Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bria Of Elmwood Park during CMS and state inspections, most recent first.
Failure to Protect Resident from Roommate Assault: The facility failed to follow its abuse prevention policy when two roommates with dementia and a history of verbal altercations remained in the same room. An LPN later found one resident hovering over the other with a glass vase; the struck resident had facial swelling, bruising, pain, and additional injuries, and was sent to the hospital where the resident was admitted with assault-related injuries.
The facility failed to staff enough nurses to meet resident needs and to ensure a licensed nurse was in charge on each shift. On one evening shift, only 6 nurses were scheduled when 8 were required, leaving only 1 nurse on the 1st floor and 1 on the 4th floor. As a result, multiple residents had blank MAR entries for scheduled medications, including pain, cardiac, inhaled, insulin, and antibiotic doses. One resident reported calling 911 after not receiving medications, another said the unit had no nurse assigned, and a third had vancomycin doses unavailable while staff awaited pharmacy delivery.
Medication administration errors affected multiple residents when ordered meds were not given or were left undocumented on the MAR. A resident with sepsis reported delayed Vancomycin after the facility ran out, another resident said he called 911 after not receiving meds, and two other residents had blank MAR entries for scheduled meds including antihypertensives, insulin, inhalers, and other ordered therapies. The DON confirmed that undocumented doses were not considered given.
Failure to Timely and Completely Report Alleged Abuse: The facility did not follow its abuse reporting policy after an alleged verbal abuse incident involving a resident and a CNA. The Administrator sent an incomplete preliminary report from a Gmail account instead of a facility-reported incident form, leaving out required resident details such as name, age, dx, and mental status, and the official incident form was not submitted until several days after staff were notified. The report also noted that police were called, the CNA was suspended, and the resident's spouse and MD were notified.
The facility failed to follow its abuse investigation policy for two residents who alleged abuse. One resident reported hearing staff say they would choke her, but the investigation excluded resident interviews even though the policy required them. Another resident with quadriplegia and intact cognition reported rough handling, pain, and being unable to breathe after a CNA placed his head in a pillow; the facility interviewed staff and a therapist but did not interview other residents assigned to the accused CNA, stating nearby residents were non-verbal or unavailable. The Administrator said he had not read the policy and followed a template instead.
Failure to Develop Baseline Care Plans Within 48 Hours: The facility did not open baseline care plans within the required timeframe for three residents reviewed for abuse and falls. One resident’s abuse care plan was started well after admission and the baseline plan did not include abuse. Another resident’s abuse/neglect plan was started after an abuse allegation, and a third resident with a high fall risk score had no baseline fall care plan despite a fall and an abuse allegation after admission. The Care Plan Coordinator confirmed the baseline plans were not in place as required.
A resident with sepsis was prescribed Vancomycin, but the facility failed to keep the medication on hand and failed to timely reorder it. The MAR showed multiple doses marked with a code indicating other, while progress notes documented that staff were awaiting pharmacy delivery. The DON confirmed the resident had six doses documented this way, and the resident stated the facility had run out of the medication.
Two residents with severe cognitive impairment and complex medical conditions, including dependence on G-tube feeding for all or most nutrition, did not receive enteral nutrition and hydration as ordered. For one resident, hospice and the POA agreed to stop G-tube feeding due to emesis and perceived respiratory distress, but no alternative interventions were tried, the RD was not notified, and the existing POLST directing artificial nutrition and hydration by any means was not revised. For the other resident, surveyors found the feeding pump alarming, the formula carton and tubing completely dry, and the carton dated two days earlier, even though the ordered rate meant it should have been replaced the previous day; there was no documentation explaining the lack of feeding or any provider notification. Facility policies on tube-feeding management, documentation, and adherence to advance directives were not followed.
A resident with severe cognitive impairment, trach/vent dependence, and multiple chronic conditions was found with bilateral mitt restraints that staff could not explain, could not easily remove, and did not release on schedule. The mitts were dirty, one contained dried blood, and family members said they were not informed before use and had seen the restraints applied too tightly with blisters. Records showed the restraints were not care planned or properly coded, alternatives were not documented as tried, and staff were unfamiliar with the restraint policy and monitoring tools.
The facility failed to follow its abuse policy by not ensuring agency RNs were oriented and competent on abuse prevention before working, and by not coordinating abuse monitoring with QAPI. Agency nurses reported no facility orientation or abuse training, did not know the abuse prevention coordinator, and facility records did not show training on resident rights, reporting, or managing aggressive behavior. The QAPI binder contained only grievances and missing items, with no quarterly review of incident reports, accident reports, safety committee reports, or other data required by the abuse policy.
The facility failed to ensure CNAs received annual performance evaluations and training tied to identified areas of improvement. The CNA Supervisor stated annual performance reviews were not done, and a CNA and restorative CNA were unsure whether they had received evaluations or related in-services. The administrator said the facility does not do annual performance evaluations for CNAs because they are union staff and receive a flat annual pay increase, and the facility assessment did not identify this requirement.
Food storage and sanitation deficiencies were identified in the dietary area when an opened bag of salad/lettuce and two unopened bags were found undated in the walk-in refrigerator, scoops were left uncontained on top of bulk sugar and flour canisters, and multiple boxes of food and supplies were stored directly on the floor in the dry storage area. The Dietary Director stated the salad/lettuce should be dated, scoops should be covered, and items should not be placed on the floor; facility policy required open products to be sealed, labeled, and dated and scoops to be stored in a clean designated space.
Open Dumpsters and Propped Open Dumpster Area Door: Both outside dumpsters were observed with lids left open, containing bagged garbage beyond proper closure, loose debris, and an additional bag of trash outside the dumpsters. The Dietary Director stated the lids should be closed to keep garbage from falling out and to prevent critters from getting into or being attracted to the waste. The exit door to the dumpster area was also observed being held open with a dustpan until the Dietary Director removed it and closed the door.
The facility failed to have an RN serve as the ADON and instead assigned an LPN to cover the ADON role after the prior ADON left. The LPN confirmed taking on duties such as supervising nursing staff, overseeing resident care, processing physician orders, reviewing lab values, and managing psychotropic medication use, while the facility’s records and leadership confirmed no ADON was on staff and the required RN-qualified ADON position was vacant.
Failure to Provide QAPI Plan: The facility did not provide its QAPI plan when requested by the survey team. The DON and Administrator were unable to locate a copy, and the QAPI binder contained only departmental data collection with no QAPI plan included. The facility's QAPI policy stated that executive leadership would report annually on the current and proposed QAPI plan and goals for the coming year.
