Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bria Of Belleville during CMS and state inspections, most recent first.
A facility failed to revise care plans for LOA activities for 4 residents. Physician orders for residents with diagnoses including schizophrenia, MDD, anxiety, diabetes, CVA/TIA, malnutrition, dysphagia, bipolar disorder, and weakness documented that they may attend day program and/or go out on pass with family, but the care plans did not address signing out, coming and going, or other LOA activity. Residents stated they had cars, visited family and friends, and could leave or sign themselves in and out, while staff said they were unsure what “may attend day program” meant and had not care planned any resident for LOA.
A resident with schizophrenia, depression, psychosis, and wound care needs repeatedly told staff he wanted to leave and go to a shelter. Staff later saw him leave with bags and say he was going to the laundromat, but he did not sign out and no LOA documentation was found. Staff assumed he would return based on his usual pattern of coming and going, and the missing resident was not recognized until the next day.
A resident with schizophrenia, major depression, psychosis, and other diagnoses had Ativan and risperidone ordered, but staff left pills unattended on a bedside table and later on a desk in the resident’s room. An LPN reported seeing the medications left behind, and the Administrator and DON stated that meds should be administered directly to the resident and not left in the room.
Two cognitively intact residents with multiple comorbidities, including ESRD and mobility/coordination impairments, reported that the facility repeatedly lost their clothing, with one noting that several pairs of pants sent to laundry were not returned and that missing items were never replaced despite assurances of investigation. Resident council minutes documented ongoing concerns about missing and delayed laundry, and the administrator acknowledged significant recent problems with clothing loss related to contracted laundry services and a specific laundry aide. In addition, during a call-light response, a CNA refused a resident’s request to apply anti-itch cream due to being busy, stating she would return later; the resident, unable to reach his own back, became tearful and reported that staff routinely promise to return but do not, making him feel unimportant, while council minutes also cited CNA disrespect.
A cognitively intact resident with ESRD and multiple comorbidities reported that a dialysis technician verbally abused and threatened him after he complained about a cold dialysis room and requested a window be closed. The resident stated the technician said she would beat his a**, and later, in a hallway encounter witnessed by an LPN, the technician allegedly bent down to his ear and said she "f*** old people up" while acknowledging the presence of a camera. The technician admitted telling the resident she was going to "get him" and "get you again," claiming it was a joke, but denied threatening to beat him. The administrator confirmed the allegation of inappropriate verbal interaction was substantiated, in violation of the facility’s abuse policy prohibiting abuse and mistreatment.
A resident with multiple serious conditions and a PRN order for oxycodone-acetaminophen for pain had numerous doses of the opioid documented on the facility’s narcotic control record and in an internal investigation, but only two doses were recorded on the MAR. The DON and an LPN confirmed that all administered medications, including narcotics, are expected to be documented on the MAR per facility policy, yet the MAR did not match the narcotic control and investigation records, resulting in incomplete and inconsistent documentation of opioid administration.
A resident with multiple comorbidities and a neurogenic bladder managed by an indwelling urinary catheter had a urologist’s order for the catheter to be changed immediately and then monthly, with PRN changes if not draining. Facility documentation showed the order was transcribed to the TAR, but the monthly catheter changes were not completed or documented on at least two scheduled months, and the DON later confirmed the catheter was not changed as ordered and could not produce any revised order changing the frequency. Progress notes described delayed catheter change after bleeding from the penis, subsequent UTI treatment with oral and IM antibiotics, and later acute illness with fever, tachycardia, and emesis leading to hospital transfer, where the resident was found to meet sepsis criteria with significant pyuria and leukocytosis. The resident and a hospital case manager reported that the facility had not been changing the catheter monthly as ordered, the resident stated catheter site care was rarely done and described the situation as neglect, and facility leadership acknowledged that undocumented catheter changes were assumed not done and that specialist orders were not maintained indefinitely or systematically reconciled after hospitalizations.
The facility failed to maintain a safe, clean, and comfortable dining room environment for multiple residents when housekeeping services were not consistently provided. Staff interviews showed that no one was regularly assigned to clean the dining room floor between meals, and several housekeepers reported they either had never been assigned to that area or could not manage both resident rooms and the dining room. Dietary staff cleaned only tables and stated that floors were the responsibility of housekeeping, but that there were not enough housekeepers and the floor machine had been broken for several weeks. The housekeeping supervisor confirmed significant staffing shortages following a change in housekeeping companies and a floor buffer machine that had been inoperable for over eight weeks, preventing proper floor cleaning. Observation revealed the dining room floor littered with trash, liquid spills, and sticky residue.
Two residents with complex medical histories and intact cognition experienced misappropriation of funds after their debit cards were accessed without authorization, resulting in significant financial losses. Facility investigations identified staff involvement and led to police reports, but the incidents occurred despite existing abuse prevention policies and care plan interventions for financial monitoring.
An agency LPN was verbally inappropriate with a resident who had dementia and a BIMS score of 3, calling him a demon and a woman beater and laughing at him during a prolonged interaction. Witnesses stated the nurse continued provoking the resident, including a finger-gun exchange, while staff had to redirect attention to another resident needing care.
A resident with multiple serious medical conditions experienced an acute change in condition, including shortness of breath and low oxygen saturation. Staff delayed calling EMS for about an hour after the change was first noticed, and there was no documentation of when the change began, when EMS was called, or physician notification. Upon EMS arrival, the resident was unresponsive and later died at the hospital. The facility failed to follow its policy for timely notification and documentation during a significant change in condition.
Two residents, both cognitively intact and with significant medical histories, engaged in a physical altercation following a verbal dispute over room privacy. Although staff intervened promptly and no injuries occurred, the facility failed to update care plans and document the incident as required, resulting in a deficiency related to the prevention and management of resident-to-resident abuse.
A resident who was dependent for mobility and transfers developed multiple new and re-opened pressure ulcers after staff failed to consistently turn and reposition the resident as required by the care plan. Despite documented interventions and facility policy, the resident was observed in the same position for hours, reported poor care, and was found to have slow-healing, in-house acquired pressure wounds.
A resident with severe cognitive impairment and high fall risk experienced multiple falls, including one resulting in a hip fracture, due to the facility's failure to implement and follow progressive interventions and provide adequate supervision. Despite care plan interventions and staff awareness of the resident's needs, the resident was able to attempt self-transfers without assistance, leading to injury.
Surveyors observed that food containers were not labeled or dated, scoops were stored inside bulk food, and food items were placed directly on the floor. Eggs were stored above items requiring freezing, dishware had visible debris, and the dishwashing machine lacked sanitizer. Staff interviews confirmed improper food storage and cleaning practices, affecting all residents.
A resident with severe cognitive impairment and a history of wandering was pushed to the floor by another resident with a history of agitation and aggression. The incident occurred after the cognitively impaired resident entered the other resident's room while looking for the bathroom, and was witnessed by staff. Despite both residents having care plans identifying their risks, the facility failed to prevent the abusive interaction.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruising and shoulder pain. Staff attributed the injuries to the resident's positioning in bed and degenerative changes, but did not conduct an investigation or report the injury as required by facility policy for injuries of unknown origin.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruising and shoulder pain. Although an x-ray showed degenerative changes and possible subluxation, the facility did not conduct an investigation into the injury of unknown origin as required by its abuse policy.
A resident with a history of repeated falls, hemiplegia, and mobility deficits experienced multiple falls, but the care plan was not consistently updated with new interventions after each incident. Despite facility policy requiring care plan revisions based on root cause analysis after every fall, documentation showed that interventions were either missing or minimally addressed, resulting in a deficiency in fall prevention and management.
A resident with end stage renal disease did not have required monitoring of their dialysis access site documented on several days, and the facility failed to ensure communication with the outpatient dialysis center as per policy. Physician orders and facility protocols for checking the dialysis site and completing communication forms were not followed, as confirmed by facility leadership.
A resident with a documented cinnamon allergy and asthma was served raisin toast containing cinnamon, despite clear documentation of the allergy on multiple records. Staff failed to communicate and verify the allergy, resulting in the resident being repeatedly offered foods containing the allergen.
The facility did not display daily nurse staffing information in a visible and accessible location for residents, staff, or visitors, as required by policy. Instead, the staffing schedule was kept at the nurse's station and not posted publicly.
A resident with epilepsy did not receive her prescribed seizure medication, Vimpat, for several days, resulting in multiple seizures and hospitalization. The facility's staff acknowledged issues with prescription management and pharmacy communication, which contributed to the medication not being administered as ordered. The resident's care plan required medication administration to manage her condition, but the facility failed to ensure the medication was available and administered.
Staff at the facility were observed using cell phones in resident areas, leading to an un-homelike environment. Multiple staff members, including LPNs and CNAs, were seen on their phones at nurse's stations and other areas, despite facility policies prohibiting such use. Residents reported feeling neglected, as staff were often on their phones instead of attending to their needs.
The facility failed to provide food at acceptable temperatures, with several residents reporting cold and unappetizing meals. Food temperatures were recorded below the required threshold, and the Dietary Manager admitted to infrequent temperature checks. The Administrator was unaware of a plate warmer issue, which contributed to the problem. Resident Council Minutes also documented complaints about cold food.
The facility failed to provide nourishing snacks between meals or at bedtime for several residents, including those with diabetes and renal dialysis needs. Snacks were left at the nurse's station, and residents who could access them took all the available snacks, leaving none for others. The dietary manager noted that snacks were not consistently offered by staff, and the kitchen was locked after hours, limiting access to additional snacks. This failure contributed to inadequate nutrition for some residents.
