behaviors that necessitated the use of these medications for residents R15 and R29, and failed to attempt a GDR for resident R2, despite the absence of documented harmful behaviors. Resident R15 was receiving Quetiapine for unspecified dementia with agitation, but the care plan did not identify specific behaviors requiring the use of this antipsychotic medication. Observations showed that R15 was easily reassured and redirected, and the behavior monitoring report documented various behaviors such as entering other residents' rooms and expressing frustration, but these were not linked to the use of the medication. Similarly, resident R29 was prescribed Quetiapine for senile degeneration of the brain, but the care plan did not specify behaviors justifying the medication. Observations indicated that R29 was mostly calm and cooperative, with occasional instances of refusing care and expressing frustration. Resident R2, who was on Venlafaxine and Aripiprazole for bipolar disorder, had no documented harmful behaviors in the past year. The facility did not attempt a GDR, citing clinical contraindications, but there was no documentation of any GDR attempts in the past year. The Director of Nursing confirmed the lack of documentation and noted that R2 typically did not exhibit behaviors warranting the use of antipsychotics, aside from occasionally refusing care.
Inadequate Resident Transfer Assessment Leads to Injury
Penalty
Summary
The facility failed to properly assess a new resident's transfer needs, leading to an inappropriate transfer method being used. The resident, identified as R27, was initially documented as requiring a mechanical lift for all transfers. However, the Director of Nursing (DON) instructed staff to use a stand pivot transfer with two-person assistance, without any doctor's order or assessment to support this method. This incorrect transfer method resulted in a near fall incident where the resident's right foot was dragged across the floor, causing pain and bruising. Subsequent nurse's notes and an x-ray confirmed that the resident suffered a broken toe due to the incident. The resident expressed fear of falling during the transfer, and it was noted that five staff members were needed to stabilize and eventually transfer the resident back to bed using a mechanical lift. The lack of a proper assessment and the incorrect transfer method directly contributed to the resident's injury, highlighting a deficiency in the facility's supervision and accident prevention measures.
Failure to Assess PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and identify triggers for a resident with a primary diagnosis of PTSD, as required by their Behavioral Health Services Program policy. The policy mandates that the facility should identify any previous history of mental illness, trauma, and other related disorders to develop an individualized plan of care. However, the facility did not conduct a comprehensive PTSD assessment for the resident, who was admitted with PTSD as a primary diagnosis. The Social Services Director acknowledged that attempts should have been made to assess the resident for history of trauma and triggers, but no such assessments were completed. The resident, who also has diagnoses of dementia, psychotic disorder, and experiences social isolation, hallucinations, and delusions, was not provided with a care plan that identified specific environmental factors triggering their behaviors. The Behavioral Practitioner noted the resident's chronic PTSD and the need to gain the resident's trust to obtain background stories, but the Trauma Informed Care assessment was refused by the resident. Despite this, the care plan did not reflect any identified triggers or individualized interventions, which is a requirement for residents with PTSD according to the facility's policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents in the Memory Care Unit. On two separate occasions, one resident approached another and made physical contact with closed hands. The first incident occurred when one resident was talking to another, and the aggressor approached and struck the resident on the shoulder. Staff intervened immediately, and no visible injuries or psychosocial needs were noted. Both residents involved had severe cognitive impairments, as indicated by their low BIMS scores. In a subsequent incident, the same two residents were involved in another altercation. The aggressor again approached the other resident and made contact with closed hands. The resident attempted to defend herself by striking back and using a wet floor sign. Staff separated the residents promptly, and no injuries or psychosocial needs were observed. Both residents remained at their baseline condition following the incidents.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to initiate appropriate interventions to prevent resident-to-resident abuse involving two residents, R1 and R2, in the Memory Care Unit. R1, diagnosed with Dementia without Behavioral Disturbance and other mood disorders, and R2, diagnosed with Unspecified Dementia with Agitation, were involved in multiple altercations. On 11/29/24, R1 struck R2 on the shoulder, and on 12/2/24, another altercation occurred where both residents made contact with each other. Despite these incidents, the facility did not implement effective interventions to prevent further interactions between R1 and R2. The facility's response to these incidents was inadequate. Although R2's room was moved to another wing on 12/2/24, this intervention did not prevent further interactions with R1, as R2 continued to wander into other residents' rooms, including R1's. The care plan for R2 did not address the incidents of being struck by R1 or include any interventions to ensure R2's safety from R1. Additionally, R1 was placed on 15-minute checks instead of the recommended 1:1 monitoring, and this was not documented in R2's care plan. Further complicating the situation, R1 was moved to a non-secure unit on 12/19/24, which was unsuccessful due to R1's elopement risk, leading to R1's return to the Memory Care Unit on 12/28/24. No interventions were implemented to keep R1 away from R2 after R1's return, leaving R2 vulnerable to further interactions. The facility's failure to implement and document effective interventions and monitoring contributed to the ongoing risk of resident-to-resident abuse.