Failure to Complete QAPI PIP: The facility's QAPI committee did not complete a PIP within the past year. The Administrator provided a QAPI binder with departmental data, but there was no evidence of corrective action or a completed PIP. The MD said he was not invited to QAPI meetings and had no knowledge of a PIP, and the DON, MDS nurse, restorative nurse, activity director, and infection preventionist also could not recall one being completed.
The facility failed to ensure the medical director was invited to and attended QAPI committee meetings. Review of QAPI sign-in sheets showed the MD did not attend any meetings over the review period, and the administrator stated they never invited the MD to participate. The MD confirmed they were not notified of the meetings, while the QAPI policy stated the committee includes the MD and the administrator has oversight responsibility for QAPI.
Staff failed to follow infection control practices for residents on contact isolation and EBP. A CNA provided care wearing only gloves to a resident on contact precautions, staff did not consistently wear or remove gowns correctly during ADL care for a resident on EBP, a resident with a G-tube had no EBP sign posted outside the room, personal clothing was hung inside a resident room, and hand sanitizer containers on the second floor were empty.
Missing COVID-19 Staff Vaccination Documentation: The facility failed to maintain documentation of staff screening, education, offering, and current COVID-19 vaccination status for all staff. The IP nurse stated the facility did not offer the COVID-19 vaccine to staff and instead expected them to obtain it outside the facility due to insurance. When surveyors requested immunization status, the IP nurse said there was no staff vaccination list, only prior-year proof submitted by staff, and she could not provide education materials about the risks and benefits of the vaccine.
The facility failed to ensure agency RNs were trained on the abuse prevention policy before working independently. One agency RN said it was the first day in the building and had received no facility orientation or abuse training, while another agency RN also denied any training and did not know the abuse prevention coordinator or how to report abuse. Training records did not show instruction on resident rights, abuse definitions, reporting procedures, photo/recording prohibitions, or managing aggressive behavior. The facility also lacked documented quarterly QAPI review of incident-related data required by its abuse policy.
Failure to Train All Staff on QAPI Program: Multiple staff members, including CNAs, LPNs, RNs, activity staff, housekeeping, and the infection preventionist, stated they did not know what QAPI was and had not received training on the facility’s QAPI program. The DON and Administrator also acknowledged there were no staff in-service records for QAPI training, despite the facility policy stating all employees would participate in ongoing QAPI efforts and that facility-wide training would be provided.
Surveyors found that staff failed to follow professional standards for medication storage, labeling, and controlled substance documentation, and did not properly document or communicate a major change in a resident’s enteral feeding order. Multiple open insulin vials and pens on several medication carts lacked required open dates, had expired beyond-use dates, or were left in active stock for residents who had been discharged or were deceased. Some insulin and an albuterol inhaler were stored without pharmacy labels or resident names, and loose pills and an expired stock allergy medication were found mixed with active medications. Controlled substance count sheets on several carts had missing nurse signatures for shift counts, and the documented remaining doses for several controlled medications did not match blister card counts; in one case, an oxycodone card had an altered label and was tracked on plain copy paper instead of an individual controlled drug record. In addition, a resident with severe malnutrition, anoxic brain damage, tracheostomy, and gastrostomy status, care planned as NPO and dependent on tube feeding, had the G-tube feeding order discontinued without any documentation in the record or notification of the physician or dietitian by the LPN who received the order.
The facility failed to provide sufficient RN staffing on a high-acuity respiratory unit, resulting in widespread late administration of scheduled medications. Two RNs, including an agency RN who arrived late to the shift, were assigned to 32 residents, many with ventilators, trachs, G-tubes, wounds, epilepsy, diabetes, quadriplegia, and other complex conditions. One RN reported that medications were late every day and that the volume of G-tube medications made timely administration impossible, while a floor manager RN confirmed that most medications scheduled for the morning were not given by the due time. Medication audits showed that half of the unit’s residents received morning medications late, in some cases more than three hours past the scheduled time. The DON acknowledged that such delays constitute timing medication errors but maintained that two nurses were sufficient, while other staff, including an RN, an LPN, and the Infection Preventionist, stated that the unit needed a third nurse due to the acuity and workload.
Failure to Protect Resident Dignity During Catheter Care and Blood Glucose Monitoring: An LPN performed BG checks and gave insulin to two residents at dining room tables with other residents present, without privacy. The facility also left urinary catheter drainage bags uncovered for three residents, including two cognitively intact residents who expressed concern about the lack of privacy. Staff and the DON acknowledged that BG checks, insulin administration, and urinary drainage bags should be handled privately.
PASRR screening was not updated for residents with new mental illness diagnoses, and two residents were not screened as indicated by their PASRR Level I outcomes. One resident had psychosis, dementia, depression, severe cognitive impairment, and active psychotropic orders, while another had diagnoses including schizoaffective disorder and psychosis. Two additional residents had diagnoses such as schizophrenia, major depressive disorder, and unspecified psychosis, and their PASRR Level I outcomes indicated referral for Level II onsite. The SSD stated he used the PASRR end date to guide screening and was not taught to submit a new Level I when a new mental illness diagnosis was present.
The facility failed to ensure the 3rd floor crash cart was checked daily. Surveyors found multiple missing crash cart checks on the log, and an RN and the DON both stated the cart should be checked every day to confirm the AED and other equipment are working and present. The facility policy also required daily crash cart checks and daily AED checks.
Improper LAL Mattress Layering and Incorrect Weight Setting: A facility failed to keep multiple residents’ LAL/air loss mattresses free of excess linen layers, and one resident’s mattress was set above the level matched to the resident’s recorded weight. A wound care nurse stated the expected setup was a flat sheet with either a pad or brief, but residents were observed with fitted sheets, pads, briefs, and in one case additional folded linen layers. One resident with a Stage 3 pressure ulcer and another with active wounds were among those affected, and one cognitively intact resident with morbid obesity and a Stage 3 pressure ulcer had a mattress setting that did not align with the documented weight.
Respiratory equipment was not properly contained, changed, or dated for multiple residents. A resident had a BiPAP mask left on a dresser, another resident had oxygen and nebulizer equipment that was not contained or labeled, and two residents had respiratory supplies observed with dates that did not match the required change schedule or were undated. Records showed these residents had significant respiratory diagnoses and active orders for oxygen, BiPAP, trach collar, nebulizer, and suction equipment.
Controlled substance documentation was incomplete for multiple residents when an LPN and RN failed to sign out administered doses and shift-to-shift count sheets showed missing nurse initials and count mismatches. A resident’s Oxycodone blister card also had an altered pharmacy label, no individual controlled drug record sheet, and the medication was tracked on handwritten copy paper instead of the required control form.
Late Administration of Scheduled Medications: Multiple residents had scheduled meds given well past the ordered time, including seizure meds, beta blockers, losartan, and amiodarone. Staff reported the unit was short on nursing coverage and that meds were already running late, while the DON stated that meds given more than 1 hour past the scheduled time are timing med errors and physician notification is expected.