The facility failed to provide adequate showers and incontinent care to three residents who were dependent on staff for assistance with activities of daily living. One resident with a chest port reported not receiving showers due to staff concerns about getting the port wet, and was left in a soiled brief overnight. Another resident reported infrequent showers, and a third resident's family raised concerns about nursing care. Facility policy required scheduled showers and assistance, but documentation and resident council minutes indicated these were not consistently provided.
A resident with ALS and COPD experienced a change in condition, reporting shortness of breath. The facility failed to consistently monitor and document her vital signs, leading to her hospitalization and intubation. Despite staff being aware of her distress, there was confusion in documentation and communication, contributing to the deficiency.
A resident with a complex medical history was sent to the hospital due to respiratory issues, but the facility failed to notify her family about the change in condition. The family only discovered her hospitalization upon visiting the facility. The facility's policy mandates notifying the resident's family and documenting the communication, which was not adhered to in this case.
A resident with chronic respiratory issues was not transferred to the hospital in a timely manner after showing signs of distress, resulting in a diagnosis of sepsis and acute respiratory failure. Additionally, several residents did not receive prescribed wound care treatments, indicating systemic issues in the facility's wound care practices. Interviews revealed lapses in communication and documentation among staff.
A resident with chronic respiratory issues experienced a significant change in condition, including shortness of breath and low oxygen saturation. Despite the facility's policy, the physician and family were not notified, and the resident was eventually hospitalized for sepsis and hypoxia. Staff interviews revealed miscommunication and documentation issues, contributing to the deficiency.
The facility failed to protect residents' clothing from loss, affecting four cognitively intact residents who reported missing items such as jeans, shirts, and shoes. Despite reporting the issues to staff, the residents did not receive assistance in locating or replacing their belongings. The facility's policies on missing items and grievances were not followed, and ongoing issues with clothing management were documented in Resident Council Minutes.
The facility failed to maintain proper food temperatures before and during meal service, affecting all 121 residents. Multiple residents and CNAs reported that the food was consistently cold. An inspection revealed that the food warmer was malfunctioning, and food was often left uncovered and exposed to contamination. The facility's policies on food preparation and meal distribution were not followed.
The facility failed to assess, monitor, and treat pressure ulcers for two residents. One resident did not receive wound care due to a lack of orders and communication failures, while another had an uncovered wound despite prescribed treatments. Staff did not follow the facility's wound management and admission policies, leading to inadequate care.
The facility failed to provide timely and complete incontinent care for two residents, leading to significant discomfort and potential health risks. One resident was left in a soiled brief for an extended period, and the CNA did not follow proper hygiene protocols. Another resident often remained in a wet state for long periods, especially at night, despite using the call light for assistance. Interviews revealed inconsistencies in care routines, and the facility's Incontinence Care Policy was not consistently followed.
The facility failed to protect two residents from abuse and neglect. One resident reported feeling sexually assaulted by a CNA, while another resident experienced mistreatment from two different CNAs. The incidents were documented, and the involved CNAs were either suspended or sent home.
The facility failed to follow its Abuse Policy and Prevention Program, resulting in two residents experiencing abuse and neglect. One resident felt sexually assaulted by a CNA, while another resident reported neglect and verbal abuse. Both incidents were corroborated by witnesses, and the facility's response included suspending the involved CNAs and involving law enforcement.
A resident with severe cognitive impairment and multiple pressure ulcers was not properly repositioned or provided with necessary wound care, leading to the worsening of their condition. The resident was observed sitting for extended periods without being turned, and their wound-vac was not re-applied after returning from the hospital. Facility staff admitted to not following the care plan and policies for pressure injury prevention.
The facility failed to serve meals at regular times, affecting all 117 residents. Observations showed breakfast and lunch trays being passed late, and residents and staff reported consistent delays. The issue was attributed to kitchen staffing problems and the recent departure of the Dietary Manager.
The facility failed to ensure safe mechanical lift transfers and follow care plan interventions for four residents. Observations showed that staff did not provide hands-on guidance during transfers and did not ensure call lights were within reach or proper footwear was used, leading to multiple falls and safety risks.
The facility failed to remove expired stock medications from the front hall medication room and two medication carts, potentially affecting 54 residents. Inspections revealed several expired medications, and interviews indicated a lack of clarity regarding responsibility for checking and disposing of expired medications.
The facility failed to ensure that residents were offered and received pneumococcal vaccinations as per CDC recommendations. Five residents with various diagnoses had no documentation of pneumonia vaccination in their electronic medical records. The Infection Preventionist nurse confirmed that no pneumonia vaccines had been administered or offered during her tenure, contrary to the facility's policy.
The Facility failed to assist two residents with their ADLs. One resident, who is severely cognitively impaired, was left in a soiled adult brief overnight, while another resident, who had a stroke, was told to change herself after an episode of incontinence. The latter also reported verbal abuse from a CNA.
A resident with Type Two Diabetes and chronic ulcers did not receive prescribed daily wound treatments for four consecutive days. The wound nurse and the resident confirmed the missed treatments, and the administrator was unaware of the issue. The facility's policy did not ensure that physician's orders were completed as prescribed.
The facility failed to provide timely and complete incontinent care for three residents, leading to deficiencies in their care. One resident was not attended to promptly despite requesting a change, and the CNAs did not perform proper hand hygiene or cleaning. Another resident was left unchanged since the previous night, and a third resident received inadequate care with improper hygiene practices.
A facility failed to administer medications according to physician orders, resulting in incorrect doses being given to a resident. An LPN administered a 1000 mg dose of Fish Oil instead of the prescribed 1200 mg and almost gave an incorrect dose of Folic Acid. The LPN also failed to provide proper instructions for using a Symbicort Inhaler, and the medication cart was left unlocked and unattended.
The facility failed to provide appetizing and palatable meals for two residents with Moderate Protein-Calorie Malnutrition, leading to significant weight loss and dissatisfaction. Complaints included poor food quality, inconsistency, and issues documented in Resident Council Meeting Minutes.
The facility failed to perform proper hand hygiene and cleanse multi-use resident equipment, leading to potential infection risks for four residents. CNAs and an LPN were observed not following hand hygiene protocols during resident care and medication pass, as well as not cleaning equipment between uses.
Staff failed to administer several significant medications to a resident during a scheduled medication pass. The resident, with multiple diagnoses including Bipolar Disorder and Hypertension, did not receive their scheduled doses due to medication shortages and discarding of doses. Despite the facility's policy on medication administration, the issue was not addressed by the DON, leading to missed doses.
The facility failed to monitor the administration of medications as ordered by the physician for five residents, resulting in significant medication errors. One resident received another resident's medication due to a nurse's inattention, while another resident was handed a cup of pills that were not hers. A third resident took medication from another resident, and a fourth resident received another resident's medication due to a bed number mix-up. The fifth resident was administered a higher dose of medication than prescribed due to a mix-up with home supply medication.
Care plans did not address residents’ leave of absence activities
Penalty
Summary
The facility failed to revise the comprehensive care plans for leave of absence activities for 4 of 4 residents reviewed for care plans. R2’s physician orders documented schizophrenia, major depressive disorder, unspecified psychosis, cellulitis of the neck, iron deficiency anemia, prediabetes, thrombocytosis, and an unspecified burn of multiple sites of the head, face, and neck, and also stated that he may attend day program and may go out on pass with medication with family. However, R2’s care plan did not document anything related to being able to sign himself out or leave the facility. R3’s physician orders documented generalized anxiety disorder, hyperglycemia, a motor vehicle collision injury, type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, and major depression, and also stated he may attend day program. R3’s MDS documented that he was cognitively intact for decision making, and he stated he owned a car, could leave the facility whenever he wanted, and was not really driving because his health had not been good, yet his care plan did not address coming and going or leaving the facility. R4’s physician orders documented severe protein-calorie malnutrition, gait and mobility abnormalities, dysphagia, depression, bipolar disorder, altered mental status, personality disorder, and weakness, and also stated he may go to day programs and may go out on pass with medications with family. His care plan did not address any LOA activity, and he stated he had a car at the facility, visited family and friends, and came and went as he wanted. R6’s physician orders documented cerebral infarction, type 2 diabetes mellitus with hyperglycemia, transient ischemic attack, anxiety disorder, other specified disorders of brain, weakness, and tachycardia, and also stated she may attend day program and may go out on pass with medication with family. Her care plan did not document anything related to being able to sign out or leave the facility for LOA, and she stated she went out to visit family and friends and signed herself in and out. Staff stated they were not sure what “may attend day program” meant, had not care planned any resident for LOA, and would only care plan LOA if there was an order for it.
Failure to Follow Sign-Out Procedures for a Resident Who Left the Facility
Penalty
Summary
The facility failed to ensure critical sign-out procedures were implemented and followed for a resident who had expressed a desire to leave the facility. The resident had diagnoses including schizophrenia, major depressive disorder, unspecified psychosis, cellulitis of the neck, iron deficiency anemia, prediabetes, thrombocytosis, and an unspecified burn of the head, face, and neck. He was prescribed lorazepam and risperidone, and his records documented that he was cognitively intact, ambulatory, and required supervision for ambulation. His care plan also noted that he ambulated about the facility with supervision and that he had expressed a desire to move to a less structured environment. The resident had previously told social services and nursing staff that he wanted to leave the facility and go to a shelter. Staff documented that he was educated that this was not a safe discharge because he needed wound care, and he agreed to remain at the facility at that time. Later, he was observed leaving the facility with two clear bags of clothes and stated he was going to the laundromat. Staff believed he was on leave of absence based on his usual pattern of coming and going, but the resident did not sign out and no sign-out documentation was found in the facility records for that departure. Staff from multiple shifts stated they assumed the resident had signed out or would return as he had in the past, and the absence was not immediately treated as a missing resident event. The report states that the resident was not reported until the following day, when staff realized he had not returned. The facility’s incident report identified the event as a missing resident-unauthorized departure, and the resident remained missing as of the date of the report.