Failure to Address Burns and Falls in Residents
Penalty
Summary
The facility failed to notify the physician and obtain wound treatment orders for a resident who sustained second-degree burns. The resident, who has a diagnosis of mild intellectual disability, spilled hot tea on her lap, resulting in burns that were not treated or seen by medical staff. Despite the burns being reported to an agency LPN and the emergency department, there was no documentation of physician orders, measurements, or treatments for the burns until several weeks later. The facility's policy requires immediate notification and treatment for such injuries, which was not adhered to in this case. Additionally, the facility failed to investigate, monitor, and implement new fall interventions for two residents who were at high risk for falls. One resident experienced multiple falls, including incidents where she sustained a laceration to the forehead and was found lethargic, requiring Narcan administration. Despite these incidents, there were no follow-up vital signs documented for 72 hours post-fall, and no new interventions were implemented to prevent further falls. The facility's policy mandates thorough investigation and documentation of falls, which was not followed. Another resident also experienced multiple falls, including an unwitnessed fall and an incident where she was found with a cut on her forehead. Similar to the first resident, there was no investigation or post-fall interventions documented, and follow-up vital signs were not recorded. The facility lacked an accurate system to track and monitor falls, which contributed to the failure to address the residents' fall risks adequately.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that nurse aides providing direct patient care were not employed full-time for more than four months without successfully completing a state-approved training and competency evaluation program. This deficiency was observed when V4, a nurse aide, was seen working with residents on the secured unit. V4's personnel file indicated that she was eligible to work according to the Illinois Department of Public Health - Health Care Worker Registry, but her certification program information was incomplete, with no record of training or competency evaluation. V4 was initially hired as a housekeeper and later transitioned to a Certified Nurse Aide role. Despite enrolling in a CNA program, V4 did not pass the required skills competency portion. The Director of Nursing/Administrator in Training confirmed that V4 was employed full-time as a CNA and provided direct care, including toileting, transferring, and feeding residents, without completing the necessary state-approved competency training program. This oversight had the potential to affect all 44 residents in the facility.
Failure to Prevent Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of falls for two residents, R1 and R2, who were identified as high risk for falls. R1, who had severe dementia with agitation and was legally deaf, experienced multiple falls due to inadequate supervision and lack of proper footwear. Despite being assessed as high risk for falls, R1 was left unattended on several occasions, resulting in injuries including a laceration to the head and a hematoma. The staff failed to ensure R1 was under direct supervision and wearing non-skid footwear, as required by the care plan. R2, admitted with a history of weakness and recent fractures, also experienced falls due to insufficient supervision. R2's fall in the dining room, where no staff were present, resulted in serious injuries including a fractured right hip, pelvis, and T12 compression fracture. The facility's failure to provide adequate supervision, as documented in R2's care plan, contributed to these incidents. Staff interviews revealed that there were not enough personnel present to monitor residents effectively, leading to R2 being left alone and unsupervised. The facility's policy on fall prevention, which mandates staff to observe residents for safety and implement appropriate interventions for those at high risk, was not adhered to. The lack of adequate staffing and supervision, as well as the failure to follow care plans and ensure the use of non-skid footwear, directly contributed to the falls and subsequent injuries sustained by R1 and R2.