An LTC facility left expired and unlabeled insulin in medication carts, including insulin for residents who had been discharged or died, and also stored an unlabeled inhaler, expired stock medication, and loose pills in the carts. Surveyors found multiple insulin vials and pens without open dates or with expired dates, and a controlled oxycodone blister card with an altered pharmacy label and no proper control record. Staff acknowledged the medications were expired or improperly labeled, but they remained in active storage.
A resident with severe cognitive impairment, multiple complex medical conditions, and a POLST directing provision of artificial nutrition and hydration via surgically placed tubes was care planned as NPO with enteral feeding for all nutrition needs, yet had no active tube feeding orders and was observed on multiple occasions without any feeding infusing. An RN reported that hospice had discontinued the feeding, the POA stated she had been told feeding could not be restarted despite wanting it continued, and the DON was unaware the feeding had been stopped. The MD acknowledged hospice stopped the feeding due to aspiration risk and stated that the POLST should be revised if G-tube feeding is discontinued, while facility policy affirms residents’ rights to determine life-sustaining treatments, including artificial hydration and nutrition.
A resident with quadriplegia and cognitive intactness was found in bed with a pressure-sensitive call light placed out of reach and not usable by the resident. The resident stated staff expected use of the chin to activate it, but the resident could not do so and had been yelling for help instead. The resident’s family member reported staff had been told the resident needed a blow-activated call light, and an LPN and the DON acknowledged the resident needed a call light the resident could actually use.
Resident identifying information was posted by a resident’s door on a birthday sign that showed the resident’s full name and DOB. An LPN, RN, and Central Supply staff identified it as a HIPAA violation, and the AD stated the Activities Dept had been posting birthday flyers with residents’ full names and full DOBs for months. The resident had psychosis, dementia, depression, and a severely impaired BIMS score.
MDS coding was inaccurate for a resident who used mitt restraints. The resident had multiple serious diagnoses, including trach and ventilator dependence, and the physician orders and MAR documented mitts to both hands, but the MDS did not code any restraint use. The MDS nurse confirmed the mitt restraints should have been coded, and the care plan did not address the restraint use.
A resident with schizoaffective disorder, anxiety disorder, dementia with behavioral disturbance, and bipolar disorder did not receive an updated PASRR Level I screening after admission. The record showed moderate cognitive impairment and active orders for risperidone for psychotic behavior, but the only PASRR document was an older nursing facility placement screening noting bipolar disorder. The facility did not provide a PASRR policy when requested.
A resident with multiple serious diagnoses, including trach and vent dependence, had bilateral mitt restraints ordered for pulling at the trach, but the restraint use was not reflected in the care plan. Staff who observed the resident with the mitts were unsure why they were in place, and the MDS nurse confirmed the MDS was miscoded and no restraint care plan had been developed. Family members stated they had not been informed before the restraints were started and reported ongoing concerns about the resident’s care.
A resident with acute respiratory failure, tracheostomy, schizoaffective disorder, epilepsy, and a high fall-risk score had a care plan intervention requiring the bed to be kept in the lowest position. Despite this, nursing documentation and leadership interviews confirmed that the resident’s bed was left in a high position, after which the resident was found on the floor and sent to the hospital. The DON, Restorative Nurse, and Administrator each stated that staff are responsible for implementing care plan interventions and are expected to follow the care plan, consistent with the facility’s policy that the comprehensive care plan drives the care and services provided.
The facility failed to ensure effective nurse-to-nurse handoff communication and documentation during hospital transfers for two residents with complex medical conditions, including ventilator dependence, hospice care, ESRD, and heart failure. In multiple transfers, hospital transfer forms lacked the name of the receiving hospital nurse, progress notes did not document any nurse-to-nurse report, and SBAR forms omitted critical information such as hospice status. The DON stated that nurses are expected to obtain MD orders, complete transfer and SBAR forms, notify family, call and give report to the hospital, and send a face sheet and POS, but staff interviews and record review showed that these steps, particularly the verbal handoff and its documentation, were not consistently completed.
Two residents with high fall-risk scores and multiple comorbidities experienced falls that were not properly documented or evaluated according to facility policy. In both cases, nursing staff documented that the residents were found on the floor and sent to the hospital, but did not complete required fall reports, risk management entries, or post-fall and pain assessments. The DON and Administrator stated that any fall risk score greater than 10 indicates high fall risk and that staff are expected to complete fall risk evaluations and update care plans after each fall, as outlined in the facility’s fall prevention and management policy.
A resident with complex medical conditions, including ventilator dependence and anoxic brain damage, was enrolled in hospice, but the facility did not add hospice orders to the physician order sheet or indicate hospice status on the face sheet. When the resident later had tachycardia and seizure-like activity, an agency RN obtained an order to send the resident to the hospital and provided face sheets and physician orders to EMTs, but was unaware the resident was on hospice and did not communicate hospice status during the transfer. Review of the transfer form showed no documentation of hospice, and leadership acknowledged hospice status should appear in the POS and on the face sheet, in contrast to facility hospice policy and CMS requirements for coordinated hospice care.
The facility failed to honor residents’ rights to receive visitors at any time by enforcing fixed visiting hours ending at 8 p.m., despite a written policy allowing 24-hour open visitation with only quiet hours. Two nonverbal, fully dependent residents with complex conditions, including anoxic brain damage, chronic respiratory failure, tracheostomy and gastrostomy status, had family members who were told by staff, including an LPN, that visiting hours were over and they had to leave at 8 p.m., even when one family member was addressing concerns about tube feeding and another was waiting for incontinence care. Staff consistently described visiting hours as ending at 8 p.m., and the DON acknowledged the use of visiting hours and the need for administrative approval for overnight stays, while there was no documentation that these visitation limits were based on individualized clinical need, resident preference, safety, or roommate rights.
The facility failed to ensure that three nonverbal, fully dependent residents with PEG/GT tubes received enteral nutrition as ordered and that tube feeding intake was accurately documented. A resident’s spouse repeatedly found the feeding pump off or inactive during ordered continuous feeding times, with staff and telehealth documentation confirming missed hours of feeding. For two other residents, surveyors observed that the volume of formula remaining in the feeding containers and the total volume displayed on the pumps did not match the prescribed rates, labeled start times, or ordered daily volumes, and one container lacked a start time label altogether. The DON acknowledged that pumps might not have been reset when new bottles were hung and that there was no dedicated flow sheet to track bottle changes, while records lacked documentation of feeding interruptions, restarts, and total daily volumes despite facility guidelines requiring pump clearing each shift and documentation of tube feeding delivered.
