Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Archer Heights Healthcare during CMS and state inspections, most recent first.
Expired Food Handler Certification for Dietary Aide: A dietary aide continued working with an expired food handler certification while handling food duties. Survey review showed the aide’s certification had expired, time cards confirmed multiple shifts worked after expiration, and both the RD and Dietary Mgr acknowledged the lapse. Facility policy and the dietary aide job description required a valid Food Handlers certificate.
Dietary staff did not follow the planned menu or resident preferences when a cook served eggs, toast, and oatmeal instead of the breakfast egg and sausage casserole listed on the menu. The dietary manager confirmed sausage products were available in the freezer and stated the cook should have followed the menu to provide enough protein and nutrients. A resident reported receiving toast, a boiled egg, and oatmeal for breakfast and said he did not get meat with every meal. The RD stated substitutions must match the menu’s nutritional value and calorie intake.
Missing Refrigerator and Freezer Temperature Logs: The facility failed to consistently monitor and document temps for the walk-in refrigerator, walk-in freezer, and sandwich cooler. Surveyors observed missing log entries and signatures on multiple dates, and the Dietary Manager-Temporary later provided logs with temperatures and initials entered but no times. The DM stated the logs are completed twice daily to keep food at safe temps and prevent spoilage.
EBP signage was not visibly posted for a resident with a wound who required EBP, and staff did not maintain infection control practices with soiled linen. A CNA was observed throwing a resident’s soiled linens on the floor during ADL care, and three bags of soiled linen were found on the floor in the clean laundry processing area. The IP stated residents with wounds should have an EBP sign on the door and that soiled linen should not be placed on the floor.
Disposable razors were found at the bedside or in resident areas for four residents, despite facility policy stating razors and razor blades are not allowed in resident rooms unless administration has granted permission and supervision is being provided. Residents with orders for aspirin or Xarelto stated staff let them keep the razors and that they discarded them in regular trash without supervision, and one cognitively intact resident who required supervision for shaving was observed with a razor on the dresser and said staff did not observe him shave or dispose of it in a sharps container.
Psychotropic medications were administered to multiple residents without timely informed consent, and some records did not match the documented psychiatric diagnoses supporting the orders. Residents received antipsychotic, antidepressant, anti-anxiety, and sleep-related medications before consents were signed, while MARs and order records showed ongoing administration. In several cases, the face sheet or consent form did not include the diagnosis tied to the medication order, and an ADON and psychiatric NP confirmed inconsistencies in the diagnosis and consent documentation.
An LPN left a treatment cart unlocked and unattended while residents were in the hallway, with medication solutions accessible in the cart. Surveyors also found two residents’ insulin vials without open or expiration dates; the DON and pharmacist stated insulin expires 28 days after opening, but the vials were not labeled accordingly.
A facility failed to provide feeding assistance for a dependent resident on a puree diet and failed to clean and cut the nails of two dependent residents. The resident needing meal assistance was observed with an untouched tray while staff left without ensuring the meal was eaten or offering an alternative, despite severe cognitive impairment, dysphagia, and recent weight loss. Two other residents were observed with long nails and debris under the nails, and both stated they wanted nail care but had not received it.
The facility failed to follow its abuse policy and protect residents from physical abuse when an argument between two roommates over noise escalated into a physical altercation. A CNA entered the room after hearing about a fight and found one resident standing over another, punching him, and separated them while calling for help. An LPN then found the injured resident on the floor bleeding from the head and obtained conflicting accounts from both residents about whether the dispute involved loud talking or television volume. The injured resident sustained facial and scalp lacerations and a nasal bone fracture, consistent with being struck and punched multiple times, as confirmed by ED evaluation. The facility’s own abuse policy defines such willful infliction of injury, including hitting, as physical abuse requiring medical attention, and staff intervention occurred only after the assault was already in progress and significant injuries had occurred.
A resident with asthma and other medical conditions, who was cognitively intact, shared a room with a cognitively intact roommate diagnosed with nicotine dependence and dementia who repeatedly smoked in their room despite a facility smoke‑free interior policy, a documented history of in‑room smoking, a care plan addressing this behavior, and a signed smoking contract prohibiting possession and use of smoking materials in the room. Staff, including an LPN, confirmed that the smoker continued to smoke in the shared room and that the asthmatic roommate complained about the smoke. The smoker admitted he chose to smoke in his room rather than go to designated outdoor areas, resulting in the facility’s failure to maintain a safe, clean, and comfortable environment free from in‑room smoking.
Staff failed to follow Enhanced Barrier Precautions and infection control policies during incontinence care for a cognitively intact resident with multiple comorbidities, including diabetes with foot ulcer, kidney failure, and dialysis dependence. A CNA wore contaminated gloves in the hallway, accessed the linen cart without changing gloves, and provided incontinence care without a gown, despite posted EBP instructions requiring gown and gloves for high-contact care. The privacy curtain was not used, the room door remained open, and a soiled brief was left on the floor. An LPN and the DON confirmed that facility policy requires gown and glove use for EBP residents and proper bagging and disposal of soiled linens and incontinent products.
Multiple residents reported and surveyors observed persistent uncleanliness in resident rooms, including trash and debris on floors and under beds, despite facility policies requiring daily cleaning. Staff interviews revealed inconsistencies in cleaning practices, and care plans did not address potential hoarding behaviors, resulting in a failure to provide a safe and homelike environment.
A resident with intact cognition was given medication at the medication cart and took it without a nurse present to observe ingestion. The LPN responsible was multitasking and did not ensure the medication was swallowed. There was no physician's order or assessment for self-administration, and facility policy requires direct observation during medication administration.
Multiple residents and staff reported and surveyors observed persistent cleanliness and maintenance issues, including unemptied garbage, insect infestations, soiled and unsanitary shower rooms, and broken equipment. These deficiencies were present throughout the facility, affecting resident rooms, shared bathrooms, dining areas, and staff spaces, despite facility policies requiring daily cleaning, pest control, and regular maintenance.
A resident who was cognitively intact but required substantial assistance for daily activities and had hand contractures was unable to access their call light, which was found out of reach. Staff confirmed the call light's placement prevented the resident from requesting help, despite facility policy and the care plan requiring it to be accessible.
A nurse administered an antihypertensive medication to a resident without assessing or documenting blood pressure as required by the physician's order and facility policy. Both the LPN and DON confirmed that blood pressure should be checked before giving such medications to ensure safe administration.
Multiple incidents of resident-to-resident physical abuse occurred, including altercations on the smoking patio, in a shared room, and in the dining room. In each case, verbal disputes escalated to physical violence, with staff intervening after the events. Some residents had documented behavioral issues or prior conflicts, but preventive measures were not effectively implemented, resulting in physical harm and distress.
The facility did not ensure proper cleaning or maintenance of water and ice machines, resulting in visible mineral buildup, leaks, and unsanitary conditions. Staff and residents accessed water and ice from these machines and from sinks also used for handwashing, which were not properly maintained. Facility leadership and staff were unclear about responsibilities for cleaning and servicing the machines, and established policies for regular cleaning and maintenance were not followed.
The facility did not provide enough seating in day/dining rooms for ambulatory residents and failed to maintain cleanliness and timely repairs in resident rooms and common areas. Multiple residents reported having to stand or use uncomfortable alternatives due to a lack of chairs, and observations revealed persistent issues such as sticky floors, stained walls, and delayed maintenance of reported problems. Housekeeping and maintenance staff were unclear about cleaning schedules, and resident council minutes reflected ongoing concerns about room cleaning.
Two residents with cognitive and behavioral impairments were involved in an incident where one physically struck the other over a wheelchair, with staff failing to provide adequate supervision or immediate intervention. In a separate case, a resident assessed as a moderate fall risk did not receive recommended side rails and alarms, resulting in a fall and head injury, despite staff and assessment documentation supporting the need for these interventions.
A resident with a history of substance abuse and mental health conditions became intoxicated and reported non-consensual sexual activity while under the influence of alcohol and drugs. Multiple residents were able to access and use alcohol and illicit substances within the facility, despite existing policies prohibiting contraband. Staff only checked residents' bags and not their persons, leading to lapses in supervision and enforcement, and resulting in harm to at least one resident.
Several instances were identified where medications, including pills, inhalers, and insulin pens, were left unsecured at the bedside or in unlocked carts, and residents were not on self-administration programs. Staff interviews and record reviews confirmed that medications were not always administered or stored according to facility policy, with some medications lacking physician orders and being left accessible to residents without proper authorization.
A resident dependent on staff for ADLs did not receive timely personal hygiene, including nail care, and was found in soiled conditions with unkempt hair, dirty hands, and a foul-smelling room. The assigned CNA had not provided required morning care or checked on the resident since the start of the shift, despite the care plan indicating a self-care deficit and the need for staff assistance.
A resident with chronic respiratory conditions did not receive prescribed BIPAP therapy at night as ordered following hospital discharge. Facility records showed no documentation of BIPAP or CPAP treatment, and staff interviews revealed a lack of communication and follow-through in reconciling and implementing hospital recommendations. The resident's care plan did not address the required therapy, and the necessary equipment was not available, resulting in a failure to provide and document appropriate respiratory care.
A resident with COPD and other medical conditions was given oxygen at 5L/min via nasal cannula, despite a physician's order for 3L/min. An LPN did not check the oxygen concentrator setting during her shift and was unaware of the incorrect dosage until it was pointed out by a surveyor. Both the DON and a nurse practitioner confirmed that the order was for 3L/min and that oxygen should be administered as prescribed.