Failure to Assess and Treat Pressure Wound
Penalty
Summary
The facility failed to properly assess, notify the physician, and obtain a treatment order for a newly identified pressure wound on a resident's left buttock. The facility's policy requires that upon notification of skin breakdown, the pressure area should be assessed, documented, and the physician notified for treatment orders. However, this protocol was not followed for the resident, who was readmitted to the facility with a history of fractures and was noted to have an open area on the left buttock during the initial skin assessment. Despite the presence of the wound, there was no documentation of the pressure wound in the resident's Treatment Administration Record, nor was there a physician's order for its treatment. The wound was only discovered later by an LPN who found a heavily soiled bandage on the resident's left buttock, revealing a Stage 2 pressure wound. The LPN confirmed that she was unaware of the wound and that no previous assessment, physician notification, or treatment orders had been completed.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to obtain and administer physician-ordered medication for a resident diagnosed with severe dementia, agitation, and anxiety. The resident was prescribed Alprazolam, an anti-anxiety medication, to be taken three times daily. However, the medication was not administered on multiple occasions, specifically on June 29, June 30, July 1, and July 2, 2024, at the scheduled times of 8:00 A.M., 12:00 P.M., and 4:00 P.M. The facility's Medication Administration policy requires documentation of any omitted doses, but no such documentation was present for these dates. The Director of Nurses confirmed the omission of doses due to the unavailability of the medication, stating that the hospice nurse was supposed to order the medication, but it was not delivered. The facility had options to obtain the medication from an emergency box or local pharmacies like Walmart or CVS, but these were not utilized. An LPN also confirmed the medication was unavailable during their shifts, leading to increased agitation and anxiety in the resident. The facility's failure to ensure the availability and administration of the prescribed medication resulted in a deficiency in pharmaceutical services provided to the resident.
Failure to Administer Timely Antibiotic Medication
Penalty
Summary
The facility failed to administer a physician-prescribed antibiotic medication to a resident diagnosed with lower extremity cellulitis. The resident, who had Methicillin Resistant Staphylococcus Aureus (MRSA) in her leg wound, was discharged from the hospital with an order to take Linezolid 600 mg by mouth every twelve hours for seven days. The resident returned to the facility on June 15, 2024, at 1:45 PM, but the medication was not administered until 8:00 PM on June 16, 2024, resulting in a 35-hour gap between doses. The facility's Medication Administration Policy requires medications to be prepared and administered within one hour of the designated time or as ordered, using the six rights of administration. The Director of Nursing confirmed that the medication should have been delivered and administered as scheduled. The delay occurred because the medication was not delivered to the facility until 7:32 PM on June 15, 2024, and the first dose was not given until the following evening, leading to a significant medication error.
Failure to Timely Collect Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were collected as scheduled for a resident who was being monitored for infections. The resident had a physician order for a complete blood count (CBC), basic metabolic panel (BMP), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) test to be collected on a specific date and sent to an infectious disease physician. However, the laboratory tests were not collected until three days after the scheduled date, resulting in the rescheduling of the resident's appointment with the infectious disease physician. The Director of Nursing confirmed that the laboratory tests were supposed to be drawn on the scheduled date to coincide with the resident's appointment. The delay in collecting the laboratory tests was attributed to a lack of awareness of the orders by the nursing staff and repeated failures by the laboratory to process the orders despite multiple follow-up calls by a registered nurse. The nurse confirmed that she had ordered the tests as STAT and had contacted the laboratory multiple times, but the tests were still not drawn in a timely manner.
Undignified Labeling of Residents' Clothing
Penalty
Summary
The facility failed to ensure residents' clothing was labeled in a dignified manner. During a tour of the Laundry Department, the Housekeeping Supervisor stated that the facility no longer provides labels for residents' clothing and instead uses a black marker to write names on the inside of the clothing. This method is problematic as it is difficult to read on dark clothing and can ruin nicer articles of clothing. Observations showed multiple pieces of clothing with residents' names or initials written on the collars. During a Resident Council Meeting, two residents demonstrated how the marker had bled through and smeared on their white tops. Another resident was observed with black marks that had bled through the collar of their gray t-shirt.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances or recommendations from residents were considered, addressed, and acted upon. The Resident Grievances/Complaints policy outlines that complaints and grievances should be directed to the appropriate Department Head and resolved within 15 days, with the Administrator receiving copies of the minutes for follow-up. However, multiple grievances documented in the Resident Council Meeting Minutes, such as missing clothes, call light issues, maintenance requests, and transportation issues, were not properly investigated or resolved. The reports lacked documentation of an investigation, resolution, and notification to the residents about the outcomes. The Resident Council President stated that residents do not receive verbal or written reports about the initiation or resolution of their complaints/grievances. The President expressed frustration that the same issues are repeatedly brought up without resolution. Specific grievances included missing laundry, no heat in the dining room, and ants in the building, among others. Despite these complaints being documented, there was no evidence that the facility took appropriate actions to investigate and resolve them, leading to ongoing dissatisfaction among the residents.
Failure to Post Daily Direct Care Staff Hours and Resident Census
Penalty
Summary
The facility failed to post the daily direct care staff hours and resident census, potentially affecting all 44 residents. During a tour on 6/2/24 at 9:15 AM, no daily nursing hour data and census sheet were observed throughout the building. The Director of Nursing (DON) stated at 12:00 PM that she was unaware of the requirement to post this information and confirmed that she had not done so since starting in March 2024. Subsequent checks on 6/3/24, 6/4/24, and 6/5/24 also found no posted data. The facility did not provide a policy on staff posting by the time of the Exit Conference on 6/5/24. The CMS Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 6/5/24 and signed by the Administrator, documented 44 residents in the facility.