A resident with complex medical conditions was treated for hypokalemia and received potassium supplementation, but staff failed to ensure timely laboratory monitoring and did not act upon a critically high potassium result. An LPN reviewed a critical potassium value of 8.4 mEq/L but did not initiate emergent intervention or escalate the situation as required by facility policy. The lack of timely response and failure to follow protocols resulted in the resident not receiving necessary medical care and subsequently experiencing cardiac arrest and death.
A resident with significant cardiac and vascular conditions had a critically high potassium level identified by lab testing, but the LPN who received the result did not ensure timely provider notification or initiate appropriate clinical intervention. The LPN documented an attempt to notify the NP but did not escalate the issue or provide further care, and the critical result was cleared from the EMR, preventing further action. The resident was later found unresponsive and died, with the facility's failure to follow its policy for critical lab notification resulting in Immediate Jeopardy.
A resident with multiple comorbidities was treated for hypokalemia and received potassium supplementation, but the facility failed to ensure ongoing assessment and timely laboratory monitoring. Orders for potassium were entered incorrectly, resulting in prolonged administration, and there was no documentation of follow-up labs or clinical intervention after a critically high potassium level was identified. The resident was later found unresponsive, with the death certificate listing cardiopulmonary arrest as the cause of death.
A CNA failed to follow infection prevention protocols by not changing gloves or performing hand hygiene while providing care to two residents. The CNA used soiled gloves to handle personal items, clean linens, and touched multiple surfaces, including a linen cart, without proper glove removal or hand hygiene. This breach of protocol was confirmed by facility leadership and was inconsistent with established infection control policies.
A resident with multiple medical conditions left the facility without proper discharge planning or documentation, including the absence of required AMA education, physician notification, and completion of forms. The resident departed without medications or belongings, and the facility was unable to confirm the resident's location or condition after discharge.
Failure to assess and communicate resident respiratory decline: A resident with COPD and heart failure had a change in condition when staff found the nasal cannula off and the resident breathing heavily with low O2 saturation. The nurse called 911, but vital signs, a thorough assessment, and an SBAR were not completed or documented, and the resident’s status was not fully communicated to EMS or the provider before transfer. The resident was later intubated, admitted to the ICU, and expired.
Broken Shower Chair and Unlatched Shower Room Door: Staff failed to remove a cracked shower chair from use, and a resident fell after using it. The resident also reported another resident entered the shower area while she was bathing. Surveyor observation found the shower room door did not latch, and the DON and Maintenance Director stated staff communication about the broken equipment failed and no maintenance policy/documentation was provided.
Failure to Protect Resident from Roommate Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy and failed to protect one resident from physical abuse by a roommate with a documented history of verbal altercations. The abused resident had dementia, severely impaired cognition, poor ambulation, and was identified in the care plan and abuse screening as vulnerable to abuse and neglect. The other resident also had dementia, moderately impaired cognition, and a care plan documenting verbal and physical aggression, including prior verbal altercations with the roommate and a later physical altercation. Facility records showed repeated verbal conflicts between the two roommates before the incident, including disputes about clothing and use of the roommate’s closet. Progress notes documented that the residents were separated during some of these verbal altercations, but they remained assigned to the same room. Staff interviews confirmed that the residents had argued multiple times and that room changes should have occurred earlier, with several staff stating they did not know why the residents were not separated despite the ongoing conflicts. On the night of the incident, an LPN entered the room and observed one resident hovering over the other with a glass vase in hand. The resident who was struck was frightened and had swelling and bruising to the left side of the face, along with pain and additional bruising and swelling to the hands and upper arm. The resident was given Tylenol, an ice pack, and medication for elevated blood pressure, then transferred to the hospital for evaluation and treatment. The ambulance record documented that the resident had been attacked by the roommate and had facial swelling, bruising, and pain; the hospital admitted the resident with a diagnosis of assault.
Insufficient Nursing Staffing and Missed Medication Administration
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and failed to have a licensed nurse in charge on each shift. The report states the facility assessment required 2 nurses on each floor per shift, with a total of 8 nurses required for the 4 floors, and facility staff confirmed that 2 nurses were supposed to be assigned to the 1st, 2nd, and 4th floors and 3 nurses to the 3rd floor on mornings and evenings. On the evening shift in question, the nursing assignment sheet showed only 6 nurses scheduled, with only 1 nurse assigned to the 1st floor and 1 nurse assigned to the 4th floor. Resident R2, who had a BIMS score of 14 and diagnoses including pain-related medication needs, hypertension treatment, and famotidine use, stated that on the evening shift he did not receive pain medication or other medications and called 911 because no nurse arrived in time. R2’s MAR showed blank entries for famotidine, metoprolol tartrate, and topiramate on that shift. The DON stated that if something is not documented, it was not done, and acknowledged that the facility normally tries to have nurses from different floors do med passes when short-staffed. Resident R8, who had a BIMS score of 14 and orders for hydralazine, metoprolol tartrate, gabapentin, and Lantus, had blank MAR entries for multiple scheduled medications on the same evening shift. Resident R9, who had a BIMS score of 15 and an order for Advair every 12 hours, stated there was no nurse assigned to the unit and that the inhaler due at 8:00 p.m. was a problem; the MAR showed blank entries for Advair on multiple dates including the evening shift in question. For R3, who had sepsis and a BIMS score of 13, the report states vancomycin was not available as ordered, with progress notes documenting that staff were awaiting pharmacy delivery and the DON later identifying 6 missed doses. The medication administration policy required medications to be given at the proper time, dose, and route, and if not given as ordered, the reason had to be documented on the MAR.
Medication administration errors and missed doses
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not following policy procedures, physician orders, and prescribed medication schedules for four residents reviewed. R3, who had a diagnosis of sepsis and a BIMS score of 13, reported that the facility did not have Vancomycin and that he finally received it later. The physician order required Vancomycin 25 mg/ml, 5 ml every 6 hours, but the MAR documented code 9 entries on multiple scheduled doses on 5/17 and 5/18. Progress notes stated the nurse was awaiting pharmacy delivery of the medication, and the DON confirmed that six doses were not received because the medication was unavailable. R2, who had diagnoses including hypertension, epilepsy, and alcohol abuse and a BIMS score of 14, stated that he called 911 because he did not receive his pain medication or any other medications on the 3 pm to 11 pm shift. The MAR for that shift had blank entries for Famotidine, Metoprolol Tartrate, and Topiramate, and the DON stated that if it is not documented, it was not done. R8, who had type II diabetes mellitus and a BIMS score of 14, had blank MAR entries for Metoprolol Tartrate, Gabapentin, Sucralfate, Lantus, and Hydralazine on the evening shift. R9, who had shortness of breath, COPD, and acute respiratory failure with hypoxia and a BIMS score of 15, stated that an inhaler due at 8:00 pm was a problem, and the MAR showed blank entries for Advair on multiple evenings. The facility policy stated medications must be administered safely and appropriately at the proper time, dose, and route, and if not given as ordered, the reason must be documented on the MAR.