A resident with a history of COPD and bilateral below-knee amputations did not receive prescribed morphine for pain management, despite documentation indicating administration. The facility failed to manage the medication process effectively, as narcotic sheets were missing and the medication was not found in the narcotic drawer. Staff interviews revealed inconsistencies in documentation and administration, leading to unmanaged pain for the resident.
The facility failed to adhere to proper food storage and sanitation practices, potentially affecting all 207 residents on an oral diet. Observations included undated and unlabeled food items, staff storing personal food in resident areas, and a lack of sanitizer in the kitchen. These actions violate the facility's policies on food safety and sanitation.
The facility failed to maintain a sanitary and comfortable environment for four residents. One resident reported infrequent room cleaning, while another's room had missing furniture parts and stained floors and curtains. A resident with a g-tube had a dried substance on the pole and dust on the oxygen concentrator. Staff were unclear about cleaning responsibilities, leading to these deficiencies.
The facility failed to secure and properly manage medications, particularly narcotics, on the fourth floor. An unlocked medication refrigerator allowed access to narcotics, and expired medications were found. Controlled substances like Diazepam were improperly stored, and inhalers lacked clear labeling. Discrepancies in narcotic medication documentation were noted, contrary to facility policies requiring secure storage and accurate inventory reconciliation.
The facility failed to monitor personal refrigerator temperatures and ensure thermometers were present for four residents, leading to expired food being found. Staff interviews revealed confusion about who was responsible for these checks, contrary to the facility's policy requiring daily temperature logs and monitoring.
The facility failed to ensure proper infection control measures, including PPE use during wound care, posting EBP signage, and maintaining PPE bins outside isolation rooms. Staff did not perform hand hygiene when passing meal trays, even after touching personal items. Interviews revealed a lack of adherence to infection control protocols, with the absence of an IP nurse contributing to these deficiencies.
The facility failed to ensure call light accessibility for two residents, affecting their ability to request assistance. One resident, with multiple diagnoses including osteoarthritis and dementia, had her call light on the floor behind her bed, out of reach. Another resident, also with dementia and other health issues, had the call light on the floor underneath the bed. Both residents' care plans required the call light to be within reach, but this was not adhered to, as confirmed by facility staff.
The facility failed to refer three residents for a Level II PASARR evaluation after new mental disorder diagnoses. One resident was admitted with bipolar and adjustment disorders, but the PASARR did not reflect these conditions. Another resident had Major Depressive Disorder, but the PASARR documentation did not indicate this, and the care plan did not address it. A third resident's PASARR documentation was incomplete, missing the Major Depressive Disorder diagnosis. The facility's policy requires PASARR screening prior to or shortly after admission, which was not followed.
The facility failed to update the PASARR for three residents with new mental health diagnoses, including Major Depressive Disorder and bipolar disorder. The initial screenings did not reflect these conditions, and necessary Level II screenings were delayed or not conducted. The Business Office Manager acknowledged the oversight and initiated corrective actions, but the facility did not adhere to its policy requiring timely PASARR screenings.
A resident with a history of diabetes and foot ulcers did not receive daily wound care as ordered, leading to dirty dressings and self-care by the resident. Facility records showed multiple days without documented care, and staff confirmed the expectation for daily dressing changes.
The facility failed to investigate a fall incident involving a resident with multiple medical conditions and did not implement fall interventions as per the care plan. Additionally, the facility did not ensure adequate supervision to prevent a resident from smoking in a room, despite policies prohibiting indoor smoking. These deficiencies highlight lapses in adhering to safety protocols and resident supervision.
The facility failed to provide proper respiratory care for two residents receiving oxygen therapy. One resident's nasal cannula tubing was not changed weekly, and their CPAP mask was improperly stored. Another resident received oxygen without a physician's order, and their tubing was found on the floor. Both residents were cognitively intact and had diagnoses requiring supplemental oxygen. The facility did not adhere to its policies for equipment change and physician orders.
A resident with severe cognitive impairment was prescribed and administered Remeron for depression without obtaining informed consent beforehand. The facility's policy requires informed consent prior to prescribing psychotropic medications, but consent was only obtained verbally after the medication had been administered for several weeks.
Two residents in a facility experienced abuse due to inadequate protection measures. One resident was pushed by another, resulting in a head injury, while another resident was physically assaulted during a verbal altercation. The facility's investigation and response were insufficient, failing to acknowledge and address the aggressive behaviors effectively.
A resident with a surgical wound did not receive necessary treatment and services, leading to wound deterioration and avoidable pain. The resident's dressing was not changed as ordered, and pain medication was not documented as administered. Staff interviews revealed a lack of proper documentation and assessment for self-care, contributing to the resident's condition worsening.
The facility failed to maintain a clean environment, affecting all 208 residents. Observations showed dirty floors with food particles and dirt in dining areas and hallways. Staff and residents acknowledged the unclean conditions, with some residents cleaning their own rooms due to housekeeping shortages. The facility's administrator confirmed recent housekeeping issues and the appointment of a new manager.
The facility failed to report suspected abuse incidents within the required timeframe, affecting four residents. In one case, a resident was pushed and injured by another resident, but the incident was reported six days late. In another case, a verbal disagreement escalated to physical abuse, but the administrator was not informed of the physical aspect. Staff did not follow the facility's policy for immediate reporting to the state survey agency and the abuse prevention coordinator.
The facility failed to investigate a fall incident where a resident was allegedly pushed by another, resulting in a head injury. Additionally, an allegation of verbal and physical abuse between two residents was not investigated. Key witnesses were not interviewed, and relevant records were not reviewed, leading to deficiencies in addressing potential abuse.
A resident left the facility unsupervised for an appointment and did not return for four days, as the facility failed to complete a timely community survival skills assessment. The resident's intact cognition was noted, but the assessment was delayed, leading to a lack of awareness of the resident's whereabouts. Staff interviews revealed communication gaps regarding pass privileges and monitoring processes.
The facility failed to maintain the third-floor community shower room in a sanitary and functional condition, affecting 52 residents. Observations revealed a stained toilet bowl, accumulated dust on the toilet water tank, and a broken shower faucet. An LPN confirmed the issues, and the Housekeeping Director acknowledged staffing challenges, with plans to hire more staff. The facility's housekeeping policy mandates daily cleaning, which was not followed.
A facility failed to protect two residents from abuse by another resident with known violent behavior. The aggressive resident was admitted without timely background checks or a care plan, despite a history of aggression and a criminal record. This oversight led to physical assaults on two residents, causing significant injuries. The facility's assessments and care planning were inadequate, contributing to the failure to prevent these incidents.
A resident with multiple diagnoses, including legal blindness and dementia, was inaccurately assessed, leading to unaddressed aggressive behaviors. The resident assaulted two other residents, causing significant harm to one. Facility staff confirmed the inaccuracies, noting the absence of a specific policy for aggression screening and trauma assessments.
A facility failed to develop a care plan for a resident with known aggressive behaviors, leading to two incidents where the resident physically assaulted other residents, causing harm. Despite prior knowledge of the resident's history of aggression and dementia, the care plan was not updated until after these incidents, contrary to facility policies requiring timely updates to care plans.
A resident with a known history of aggression was inadequately supervised, leading to assaults on two other residents, causing significant injuries. Despite prior incidents and staff awareness of the resident's violent tendencies, the care plan was not updated to address these behaviors, and no specific supervision measures were implemented.
The facility failed to conduct quarterly QAPI meetings and did not address abuse data collection, affecting all 200 residents. Meeting minutes from March 2024 lacked abuse reporting, and no further minutes were available until October 2024. Staff confirmed that incidents of physical abuse were not reviewed in QAPI meetings, and facility policies did not adequately address abuse prevention.
Expired Food Handler Certification for Dietary Aide
Penalty
Summary
The facility failed to ensure proper food safety practices by allowing a dietary aide to continue working after the aide’s food handler certification had expired. Survey review showed that V16’s state food and safety certificate was issued on 10/31/2022 and listed an expiration date of 10/31/2025, yet time cards showed V16 worked multiple shifts during the periods of 3/29/2026 to 4/11/2026 and 4/12/2026 to 4/26/2026. During interviews, the Registered Dietician stated that all staff should have food handling certification and that dietary staff should probably not be handling food on an expired license. The Dietary Manager also stated that one person did not have an updated food handler certification and confirmed that V16 had been working on an expired food handling certification since October 2025. The facility policy required dietary personnel to use proper food handling techniques to promote food safety, and the Dietary Aide job description stated that dietary aides must possess a valid Food Handlers certificate.
Dietary staff failed to follow planned menu and therapeutic meal requirements
Penalty
Summary
The facility failed to ensure dietary staff followed the planned menu, therapeutic diets, and resident preferences. On 4/28/2026, a dietary cook stated residents were served eggs, toast, and oatmeal, and that some residents received boiled eggs or no eggs depending on their ticket likes and dislikes; she also stated sausage did not come in, so she did not make the egg casserole listed on the menu and instead made the other items on the menu. The dietary manager later verified that the freezer contained frozen pork breakfast sausage, sausage crumbles, chicken tenders, ground turkey and beef, burgers, bacon, ravioli, and meatballs, including sausage crumbles with dates showing product was available for use. The dietary manager stated the sausage crumbles were used to prepare the egg and sausage casserole on the breakfast menu and that the cook should have followed the breakfast menu for that day. A resident stated he received toast, a boiled egg, and oatmeal for breakfast and also stated the food was terrible and he did not receive meat with every meal. The registered dietician stated the menu came from an outside food agency and was approved by a certified dietician, and that substitutions should replace the nutritional value and calorie intake on the menu because failing to do so can lead to weight loss. The facility policy required menus to meet daily recommended intake guidelines and substitutions of similar nutritional value when items were unavailable.