Medication Left Unattended in Resident Room
Penalty
Summary
The Facility failed to ensure that no medication was left unattended on a bedside table for one resident who was reviewed for unattended medicine. The resident had diagnoses including schizophrenia unspecified, major depressive disorder recurrent moderate, unspecified psychosis not due to substance or known physiological condition, cellulitis of the neck, iron deficiency anemia, prediabetes, thrombocytosis, and an unspecified burn of multiple sites of the head, face, and neck. The resident’s physician orders included Ativan 0.25 mg by mouth twice a day for compulsiveness and risperidone 1 mg by mouth twice a day for schizophrenia. A police report documented that staff reported the resident had left the facility the prior evening, and when an LPN went into the resident’s room, the resident’s medications were seen sitting bedside from the night before. Later, the same LPN stated she found pills lying on the resident’s desk and believed they were lorazepam and other pills, adding that medications are never supposed to be left lying around and should always be watched while the resident takes them. The Administrator and DON also stated that medication should not be left behind and should be administered directly to the resident without being left in the room.
Failure to Protect Resident Belongings and Provide Respectful, Timely Assistance
Penalty
Summary
The deficiency involves the facility’s failure to honor resident rights related to dignity, self-determination, communication, and protection of personal belongings for two cognitively intact residents. One resident with metabolic encephalopathy, type 2 diabetes mellitus, cognitive communication deficit, lack of coordination, chronic atrial fibrillation, heart failure, and end stage renal disease reported that the facility frequently loses his clothing, leading his sister to bring in receipts for reimbursement and prompting him to obtain clothing from Goodwill because of the repeated losses. Another resident with metabolic encephalopathy, hypertension, cervical spinal stenosis, cervicalgia, and end stage renal disease, who uses a motorized wheelchair and has bilateral upper and lower extremity impairments, reported that the facility loses his clothing, stating that he sent seven pairs of pants to the laundry and received only one pair back, and that the facility has never replaced missing items and only tells him they will investigate. Resident council minutes from two separate months documented ongoing concerns about laundry, including missing items, delayed laundry, and clothes still not being returned. The administrator acknowledged there had been a lot of missing clothing over the past few months, associated with changes in contracted laundry services and rehiring of a previously problematic laundry aide. The deficiency also includes staff failure to respond to a resident’s request for assistance in a manner that supports dignity and timely care. During observation, a CNA entered the second resident’s room in response to a call light; when the resident, who could not reach his own back due to physical impairments, requested application of anti-itch cream, the CNA stated that staff were cleaning up breakfast, did not have time, and would come back later. The resident became tearful and stated that whenever he asks staff for help, they say they will return but never do, that he observes staff helping other residents but not him, and that this makes him feel like he does not matter to staff. Resident council minutes also documented concerns about CNAs being disrespectful. The DON stated she expects staff to honor and follow the facility’s Resident Rights Policy, which includes procedures for accommodating resident needs and protecting personal items from loss or theft, but the reported experiences and observations show that these expectations were not met for the affected residents.
Failure to Protect Resident From Verbal Abuse by Dialysis Technician
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from verbal abuse by a dialysis technician. The resident, who has metabolic encephalopathy, cognitive communication deficit, hypertension, cervical spinal stenosis, cervicalgia, and end-stage renal disease, uses a motorized wheelchair and has bilateral upper and lower extremity impairment. The resident was care planned as being at risk for abuse and neglect. According to the facility’s abuse investigation and resident questionnaire, the resident reported that a dialysis technician was verbally abusive to him both in the dialysis area and later in the hallway by the nurses’ station. The resident stated that the technician threatened him after he complained that it was cold in the dialysis room and requested that a window be closed, and that the technician said she would “beat his a**,” which made him feel scared, threatened, and low. An LPN corroborated that the resident told her he had been threatened by the dialysis technician after asking about the window, reporting that the technician said she would “f*** old people up.” The LPN further stated that when the technician came out of the bathroom, the resident told her he used to be a cop and that she could not say such things to people, and the technician then bent down to the resident’s ear and repeated that she “f*** old people up,” adding that she knew the camera was there and did not care. The dialysis technician acknowledged interactions with the resident about the window and stated she told him she was going to “get him” and “get you again,” but claimed these comments were made jokingly and denied stating she would beat his a**. The administrator confirmed that an abuse investigation involving this dialysis technician and the resident was substantiated for inappropriate verbal interaction, and the DON stated she expects staff to follow the facility’s abuse policy, which prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.
Failure to Accurately Document Opioid Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration of an opioid medication on a resident’s Medication Administration Record (MAR). The resident had multiple significant medical diagnoses, including Type 2 Diabetes Mellitus, altered mental status, end stage renal disease, osteomyelitis, hypertension, hypoxic ischemic encephalopathy, pressure ulcers, and gangrene, and had a care plan identifying an alteration in comfort related to advanced disease processes. A physician’s order directed that oxycodone-acetaminophen 10-325 mg be given by mouth every four hours as needed for pain. The MAR for the month shows that this medication was documented as administered only on two occasions. In contrast, the facility’s Oxycodone-Acetaminophen Medication Monitoring/Control Record lists numerous administrations of the same medication over several days, including multiple doses on specific dates that are not reflected on the MAR. An internal investigation record further lists additional administration times for the oxycodone-acetaminophen that differ from both the MAR and the Medication Monitoring/Control Record, including doses on multiple days and times not documented on the MAR. During interview, the DON acknowledged that the resident’s MAR did not match the Oxycodone Medication Monitoring/Control Record and did not document all dates the medication was administered. The DON and an LPN/Charge Nurse both stated that when a medication, including a narcotic, is given, it should be documented on the resident’s MAR, consistent with the facility’s Medication Administration Policy, which requires staff to document each medication as it is prepared on the MAR. The discrepancy between the MAR and the narcotic control records demonstrates that nursing staff did not consistently document the administration of the ordered opioid medication on the MAR as required.
Failure to Follow Urology Orders for Indwelling Catheter Care Leading to UTI and Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide appropriate care for a resident with an indwelling urinary catheter, resulting in a urinary tract infection with sepsis requiring hospitalization and IV antibiotics. The resident had multiple significant diagnoses, including cerebral infarction, osteomyelitis, diabetes mellitus, peripheral vascular disease, chronic kidney disease, congestive heart failure, diabetic polyneuropathy, a stage 4 pressure ulcer, and a neurogenic bladder managed with an indwelling urinary catheter. The resident was cognitively intact and dependent on staff for mobility. A urology consult on 7/8/25 documented that the resident’s catheter had not been changed at the facility and that the resident reported the facility could change it with an order. The urologist assessed the resident and ordered an indwelling urinary catheter change that day and monthly thereafter, indefinitely, with PRN changes if the catheter was not draining. Following the urology visit, a facility progress note on 7/8/25 documented that the resident returned from the appointment with a new order to change the indwelling urinary catheter that day and monthly thereafter. The Treatment Administration Records (TARs) for October and November 2025 showed a standing order to change the catheter monthly on night shift starting on the 8th of each month, but there was no documentation that the catheter was changed on 10/8/25 or 11/8/25 as ordered. A progress note on 10/9/25 recorded that the resident had bleeding from the penis and that the monthly catheter change, due the previous day, was then performed. Subsequent notes documented a urinalysis collected on 10/20/25 and initiation of nitrofurantoin for a UTI on 10/23/25, as well as continuation of IM antibiotics related to UTI on 11/4/25. The DON later acknowledged that the catheter was not changed as ordered in October or November 2025 and could not produce any order or physician notification changing the monthly order to PRN only. On 12/3/25, a progress note described the resident as shaky with elevated temperature and tachycardia, with a blood sugar of 319, followed by emesis and transfer to the hospital. The hospital history and physical documented that the resident reported noticing sediment in his urine, stated his catheter had been changed three days prior but that it had been over 40 days since the previous change, and that he had been telling facility staff about it. The hospital documented that the resident met sepsis criteria with a markedly elevated white blood cell count, fever, tachycardia, increased respiratory rate, and significant pyuria and hematuria on urinalysis. The resident later stated that prior to moving to the facility his catheter tubing and bag had been changed monthly and he did not get UTIs, and that at the facility his catheter bag and tubing were not changed monthly despite his belief that there was a physician’s order to do so. He reported being hospitalized twice in recent months for severe UTIs requiring IV antibiotics and expressed frustration that staff were not following physician orders, describing the situation as neglect. The facility’s catheterization policy addressed changing catheters PRN when not draining but did not address following physician orders for catheter changes, and the DON stated the facility does not do indefinite orders and that specialist orders were considered no longer in effect once a resident goes to the hospital, despite no documentation of revised orders for this resident. The resident also reported that staff did not clean around his catheter site daily and that this care was rarely performed. A wound care nurse stated that the catheter was ordered to be changed on night shift and that if it was not signed off, it was not done, and further stated that when the resident was readmitted from the hospital, the nurse should have restarted the previous orders for consistency unless otherwise specified. A hospital case manager confirmed that urology had ordered monthly catheter changes during a July 2025 hospitalization and that during the December 2025 hospitalization the resident again reported that the facility had not been changing his catheter monthly as ordered, leading physicians to again order monthly catheter changes. The administrator acknowledged that if a catheter change was not documented on the TAR, she assumed it was not completed. Overall, the documented failures included not completing monthly catheter changes as ordered, not following the urologist’s written orders, not verifying or reinstating specialist and hospital discharge orders, and not consistently performing catheter site care, culminating in the resident developing a UTI with sepsis requiring hospitalization and IV antibiotics.