Failure to Timely and Completely Report Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse reporting policy and did not submit a complete facility-reported incident to IDPH within the required timeframe for one resident involved in an alleged abuse event. IDPH received an abuse allegation on 3/20/26 involving alleged verbal abuse by facility staff toward R6. During surveyor interview, the Administrator stated that when abuse is alleged, staff report it to him, the alleged perpetrator is suspended if it is a staff member, a police report is made, the resident or reporting person is interviewed, and a report is sent to the State within 2 hours, with 5 working days to complete the investigation and final submission. For the 5/14/26 allegation involving R6, the Administrator provided an email sent from a Gmail account as the preliminary report rather than a facility-reported incident form. The email stated that a CNA allegedly yelled at R6 while answering a call light, that the resident's husband witnessed the event, and that the CNA was suspended, police were called, and the physician and husband were notified. However, the email submitted to IDPH on 5/15/26 omitted required information including R6's last name, age, diagnosis, and mental status, and the facility-reported incident form was not submitted until 5/20/26, 5 days after staff were made aware of the allegation. The facility's abuse policy required immediate notification to the Department of Public Health by telephone or fax and required the report to include the resident's identifying and clinical information and the date, time, location, and circumstances of the alleged incident.
Failure to Complete Required Abuse Investigations
Penalty
Summary
The facility failed to follow its abuse investigation policy and failed to conduct a thorough investigation for two residents who alleged abuse. For one resident, IDPH received an allegation that an unknown male CNA told her they could choke her. The facility’s initial report stated the resident said she overheard two staff members saying they would choke her out, and the final report concluded the allegation was unsubstantiated based on staff statements and the fact that staff respond to her room in pairs. However, the facility did not document interviews of other residents who may have had contact with the alleged perpetrator, and the Administrator later affirmed that resident interviews were excluded from the investigation. For another resident with quadriplegia who was dependent on staff for all ADL care and had a BIMS score of 15, the resident reported that two CNAs were handling him and that one CNA put her hands on him, turned him too quickly, told him to shut up when he said he was in pain, and put his head in the pillow so he could not breathe. The initial facility report stated the resident alleged a CNA hit him in the face, and the final report concluded the allegation was unsubstantiated after interviews with the resident, the accused CNA, a CNA witness, and a respiratory therapist. The report stated that nearby residents were not interviewed because of their diagnoses. During surveyor interviews, the Administrator stated he had not read the abuse policy and had followed a template and regional guidance instead. The facility abuse policy required the appointed investigator to attempt to interview the person who reported the incident, anyone likely to have direct knowledge, the resident if able, residents to whom the accused regularly provided care, and employees with whom the accused regularly worked. The investigation documentation and staff statements showed that these required resident interviews were not completed for either abuse allegation.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents reviewed for abuse and falls. For one resident, admitted on [DATE], the potential for abuse care plan was not initiated until 4/27/26, 18 days after admission, and the Care Plan Coordinator stated that baseline care plans should be opened by nurses within 72 hours and developed within 48 hours. When the surveyor asked whether the baseline care plan included abuse, the EMR showed it did not, and the abuse care plan was not initiated until 4/27/26. For another resident, admitted on [DATE], a facility-reported incident documented an allegation that the resident overheard two staff members saying they would choke her out. The abuse/neglect care plan was not initiated until 3/25/26, after the allegation and 6 days after admission, and the baseline care plan did not include abuse. For a third resident, admitted on [DATE], the admission fall risk evaluation showed a score of 11, indicating high risk. The resident had a fall on 5/16/26 when staff found her on the floor beside her bed, yet the fall care plan was not initiated until 5/18/26. The resident also had an abuse allegation on 5/14/26 when her husband stated a CNA allegedly yelled at her, and the abuse care plan was not initiated until 5/17/26. The Care Plan Coordinator stated the resident did not have a baseline fall care plan and that only the comprehensive abuse care plan was available.
Failure to Ensure Ordered Vancomycin Was Available
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of one resident with sepsis when the facility failed to follow its medication ordering and receiving procedures, failed to timely reorder medication, and failed to ensure prescribed Vancomycin was available for administration. The resident’s physician ordered Vancomycin 25 mg/ml, 5 ml every 6 hours, and the resident had a BIMS score of 13 indicating cognition intact. During interview, the resident stated the facility did not have the Vancomycin and had run out of it, and that the resident finally received it later. Record review showed the May 2026 MAR documented a code of 9 for Vancomycin doses on 5/17 at midnight, 6 a.m., 12 p.m., and 6 p.m., and on 5/18 at midnight and 6 a.m. Progress notes stated the nurse spoke with pharmacy and that the medication would be delivered, and later noted the facility was awaiting pharmacy delivery. The DON stated staff had to make sure the medication was on hand, should reorder and alert the pharmacy when the medication was running low, and confirmed that the resident had six doses documented with a 9. The medication administration policy stated that if medication is ordered but not present, staff should check whether it was misplaced and then call the pharmacy to obtain it.