Missing Refrigerator and Freezer Temperature Logs
Penalty
Summary
The facility failed to ensure safe food storage practices by not monitoring and documenting refrigerator and freezer temperatures of stored foods daily. On 4/27/2026 at 9:46 AM, the walk-in refrigerator cooler thermometer read 41 degrees Fahrenheit, and the surveyor observed missing daily refrigerator tracking temperature entries for 4/19/2026, 4/24/2026, and 4/26/2026. At 9:50 AM, the walk-in freezer read -3 degrees Fahrenheit, and missing daily refrigerator tracking temperature entries were also observed for the same dates. At 9:53 AM, the sandwich cooler was observed at 36 degrees Fahrenheit with missing daily refrigerator tracking temperature entries and signatures for 4/19/2026, 4/24/2026, and 4/26/2026. At 9:59 AM, V3, the Dietary Manager-Temporary, verified that the walk-in refrigerator, refrigerator cooler, and walk-in freezer had missing daily log-in temperatures. Later, V3 provided the logs with temperatures and initials filled in for those dates, but no times were entered. V3 stated the refrigerator, cooler, and freezer logs are completed every morning and night to keep temperatures at the recommended standards and prevent food from spoiling, and the facility policy stated temperatures are to be recorded on the refrigerator and freezer tracking logs at least two times a day.
EBP Signage Missing and Soiled Linen Mishandled
Penalty
Summary
Enhanced Barrier Precaution signage was not visibly posted for a resident with a wound who required EBP. R231 was admitted with diagnoses including cellulitis of the left lower limb and an unspecified open wound of the left lower leg, and the facility’s Enhanced Barrier Precautions Tracking Log identified R231 as requiring EBP due to a wound. During observation, R231 was in bed with a dressing to the left leg, but the room door did not have an EBP sign posted. The Infection Preventionist stated that residents with wounds should have an EBP sign on the door and that staff should wear gown and gloves when performing high-contact care. Infection control practices were also not maintained in the laundry and during resident care. In the laundry clean processing area, three bags of residents’ soiled linen were observed on the floor, and the Laundry and Housekeeping Manager stated the bags were soiled linen dropped off by floor technicians and should not be placed on the floor or in the clean laundry processing area because it can cause contamination. In addition, while providing ADL care to R53, a CNA was observed throwing R53’s soiled linens on the floor next to the bed. R53 had diagnoses including peripheral vascular disease and a BIMS score of 9, indicating some cognitive impairment. The CNA stated she was about to get the linen off the floor. The facility’s Linen Handling policy stated that clean and soiled linen should remain separate and that soiled linens shall not be placed on the floor.
Disposable Razors Kept at Bedside and Not Properly Supervised
Penalty
Summary
The facility failed to ensure that disposable razors were not kept at the bedside and failed to ensure proper disposal of razors in accordance with facility policy for four residents reviewed for hazards. On 4/27/26, one resident was observed with three disposable razors in the top drawer of the bedside table, and the resident stated that staff did not ask for the razors back and that they were thrown in the garbage when finished. The resident’s record showed a diagnosis of long-term aspirin use and an order for Aspirin 81 mg daily. On 4/28/26, another resident showed four disposable razors in a bath basin and stated that staff allowed him to keep them and that he threw them away in the bathroom garbage can; this resident had an order for Xarelto 20 mg daily for atrial fibrillation. A third resident revealed two disposable razors and stated that nurses gave them to him and let him keep them, and that he discarded them in the garbage when done; this resident had an order for Aspirin EC 81 mg daily and a history of cerebral infarction. All three residents stated they used the razors without staff supervision. A fourth resident with diagnoses including paranoid schizophrenia, anxiety, insomnia, and major depressive disorder was cognitively intact per BIMS and required supervision or touch assistance for shaving per the MDS. That resident was observed lying in bed with a shaving razor on the dresser and stated that he shaved himself about twice a week, tossed the razor in the trash when finished, and was not observed by staff while shaving or disposing of the razor in a sharps container. An LPN stated razors should not be at the bedside, while the DON and Director of Social Services stated disposable razors are not allowed to be kept at bedside even if residents are alert, and that residents on blood thinners need to be supervised. The facility policy stated razors and razor blades are not allowed in resident rooms or on the resident’s person unless permission has been granted from administration and supervision is being provided.
Psychotropic medications given without timely consent and with incomplete diagnosis documentation
Penalty
Summary
The facility failed to ensure that psychotropic medication consents were obtained before medications were started or administered, and it also failed to ensure that the correct medical diagnoses were documented for the use of psychotropic medications. This affected 5 residents reviewed for unnecessary medications. The facility policy stated that psychotropic medication shall not be prescribed without the informed consent of the resident, resident's guardian, or other authorized representative. For R2, Olanzapine 5 mg was started on 4/6/26 and administered through 4/27/26 before a psychotropic consent was obtained on 4/28/26. R2 had diagnoses including schizoaffective disorder, bipolar disorder, and hypertension. For R5, Risperidone 1 mg and Mirtazapine 15 mg were started on 3/4/26 and given in March and April 2026 without consent, while Sertraline 50 mg was started on 4/16/26 and had a consent dated 4/28/26. R5 had diagnoses including type 2 diabetes mellitus, schizoaffective disorders, schizophrenia, bipolar type, major depressive disorder, generalized anxiety, and PTSD. For R195, psychiatric progress notes listed PTSD with psychotic features, schizoaffective disorder, insomnia, and prior hospitalizations for suicidal ideation, but these diagnoses were not listed on the face sheet. R195 received Hydroxyzine, Aripiprazole, Mirtazapine, and later Trazodone from February through April 2026 before signing psychotropic consent on 4/28/26, and the consent did not include all of the psychiatric diagnoses documented in the record. For R63, Sertraline, Mirtazapine, and Melatonin were ordered for generalized anxiety disorder, major depressive disorder, and insomnia, but the medical diagnoses list did not document insomnia or major depressive disorder; psychotropic consents for several of these medications were not signed until 4/28/26, and the MARs showed continuous administration without consent. For R163, Mirtazapine 15 mg was ordered for major depressive disorder and administered in March and April 2026 before consent was signed on 4/28/26, and the consent did not list major depressive disorder under the diagnosis portion.
Unlocked treatment cart and unlabeled insulin vials
Penalty
Summary
The facility failed to ensure that a treatment administration cart was kept locked and unattended medication supplies were secured. On 4/29/26 at 10:02 AM, surveyors observed the second-floor treatment cart unlocked and unattended, with chemical medication solutions accessible in the bottom drawer while residents were ambulating in the hallway. When the observation was brought to an LPN, she stated that a CNA/wound technician had brought supplies from the cart while she was in the middle of a dressing change and that the cart should remain locked when not in use. The facility policy stated that medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. The facility also failed to label opened insulin vials with open and expiration dates and failed to discard expired insulin for two residents. R173, who had diagnoses including DM, dementia, HTN, and depression, had Humalog insulin with no open or expiration dates written on the vial; the box showed an opening date of 2/8/26. R4, who had diagnoses including DM type 2, dementia, HTN, and atrial fibrillation, had insulin glargine with no open or expiration date written on the vial; the box showed an opening date of 3/25/26. An LPN stated insulin should be labeled with an open date so staff know when it expires and when to discard it. The DON stated nurses are expected to put the open and discard date on insulin vials because they expire after 28 days, and the pharmacist stated insulin should not be used past 28 days after opening.
Failure to Provide Feeding Assistance and Nail Care
Penalty
Summary
The facility failed to provide feeding assistance for dependent residents and failed to clean and cut residents’ nails. These failures affected three residents: one resident who required substantial/maximal assistance and had severe cognitive impairment, and two residents who were dependent on staff for hygiene and grooming. The report states that the facility failed to provide feeding assistance for dependent residents receiving pleasure from eating and failed to clean and cut residents’ nails. One resident with diagnoses including congestive heart failure, dysphagia following cerebral infarctions, chronic kidney disease, COPD, and muscle wasting/atrophy was observed lying in bed extremely thin on a puree diet. An LPN placed the puree meal on the bedside table and positioned the resident upright, then left. Later, the resident’s untouched lunch remained on the tray, and a CNA asked whether the resident wanted the food. The resident pushed the tray away, and the CNA removed it without offering an alternative meal. The resident later indicated wanting something else. The resident’s record showed a BIMS score of 0, substantial/maximal assistance needs, a significant weight loss of 6% in one week, and a care plan calling for one-to-one staff intervention to promote proper nutritional intake. Two other residents were observed with long nails and dark debris under the nails. One resident had diagnoses including traumatic amputation, COPD, asthma, diabetes, CHF, schizoaffective disorder, anxiety, major depressive disorder, insomnia, hypertension, heart failure, peripheral vascular disease, and chest pain, with severe cognitive impairment and dependence on staff for personal hygiene and hand washing. The other resident had diagnoses including muscle wasting and atrophy, protein calorie malnutrition, peripheral vascular disease, cataract, lack of coordination, hypertension, and hidradenitis suppurativa, with cognitive intactness but dependence on staff for showers, baths, toileting, personal hygiene, and hand washing. Both residents stated they wanted their nails cut and reported they could not do it themselves. Staff interviews indicated nail care should be done daily or at least weekly, that dependent residents should receive grooming and nail care, and that staff should clean and cut nails, but the residents’ nails remained long and unclean during the observations.