Failure to Maintain Clean and Safe Dining Room Environment Due to Inadequate Housekeeping
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate housekeeping services to maintain a safe, clean, and comfortable environment for four residents reviewed for physical environment. Multiple staff interviews revealed that no staff, including housekeepers, were consistently cleaning the dining room floor between meals. A CNA stated that no one cleans the dining room floor between meals. One housekeeper reported that the floor machine had been broken for over six weeks and that she was not assigned to clean the dining room floor and had never done so. Another housekeeper stated she tried to clean the dining room floor between meals but could not manage both resident rooms and the dining room at the same time, and that the floor technician could not use the floor machine because it had been broken for over eight weeks. Dietary staff reported they were responsible only for cleaning tables and that housekeepers were supposed to clean the floors, but that no one was cleaning the dining room floor between meals due to insufficient housekeeping staff and the broken floor machine. Another housekeeper, working full time, stated he did not know who cleaned the dining room floor and that it was not on his assignment and he had never been assigned to clean it. A different housekeeper stated she cleans the dining room between meals but was late doing so on the day of observation because she was cleaning resident rooms. The housekeeping supervisor stated that after a change in housekeeping companies, multiple housekeepers quit or went on leave, leaving him as the only housekeeper for the month of December despite working over 40 hours per week, and that the floor buffer machine had been broken for over eight weeks, preventing proper floor cleaning, including deep cleaning. On observation, the dining room floor had trash such as milk cartons, napkins, and straws, along with multiple liquid spills and sticky residue.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent misappropriation of funds for two residents who were cognitively intact and at risk for abuse. One resident, admitted with multiple diagnoses including end stage renal disease, diabetes, and major depressive disorder, discovered several unauthorized ATM withdrawals totaling thousands of dollars after his debit card was given to a staff member who claimed payment was needed for his account. The resident noticed the missing funds when his card was declined and subsequently contacted his bank and the police. The facility's internal investigation revealed that the staff member misused the resident's credit card and misappropriated cash payments for personal use. Another resident, also cognitively intact and with a history of cerebral infarction, diabetes, and other serious conditions, reported that his debit card was taken from his room and approximately $2,000 in unauthorized transactions occurred. The resident discovered the missing funds after reviewing his bank account and reported the incident. The bank provisionally credited the resident's account while the police investigation was ongoing. The facility's investigation included interviews and review of surveillance footage, leading to the suspension of two employees suspected of involvement. Both incidents were documented in the residents' care plans as abuse risks, with interventions for additional financial monitoring. The facility's abuse prevention policy affirms residents' rights to be free from misappropriation of property and outlines the facility's responsibility to prevent such occurrences. Despite these policies, the facility did not prevent the misappropriation of funds in these cases.
Inappropriate Verbal Interaction With Resident With Dementia
Penalty
Summary
The facility failed to provide appropriate services to a resident with dementia and significant cognitive impairment. R6’s EMR documented unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, along with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The resident’s MDS documented a BIMS score of 3 out of 15 and dependence for most transfers and several ADLs, indicating substantial cognitive and physical assistance needs. The deficiency arose during an abuse allegation involving an agency LPN and R6. Facility records and witness statements documented that the LPN was verbally inappropriate with R6, including calling him a demon and a woman beater, telling him he was not a pastor because he had the devil or a demon inside him, and laughing at him. Staff reported that the interaction lasted 15 to 30 minutes and included a finger-gun exchange between the nurse and the resident. Witnesses stated the nurse continued engaging with R6 despite being told another resident needed attention, and one CNA had to obtain oxygen and an SpO2 reading for that other resident before finding another nurse.
Delay in Emergency Response and Incomplete Documentation Following Resident's Acute Change in Condition
Penalty
Summary
The facility failed to provide timely emergency medical intervention for a resident who experienced an acute change in condition. The resident, who had multiple significant diagnoses including rib fractures, vertebral fractures, dysphagia, severe malnutrition, and acute thrombosis, was noted to be cognitively impaired and at risk for altered nutrition and hydration. On the day of the incident, the resident was observed to be eating normally during breakfast and lunch, but was later found by a CNA to be wheezing and with glazed eyes. The CNA alerted the LPN and ADON, who responded to the change in condition. Despite the resident exhibiting shortness of breath, audible crackles, and a dangerously low oxygen saturation of 65%, there was a delay in calling Emergency Medical Services (EMS). Documentation revealed uncertainty and lack of clarity regarding the exact times of the change in condition, when EMS was called, and when the physician was notified. There was no documentation of when the change began, no SBAR form completed, and no evidence that the physician or on-call provider was notified prior to EMS being called. The facility's own policy requires notification of the physician or nurse practitioner in the event of a significant change in condition, except in a medical emergency. EMS records and staff interviews indicated that EMS was called approximately one hour after the initial change in condition was noticed. Upon EMS arrival, the resident was unresponsive, tachypneic, and had evidence of aspiration. The resident was transferred to the hospital, where she later expired. The lack of timely EMS notification and incomplete documentation contributed to the delay in treatment for the resident.
Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, as evidenced by an altercation involving two residents with cognitive capacity for decision-making. One resident, with diagnoses including nontraumatic subarachnoid hemorrhage, malnutrition, chronic bronchitis, depression, heart failure, pleurisy, anxiety, and spinal stenosis, was noted to be independent in most activities of daily living and cognitively intact. The other resident involved had diagnoses of type 2 diabetes, morbid obesity, chronic respiratory failure, depression, anemia, hyperparathyroidism, and chronic kidney disease, and required minimal assistance for most activities. Both residents engaged in a physical altercation after a verbal dispute regarding room privacy, resulting in each striking the other, though no injuries were reported. The incident was witnessed by staff, who intervened immediately to separate the residents. However, the facility failed to update the care plans for both residents to address the altercation that occurred. The care plan for one resident referenced a previous altercation but did not include the most recent event, and the progress notes also lacked documentation of the incident. Similarly, the other resident's care plan did not reflect the altercation, despite her being identified as at risk for abuse and neglect due to her medical conditions. Interviews with staff and the residents confirmed the sequence of events, with both residents acknowledging their involvement in the altercation and the reasons behind it. The facility's policy affirms the right of residents to be free from abuse and outlines the definition of abuse, including willful infliction of injury or pain. Despite this policy, the lack of timely and appropriate care plan updates and documentation following the incident demonstrates a failure to ensure residents are protected from all forms of abuse, as required.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident who was dependent for mobility and transfers and had no cognitive deficits. Despite a care plan that required turning and repositioning every one to two hours, the resident was not consistently turned or repositioned, as evidenced by the resident's own statements and observations by surveyors. The resident reported not being turned or pulled up for extended periods and expressed concerns about poor care and fear of being left in pain. Multiple progress notes and wound evaluations documented the development of new, in-house acquired pressure ulcers, including stage III and unstageable wounds, as well as a re-opened pressure ulcer. The resident was also observed to be incontinent and in the same position for several hours during the survey. The medical record review showed that the resident was admitted with intact skin and no wounds, but subsequently developed several pressure ulcers over time, with slow healing noted. Staff interviews indicated that the resident sometimes refused a pressure-reducing mattress and could turn himself slightly, but the care plan interventions for regular turning and repositioning were not consistently implemented. Facility policy required standards of practice to prevent or reduce pressure injuries, but these were not followed, resulting in the resident developing multiple pressure ulcers while under facility care.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement and follow progressive interventions and provide appropriate supervision to prevent falls for a resident with severe cognitive impairment and a high risk for falls. The resident, who had diagnoses including metabolic encephalopathy and required partial to moderate assistance with mobility and transfers, experienced multiple falls. Despite being identified as high risk and having a care plan that included interventions such as prompting or assisting with position changes, toileting, and encouraging the use of the call light, the resident attempted to self-transfer to the bathroom and fell, sustaining a head injury. The care plan also included education for the resident to use the call light and wait for staff assistance, but the resident's severe cognitive impairment limited the effectiveness of this intervention. Following the initial fall, the resident was found on the floor again after attempting to get up independently, which resulted in a fracture of the left inferior pubic ramus. Documentation shows that the resident was not always toileted prior to being put to bed, and staff interviews indicated that the resident could stand but required significant assistance. The facility's policy emphasized the need to identify residents at risk for falls and to implement preventative strategies, but the failure to provide adequate supervision and timely assistance contributed to the resident's repeated falls and subsequent injury.