Failure to Provide Ordered Enteral Nutrition and Honor POLST for Artificial Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered enteral nutrition and hydration, to follow tube-feeding policies, and to honor an existing POLST directive for artificial nutrition and hydration. One resident (R11) had a history of anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status, and was assessed as severely cognitively impaired and dependent for all ADLs. His care plan documented NPO status with enteral feeding for all nutrition needs, including monitoring tolerance, weight, labs, skin, hydration, and providing additional fluids via feeding tube as ordered. Physician orders included a nutritionist consult after emesis and instructions to check residuals and hold feeding if residuals were ≥100 ml, with MD notification if residuals remained high. However, at the time of surveyor observations, R11 had no active G-tube feeding order, only water flush and medications, and was repeatedly observed in bed with a G-tube plunger at bedside, no feeding pump, and no feeding infusing. Staff interviews revealed that R11’s feeding had been stopped by hospice on a prior date due to episodes of emesis and perceived respiratory distress. The hospice RN stated that R11 had been on 2 cal formula at 50 ml/hr with a total volume of 425 ml and that hospice discussed with the family that feeding could cause respiratory distress; no other interventions such as reducing rate or volume were attempted before stopping feeding entirely, and hospice believed the resident was near end of life. The hospice RN acknowledged telling the POA that at end of life the resident did not need feeding. The POA reported having no clinical experience, relying on hospice’s explanation, and believing that because the resident was at end of life he did not need feeding; she also stated the resident did not receive water except with medications and was not being turned and repositioned every two hours as care-planned. The facility dietitian reported she was not notified that feeding had been stopped, described not feeding at all as “extreme,” and stated that the facility should be following the resident’s POLST form when determining care. R11’s Illinois Department of Public Health POLST form, signed by the POA, documented in section D that artificial nutrition and hydration should be provided by any means, including new or existing surgically placed tubes. The DON stated she was not aware that R11’s feeding had been discontinued and agreed the facility should follow the POLST. The attending physician/medical director acknowledged being aware that hospice had stopped the feeding due to aspiration risk and that the longer the resident was fed, the longer he would live, and stated that if the G-tube feeding was discontinued, the POLST should be readdressed and a new form obtained. The facility’s advance directive/DNR policy stated that life-sustaining treatments include IVs, tubes, and artificial hydration and nutrition to maintain life unless there are specific directions from the resident or family not to, and that changes to advance directives require voiding the old form and initiating a new one. No documentation was presented showing that R11’s POLST had been revised to reflect a decision to withhold artificial nutrition and hydration. A second resident (R1) with acute and chronic respiratory failure, type 2 diabetes, protein-calorie malnutrition, dysphagia, a stage 3 pressure ulcer, traumatic brain injury, epilepsy, encephalopathy, tracheostomy, and gastrostomy status was also affected. R1’s MDS documented severe cognitive impairment and that more than 51% of nutrition was via enteral feeding. The care plan indicated R1 was NPO due to dysphagia, that tube feeding would provide approximately 100% of estimated needs, and that staff should monitor tube-feeding tolerance; it also noted R1’s increased risk of abuse due to fragility, poor cognition, and poor communication, with a goal to remain free from mistreatment. Physician orders specified continuous enteral feeding of 2 Cal HN at 40 ml/hr for 20 hours daily (on at 2 pm, off at 10 am) via G-tube, with Jevity 1.5 as a substitute at 52 ml/hr for 21 hours if needed. During observation, R1 was found in bed, unarousable, with the enteral feeding pump alarming “FEED ERROR.” The feeding carton was completely desiccated, with only a quarter-sized amount of dried, cracking formula inside, and the tubing contained dry residual formula occupying less than 10% of its length. The carton was labeled with a date indicating it had last been hung two days earlier, with no time noted. Nursing staff and the DON confirmed that at the ordered rate of 40 ml/hr, the 1-liter carton would last approximately 25 hours and that another carton should have been hung the previous day. The DON acknowledged that R1 was completely dependent on staff for enteral feeding and hydration. There was no documentation in the medical record between the date the carton was hung and the survey date indicating that feeding had been held, that a provider had been notified, or that any rationale existed for not administering the feeding. Progress notes for R1 documented on a later date that the resident was in bed with head of bed elevated, vital signs stable, medications given, and “GTF ongoing, on at 2pm off at 10am,” with trach and G-tube sites intact and no signs of infection, and that the resident was repositioned every two hours. This documentation did not reflect the observed absence of active feeding or the dry feeding set. The dietitian confirmed that R1 was NPO and that 100% of nutritional needs were delivered via tube feeding, and explained that the current order met 100% of estimated needs. The medical director stated that a patient with diabetes who does not receive ordered enteral feeding could be expected to develop hypoglycemia, dehydration, or electrolyte imbalances. Nursing staff assigned to the unit on the relevant shifts either denied being assigned to R1, did not recall the resident, or stated they did not change tube-feeding cartons, indicating that night shift was responsible for changing sets at midnight and dating them accordingly. The facility’s Tube Feeding Management policy required continuous tube feedings to be based on a 22-hour consumption period or other time frame per RD assessment, with the health care provider notified if the ordered amount was not infused, and required labeling of tube feedings with resident name, rate, total volume, date, and time hung. The policy also required that the pump be cleared at the end of each shift, that tube feeding delivered be documented, and that the health care provider be alerted to any issues or concerns. In R1’s case, the feeding set remained in place well beyond the expected infusion period without replacement, the pump alarmed without effective response, and there was no documentation of the interruption or of provider notification. In R11’s case, enteral feeding was discontinued without updating the POLST or notifying the dietitian, despite the existing POLST directive to provide artificial nutrition and hydration by any means.
Improper Use and Monitoring of Mitt Restraints
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary restraint use and failed to follow its restraint program and policy. The resident had multiple serious diagnoses, including nontraumatic intracerebral hemorrhage, cerebral palsy, acute respiratory failure, dysphagia, dependence on ventilator status, depression, and severe cognitive impairment. The resident’s physician orders included bilateral mitts related to pulling at the trach, but the resident’s care plan did not identify restraint use, and the resident’s MDS did not code the mitt restraints. Survey observation found the resident lying in bed with bilateral mitt restraints in place, and staff were unsure why the restraints were being used. One agency RN stated she had not received restraint training from the facility and was unable to untie one mitt because it was tied so tightly that she could not fit more than two fingers under it. The surveyor observed that the mitts were not applied in a manner that allowed for easy release. It took approximately 2 to 3 minutes to untie the knots and release one restraint, and the RN retied it in a double knot. The mitts were observed to be dirty, and one mitt had dried blood on the inside where it tied around the resident’s wrist. Family members stated they had not been informed before the restraints were started, said the mitts were often left on, and reported that they had removed them in the past because they were too tight and had caused blisters. The family also stated they had been trying to get the resident transferred to another facility, but the other facility would not accept the resident while the mitts were in use. The record and interviews showed that required restraint processes were not followed. Staff and the provider were unable to identify all interventions tried before restraint use, and the restraint assessment documented that alternatives such as reorientation, toileting, pain management, diversional activity, increased supervision, non-restrictive devices, and repositioning were not attempted prior to restraint initiation. The restraint assessment, care plan, and root cause analysis were not completed until after the survey began. Survey observation also showed that the resident’s mitts were not released for more than 4 hours despite staff statements that restraints should be released every 2 hours. Multiple staff members stated they were unfamiliar with the restraint policy, unsure who was responsible for releases, and unable to produce the facility’s restraint monitoring documentation.