Deficiencies in Kitchen Sanitation and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that the kitchen equipment was clean and free of debris, and did not properly date cooked food items to ensure they were used before expiration. Additionally, the facility did not monitor and record the required refrigerator and freezer temperatures, food temperatures of served foods, and the required dishwasher sanitation levels. These deficiencies were observed during a survey, where undated food items and missing thermometers were found in the kitchen and food storage areas. The facility's policies on refrigerator and freezer storage, dish machine sanitation, and food storage were not followed, leading to these lapses in compliance. During the survey, it was noted that the facility's logs for refrigerator and freezer temperatures, sanitizing solution checks, and dishwasher temperature/sanitizer levels were incomplete or missing for several dates. The kitchen staff verified these missing logs and checks. The facility's room roster confirmed that 44 residents were currently residing in the facility, all of whom could potentially be affected by these deficiencies. The observations and interviews with the kitchen staff highlighted significant gaps in the facility's adherence to its own policies and procedures regarding food safety and sanitation.
Deficiencies in Infection Control and Legionella Management
Penalty
Summary
The facility failed to place appropriate signage in a conspicuous location to clearly identify the category of transmission-based precautions, instructions for PPE, and/or instructions to see the nurse prior to entering a resident's room. This deficiency was observed for one resident who required transmission-based precautions due to a diagnosis of MRSA in leg wounds. Despite the resident's readmission with this diagnosis, the room lacked the necessary signage between specific dates, which could lead to improper handling and increased risk of infection transmission. Additionally, the facility failed to have interventions in place to mitigate the growth and spread of Legionella and did not maintain logs of these interventions. The Director of Nursing/Infection Preventionist indicated that the Maintenance Supervisor was responsible for Legionella management, but the only documentation provided was a log of water flushes. The facility's Infection Control Plan and Quality Assurance Performance Improvement (QAPI) Agenda lacked inclusion of a Legionella prevention policy, monitoring measures, and a flow diagram of the building's water system. This oversight has the potential to affect all residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections, ensuring antibiotic usage was appropriate, and using a nationally recognized surveillance criteria to define infections. This deficiency was identified for three residents reviewed for the Antibiotic Stewardship Program out of a sample of 43 residents. The facility's Infection Control Surveillance and Monitoring policy, dated 4/11/22, outlines the procedures for routine surveillance and monitoring to ensure compliance with infection control practices. However, the Director of Nursing/Infection Control Preventionist (DON/ICP) admitted to not formally tracking or documenting observations of infection control practices and not conducting any reports since starting in March. Additionally, residents treated for infections were not tracked or trended according to caregivers, locations, or other sources that could be controlled, and antibiotic usage was not reviewed. The findings indicate that the facility's failure to adhere to its own infection control policy has the potential to affect all 44 residents residing at the facility. The DON/ICP's lack of formal audit processes and failure to track and trend infections and antibiotic usage contributed to the deficiency. The facility's policy requires the DON/ICP and/or Administrator to maintain records of surveillance and monitoring, but this was not being done, leading to a lack of proper infection control and antibiotic stewardship within the facility.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the Infection Prevention and Control Plan. The facility's policy required at least a part-time Infection Control Preventionist, which could be the Director of Nursing (DON) with an approved Infection Control Certification. However, the designated Infection Preventionist, who was also the DON, had not completed the required specialty training in Infection Prevention and Control. This was confirmed through interviews with the DON and the Administrator, who stated that the DON had not had time to complete the training due to other responsibilities. This deficiency has the potential to affect all 44 residents in the facility.
Failure to Document and Offer Required Immunizations
Penalty
Summary
The facility failed to offer and document immunizations and vaccinations for five residents as per their policy. The policy, dated 5/19/23, requires verification of the last vaccination date, assessment of vaccination status upon admission, and documentation of immunizations on the resident's Immunization Record and Medication Administration Record. However, the records for five residents lacked documentation that the influenza and/or pneumococcal vaccinations were offered, given, or refused. Specifically, the records for residents R12, R14, R39, R40, and R96 were missing this critical information. Additionally, the facility's Infection Preventionist/Director of Nursing confirmed that the immunizations should be documented but acknowledged that refusals were not properly recorded, either through signed declinations or verbal documentation. Resident R12's Immunization Record did not show any documentation regarding the influenza vaccination. Similarly, R14's record lacked documentation for the influenza vaccination. For residents R39 and R40, there was no documentation for either the influenza or pneumococcal vaccinations. R96's record was missing documentation for the pneumococcal vaccination. The Infection Preventionist/Director of Nursing admitted that while R39 and R40 had refused the influenza vaccination, this refusal was not documented properly, raising questions about the facility's adherence to its own immunization policy.