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards to prevent foodborne illness. Observations revealed that bulk food containers in the kitchen were not labeled or dated, and scoops were stored directly inside the food, contrary to facility policy. In the walk-in refrigerator, cartons of milk and applesauce were found lying directly on the floor, and pasteurized shell eggs were stored above boxes of nutritional shakes that required freezing. Additionally, saucers stored near the walk-in freezer had visible crumbs and debris, and the dish room floor was covered in food debris. The dishwashing machine was found to be operating without sanitizer, as evidenced by a test strip that did not change color and an empty sanitizer bucket. Interviews with dietary staff confirmed a lack of adherence to proper food storage protocols, including the improper placement of eggs and the failure to keep food off the floor. The dietary manager acknowledged the issues with labeling, storage, and cleaning, and the registered dietitian explained the importance of proper food storage to prevent contamination. The facility's policies require all food containers to be labeled and dated, scoops to be stored outside of food containers, and all foods to be stored off the floor and at appropriate temperatures. These deficiencies had the potential to affect all 108 residents in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with severe cognitive impairment and a history of encephalopathy, altered mental status, and cognitive communication deficit was involved in an incident where he was pushed to the floor by another resident. The resident who was pushed was known to wander into other residents' rooms due to his cognitive deficits and occasional incontinence, sometimes forgetting where the bathroom was. On the day of the incident, he entered another resident's room while looking for the bathroom. The resident who pushed him had diagnoses including Alzheimer's disease, traumatic brain injury, adjustment disorder, and intellectual disabilities, and was documented as being at risk for abuse and displaying behaviors such as agitation and aggression. On the day of the incident, a witness observed the cognitively intact resident push the cognitively impaired resident, causing him to fall to the floor. The incident was reported by a staff member who witnessed the event, and the resident who was pushed was assessed with no injuries noted at the time. Prior to the incident, the resident who pushed had exhibited agitation and verbal aggression, and the resident who was pushed had a care plan identifying his risk for abuse and neglect. Despite these known risks and behavioral histories, the facility failed to prevent the abusive interaction between the two residents, resulting in one resident being pushed to the floor by another.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for one resident who was observed with multiple large and small reddish/purple bruises and purpura on her bilateral forearms and right hand. The resident, who has severe cognitive impairment, dementia, stage 4 chronic kidney disease, hypertension, and dysphagia, was noted to be dependent on staff for bed mobility and had limitations in range of motion. Progress notes indicated that a nurse discovered a bruise on the resident's lower left arm and that the resident complained of shoulder pain, prompting an x-ray. The x-ray revealed degenerative changes and possible anterior subluxation of the shoulder, but no recent fracture. Despite these findings, there was no facility investigation into the cause of the injury to the resident's right shoulder. Interviews with facility staff confirmed that no investigation was conducted regarding the bruising or shoulder injury. The administrator and DON stated that the bruising was attributed to the resident lying in bed with her arms pressed against the bed rail, and that the shoulder pain and subsequent x-ray findings were considered to be related to degenerative changes. The facility's abuse policy requires an internal investigation and reporting to authorities for injuries of unknown source, but this process was not followed in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was observed with multiple large and small reddish/purple bruises and purpura on her bilateral forearms and right hand. The resident, who has severe cognitive impairment, dementia, stage 4 chronic kidney disease, hypertension, and dysphagia, was noted to be dependent on staff for bed mobility and had limitations in range of motion. Progress notes indicated that a nurse discovered a bruise on the resident's lower left arm and that the resident complained of shoulder pain, prompting an x-ray. The x-ray revealed mild degenerative arthritic changes and possible anterior subluxation of the humeral head, but no recent fracture. Despite these findings and the facility's abuse policy requiring an internal investigation for injuries of unknown source, no investigation was conducted into the resident's right shoulder injury. The administrator and DON stated that the bruising was attributed to the resident lying with her arms against the bedrail and that the shoulder pain and subsequent x-ray occurred afterward. However, there was no documentation of an investigation to determine the source of the injury, as required by facility policy.
Failure to Update Care Plan with Progressive Interventions After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan with progressive interventions following multiple falls for one resident with a history of repeated falls, hemiplegia, and difficulty walking. The resident required varying levels of assistance for mobility and transfers, as documented in the Minimum Data Set. Despite being identified as high risk for falls due to cognitive and functional deficits, the care plan was not consistently updated with new interventions after each fall event. Multiple nursing notes documented a series of falls experienced by the resident, including incidents where the resident was found on the floor after attempting to use the urinal, transferring to the toilet, or moving from bed to wheelchair. In several instances, no new interventions were added to the care plan following the falls, and in other cases, only minimal interventions such as education or equipment checks were documented. The care plan did not reflect a systematic approach to updating interventions based on the root cause of each fall, as required by facility policy. Facility policy mandates that the care plan be evaluated and modified as needed after each fall, with new interventions based on root cause analysis. However, the record review and staff interview confirmed that this process was not consistently followed for the resident in question. The lack of timely and progressive updates to the care plan after each fall event constituted a deficiency in the facility's fall prevention and management practices.
Failure to Monitor and Communicate Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the outpatient dialysis center and did not consistently monitor the dialysis access site for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a diagnosis of end stage renal disease and was documented as cognitively intact and dependent with mobility. Physician orders required that the resident's dialysis access site be checked for thrill and bruit, as well as for signs and symptoms of infection, every day and night shift. However, the Treatment Administration Record (TAR) for the specified month showed that these checks were not documented as completed on multiple days. Additionally, the facility's policy required that the dialysis site be checked every shift and that a Dialysis Communication form be completed and sent with the resident for each treatment, with documentation reviewed upon the resident's return. Interviews with the Assistant Director of Nursing and the Administrator confirmed that there was no additional documentation to show that the required monitoring and communication had occurred. The lack of documentation and communication represents a failure to follow physician orders and facility policy for dialysis care.
Failure to Accommodate Food Allergy in Meal Service
Penalty
Summary
A deficiency occurred when a resident with a documented cinnamon allergy was served raisin toast containing cinnamon for breakfast. The resident's allergy was clearly indicated on the face sheet, allergy report, and diet card, and the facility's product details confirmed that the raisin bread contained ground cinnamon. Despite these records, dietary and nursing staff failed to communicate and verify the allergy, resulting in the resident being served the allergen. The dietary aide relied on CNAs to communicate dietary restrictions, but the CNA did not relay the allergy information and assumed the raisin bread did not contain cinnamon before delivering it to the resident. The resident, who is cognitively intact and has a history of asthma affected by cinnamon, reported that this issue has occurred repeatedly during their stay. The dietary manager and registered dietitian acknowledged that staff should have checked for allergies and communicated them to ensure safe food service. The facility's policy requires providing safe foods and appropriate substitutions for individuals with food allergies, but this was not followed in this instance.
Failure to Publicly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to display the daily nurse staffing information in a clearly visible and accessible location for residents, staff, and visitors. During a facility tour, surveyors observed that the required staffing information was not posted anywhere in public view. An interview with the receptionist confirmed that the daily nursing staff schedule was kept at the nurse's station and was not accessible to the public. Facility policy requires that the number of licensed nurses and unlicensed nursing personnel responsible for direct resident care be posted in a prominent and readable location within two hours of each shift's start. At the time of the survey, the facility census was 108 residents. No specific residents or staff members were directly affected or mentioned in relation to the deficiency, and no medical history or resident conditions were described in the report.
Failure to Administer Seizure Medication Leads to Hospitalization
Penalty
Summary
The facility failed to administer a seizure medication, Vimpat, to a resident diagnosed with epilepsy, resulting in multiple seizures and hospitalization. The resident, who is cognitively intact, reported not receiving her medication for two days, which led to four seizures and subsequent hospital admission. The resident's care plan indicated the necessity of medication administration to manage her seizure disorder, yet the medication was not given as ordered on several occasions. The facility's records show that the resident's Vimpat was not administered on specific dates due to issues with prescription management and pharmacy communication. The resident experienced several seizures during this period, with documentation indicating that the facility was aware of the medication shortage but failed to resolve it promptly. The facility's staff, including a Family Nurse Practitioner and an LPN, acknowledged the medication administration issues and the impact on the resident's health. The facility's Medication Administration Policy requires timely notification and documentation when medications are not administered as ordered. However, the report highlights a lack of initiative from the nursing staff to ensure prescriptions are filled and available, leading to the resident's seizures and hospitalization. The facility's administrator noted that insurance issues delayed the medication's availability, but the facility eventually paid for and obtained the medication from a local pharmacy.
Staff Cell Phone Use Creates Un-Homelike Environment
Penalty
Summary
The facility was found to have allowed its staff to use cell phones in resident areas, creating an un-homelike environment for residents. Observations were made of several staff members, including LPNs and CNAs, using their cell phones at various locations within the facility, such as nurse's stations, hallways, and near the dining room. These observations were made over several days and included instances where staff were seen playing games or otherwise engaged with their phones during work hours. Residents expressed dissatisfaction with the staff's cell phone usage, stating that it interfered with their care. Multiple residents reported feeling neglected and noted that staff were often on their phones instead of attending to their needs, such as responding to call lights or assisting with feeding. The facility's policies, including the Cellular Phone and Electronic Tablet Policy and the Resident Rights Policy, explicitly prohibit personal cell phone use during work time, yet these policies were not adhered to, as evidenced by the staff's actions and the residents' complaints.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide palatable food at an acceptable temperature for several residents, as observed and reported by both residents and staff. On multiple occasions, food temperatures were recorded below the acceptable threshold, with potatoes and eggs served at temperatures as low as 92.6 degrees Fahrenheit. Residents expressed dissatisfaction with the food, describing it as cold, unidentifiable, and unappetizing. One resident's grievance highlighted dietary concerns, which were communicated to the facility by the resident's family. The Dietary Manager acknowledged that food temperatures on hall trays were only checked occasionally and noted complaints about cold eggs. The facility had a plate warmer that was initially thought to be broken, but it was later found to be functional. The Administrator was unaware of the plate warmer issue until recently and was informed that using the pellet warming system could break cold plates. The Resident Council Minutes also documented complaints about cold food and the need for breakfast improvement. The facility's Food Preparation Policy requires hot foods to be held at temperatures greater than 135 degrees Fahrenheit.