Failure to implement abuse policy and QAPI oversight
Penalty
Summary
The facility failed to implement its abuse policy by not ensuring agency nurses were educated and competent on the policy before working in the building, and by not coordinating abuse prevention activities with the QAA/QAPI program. The facility’s abuse policy, reviewed in 9/2017, states that during orientation new employees will be taught sensitivity to resident rights and needs, what constitutes abuse, neglect, exploitation, and misappropriation of property, reporting procedures, resident abuse prevention, and how to assess, prevent, and manage aggressive, violent, and catastrophic reactions. The policy also requires at least quarterly review of concern identification reports, accident reports, incident reports, missing items reports, and safety committee reports to identify patterns or trends that may constitute abuse, neglect, mistreatment, or misappropriation. On the survey, agency RNs were observed working alone in resident care areas without evidence they had received facility orientation or abuse training. One agency RN stated it was the first day working in the facility and affirmed no orientation or abuse training had been received from the facility. Another agency RN stated it was the first time in the facility and denied receiving any training or orientation prior to working shifts. A third agency RN also denied receiving training or orientation and did not know who the facility’s abuse prevention coordinator was. Facility and agency documents reviewed did not show that these agency nurses were trained on the facility’s abuse policy, and the competency test forms lacked documentation of prior training and did not show training on resident rights, photographs/recordings, or managing aggressive or violent resident reactions. One agency nurse also identified the wrong person as the abuse prevention coordinator. The facility also failed to carry out the quarterly abuse-related review required by its policy through the QAPI process. The administrator confirmed the QAPI binder did not contain quarterly review of accident reports, incident reports, safety committee reports, or environmental hazard reports to assess patterns or trends related to suspicious bruising, unexplained accidents, or other unusual occurrences. Multiple QAPI members stated that grievances and missing items were discussed, but they did not recall review of abuse-related data such as incidents, suspicious bruising, unexplained events, or other reports. The DON confirmed the only abuse-related data in the binder was grievances and missing items, and the administrator stated the facility had not been completing the required review process before creating a new tracking tool during the survey.
Failure to Provide Annual CNA Performance Evaluations and Related Training
Penalty
Summary
The facility failed to ensure certified nursing assistants received annual performance reviews and training based on areas identified in those reviews. The facility census documented 170 residents. During interviews, the CNA Supervisor stated the CNAs do not get annual performance reviews and that the supervisor had not received a performance evaluation. The supervisor also stated the CNAs' performance evaluations are not completed at the facility. A CNA could not recall whether a performance evaluation had been completed in the last year, and a restorative CNA was unsure whether a performance evaluation or related training had been provided. The administrator stated there was no policy for nursing assistants to receive annual performance evaluations and explained that the facility does not do annual performance evaluations because CNAs are in a union and receive a flat 4% annual pay increase. The facility assessment did not identify nursing assistants as requiring annual performance evaluations and training based on areas identified in the performance review.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to comply with proper food storage and sanitation protocols in the kitchen and storage areas. During observation with the Dietary Director, an opened bag of salad/lettuce that was approximately three-quarters used was found undated in the walk-in refrigerator, along with two unopened bags of salad/lettuce that were also undated. The Dietary Director stated the salad/lettuce bags should be dated and that the facility considered them good for 3 days after opening. During the same observation, one scoop was found uncontained on top of a bulk sugar canister and another scoop was uncontained on top of a bulk flour canister. In the walk-in dry food storage/pantry area, a box of napkins, a box of hot/cold cups, a box of rice, and a box of fruit cocktail were observed lying directly on the floor. The Dietary Director stated the scoops should be covered and not left laying on top, and that staff knew not to place boxes on the floor because it prevents cleaning and could allow contamination during floor cleaning. Facility policy required open products to be sealed, labeled, and dated, bins to be labeled and dated, scoops to be stored in a clean designated space, and goods not to be left on the floor.
Open Dumpsters and Propped Open Dumpster Area Door
Penalty
Summary
The facility failed to ensure that the outside dumpsters were closed. During observation of the external dumpster area, both dumpsters were seen with their lids left open and containing bagged garbage filled beyond the point of proper closure, loose debris, and an additional bag of trash outside the dumpsters. The Dietary Director stated that the garbage company should have already come, that the dumpsters should be closed so garbage does not fall out, raccoons do not get into it, and so the garbage does not attract critters. During a later observation, the exit door leading to the dumpster area was found being held open with a dustpan. The Dietary Director questioned what was happening, removed the dustpan that was propping the door open, and closed the exit door. The Dietary Director stated that this was also a critter issue. The facility policy stated that garbage and refuse are to be disposed of properly and in a timely manner, that waste is to be properly contained in dumpsters or compactors with lids and covered, and that garbage storage areas are to be maintained in a sanitary condition to prevent the harborage and feeding of pests and rodents.
ADON Duties Assigned to an LPN Instead of an RN
Penalty
Summary
The facility failed to employ a Registered Nurse (RN) to serve as the assistant director of nursing (ADON) as required by state regulations, and it also failed to ensure that the staff member covering the ADON duties was an RN. The facility census showed 170 residents, and the facility was licensed for 245 beds. During the entrance conference, the Director of Nursing stated that the facility did not have an ADON and that the prior ADON had left approximately a month earlier. The Administrator later confirmed that the facility did not have an ADON on staff. Record review and staff interviews showed that V11, a Licensed Practical Nurse (LPN), had been pulled from floor duties and was covering the responsibilities of the ADON. The Administrator stated that V11 was assuming the ADON responsibilities while the facility did not have an ADON. V11 confirmed being an LPN, not an RN, and stated that the new duties included supervising nurses, supervising resident care, ensuring lab values were reported to providers, processing physician orders, and managing psychotropic medication use. V11 also stated that these duties had been performed for several days each week and that V11 no longer had a direct care assignment unless another nurse called in. The former ADON’s timekeeping records showed the final day of work was 2/24/2026, and the HR Director confirmed the final day of work was 2/20/2026. The facility job description for the ADON listed duties including acting as DON in the DON’s absence, assisting with day-to-day nursing department functions, chart audits, lab report review, and staffing needs. Illinois regulations cited in the report state that skilled nursing facilities with 100 or more occupied beds must have an ADON who is a registered nurse.
Failure to Provide QAPI Plan
Penalty
Summary
The facility failed to disclose its quality assurance performance improvement (QAPI) plan when requested by the state survey agency. During the entrance conference on 3/23/2026 at 9:40 AM, the QAPI plan was requested and was required to be provided to the survey team within 4 hours of the entrance to the facility. By 1:50 PM that same day, the QAPI plan had not been provided. The facility census on 3/23/2026 showed 170 residents residing in the facility. On 3/25/2026 at 10:38 AM, the Administrator provided the survey team with the facility's QAPI binder, which contained data collection from departments within the facility, but there was no QAPI plan in the binder. When the surveyor asked for the QAPI plan, the Administrator confirmed it was not in the binder, checked other binders in the office, and stated, "I don't know where the QAPI plan is." On 3/26/2026 at 3:38 PM, the DON stated that the DON was part of the facility's QAPI committee, recalled seeing the QAPI plan at one point, but could not recall what it stated and did not have a copy. The facility's QAPI policy dated 1/2024 stated that executive leadership would report annually on the status of the current QAPI plan, the proposed QAPI plan, and goals for the coming year, and that this report would be made available to the board, management team, staff, resident/family council, and other stakeholders as designated.