Failure to Prevent and Timely Intervene in Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy and protect residents from physical abuse when two roommates became involved in a physical altercation. A CNA reported hearing someone say there was a fight and, upon entering the room, observed one resident standing over the other and punching him. The CNA separated the residents and escorted the aggressor out while calling for assistance. An LPN heard commotion from the same room, entered, and found one resident on the floor bleeding from the head. The LPN assessed him and obtained information from the other resident that an argument about the television volume had escalated, with one resident stating that the other got in his face, leading him to hit the resident, who then fell to the floor. The injured resident later stated that he had walked into his old room where his roommate was on the phone arguing with his girlfriend. He reported asking the roommate to lower his voice, after which the roommate approached him with a cane and hit him in the face, causing him to fall, and then punched him several more times until the aide intervened. The aggressor resident stated that he was in the room when his roommate came in and turned the television up loudly, and that after asking him to turn it down, the roommate walked toward him and cursed at him, leading him to punch the roommate first because he thought he was going to be hit. He reported punching the roommate again when he tried to get back up, and that the aide came in between them before he could hit him again. Clinical documentation shows that the injured resident was found on the floor with blood coming from his nose and the back of his head, with a busted lip and bleeding from the back of his head. Hospital records describe a 55-year-old male who presented with a chief complaint of battery, reporting that he was punched in the face at the nursing home. Examination revealed a scalp laceration, a 3 cm vertical laceration of the left upper lip and face, and imaging showed an acute on chronic fracture of the nasal bones with a new fracture of the nasal process of the left maxillary bone. The facility’s abuse policy defines abuse as the willful infliction of injury and physical abuse as infliction of injury other than by accidental means requiring medical attention, including hitting and controlling behavior through corporal punishment. The events described demonstrate that the residents engaged in a willful physical altercation resulting in injuries that met the facility’s definition of physical abuse, and staff did not intervene until after the altercation had already progressed to the point of significant injury.
Failure to Prevent In‑Room Smoking Exposing Roommate to Smoke
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and smoke‑free environment for a resident sharing a room with a known smoker. One resident with medical diagnoses including anxiety disorder, bipolar disorder, paraplegia affecting the right side, cerebral infarction, and asthma, and who was documented as cognitively intact, reported that his roommate was constantly smoking in their room. The roommate had medical diagnoses including nicotine dependence, cognitive communication issues, dementia, major depressive disorder, memory deficit following cerebral infarction, and chronic osteomyelitis, and was also documented as cognitively intact. Despite a facility policy that the interior of the facility remain smoke‑free and that smoking occur only in designated areas, the smoking roommate admitted to smoking in the shared room and stated he did so because he did not feel like going outside and did not care about the rules. The smoker’s record showed a long-standing pattern of smoking in his room, with social service notes documenting multiple dates over several months when he was observed smoking in his room. His care plan identified a behavior of smoking cigarettes in his room, and a Smoking Risk Review concluded he may not be capable of handling or carrying smoking materials and required supervision when smoking. A smoking contract specified that he would not smoke anywhere else in the building, would surrender all smoking materials, and would not possess smoking materials in his room or clothing, with stated consequences for violating the policy. Nonetheless, staff, including an LPN, confirmed that the resident continued to smoke in his room while he was roommates with the resident who had asthma, and that the asthmatic resident complained about the smoking because he did not want his asthma to flare up. These actions and inactions resulted in the resident with asthma being exposed to cigarette smoke in his room, contrary to the facility’s smoking safety policy and the resident’s right to a safe, clean, and comfortable environment.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s Enhanced Barrier Precautions (EBP) and infection control policies during incontinence care for one resident. On 1/17/2025 at 3:45 PM, a CNA (V7) was observed exiting and re-entering the resident’s room and walking down the hallway while wearing contaminated gloves, then going to the linen cart to obtain a facecloth without removing the gloves. V7 then returned to the resident’s room and performed incontinence care without wearing a gown, despite an EBP sign posted on the resident’s door stating that staff must wear both gown and gloves for high-contact resident care activities such as changing briefs or assisting with toileting. During this care, the privacy curtain was not pulled, the room door remained open, and a soiled brief was observed on the floor next to the resident’s bed. In subsequent interviews, V7 acknowledged that the resident was on EBP and stated she should not have been wearing gloves in the hallway. An LPN (V8) confirmed that the resident was on EBP and stated that to prevent the spread of infection, staff should wear a gown and gloves during care and that soiled linen and incontinent products should not be thrown on the floor but placed in a bag and disposed of properly. Another LPN (V9) and the DON (V2) both stated that staff should wear gown and gloves when performing incontinence care for residents on EBP and that soiled linen and incontinent products should be bagged and disposed of properly. The resident involved was cognitively intact, with diagnoses including Type 2 diabetes mellitus with foot ulcer, unspecified kidney failure, dependence on renal dialysis, and acquired absence of the right leg above the knee. The facility’s EBP policy required gowns and gloves for high-contact care activities, and the Infection Control Policy required all personnel to adhere to the Infection Control Program in their daily assignments.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by observations of uncleanliness and debris in multiple resident rooms. Surveyors observed trash, paper, and other debris on the floors and under beds in the rooms of four residents. One resident reported that housekeeping had not cleaned his room despite repeated requests over a two-week period, and trash was observed on the floor and under his bed. Another resident confirmed that trash was consistently present on the floor in his room. In another room, surveyors found multiple empty bottles, paper, napkins, and a meal tray slip stuck to the floor, which the housekeeper acknowledged was present despite stating the room had been cleaned that morning. The same resident reported that her room had not been cleaned for about ten days and that the bathroom remained uncleaned even after she reported the issue to staff multiple times. Interviews with staff revealed inconsistencies in cleaning practices, with the regional nurse consultant stating that rooms are cleaned daily and that floor nurses are responsible for ensuring cleanliness, while the housekeeper admitted to cleaning a room that still contained significant debris. Residents' care plans did not document any focus on hoarding behaviors, and the facility's policies require a safe, clean, and comfortable environment. The observations and resident interviews directly contradict the facility's stated cleaning protocols and policies, resulting in a failure to provide the required homelike environment.
Failure to Ensure Proper Medication Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition was observed taking medication at the medication cart without a nurse present to ensure the medication was swallowed. The resident's physician order sheet did not document a focus for self-administration of medication, and there was no evidence of a physician's order, resident education, care plan, or assessment for self-administration. The resident reported that the LPN handed her the medication and then walked away for a few seconds, during which time the resident took the medication and drank water without supervision. The LPN confirmed she did not observe the resident take the medication because she was multitasking. The Director of Nursing stated that self-administration of medication requires specific interventions for safety, including a physician's order and assessment, and that nurses are required to observe residents to ensure medications are swallowed. Facility policy requires medications to be administered in accordance with good nursing practices and only by authorized personnel, with sufficient staff and systems in place to ensure safe administration without unnecessary interruptions.
Widespread Environmental Cleanliness and Maintenance Failures
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for all 196 residents, as evidenced by multiple observations, interviews, and record reviews. Residents and staff reported and surveyors observed widespread cleanliness issues, including garbage not being emptied daily in resident rooms, accumulation of food waste, and the presence of flies and gnats throughout the facility. Specific instances included garbage cans in resident bathrooms and rooms remaining unemptied for several days, leading to infestations of fruit flies and gnats, and residents expressing dissatisfaction with the frequency and quality of cleaning services. Significant sanitation concerns were documented in shared shower rooms, where surveyors observed soiled and wet paper products, brown-stained towels, suspected fecal matter, and mold or mildew on ceiling tiles and grout. The shower drains were covered in hair and infested with small flying insects. Equipment in the shower rooms was found to be in disrepair, such as a shower head pole that was not properly secured to the wall, and a handheld shower nozzle left dangling without a mounting pole. Staff acknowledged these issues, with housekeepers and CNAs noting the persistent dirtiness, presence of mold or mildew, and lack of proper equipment maintenance. Maintenance staff were unaware of some of the problems, indicating a breakdown in communication and reporting. Additional observations included sticky and debris-laden dining room floors, a shower bed with a drain pan containing foul-smelling, murky liquid with solid brown particles, and further insect infestations in various facility areas, including staff bathrooms. Facility policies and job descriptions provided by the facility require daily cleaning, prompt garbage removal, pest control, and regular maintenance, but these standards were not met. Residents involved had intact cognition and were able to clearly articulate their concerns and dissatisfaction with the environment, and some were dependent on staff for all activities of daily living and mobility.
Call Light Not Accessible to Resident Requiring Assistance
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. The resident, who was cognitively intact but required substantial to maximal assistance for most activities of daily living and had left hand contractures, was observed attempting to sit up in bed and searching for the call light to request assistance. The call light was found hanging on top of the overhead light, far from the resident's reach, making it inaccessible for the resident to use when needed. Interviews with staff, including a CNA, the ADON, and the DON, confirmed that the call light was not within reach and that this would prevent the resident from being able to request help. The resident's care plan specifically instructed staff to ensure the call light was within reach and to encourage its use for assistance. The facility's policy also required that all residents have the call light system available and easily accessible at the bedside or another reasonable location.