Failure to Provide Nourishing Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing snacks between meals or at bedtime for four out of five residents reviewed for snacks. Observations and interviews revealed that snacks were typically left at the nurse's station, and residents who were able to access them would take all the available snacks, leaving none for others. This issue was particularly problematic for residents with specific dietary needs, such as those with diabetes or those dependent on renal dialysis. For instance, one resident with diabetes and end-stage renal disease reported not receiving snacks unless her roommate retrieved them for her. Another resident, also diabetic, stated she never received snacks. The dietary manager acknowledged that snacks were not consistently offered by staff, and the kitchen was locked after dietary staff left, limiting access to additional snacks. The administrator confirmed that a snack cart was brought to the nurse's station, but it was up to the CNAs to deliver them to resident rooms. The facility's policy required that the time between the evening meal and breakfast not exceed 14 hours unless a nourishing snack was provided at bedtime. However, the facility did not adhere to this policy, as evidenced by residents' complaints and the lack of available snacks, which contributed to one resident's significant weight loss due to inadequate nutrition.
Inadequate Shower and Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate showers and incontinent care to three residents who were dependent on staff for assistance with activities of daily living. One resident, who had a port in her chest, reported not receiving showers because staff did not want to get the port wet and would not cover it. She also mentioned infrequent bed baths and rarely having her hair washed. Observations confirmed that this resident was left in a soiled brief overnight without being changed until the morning, despite being unable to feel when she needed changing. Her care plan indicated she required assistance with daily care needs, and records showed significant gaps between documented showers. Another resident reported receiving only two showers in three weeks, with documentation supporting infrequent showers. A third resident also expressed that showers were infrequent, and a grievance from the resident's family highlighted concerns about nursing care. The facility's policy stated that showers should be scheduled and assistance provided as needed, yet the administrator acknowledged that residents should receive showers twice a week. Resident Council Minutes further documented complaints about inadequate changing and showering by CNAs.
Failure to Monitor and Document Resident's Change in Condition
Penalty
Summary
The facility failed to adequately assess, monitor, and document the vital signs of a resident (R2) who experienced a change in condition. R2, who had a history of amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), and other health issues, reported feeling unwell and experiencing shortness of breath. Despite these complaints, there was a lack of documented vital signs, including oxygen saturation levels, from 9/19/2024 until the resident was sent to the hospital on 9/25/2024. The only recorded oxygen saturation on 9/25/2024 was at 6:56 PM, which showed a low level of 79% before being increased to 91% with supplemental oxygen. The report highlights discrepancies in the documentation and communication among the facility staff. A physical therapist and a certified nursing assistant (CNA) noted the resident's distress and informed the nursing staff, but there was confusion about who documented the resident's condition in the progress notes. The Licensed Practical Nurse (LPN) involved was new to the facility and did not recall writing the note or testing the resident for COVID-19, despite the resident later testing positive at the hospital. The facility's electronic charting system showed no vital signs recorded for the resident on the day of the incident, except for the oxygen saturation level noted during the medical doctor's consultation. The facility's policy requires that any change in a resident's condition be documented and communicated to the resident's physician and responsible party. However, the lack of consistent monitoring and documentation of the resident's vital signs, as well as the failure to notify the nurse practitioner of the resident's respiratory distress, contributed to the resident's hospitalization and subsequent intubation. The facility's failure to adhere to its policy and ensure proper documentation and communication led to a deficiency in the care provided to the resident.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for one resident, identified as R2, who was reviewed for change of condition. R2 had a complex medical history, including amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease, among other conditions. On a specific date, R2 was sent to the emergency department due to shortness of breath and low oxygen saturation levels. Despite the severity of the situation, no family member was documented as being contacted about R2's change in condition before she was sent to the hospital. Interviews revealed that R2's family was unaware of her hospitalization until they visited the facility and found her belongings being packed. The facility's administrator acknowledged the lack of family notification and stated that such communication should have been documented in the nurse's notes. The facility's policy requires notifying the resident, their physician, and responsible party of any change in condition, and documenting this communication. However, this protocol was not followed in R2's case, leading to the deficiency noted in the report.
Delayed Medical Response and Inadequate Wound Care in LTC Facility
Penalty
Summary
The facility failed to assess, monitor, and transfer a resident, identified as R2, to the hospital in a timely manner after a change in condition was observed. R2, who had a history of chronic respiratory failure with hypoxia and chronic pulmonary embolism, developed a venous wound on her right leg. Despite physician orders for regular wound care and monitoring, there were multiple instances where R2 did not receive her prescribed treatments. On the morning of July 27, 2024, R2 exhibited symptoms of distress, including shaking and low oxygen saturation, but was not transferred to the hospital until the afternoon, resulting in a diagnosis of sepsis and acute respiratory failure. The report also highlights deficiencies in wound care management for several other residents, including R1, R3, R4, and R5. These residents, who had various chronic conditions and wounds, did not receive their prescribed wound treatments on numerous occasions. The lack of documentation and adherence to treatment orders for these residents indicates a systemic issue in the facility's wound care practices. Interviews with facility staff, including LPNs and CNAs, revealed communication and procedural lapses. Staff members failed to consistently monitor vital signs and document changes in residents' conditions. The facility's administration acknowledged that the response time for medical emergencies was inadequate, and there was a lack of proper documentation and follow-up on residents' health status. These deficiencies contributed to the delayed medical intervention and inadequate wound care for the residents involved.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and resident representative of a change in condition for a resident with chronic respiratory failure, chronic pulmonary embolism, and a non-pressure chronic ulcer. The resident was found shaking, warm to touch, and short of breath with an oxygen saturation of 85%. Oxygen was administered, and the resident's condition slightly improved, but the resident continued to experience shortness of breath. Emergency Medical Services (EMS) were called, and the resident was eventually transported to the hospital, where they were admitted for sepsis and hypoxia. The report highlights that there was no documentation of the physician or family representative being notified of the resident's change in condition. The resident's daughter stated she was not contacted by the facility and was informed by the hospital instead. The nurse practitioner was also not notified of the incident. The facility's policy requires notifying the resident's physician and responsible party of a change in condition, which was not followed in this case. Interviews with staff revealed that there was confusion and miscommunication regarding the notification process. The night nurse did not contact the resident's daughter, and the oncoming nurse was informed of the ambulance's arrival but did not follow up with the family. Additionally, there were issues with the transfer paperwork, which delayed communication with the hospital. The facility's policy on change in resident condition was not adhered to, leading to a deficiency in communication and documentation.
Failure to Protect Residents' Clothing from Loss
Penalty
Summary
The facility failed to protect residents' clothing from loss, affecting four residents who were reviewed for a homelike environment. These residents, who are cognitively intact, reported missing clothing items, including jeans, shirts, and shoes. Despite reporting the missing items to various staff members, including CNAs and laundry staff, the residents did not receive assistance in locating or replacing their belongings. The facility's staff appeared to be unclear about their responsibilities regarding labeling and tracking residents' clothing, leading to confusion and inaction. The facility's policies on missing items and grievances indicate that all reports of missing items should be taken seriously, with a search conducted and options discussed with the resident if the items are not found. However, the staff did not follow these procedures, as evidenced by the lack of communication and resolution for the residents' complaints. The facility's Resident Council Minutes also documented ongoing issues with clothing not being returned and incorrect items being sent to residents' rooms, highlighting a systemic problem with managing residents' personal belongings.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures before and during meal service, affecting all 121 residents. Multiple residents reported that their food was consistently cold, whether they ate in their rooms or in the dining room. Specific examples include one resident who stated that the food is always cold, another who mentioned that the cold food could be colder, and another who noted that the food is sometimes hot and sometimes cold. These complaints were corroborated by Certified Nursing Assistants (CNAs) who confirmed that residents frequently complained about the temperature of their food. During an inspection, the Dietary Manager and District Manager were observed checking food temperatures. The Chicken Parmesan patty was initially found to be at 112 degrees Fahrenheit, well below the required temperature. The food was reheated to 162.6 degrees Fahrenheit, but the process revealed that the warmer section had not been functioning correctly for a while. Additionally, the process of plating and delivering food was inefficient, with food often left uncovered and exposed to contamination. For instance, noodles were pushed off a tray and back into the warmer, and food carts were left in hallways for extended periods, leading to further cooling of the food. The facility's policies on food preparation and meal distribution were not followed. The Food Prep Policy requires that hot foods be held at temperatures greater than 135 degrees Fahrenheit and that any food dropping below this temperature be reheated to 165 degrees Fahrenheit. The Meal Distribution Policy mandates that all food items be covered during transport and delivered promptly to maintain appropriate temperatures. These policies were not adhered to, as evidenced by the multiple instances of food being served at unsafe temperatures and the inefficient delivery process. The facility's Resident Council Meeting minutes also documented ongoing issues with food quality and temperature, further highlighting the systemic nature of the problem.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to assess, monitor, and treat pressure ulcers for two residents, R3 and R6. R3 was admitted with multiple wounds but did not receive appropriate wound care due to a lack of orders and communication failures among staff. Despite having a follow-up appointment at a wound clinic, the appointment was canceled, and no alternative wound care plan was implemented. The staff did not perform wound care on R3 as expected, and the facility's medical doctor was not contacted for necessary orders, resulting in untreated wounds for several days. R6, who was admitted with severe cognitive impairment and multiple diagnoses, also did not receive proper wound care. During a wound treatment session, it was discovered that R6's wound was not covered with the prescribed dressing, and pieces of calcium alginate were found in the wound bed and brief. The staff failed to ensure that R6's wound was properly dressed and monitored, despite the resident's high risk for infection and other complications. The facility's policies on wound management and admission procedures were not followed, leading to inadequate care for both residents. The staff did not assess wounds upon admission, did not obtain necessary orders, and did not perform wound care as required. These failures were confirmed through interviews with various staff members, including the LPNs, the Director of Nursing, and the Administrator, who all acknowledged the lapses in care and communication.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents, leading to significant discomfort and potential health risks. Resident 1, who has multiple medical conditions including Multiple Sclerosis and paraplegia, reported being left in a soiled incontinence brief for an extended period. The Certified Nursing Assistant (CNA) responsible for her care admitted to not checking on her regularly and only cleaning her when she requested it. During the observed care, the CNA did not follow proper hygiene protocols, such as washing hands or changing gloves appropriately, and did not thoroughly clean or dry the resident, leaving her in a soiled state for a prolonged period. Resident 7, who has a moderate cognitive impairment and is always incontinent of both bowel and bladder, also experienced neglect in incontinent care. The resident and her daughter reported that she often remained in a wet state for long periods, especially at night. On one occasion, the resident used the call light for assistance but was left unattended for over 30 minutes. When staff finally attended to her, they found her in a wet incontinence brief and wheelchair pad. Although the care provided at that moment was appropriate, the delay and previous neglect were evident. Interviews with other CNAs revealed inconsistencies in the care routines, with some staff checking residents regularly and others not adhering to the expected protocols. The facility's Incontinence Care Policy mandates regular checks and proper hygiene practices, but these were not consistently followed. The Administrator confirmed that staff are expected to check on residents every two hours and provide timely and complete care, which was not done in these cases.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect, resulting in two residents experiencing distressing incidents. One resident reported feeling sexually assaulted by a CNA who responded to her call light request for pain medication. The CNA allegedly got too close to the resident's face, began rubbing her chest, and made inappropriate comments, causing the resident to feel uncomfortable and violated. The incident was witnessed by the resident's roommate, who corroborated the account. The resident expressed fear of future similar incidents and a desire to leave the facility if such behavior continued. Another resident reported being mistreated by two different CNAs on separate occasions. The first incident involved a CNA who threw a diaper at the resident and told her to clean herself up after an episode of incontinence. The resident, who had difficulty moving due to a stroke, was left distressed and in tears. A second incident involved another CNA who yelled at the resident to move herself up in bed and later threw a diaper on the table, instructing the resident to change herself. The resident struggled to clean herself and was left with residual feces until another CNA assisted her the following morning. The facility's abuse policy affirms the right of residents to be free from abuse, neglect, and mistreatment. However, the incidents involving the two residents indicate a failure to uphold this policy. The facility's reported incident forms document the allegations and witness statements, and the involved CNAs were either suspended or sent home. The police were involved in investigating the incidents, and the facility's administrator acknowledged the severity of the complaints and the need for corrective action.