Failure to Maintain Safe and Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to ensure the memory care unit had warm water and was clean and free of odors for 19 of 42 residents. During a tour, it was observed that the hallway and several rooms had pungent urine odors, sticky floors, and debris. Specific rooms had additional issues such as a bucket with brownish/black liquid and feces smeared on various surfaces. The joint bathroom between two rooms had the hot water knob turned off, resulting in only cold water being available. Maintenance staff confirmed that the hot water had been turned off for a while and that the pipes needed to be re-routed, a task that had not been scheduled for repair due to high costs. Interviews with staff revealed that the lack of hot water had been an ongoing issue for approximately a year. CNAs reported that they had to use cold water for handwashing and resident care, as the dietary staff did not consistently fill the orange jug with hot water. The Director of Nursing and the Housekeeping Supervisor both acknowledged the problem, with the latter stating that CNAs were supposed to clean the bucket in one of the rooms every two hours, but often did not. Maintenance staff also confirmed that the hot water issue had not been addressed due to the need for extensive and costly repairs. The Administrator confirmed that the Dementia Unit had been without hot water for about a year and that the necessary repairs would cost over $60,000. The lack of hot water and the unsanitary conditions in the memory care unit were not addressed promptly, leading to a failure in providing a safe, clean, and comfortable environment for the residents. The facility's policies on water temperature monitoring and housekeeping were not followed, contributing to the deficiencies observed during the survey.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were stored in their original packaging with proper labels until administered for four residents. An Agency Licensed Practical Nurse (LPN) was observed pre-popping medications and storing them in medication cups labeled only with the residents' first names. The LPN admitted to pre-popping the medications and storing them in the cart, despite knowing it was against policy. The Director of Nursing (DON) confirmed that nurses should not pre-pour medications and should administer them immediately after verifying the medication, label, and date.
Failure to Notify Resident and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and did not provide the resident and resident representative with a written notice of transfer. Specifically, a resident was transferred to a local hospital, and there was no evidence of a facility notification to the resident of the transfer/discharge in the resident's chart. The Social Services Director confirmed that the facility did not provide the resident or their representative with a written notice of transfer and also did not send notification to the local Ombudsman of monthly facility transfers/discharges.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. Specifically, the medical record of a resident who was hospitalized on an unspecified date did not contain documentation of written notice of the facility's bed hold policy. This deficiency was confirmed by the Social Services Director, who verified that neither the resident nor the resident's representative received the required bed hold policy or written notice of transfer.
Failure to Monitor Self-Catheterization and Update Care Plan
Penalty
Summary
The facility failed to monitor a physician's order for self-catheterization and did not update a resident's care plan to reflect self-catheterization needs. The facility's policy requires comprehensive assessment and periodic reassessment of each resident to develop a person-centered comprehensive plan of care. However, for one resident diagnosed with Hereditary Spastic Paraplegia and Neurogenic Bladder, the physician's order for self-catheterization was not included in the current Physician Order Sheet. Additionally, the resident's care plan did not document any problem/need areas, goals, or interventions related to self-catheterization. The resident, who is cognitively intact with a BIMS score of 15:15, had a physician's order dated several months prior, allowing self-catheterization as needed for retention, with staff required to educate and monitor for retention and UTIs weekly. Despite this, the current care plan lacked any documentation addressing these needs. Furthermore, a laboratory test result showed the resident had a urinary tract infection with Escherichia Coli. The Director of Nurses confirmed the missing documentation for monitoring and care planning related to the resident's self-catheterization.
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.
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What surveyors actually found near you
We read the 86 citations issued within 25 miles in the last 12 months — including the 3 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 Aledo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercer Manor Rehabilitation | 0 mi | ★★★★★ | 6 | 0 |
| Monmouth Rehab And Nursing | 20.7 mi | ★★★★★ | 25 | 1 |
| Arcadia Care Rock Island | 21.8 mi | ★★★★★ | 3 | 0 |
| Friendship Manor | 21.8 mi | ★★★★★ | 2 | 0 |
| Aspire Of Muscatine | 22.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.