Failure to Assess Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A deficiency occurred when a nurse failed to assess and document a resident's blood pressure prior to administering an antihypertensive medication, Procardia XL (Nifedipine), as ordered by the physician. The physician's order specified that the medication could be held if blood pressures were persistently 130/80 mmHg, and the facility's policy required medications to be administered as prescribed, including adherence to the five rights of medication administration. Despite these requirements, the resident's electronic medication administration record (eMAR) showed that blood pressure readings were not assessed or documented before administering the medication on multiple dates. Interviews with the LPN and the Director of Nursing confirmed the importance of checking blood pressure prior to administering antihypertensive medications to prevent unnecessary or potentially harmful dosing. The Director of Nursing stated that medications should not be given outside of physician parameters and that nurses are expected to assess blood pressure before administration. The facility's own policy also emphasized the need for medications to be administered in accordance with prescriber orders and good nursing practices.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. In one incident, a resident with intact cognition and a history of anger issues physically struck another resident during a dispute over seating on the smoking patio. The altercation was preceded by verbal exchanges and escalated to physical contact, with staff intervening after the event. The involved residents had no prior history of conflict, but both had behavioral concerns documented in their care plans. Another incident involved two roommates with a history of verbal arguments. One resident, who had previously threatened the other and had a diagnosis of paranoid schizophrenia, physically assaulted her roommate, causing visible injury. Staff were aware of ongoing verbal conflicts between the two but did not separate them prior to the physical altercation, citing lack of available rooms and resident refusals to move. The altercation resulted in one resident being sent to the hospital for psychiatric evaluation. A third incident occurred in the dining room, where a verbal argument between two residents escalated to physical violence. One resident, who had a history of mood distress and anger, was punched and pulled to the ground by another resident following an exchange of insults. Staff responded promptly to separate the residents, and both later apologized. The residents involved had no prior history of conflict, and the aggressor was a new admission who discharged herself against medical advice the same day. In all cases, the facility's policies on abuse prevention and resident rights were not effectively implemented to prevent these incidents.
Failure to Maintain Sanitary Water and Ice Machines
Penalty
Summary
The facility failed to maintain sanitary conditions for drinking water and ice by not properly cleaning or servicing water and ice machines used by residents and staff. Observations revealed significant mineral buildup and residue on the machines and surrounding areas, including the spouts, collection trays, and counters. The machines were also found to be leaking and in poor repair, with one machine's supporting panel split open and brown residue leaking out. Staff interviews confirmed that residents and staff accessed water and ice from these unsanitary machines, as well as from sinks that were also used for handwashing and had visible mineral buildup or personal items left on them. Housekeeping staff reported difficulty removing the buildup, and maintenance staff indicated that the machines had not been serviced by an outside company for an extended period. Further interviews with facility leadership revealed a lack of clarity regarding responsibility for the maintenance and cleaning of the water and ice machines. The Director of Nursing and Administrator were unaware of when the machines were last serviced or who was responsible for their upkeep. Facility policies indicated that the Dietary Department was responsible for monthly cleaning and disinfecting of the ice machines, while the Maintenance and Housekeeping Directors were to conduct regular safety audits. However, these procedures were not being followed, resulting in unsanitary conditions that affected nearly all residents who received oral hydration.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by insufficient seating in the day/dining rooms and inadequate cleaning and maintenance of resident rooms and common areas. Observations revealed that the first and second-floor day/dining rooms did not have enough chairs to accommodate ambulatory residents, resulting in some residents having to stand, sit on rollators, or lean on windowsills and heaters. Multiple residents reported difficulty finding seating, and staff confirmed the number of ambulatory residents exceeded the available chairs. Environmental issues were also noted throughout the facility. In one resident's room, there were black spots on the ceiling, bubbling paint on the wall, and a malfunctioning bathroom light that had not been repaired despite being reported. Other areas of concern included a hole in the second-floor hallway wall, chipped paint and stains in resident bathrooms, sticky and stained floors in dining rooms and hallways, and long-standing marks and smudges on walls and floors. Residents and staff reported that cleaning was not thorough, with some areas not being deep cleaned or stripped as needed, and maintenance issues such as water leaks and possible mold were not promptly addressed. Resident council minutes documented ongoing concerns about room cleaning, and interviews with housekeeping and maintenance staff indicated a lack of clarity regarding cleaning schedules and maintenance follow-up. Facility policies required regular environmental tours and quality control observations, but these were not effectively implemented, as evidenced by the persistent cleanliness and maintenance issues observed and reported by residents.
Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and immediate intervention during an incident involving two residents with cognitive impairments and behavioral disturbances. One resident, diagnosed with dementia and a history of physical aggression, physically struck another resident who was using a wheelchair. Staff statements and interviews revealed that the incident occurred when the aggressive resident believed the wheelchair belonged to them and, upon the other resident exiting the chair, struck the individual in the head before taking the chair. Multiple staff members did not witness the event directly, and the facility was unable to provide a witness statement from a hospice CNA who initially reported the incident. The care plans for both residents identified risks related to their cognitive and behavioral conditions, including the need for monitoring and supervision, but these interventions were not effectively implemented at the time of the incident. Additionally, the facility failed to implement necessary fall prevention interventions for another resident assessed as a moderate fall risk with a history of falls and left-sided weakness. Despite a completed assessment indicating the need for side rails and alarms, and the resident's consent for these devices, these interventions were not put in place. Instead, only floor mats and non-skid socks were used, which did not prevent the resident from rolling out of bed and sustaining a head injury. Staff interviews confirmed that side rails and alarms were considered appropriate and beneficial for this resident, but these measures were not included in the care plan or implemented in practice. Facility policies require that supervision and safety interventions be tailored to each resident's assessed needs and that the care team use assessment information to identify and address specific accident hazards. In both cases, the facility did not follow through with the interventions identified as necessary by assessment and care planning, resulting in preventable incidents affecting the safety and well-being of the residents involved.
Failure to Prevent Resident Access to Alcohol and Illicit Drugs
Penalty
Summary
The facility failed to prevent residents from accessing alcohol and illicit drugs while on the premises, resulting in at least one resident becoming intoxicated and subsequently reporting non-consensual sexual activity. One resident, with a history of substance abuse and mental health diagnoses, was found to be intoxicated and later tested positive for cocaine and marijuana. This resident reported engaging in drinking and drug use with other residents and described an incident of sexual activity that she claimed occurred while she was under the influence, leading to emotional harm and hospitalization. Multiple residents with documented histories of substance abuse and mental health disorders were identified as having access to alcohol and drugs within the facility. Progress notes and interviews revealed that residents were able to bring in contraband substances, often by concealing them on their person, as staff only checked bags and not individuals. Staff interviews confirmed that supervision was limited, and there were lapses in monitoring residents' activities, particularly during nighttime hours. Several residents admitted to drinking and using drugs together, and staff acknowledged that some residents had been found intoxicated or under the influence. Facility policies required the removal of contraband and outlined procedures for searching rooms and involving administration if contraband was suspected. However, these policies were not effectively implemented, as evidenced by repeated incidents of residents accessing and consuming alcohol and drugs. The lack of adequate supervision and enforcement of contraband policies directly contributed to the incidents of intoxication and associated harm among residents.
Failure to Securely Store and Administer Medications
Penalty
Summary
Multiple instances were observed where medications and biologicals were not securely stored according to facility policy and professional standards. In one case, a family member found a pink capsule and a white tablet on a resident's bed, which the resident stated were left by the night nurse. The resident reported that the nurse left the medication on the table and departed before ensuring the medication was taken, and that staff do not return even if called. The pills were later identified as melatonin, which was ordered, and Benadryl, for which there was no physician order. The resident's electronic medical record confirmed the absence of an order for Benadryl. Another resident was found with an inhaler left on top of an oxygen concentrator in their room. The resident stated the nurse left it for use as needed, but there was no physician order for self-administration, and the resident was not on a self-administration program. Additionally, insulin pens intended for another resident's son were found at a resident's bedside, and a cup containing eight pills was observed on a bedside table. Staff confirmed that these medications should not have been left at the bedside and that the residents were not authorized for self-administration. Further observations included medication and treatment carts left unlocked and unattended in the hallway, with staff acknowledging that carts should be locked when not in use or not in the immediate presence of a nurse. The facility's policy, last revised in 2018, requires that medications and biologicals be stored safely, securely, and only accessible to authorized personnel. These lapses in medication storage and administration practices were confirmed through staff interviews, resident statements, and review of medical records.
Failure to Provide Timely Personal Hygiene and ADL Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs) did not receive necessary personal hygiene care, including nail care, in a timely manner. On observation, the resident was found in a wheelchair, wearing a hospital gown that left the front of the body exposed, without an incontinent brief, and was wet. The resident had long nails with blackish particles underneath, dirty hands, and was eating food with their hands without cutlery. Food was observed on the resident's lap, between their legs, and on the floor. The room had a foul urine odor, and the resident's hair was unkempt and matted. The resident, who was unable to move both lower extremities, had dry, peeling, and swollen skin on the legs. The resident stated that no staff had come to assist since the previous day. Staff interviews revealed that the assigned CNA had not provided morning ADL care or incontinent care to the resident and had not checked on the resident since the start of the shift. The CNA confirmed that the resident had not refused care that morning. The resident's care plan indicated a self-care deficit and required staff assistance with personal hygiene and maintaining skin integrity, including keeping fingernails short. Facility policy and CNA job descriptions required staff to provide ADL care, including bathing, grooming, and incontinence care, but these were not carried out as required for this resident.
Failure to Provide and Document Prescribed BIPAP Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic hypercapnia who required nocturnal BIPAP therapy. Upon re-admission from the hospital, the resident was supposed to receive BIPAP treatment at night as per hospital discharge instructions. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that the resident received any BIPAP or CPAP therapy during the specified period. The resident confirmed that BIPAP treatment was only administered in the hospital and not at the facility, and stated that he did not refuse the therapy while at the facility. Additionally, the facility did not have the necessary equipment available for the resident's use. Review of the resident's care plan revealed that it did not include any plan of care for CPAP/BIPAP therapy, despite clear hospital instructions for nightly BIPAP use. There was also no physician order or documentation seeking clarification of the hospital's order for respiratory therapy. Interviews with facility staff, including LPNs, nurse practitioners, and the DON, indicated a lack of communication and follow-through regarding the reconciliation and implementation of the hospital's recommendations. Staff were unclear about their responsibilities for clarifying and carrying out admission orders, and there was no documentation that nursing staff sought clarification on the discrepancy in respiratory treatment orders. Facility policies and job descriptions required nurses to administer and document all treatments as ordered by the physician, including BIPAP/CPAP therapy. Despite these requirements, the resident's records showed no documentation of respiratory care being provided, and staff interviews confirmed that the necessary therapy was not consistently administered or documented. The lack of documentation and failure to implement the prescribed therapy constituted a deficiency in providing appropriate respiratory care as needed.