Failure to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to follow its Abuse Policy and Prevention Program, resulting in two residents experiencing abuse and neglect. One resident reported feeling sexually assaulted by a CNA who, instead of providing the requested pain medication, began rubbing the resident's chest and making inappropriate comments. This incident left the resident feeling violated and fearful of future occurrences. The resident's roommate corroborated the account, and the police were involved in the investigation. The facility's administrator acknowledged the incident and indicated that the CNA would be terminated. Another resident reported neglect and verbal abuse by a different CNA. The resident, who had a stroke and was unable to move independently, was told to change herself after an episode of incontinence. The CNA threw a diaper at the resident and left her to clean herself, resulting in incomplete hygiene care. This resident also reported a previous incident where a CNA yelled at her to get up and do things for herself, causing significant distress. A witness confirmed the CNA's inappropriate behavior, and the facility's administrator indicated that the CNA would be fired. Both incidents highlight the facility's failure to ensure a safe and dignified environment for its residents, as mandated by its Abuse Policy and Prevention Program. The residents involved were left feeling unsafe and neglected, with their needs unmet in a respectful manner. The facility's response included suspending the involved CNAs and involving law enforcement, but the initial failure to prevent these incidents indicates a significant lapse in adherence to established policies and procedures.
Failure to Provide Proper Wound Care and Repositioning
Penalty
Summary
The facility failed to provide proper wound care and to turn and reposition a resident, leading to the development and worsening of pressure ulcers. The resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed sitting in a recliner for extended periods without being repositioned. Despite having multiple severe pressure ulcers, including stage-4 ulcers and unstageable wounds, the resident was not turned or repositioned every one to two hours as required by their care plan. Additionally, the resident's wound-vac was not re-applied after returning from the hospital, and there were no orders to continue its use. The wound care nurse admitted to not calling the physician to inquire about the wound-vac and acknowledged that the resident's wounds were worsening due to prolonged sitting. The nurse also discovered three new blistered areas on the resident that had not been previously documented. The facility's transporter and dialysis staff confirmed that the resident was not repositioned during dialysis sessions, further contributing to the deterioration of the resident's skin condition. The nurse practitioner and other staff members emphasized the importance of repositioning the resident to promote wound healing, but this was not consistently done. The facility's policies on pressure injury prevention and skin care were not followed, as evidenced by the lack of regular skin assessments and failure to reposition the resident as needed. The resident's care plan included specific interventions to prevent skin breakdown, such as turning and repositioning every one to two hours, but these were not implemented. The facility administrator acknowledged the issue and indicated that the resident should not be sitting for long periods, but no immediate corrective actions were taken to address the deficiency at the time of the survey.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve meals at regular times in a manner that meets the residents' needs and per posted scheduled mealtimes. The posted mealtimes are breakfast at 7:30 AM, lunch at 12:00 PM, and dinner at 5:30 PM. However, observations on multiple dates showed that breakfast trays were being passed as late as 10:15 AM and lunch trays as late as 1:20 PM. Residents and staff reported that breakfast has been consistently late for the past couple of weeks, with some meals being served as late as 7:00 PM. The Resident Council minutes also documented complaints about late meals and inconsistent mealtimes, particularly on weekends. The facility's Infection Prevention Nurse and Administrator acknowledged the issue, citing kitchen staffing problems and the recent departure of the Dietary Manager as contributing factors. The facility's Meal Distribution Policy, dated 9/2017, outlines that meals should be transported and delivered in a timely and accurate manner, ensuring proper temperature maintenance and protection against contamination. Despite this policy, the facility has not adhered to the scheduled mealtimes, affecting all 117 residents. The Administrator confirmed that the current meal service times are unacceptable and not in line with the facility's standards. The CMS 671 form dated 5/13/24 documented that there are 117 residents in the facility, all of whom are potentially affected by this deficiency.
Failure to Ensure Safe Transfers and Follow Care Plans
Penalty
Summary
The facility failed to ensure mechanical lift transfers were conducted safely and care plan interventions were followed to prevent falls for four residents. For Resident R78, who has diagnoses including amyotrophic lateral sclerosis and is dependent on staff for transfers, the care plan required the use of a Hoyer lift with two assists. However, during an observed transfer, neither of the two CNAs provided hands-on guidance while R78 was in the lift, only guiding the resident into the wheelchair at the last moment. Resident R90, who has multiple diagnoses including metabolic encephalopathy and is moderately cognitively impaired, had a care plan that included ensuring the call light was within reach and providing proper footwear. Despite this, observations showed the call light was often out of reach, and the resident was frequently found without shoes, only wearing socks. This resident had multiple documented falls, indicating a failure to follow the care plan interventions. Resident R91, who is cognitively intact but dependent on staff for transfers, also required a Hoyer lift with two assists. Similar to R78, during observed transfers, the CNAs did not provide hands-on guidance while the resident was in the lift, only guiding the resident into the bed at the last moment. Additionally, Resident R65, who has severe cognitive impairment and a high risk for falls, had multiple falls documented. Observations showed that the fall mat was not in place as required by the care plan, and the resident was often found without proper supervision or footwear, further indicating a failure to follow care plan interventions.
Expired Medications Found in Medication Carts and Room
Penalty
Summary
The facility failed to remove expired stock medications from the front hall medication room and from two medication carts, potentially affecting 54 residents. During an inspection of the 200 hall medication cart, several expired bottles of medications were found, including Bisacodyl stool softener tablets, Geri Dryl allergy relief tablets, Acidophilus probiotic capsules, lutein capsules, sodium bicarbonate tablets, sodium chloride tablets, Coenzyme Q-10 tablets, Optimum iron tablets, and multivitamins. Similarly, the 100-hall medication cart contained expired bottles of vitamin E capsules, sodium chloride tablets, Acidophilus probiotic capsules, and Optimum iron tablets. Additionally, the front hall medication room had expired sodium chloride pre-filled flush syringes in the stock medication supply area. Interviews with staff revealed a lack of clarity regarding responsibility for checking and disposing of expired medications. An LPN stated that she did not know who was responsible for ensuring the expired medications were disposed of. The Administrator and the Director of Nursing both indicated that they expected floor nurses to check the expiration dates on stock medications daily and that the nurse management team should also be checking the medication carts and rooms for expired medications. The facility's policy on medication storage, dated April 2018, requires that outdated, contaminated, or deteriorated drugs be immediately withdrawn from stock and disposed of according to drug disposal procedures.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and received pneumococcal vaccinations in accordance with CDC recommendations. Specifically, five residents (R6, R9, R48, R82, and R91) were identified as not having any documentation of pneumonia vaccination administration or history in their electronic medical records. These residents had various diagnoses, including amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, metabolic encephalopathy, type two diabetes, chronic kidney disease, peripheral vascular disease, atherosclerotic heart disease, cerebral infarction, hemiplegia, Alzheimer's disease, and cognitive communication deficit. The Infection Preventionist (IP) nurse, who has been with the facility for over a year, confirmed that she had not arranged for the contracted vaccine clinic to administer pneumonia vaccines nor had she offered any residents the pneumonia vaccine during her tenure. The facility's Pneumococcal Vaccinations Policy, last reviewed in September 2022, mandates that all residents be screened and offered the pneumonia vaccine within the first week of admission and annually if eligible. The policy also requires documentation of vaccination or refusal in the Electronic Health Record (EHR). However, this procedure was not followed, leading to the identified deficiency.