Failure to Administer Oxygen as Ordered by Physician
Penalty
Summary
A deficiency occurred when a male resident with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), was administered oxygen at a rate of 5 liters per minute via nasal cannula, despite a physician's order specifying 3 liters per minute. The discrepancy was discovered during an observation, where the oxygen concentrator was found set at 5 liters. The LPN present confirmed that the correct setting should have been 3 liters, as per the active physician order, and acknowledged that oxygen is considered a medication that must be administered as ordered. The LPN also admitted that she had not checked the oxygen concentrator that day and was unaware of the incorrect setting until it was pointed out by the surveyor. Further interviews with the Director of Nursing and a Nurse Practitioner confirmed that the physician's order was for 3 liters per minute and that administering a higher dose was not appropriate for a resident with COPD unless specifically ordered. The facility's policy on medication administration requires that medications, including oxygen, be administered exactly as prescribed by the physician. The failure to follow the physician's order resulted in the resident receiving a higher dose of oxygen than intended.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain effectively and administer the prescribed pain medication, morphine, as documented. The resident, identified as R114, who is cognitively intact with a BIMS score of 15, reported not receiving his morphine medication since Thursday night, despite the Medication Administration Record (MAR) indicating that doses were given. The resident's medical history includes COPD, atherosclerosis, peripheral vascular disease, a pacemaker, and bilateral below-knee amputations, which necessitate pain management for phantom pain. Upon investigation, discrepancies were found between the MAR and the actual administration of the medication. The LPN, V32, could not locate the narcotic sheet or the morphine in the narcotic drawer, indicating a failure in the medication management process. The Director of Nursing (DON), V2, was also unable to find the narcotic sheet, and the medication was not present in the narcotic drawer, confirming the resident's claim of not receiving the medication. The facility's policy requires that controlled substances be regularly reconciled with the MAR, but this was not adhered to, leading to the resident's unmanaged pain. Further interviews with staff revealed inconsistencies in the documentation and administration of the medication. Several nurses, including V39, V45, and V14, claimed to have administered the medication as documented, but the lack of morphine in the narcotic box and missing narcotic sheets suggest otherwise. The pharmacist confirmed that a sufficient quantity of morphine was delivered to the facility, which should have lasted until March 27th. However, the medication was not available for the resident, indicating a breakdown in the facility's medication management and documentation processes.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, which could potentially affect all 207 residents receiving an oral diet. During a kitchen tour, the surveyor observed several deficiencies, including undated and unlabeled food items such as a box of tomatoes and a plastic bag containing various meats. Additionally, staff members were storing personal food items in the walk-in refrigerator, which could lead to cross-contamination. In the dry storage area, there were open packages and ingredient bins without labels or dates, which is against the facility's policy for food safety. Furthermore, the facility did not maintain proper sanitation levels in the kitchen. A sanitation bucket at the preparation station registered a sanitation level of 0 parts per million, indicating that no sanitizer was present. This lack of sanitizer could prevent the proper sanitization of food preparation areas, increasing the risk of spreading germs. The facility's policies clearly outline the need for proper food storage, labeling, and sanitation practices to prevent contamination and ensure food safety, but these were not followed as observed during the survey.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for four residents, as observed during a survey. One resident reported that their room was cleaned infrequently. Another resident's room was found to have a missing closet door and dresser drawer, with the floor and privacy curtain stained. A housekeeper confirmed the presence of dirt and trash on the floor and was unsure about the stains on the privacy curtain. Additionally, another resident's room was observed to be dirty with stains on the floor and no bedsheets on the bed. A resident with a gastrostomy tube was observed to have a dried brown substance covering the g-tube pole and dust on the oxygen concentrator. A Licensed Practical Nurse suggested that the substance was likely g-tube feeding and that housekeeping was responsible for cleaning the equipment. The Director of Nursing stated that housekeeping, nurses, and Certified Nursing Assistants were responsible for cleaning the g-tube and oxygen concentrator. The facility's policies and job descriptions outlined the responsibilities for maintaining a clean and homelike environment, but these were not adhered to, resulting in the deficiencies observed.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the security and proper management of medications, particularly narcotics, on the fourth floor. Observations revealed that the medication refrigerator was unlocked due to a non-functional latch, allowing access to narcotic medications without a key. An LPN admitted that the narcotic medication box inside the refrigerator was not locked, contrary to the facility's policy. Additionally, expired medications, including Lorazepam and Morphine Sulfate, were found in the refrigerator, and a multi-dose vial of Tuberculin Purified Protein solution was not labeled with an open date. Further deficiencies were noted with the storage and labeling of medications on the medication carts. Diazepam, a controlled substance, was improperly stored in an unlocked drawer instead of a locked compartment. Inhalers for several residents were not clearly labeled with open or expiration dates, leading to confusion among staff about their status. The facility's policy requires that opened medications be labeled with the open date and expiration date, but this was not consistently followed. Discrepancies in the documentation and inventory of narcotic medications were also identified. For instance, the controlled drug receipt form for a resident's Lorazepam showed a different count than the actual number of tablets present. The facility's policies mandate regular reconciliation of controlled substances with the Medication Administration Record and immediate reporting of any discrepancies, but these procedures were not adequately implemented, leading to potential risks for residents on the fourth floor.
Failure to Monitor Personal Refrigerators and Expired Food
Penalty
Summary
The facility failed to monitor personal refrigerator temperatures and ensure that personal refrigerators had thermometers for four residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, the refrigerators of residents with various medical conditions, including cerebrovascular disease, chronic obstructive pulmonary disease, and paraplegia, were found without temperature log sheets or thermometers. Expired food items, such as milk and yogurt, were also discovered in one resident's refrigerator, indicating a lack of proper monitoring and maintenance. Interviews with facility staff revealed confusion regarding the responsibility for checking the residents' refrigerators. A Certified Nursing Assistant (CNA) was unaware of who should perform these checks, while the Director of Nursing (DON) and a Nurse Consultant believed it was the responsibility of housekeeping. The facility's policy mandates that staff monitor personal refrigerators for food safety and ensure that all refrigerators have internal thermometers with daily recorded temperatures. However, this policy was not followed, leading to the potential risk of residents consuming expired food.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Staff did not don personal protective equipment (PPE) while performing wound care for a resident with methicillin-resistant Staphylococcus aureus (MRSA) infection. Additionally, Enhanced Barrier Precautions (EBP) signage was not visibly posted outside the rooms of two residents who required such precautions due to their medical conditions, including a resident with a hemodialysis catheter and another with wounds from bilateral below-knee amputations. The facility also failed to maintain PPE bins outside isolation rooms, as observed with a resident's room that had a Contact Precautions sign but no PPE bin available. Staff were observed not performing hand hygiene when passing meal trays, even after touching their own body or hair, which is against the facility's infection control policy. This was noted with a Certified Nursing Assistant (CNA) who did not sanitize hands after adjusting personal clothing and hair while distributing meal trays to residents. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), revealed a lack of adherence to established infection control protocols. The DON acknowledged that staff should perform hand hygiene before and after passing meal trays and that PPE should be donned before entering isolation rooms. The absence of an Infection Preventionist (IP) nurse prior to a recent hire contributed to lapses in maintaining PPE supplies and ensuring compliance with infection control measures.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call light devices for two residents, R35 and R41, were within their reach, which is a requirement for accommodating the needs and preferences of each resident. R35, who has a diagnosis including Bilateral Primary Osteoarthritis of the knee, Paralytic Syndrome, Hemiplegia and Hemiparesis, Vascular Dementia, Peripheral Vascular Disease, and Major Depressive Disorder, was observed with her call light on the floor behind her bed, out of reach. Despite her physical limitations, R35 stated she could use the call light if it were accessible. Her care plan emphasized the importance of having the call light within reach, yet the facility did not provide an alternative device for her use, as indicated by the blank response on her Call Light Ability Screen. Similarly, R41, diagnosed with dementia, protein-calorie malnutrition, intracapsular fracture of the left femur, sequela, hypertension, and abnormalities of gait and mobility, was observed with the call light on the floor underneath the bed. Although R41's Call Light Ability Screen indicated she could use the call light, it was not within reach, contradicting her care plan's directive. Both the Registered Nurse and the Director of Nursing acknowledged that the call light should be within reach of the residents at all times, as per the facility's policy. This oversight affected two residents and had the potential to impact all residents in the facility.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer three residents for a Level II PASARR evaluation after they received new mental disorder diagnoses. Resident R141 was admitted with diagnoses of bipolar disorder and adjustment disorder, but the initial PASARR did not reflect these mental health conditions. The Business Office Manager (V35) acknowledged that the PASARR should have included these diagnoses to ensure the resident was in the appropriate facility and that their needs could be met. A new Level I PASARR was initiated, which triggered a Level II evaluation. Resident R61 had a diagnosis of Major Depressive Disorder and other conditions, but the PASARR documentation did not reflect these mental health issues. The resident's care plan did not address the Major Depressive Disorder, and the PASARR Level I outcome did not indicate a mental health diagnosis. The Business Office Manager confirmed that a new PASARR Level I was submitted due to the new diagnosis, but it was not initially documented correctly. Resident R104 had a diagnosis of Major Depressive Disorder, but the PASARR documentation did not reflect this condition. The resident's PASARR Level I was not documented in the electronic health record, and the Business Office Manager confirmed that a new PASARR Level I was required due to the change in condition. The facility's policy requires each resident to be screened for Level I PASARR prior to or shortly after admission, but this was not adhered to in these cases.
Failure to Update PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the completion of a new Pre-Admission Screening and Resident Review (PASARR) when a new mental health diagnosis was identified for three residents. Resident 61 had a diagnosis of Major Depressive Disorder and other conditions, but the PASARR Level I Outcome did not reflect any mental health diagnosis. Despite being prescribed medication for depression, the care plan did not address this condition, and the PASARR was not updated accordingly. Resident 104 had a diagnosis of Major Depressive Disorder, but the initial OBRA-I screen did not suspect any mental illness. Although a PASARR Level I review was eventually conducted, it was not documented in the electronic health record initially, and the necessary Level II screening was delayed. The Business Office Manager confirmed the need for a PASARR Level I to trigger a Level II due to the change in condition. Resident 141 was admitted with diagnoses of bipolar disorder and adjustment disorder, but the initial PASARR did not include these mental health conditions. The Business Office Manager acknowledged the oversight and initiated a new PASARR Level I, which triggered a Level II screening. The facility's policy requires each resident to be screened for Level I prior to or shortly after admission, but this was not adhered to in these cases.
Failure to Follow Wound Care Treatment Orders
Penalty
Summary
The facility failed to adhere to wound care treatment orders for a resident, identified as R138, who was reviewed for wounds. R138 has a medical history that includes orthopedic surgical amputation, Type 2 diabetes with foot ulcers, peripheral vascular disease, and other conditions. Observations on March 24, 2025, revealed that the dressings on both of R138's great toes were dirty, with the left toe dressing showing black dark drainage. R138 reported that the dressings had not been changed since March 21, 2025, despite orders for daily changes. The resident, who is cognitively intact, sometimes changed the dressings themselves due to excessive drainage. The facility's records, including the Treatment Administration Record (TAR), showed multiple days in March 2025 when the wound care was not documented as completed. Interviews with the Wound Care Nurse, Wound Care Coordinator, and Director of Nurses confirmed that the dressings should be changed daily and that the resident should not be responsible for changing their own dressings. The facility's policy emphasizes the importance of following physician orders to promote healing, yet the failure to implement these orders as prescribed led to the deficiency.
Failure to Investigate Fall and Enforce Smoking Policies
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving a resident, R65, and did not implement fall interventions as listed on the revised care plan. R65, who has a history of multiple medical conditions including polyarthritis, diabetes, and schizoaffective disorder, experienced a fall in the shower room. Despite the presence of a staff member, the fall was not reported immediately, and no nurse assessed R65 following the incident. The fall was only documented the following day after R65 reported pain and bruising. The care plan for R65, which included placing nonskid strips beside the bed, was not followed, as observed by the Director of Nursing. Additionally, the facility failed to ensure adequate supervision to prevent a resident, R172, from smoking in a residential room. R172, who has intact cognition and a history of psychoactive substance abuse, was found with a strong smell of marijuana in his room, and a haze of smoke was observed. Although R172 claimed the smell was from his clothing after smoking outside, the social service staff suspected that R172 was smoking inside the room. The facility's policy prohibits smoking inside the facility, and residents are required to comply with smoking safety contracts. These deficiencies highlight the facility's failure to adhere to its policies and procedures regarding fall prevention and smoking regulations. The lack of immediate assessment and documentation of R65's fall, along with the failure to implement care plan interventions, contributed to inadequate resident safety. Similarly, the inability to enforce smoking policies and supervise residents effectively posed potential safety hazards within the facility.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, R73 and R98, who were receiving oxygen therapy. For R73, the facility did not change the nasal cannula tubing weekly as required, with the tubing observed to be dated 3/4/25, despite the policy stating it should be changed weekly. Additionally, R73's CPAP mask was found lying uncontained on the nightstand, which is against the facility's policy for equipment storage and infection control. R73, who is cognitively intact, was receiving oxygen at 3 liters per nasal cannula, but there was no documentation of a physician's order for this administration. For R98, the facility failed to obtain a physician's order for oxygen administration, despite the resident receiving 4 liters of oxygen. The oxygen tubing for R98 was observed lying on the floor, and there was no order for pulse oximetry checks, which are necessary to monitor the resident's oxygen needs. R98, who is also cognitively intact, was admitted with diagnoses including dependence on supplemental oxygen and COPD. The facility's policy requires a physician's order for oxygen administration and regular monitoring of oxygen saturation levels, which was not adhered to in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before prescribing a psychotropic medication to a resident, identified as R61, who was diagnosed with Major Depressive Disorder. The resident's Minimum Data Set indicated severe cognitive impairment. Despite this, the resident was prescribed Remeron (Mirtazapine) for situational depression, with the medication being administered daily from March 1, 2025, to March 25, 2025. However, the consent for the psychotropic medication was only obtained verbally on March 24, 2025, which was after the medication had already been administered for several weeks. The Director of Nursing (DON) confirmed that the facility's policy requires informed consent to be obtained before prescribing psychotropic medications. The policy mandates that psychotropic medications should not be prescribed without the informed consent of the resident, their guardian, or an authorized representative. The DON acknowledged that the consent process was not followed correctly in this instance, as the verbal consent was obtained after the medication had been prescribed and administered.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, affecting two residents. One resident, identified as R8, sustained a laceration to the back of the head requiring staples and hospitalization after being pushed by another resident, R12, in the dining room. Despite conflicting accounts from staff, a Certified Nursing Assistant confirmed witnessing the incident where R8 attempted to take food from R12's plate, leading to R8 being pushed and hitting their head on the ground. The facility's investigation did not initially acknowledge the push, attributing the fall to R8's anemia, and the Director of Nursing did not review hospital records indicating the push. Another incident involved R3 and R15, where R3 verbally threatened and physically assaulted R15 by slapping him across the face. This incident was witnessed by another resident, R9, and reported to staff, but the facility's administration initially only acknowledged a verbal disagreement. The Social Services Director confirmed being informed of the physical assault, and the police were involved, but the facility's records did not reflect appropriate interventions to address R3's aggressive behaviors. Both incidents highlight the facility's failure to adequately investigate and address resident-to-resident abuse, as well as a lack of appropriate care plan interventions for residents with known aggressive behaviors. The facility's abuse prevention policy and residents' rights documents emphasize the importance of protecting residents from abuse, yet these incidents demonstrate a significant lapse in ensuring resident safety and well-being.
Failure to Provide Adequate Wound Care and Pain Management
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a surgical wound, leading to the worsening of the wound and avoidable pain. The resident, who had a surgical amputation and other complex medical conditions, was observed with a poorly maintained dressing on her left foot. The dressing was secured with band-aids, unraveling, and appeared dirty, with no date indicating when it was last changed. The resident reported that her wound dressing had not been changed as per the physician's orders, and she experienced pain due to not receiving her prescribed pain medication. The resident's medical records showed active physician orders for daily wound care and pain management with Oxycodone. However, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicating that these treatments were administered. Interviews with staff revealed that the resident was not assessed for self-care, yet was given supplies to change her own dressing. The Director of Nursing confirmed that medications should be documented when administered and that the resident was not capable of changing her own wound dressing. The resident expressed concerns about her wound not healing and the possibility of further amputation. The Wound Care Nurse confirmed that wound dressings should be dated and documented, and that failure to change dressings as ordered could lead to infection and deterioration. The facility's policies on medication administration and wound care were not followed, contributing to the resident's condition not improving and potentially requiring further medical intervention.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary, clean environment, affecting all 208 residents. Observations revealed dirty floors with unidentified food particles, dirt splatters, and sticky surfaces in the dining room and hallways across multiple floors. Staff, including a CNA and the Director of Nursing, acknowledged the unclean conditions, with the Director noting the need for housekeeping intervention. Residents expressed dissatisfaction, with some resorting to cleaning their own rooms due to the lack of housekeeping services. Staff shortages in housekeeping were cited as a contributing factor, with some staff members taking on cleaning duties themselves. The facility's administrator confirmed recent issues with housekeeping, noting the appointment of a new housekeeping manager. Despite the facility's policy on residents' rights to a clean environment, multiple staff members, including a Restorative Technician and a Social Services Director, reported receiving complaints from residents about the cleanliness. The report highlights the facility's failure to provide a safe, clean, and comfortable environment as required by residents' rights, with staff and residents both acknowledging the ongoing cleanliness issues.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility staff failed to report suspected abuse incidents to the state survey agency within the required timeframe and did not notify the abuse prevention coordinator as mandated. This deficiency affected four residents. In one incident, a resident fell and sustained a head injury after being pushed by another resident. The incident was not reported to the state survey agency until six days later, and the abuse prevention coordinator was unaware of the pushing incident until much later. The staff involved did not follow the facility's policy of immediate reporting to the administrator or the state survey agency. In another incident, two residents had a verbal disagreement, which escalated to one resident hitting the other. The administrator was aware of the verbal disagreement but not the physical altercation. The social services director and a licensed practical nurse were aware of the physical aspect of the incident but did not ensure it was reported as abuse. The facility's policy requires that any suspicion or allegation of abuse be reported immediately to the administrator and the state survey agency. The facility's policies on abuse prevention and incident reporting clearly outline the need for immediate reporting of abuse incidents to the state survey agency and the administrator. However, in both incidents, the staff failed to adhere to these policies, resulting in delayed reporting and inadequate investigation of the abuse allegations. This lack of timely reporting and communication among staff members contributed to the deficiency identified by the surveyors.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following a fall incident involving a resident, R8, who sustained a head injury. The incident occurred when R8 attempted to take food from another resident, R12, who then allegedly pushed R8, resulting in a fall and a laceration to the head. Despite hospital records indicating that R8 was pushed, the facility's investigation concluded that the fall was due to R8's anemia, without interviewing key witnesses or reviewing hospital records. The Director of Nursing, V2, and the Administrator, V1, acknowledged that the hospital records should have been reviewed and that the Certified Nursing Assistant, V14, who witnessed the incident, was not interviewed. In another incident, the facility failed to investigate an allegation of verbal and physical abuse involving residents R3 and R15. R3 was reported to have verbally threatened and physically struck R15 over a misunderstanding about clothing. Although staff were aware of the verbal altercation, the Administrator, V1, was only informed of the verbal disagreement and not the physical assault. The Social Services Director, V19, confirmed that R15 reported being hit by R3, but no investigation was conducted to substantiate the incident. The facility's policies on abuse prevention and incident reporting require thorough investigation of all allegations or suspicions of abuse, neglect, or mistreatment. However, in both cases, the facility did not adhere to these policies, failing to gather necessary witness statements and review relevant documentation. This lack of thorough investigation and documentation led to deficiencies in addressing potential abuse and ensuring resident safety.