Failure to Assist Residents with ADLs
Penalty
Summary
The Facility failed to ensure that two residents, R58 and R99, were assisted with their Activities of Daily Living (ADLs). R58, who is severely cognitively impaired and always incontinent of bowel and bladder, was found in a saturated adult brief with a large amount of urine and feces. The brief had not been changed since the previous night, and the bed linen pad was heavily soiled. V15, a Certified Nursing Assistant (CNA), confirmed that R58 had been left wet all night and expressed concern about potential skin breakdown due to prolonged exposure to moisture and waste. R99, who had a stroke and requires assistance with daily care needs, reported that a CNA had refused to help her move up in bed and had told her to change herself after an episode of incontinence. R99 attempted to clean herself but was not able to do so completely, and V15 had to assist her the following morning. Additionally, R99 reported an incident where a CNA threw a diaper on the table and told her to clean herself up, leaving her with streaks of feces. The Facility-Reported Incident Form documented that R99 had also experienced verbal abuse from a CNA, who yelled and demanded that she get up and get herself ready. Another CNA, V15, witnessed this behavior and confirmed that the yelling was intense and that the aide walked out of the room cussing. The Administrator acknowledged R99's complaint and noted that R99 did not feel abused but was concerned about the treatment of other residents who might not be able to speak for themselves.
Failure to Administer Prescribed Wound Treatments
Penalty
Summary
The Facility failed to ensure that treatments prescribed daily by a physician were completed for four consecutive days for a resident with Type Two Diabetes, Peripheral Vascular Disease, and chronic ulcers. The resident's care plan required daily application of betadine and a dry dressing to the right great toe and left medial ankle. However, these treatments were not administered on four consecutive days, as confirmed by both the resident and the wound nurse. The resident reported that the dressings had not been changed since the previous Thursday or Friday, and the wound nurse confirmed that the treatments were not done over the weekend and the following Monday and Tuesday. The wound nurse stated that the floor nurses were responsible for applying the dressings over the weekend, but this was not done. The administrator was unaware of the missed treatments and mentioned the need for an additional wound nurse to manage the 60 wounds in the facility. The facility's policy on Physician's Orders did not address ensuring that orders are completed as prescribed, contributing to the oversight. The failure to administer the prescribed treatments was evident from the undated dressings and the resident's report.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for three residents, leading to deficiencies in their care. One resident, diagnosed with amyotrophic lateral sclerosis, COPD, and hypertension, was observed to have requested a change due to incontinence. Despite the request, the resident was not attended to promptly, and when care was finally provided, the CNAs did not perform hand hygiene, used wet washcloths without soap, and failed to clean all necessary areas properly. The CNAs also did not change gloves or perform hand hygiene during the process, and the resident's skin was not dried after cleaning, which is against the facility's policy for incontinence care. Another resident, who is severely cognitively impaired and always incontinent, was found to have been left unchanged since the previous night. The CNA providing care noted that the resident's brief was saturated with urine and feces, and the bed linen was heavily soiled. The resident's roommate confirmed that no one had checked on the resident since 11 PM the previous night. The CNA expressed concern about the resident's skin condition, noting that prolonged exposure to moisture could lead to skin breakdown. A third resident, with multiple diagnoses including diabetes, severe obesity, and chronic kidney disease, was also found to have received inadequate incontinent care. The CNAs did not perform hand hygiene before donning gloves, used wet washcloths without soap, and failed to clean all necessary areas. The resident had open areas on the buttocks, and the same gloves were used throughout the care process without changing. The facility's policy requires that incontinent care be performed every two hours and as needed, using soap and water, which was not adhered to in these cases.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to administer medications according to the physician's order for one resident. On multiple occasions, an LPN administered incorrect doses of medications to a resident. Specifically, the LPN gave a 1000 mg dose of Fish Oil instead of the prescribed 1200 mg and almost administered an incorrect dose of Folic Acid before correcting the error. Additionally, the LPN did not provide proper instructions for the use of a Symbicort Inhaler, resulting in the resident not using the inhaler correctly. The medication cart was also left unlocked and unattended in the hallway, which is against the facility's policy. The Director of Nursing (DON) acknowledged that nurses are expected to follow physician orders for medication administration, perform hand hygiene, and wipe down medical equipment as needed. The facility's Medication Administration Policy outlines specific steps for safe medication administration, including verifying the correct medication, dose, route, and time, and ensuring the medication cart is never left open and unattended. The observed deficiencies indicate a failure to adhere to these policies, leading to medication administration errors and potential risks to resident safety.
Failure to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility failed to provide appetizing and palatable meals for two residents diagnosed with Moderate Protein-Calorie Malnutrition. Resident R99 expressed dissatisfaction with the facility's food, describing it as 'disgusting' and 'nasty,' leading to the resident's daughter bringing in outside food. Resident R57 also reported the food quality as poor, mentioning that the burgers had a smell, the fries were half-cooked, and the hashbrowns were not properly browned. This resident's refusal to eat the facility's food resulted in missed doses of medication and significant weight loss from 137 pounds in January 2024 to 128 pounds in February 2024. Additionally, there were no recorded weights for March or April 2024 for R57, indicating a lack of monitoring of the resident's nutritional status. The Facility's Resident Council Meeting Minutes from February, March, and April 2024 documented multiple complaints about the food, including finding hair in the meatloaf, not receiving requested items, food arriving late, inconsistency in food quality, insufficient portions, incorrect menus, stale bread, and spoiled milk. These consistent complaints from residents highlight ongoing issues with the dietary services provided by the facility, contributing to the residents' dissatisfaction and potential health risks due to inadequate nutrition.
Failure to Perform Proper Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to perform proper hand hygiene and cleanse multi-use resident equipment, leading to potential infection risks for four residents. For instance, two CNAs provided incontinent care to a resident without performing hand hygiene before donning gloves, using wet washcloths without soap, and failing to change gloves or perform hand hygiene after the care. The same dirty gloves were used to apply ointment and handle personal items, violating infection control protocols. Another incident involved two CNAs performing incontinent care on a different resident without hand hygiene before donning gloves and using wet washcloths without soap. They also failed to perform hand hygiene after completing the care, using the same gloves throughout the process. This lack of proper hand hygiene and glove use was observed during multiple instances of resident care. Additionally, an LPN was observed assisting a resident and passing medications without performing hand hygiene before or after these tasks. The LPN also took vital signs without cleaning the blood pressure cuff between uses. The Director of Nursing and another LPN confirmed that hand hygiene should be performed before and after resident care, during medication pass, and before glove application, as per the facility's hand hygiene policy.
Failure to Administer Scheduled Medications
Penalty
Summary
Staff failed to administer several significant medications to a resident (R4) during a scheduled medication pass. R4, who has diagnoses including Metabolic Encephalopathy, Bipolar Disorder, and Hypertension, did not receive their scheduled doses of Amlodipine, Quetiapine, and Venlafaxine on 4/14/24. The eMAR documented the missed doses, and the Nurse Progress Notes indicated that the medication roll had run out. Interviews with staff revealed that R4 often requests medications and then changes their mind, leading to discarded doses and subsequent shortages. The pharmacy confirmed that medications are filled on a 7-day basis and can be retrieved from the med room if discarded or dropped. The facility's policy on medication administration requires checking for misplaced medications and contacting the pharmacy if necessary. However, the issue was not addressed by the DON despite being reported by the nurse. The resident expressed frustration with the medication administration process, and the Nurse Practitioner acknowledged the problem and discussed ways to reduce medication waste with R4. The pharmacist and administrator confirmed the procedures for medication refills and access to the med room, but the deficiency in medication administration persisted, leading to missed doses for R4.
Medication Administration Errors
Penalty
Summary
The facility failed to monitor the administration of medications as ordered by the physician for five residents, resulting in significant medication errors. One resident with moderate cognitive impairment received another resident's medication because the nurse turned her back, allowing the resident to give the medication to another. Another resident, who is cognitively intact, reported being handed a cup of pills that were not hers, and the nurse mistook her for another resident. The resident did not take the incorrect medication but expressed concerns about the potential for such errors to cause harm. A third resident with a history of cerebral infarction and Parkinson's disease received medication from another resident due to the nurse's inattention. The resident took the medication, believing it was hers. Another resident with moderate cognitive impairment received another resident's medication because the nurse mixed up bed numbers. The resident was monitored for side effects, and the medical director confirmed that no harm was caused. The fifth resident, who is cognitively intact, was administered a higher dose of medication than prescribed due to a mix-up with home supply medication. The medical director noted that the additional dosages were what the resident was taking at home, and there was no harm caused. The facility's policy on medication administration emphasizes the importance of identifying residents using two identifiers and remaining with the resident to ensure they swallow the medication. However, these procedures were not followed, leading to the medication errors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Belleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nexus Pavilion At Belleville | 0.5 mi | ★★★★★ | 8 | 0 |
| St Paul's Senior Community | 0.9 mi | ★★★★★ | 10 | 0 |
| Evercare Of Swansea | 1.2 mi | ★★★★★ | 8 | 1 |
| Memorial Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Evervella Of Swansea | 1.8 mi | ★★★★★ | 20 | 0 |
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