Failure to Complete Community Survival Skills Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a community survival skills assessment for a resident, which is necessary to determine if the resident can safely be out in the community independently. This deficiency affected a resident who left the facility for an eye doctor appointment and did not return until four days later. During this time, the facility and the resident's family were unaware of the resident's whereabouts, causing concern for the resident's safety. The resident, who has a BIMS score indicating intact cognition, was admitted to the facility with multiple medical conditions, including orthopedic aftercare and muscle wasting. Despite being cognitively intact, the resident's community survival skills assessment was not completed upon admission, as required by the facility's policy. The assessment was only completed after the resident had already left the facility unsupervised, and the staff was not aware of the resident's absence until the following day. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's pass privileges and the process for monitoring residents who leave the facility. The social service director admitted that the community survival skills assessment was not completed at admission, and the psychosocial rehabilitation services coordinator acknowledged that the assessment was delayed due to oversight. The facility's policy requires the assessment to be completed upon admission, quarterly, and when there is a significant change in condition, but this was not adhered to in this case.
Sanitation and Maintenance Deficiencies in Third-Floor Shower Room
Penalty
Summary
The facility failed to maintain the community shower room on the third floor in a sanitary and functional condition, potentially affecting all 52 residents on that floor. During an inspection, it was observed that the toilet bowl had visible brown stains and a ring of stains, indicating it had not been cleaned for several days. Additionally, the toilet water tank and cover were covered in accumulated dust. The third shower stall's faucet was broken and non-functional, which was confirmed by an LPN who mentioned that the issues were typically reported via a scanner system, although calling maintenance was considered faster. The housekeeping staff was not adequately assigned to ensure cleanliness on the third floor. A housekeeper was observed cleaning on the second floor and was unaware of who was responsible for the third floor. The Housekeeping Director acknowledged challenges in staffing the second and third floors, noting that they were in the process of hiring additional staff to address these deficiencies. The facility's housekeeping policy requires daily cleaning assignments to maintain a clean and orderly environment, which was not adhered to in this instance.
Failure to Protect Residents from Known Aggressive Resident
Penalty
Summary
The facility failed to protect two residents from abuse by another resident with known violent behavior. The resident in question was admitted without a timely background check or fingerprinting, despite having a history of aggression and a criminal record. This oversight allowed the resident to physically assault two other residents, resulting in significant injuries, including multiple facial fractures to one of the victims. The facility did not develop a care plan for the aggressive resident upon admission, despite being aware of the resident's history of aggression and previous altercations at another facility. The care plan was only updated after incidents of violence occurred, failing to address the resident's behavioral symptoms and wandering as identified in the initial assessments. The facility's social services department acknowledged that the aggressive behaviors should have been addressed in the care plan upon admission. Additionally, the facility's assessments of the resident's aggressive and harmful behaviors were inaccurate, failing to reflect the resident's known history of aggression and mental health diagnoses. Staff interviews revealed that the resident frequently exhibited aggressive behavior, yet there was no documentation of behavior monitoring or interventions. The facility's lack of timely and accurate assessments and care planning contributed to the failure to prevent the assaults.
Inaccurate Assessments Lead to Resident Aggression and Harm
Penalty
Summary
The facility failed to accurately complete assessments for a resident, identified as R3, which led to significant incidents involving aggressive behavior. R3, who was admitted with multiple diagnoses including cerebral infarction, bipolar disorder, Alzheimer's disease, vascular dementia, and legal blindness, was inaccurately assessed in several areas. The Minimum Data Set (MDS) inaccurately documented R3 as having adequate vision despite being legally blind. Additionally, the Screening Assessment for Trauma Factors and the Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors were completed inaccurately, failing to identify R3's criminal history, history of aggression, and psychiatric diagnoses. These assessment inaccuracies resulted in R3's aggressive behaviors going unaddressed, leading to physical altercations with other residents. R3 physically assaulted two residents, R2 and R7, causing significant harm to R7, who suffered multiple facial fractures. The incidents were partly attributed to R3's inability to recognize others due to blindness, as noted by the Social Services Director. The facility's lack of accurate assessments meant that R3's care plan did not address critical needs, such as visual impairment, which could have triggered appropriate interventions. Interviews with facility staff, including the Medical Director and MDS Coordinator, confirmed the inaccuracies in R3's assessments. The MDS Coordinator acknowledged that R3's vision should have been coded as impaired, which would have prompted a Care Area Assessment for visual function. The facility did not have a specific policy for completing aggression screening and trauma assessments, relying instead on the Resident Assessment Instrument (RAI) guidelines. This lack of policy may have contributed to the oversight in accurately assessing and addressing R3's needs.
Failure to Address Aggressive Behaviors in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, R3, who had a known history of aggressive behaviors and dementia. Prior to admission, R3's referral records indicated a history of physical altercations, anxiety, and confusion, posing a danger to themselves and others. Despite this, the facility did not address these behaviors in R3's care plan upon admission or after subsequent incidents of aggression. On two separate occasions, R3 physically assaulted other residents. The first incident involved R3 hitting a roommate, R2, on the head with a cane, causing a bleeding wound. Staff and other residents expressed concerns about R3's aggressive behavior, noting that R3 was regularly agitated and could potentially harm others. Despite these concerns, R3's care plan was not updated to address these behaviors until after a second incident occurred. The second incident involved R3 physically assaulting another resident, R7, resulting in multiple facial fractures. This incident further highlighted the facility's failure to update R3's care plan in a timely manner. The facility's policies required that care plans be updated to reflect changes in a resident's condition, but R3's aggressive behaviors were not addressed until after both incidents had occurred. This oversight resulted in harm to multiple residents and demonstrated a lack of adherence to the facility's care planning policies.
Failure to Supervise Resident with Violent Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with known violent behavior, leading to physical assaults on two other residents. The resident in question, R3, had a documented history of aggression and was involved in altercations at a previous facility before being admitted to the current one. Despite this history, R3's aggressive behaviors were not addressed in the care plan upon admission, nor were they updated after incidents of violence occurred within the facility. On one occasion, R3 assaulted a roommate, R2, by hitting them on the head with a cane, causing a bleeding wound. This incident was witnessed by staff, who noted R3's regular agitation and aggressive tendencies. Despite these observations, there was no specific supervision plan in place for R3, and staff expressed concerns about R3's potential to harm other residents. The facility's policy on supervision was not adequately followed, as additional supervision measures were not implemented for R3. Another incident involved R3 physically assaulting another resident, R7, resulting in multiple facial fractures. R7, who had severe cognitive impairment, was knocked out of their wheelchair during the altercation. Staff and medical personnel were aware of R3's aggressive behavior, yet the care plan was not updated to address these behaviors until after the incidents occurred. The lack of timely and appropriate care planning and supervision contributed to the harm experienced by the residents involved.
Failure to Conduct QAPI Meetings and Address Abuse Data
Penalty
Summary
The facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings quarterly and did not ensure that abuse data collection was implemented or coordinated within these meetings. This deficiency potentially affects all 200 residents in the facility. A review of the facility's QAPI meeting minutes from March 7, 2024, revealed no reporting, tracking, or discussion of abuse or abuse outcomes. The template used for these minutes lacked any section for reporting or tracking abuse allegations. Furthermore, no QAPI meeting minutes were available from March 7, 2024, until October 21, 2024, indicating a significant gap in the facility's quality assurance processes. Interviews with facility staff, including a nurse consultant and the administrator, confirmed that QAPI meetings were not held between April 2024 and August 2024, and that incidents of physical abuse occurring on September 26, 2024, and October 10, 2024, were not reviewed in any QAPI meeting. The facility's policy on Quality Assurance Committee did not mention abuse, and the Abuse Prevention Program policy required quarterly reviews of reports to assess patterns or trends that might indicate abuse. However, these reviews were not conducted, and the incidents were not discussed in the QAPI meetings, highlighting a failure in the facility's abuse prevention and quality assurance processes.
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What surveyors actually found near you
We read the 1,716 citations issued within 25 miles in the last 12 months — including the 26 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Town Manor Rehab & Hcc | 2.6 mi | ★★★★★ | 10 | 0 |
| Ahva Care Of Stickney | 2.9 mi | ★★★★★ | 1 | 0 |
| Aperion Care International | 3 mi | ★★★★★ | 3 | 0 |
| Little Village Nrsg & Rhb Ctr | 3.3 mi | ★★★★★ | 18 | 0 |
| Nexus At Berwyn | 3.4 mi | ★★★★★ | 12 | 2 |
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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.