Failure to Complete Annual QAPI Performance Improvement Project
Penalty
Summary
The facility's QAPI committee failed to complete a performance improvement project (PIP) within the last year. During interview and record review, the Administrator provided the QAPI binder, which contained departmental data collection from 2/2025 through 1/2026, but there was no evidence of any corrective action based on the collected data or any PIP completed during that time. When asked for documentation of a PIP completed in the last year, the Administrator stated the facility did not complete one and was not aware of a regulation requiring a yearly PIP. The Medical Director confirmed he was the facility's medical director and stated his duties included resident care-related matters and policy review, but he had not attended QAPI meetings because he was not invited and was not made aware of when meetings occurred. He denied involvement in completing a PIP within the last year and denied knowledge that one had been completed. Other QAPI members, including the MDS Nurse, Restorative Nurse, Activity Director, Infection Preventionist, and DON, all stated they regularly attended QAPI meetings but could not recall a PIP being completed within the last year. The facility's QAPI policy, dated 1/2024, states the program is intended to use ongoing data review to identify gaps or patterns, prioritize opportunities for improvement, and determine which problems will become the focus of a PIP. The Administrator stated he was responsible for overall implementation and monitoring of the QAPI program, and the Medical Director and Administrator were listed as having operational/managerial control of the facility. The facility census documented 170 residents at the time of the survey.
Medical Director Not Included in QAPI Meetings
Penalty
Summary
The facility failed to ensure the medical director was invited to and attended QAPI committee meetings. The facility census showed 170 residents lived in the facility. Survey review of the QAPI binder and meeting sign-in sheets from 2/2025 through 1/2026 showed the medical director was not present at any QAPI meeting during that period. The administrator confirmed the medical director had not been attending QAPI meetings and stated, "I never invited" the medical director to participate in the meetings. The medical director confirmed being the facility’s medical director and stated the facility did not invite them to the QAPI meetings and they were not made aware when the meetings occurred. Other committee members, including the MDS nurse, restorative nurse, activity director, infection preventionist, and DON, also stated the medical director did not attend the QAPI meetings. The facility’s QAPI policy stated the QAPI committee includes the medical director and that the administrator has direct oversight responsibility for the QAPI committee and its functions.
Infection Control Failures With PPE Use, EBP Signage, and Hand Hygiene Supplies
Penalty
Summary
The facility failed to ensure staff wore appropriate PPE when providing care to residents on isolation or enhanced barrier precautions, failed to ensure an EBP sign was posted for a resident with an indwelling device, failed to ensure staff doffed an isolation gown appropriately, failed to ensure staff kept personal items outside of a resident’s room, and failed to ensure hand sanitizers were available on the second floor. These findings involved three residents reviewed for infection control and were observed during surveyor rounds, interviews, and record review. One resident, who had diagnoses including parkinsonism, anemia, schizoaffective disorder, dementia, and a history of COVID-19, had a BIMS score of 6 and was dependent for substantial to maximal assistance with ADLs. During observation, a CNA was providing a bed bath while wearing only gloves even though a contact isolation sign was posted on the door. The sign directed staff to clean hands before entering and leaving, and to wear gloves and a gown before room entry and remove them before exiting. The infection prevention nurse stated the resident was on contact precaution isolation for Klebsiella pneumonia and that staff were supposed to wear gown and gloves when providing care. The same nurse also stated the resident’s care plan still reflected EBP rather than contact isolation and said the care plan had not yet been changed. For another resident, the EBP sign was posted outside the room, and the DON stated the resident had MDRO in urine. During care, a CNA hung her blue coat inside the resident’s room before donning gown and gloves, and another CNA entered the room with gloves but no gown while assisting with turning and care. The nurse on the unit stated staff should wear gown and gloves when providing ADL care and that the gown should be removed before exiting the room. The CNA later exited the room wearing the isolation gown, then re-entered and exited without it. The infection prevention nurse stated staff should not hang coats inside resident rooms and should keep personal belongings away from resident rooms to avoid contamination. A third resident had a gastrostomy tube and was on EBP, but no EBP sign was posted outside the room. The RN stated there should have been a sign posted to inform staff what PPE to wear for infection control. The infection prevention nurse stated residents on EBP include those with indwelling medical devices such as a G-tube, urinary catheter, dialysis port, or continuous oxygen, and said the admitting nurse was expected to post the sign on the new room after transfer. The record also showed EBP orders and care plan documentation for residents with devices, and the facility’s EBP and transmission-based isolation policies stated that gown and glove use and signage were required for high-contact care activities.
Missing COVID-19 Staff Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of staff screening, education, offering, and current COVID-19 vaccination status for all staff. During an infection control interview, the LPN/Infection Preventionist stated that the facility does not offer the COVID-19 vaccine to staff and instead prefers staff to obtain it outside the facility due to insurance. The IP nurse also stated she would provide proof of vaccination submitted by staff and the education material the facility provided to staff, residents, and/or family members. When surveyors requested staff immunization status, the IP nurse stated the facility did not have a list of staff immunization status and only had what staff had provided from the prior year. She stated the previous infection control person did not keep any list, so she did not have one, and that she would start making a line list going forward. She was unable to provide any educational materials given to staff regarding the risks and benefits of COVID-19 vaccination. The facility employee vaccination policy revised 11/06/2025 stated that the facility follows federal, state, and local regulations regarding vaccination requirements and includes a process for COVID-19 vaccination, including offering resources and counseling about the importance of receiving the vaccine.
Agency RN Abuse Training and QAPI Review Deficiencies
Penalty
Summary
The facility failed to ensure agency staff were trained on the abuse prevention program and policy as required by the facility’s abuse policy and facility assessment. On 3/23/2026, an agency RN was observed alone trying to untie a resident’s restraints and stated it was the first day working in the facility and that no facility orientation or abuse training had been provided. The resident involved, R6, had diagnoses including nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcers, convulsions, tracheostomy/gastrostomy dependence, ventilator dependence, osteoarthritis, depression, and hypertension, and had an active order for mittens related to pulling at the trach. The agency RN stated familiarity with standard abuse policies from prior LTC experience, but the facility’s training documents did not show the nurse had been trained on the facility’s abuse policy or trained in accordance with it. The documents also did not show training on sensitivity to resident rights and resident needs, the prohibition against taking or distributing photographs or recordings of residents or their personal space, or how to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects residents and staff. No further evidence was provided that the nurse was educated and competent on the facility’s abuse policy. A second agency RN was later observed alone documenting in a resident’s MAR and also denied receiving any facility orientation or abuse training. That nurse stated uncertainty about what to do if abuse were observed and did not know who the facility’s abuse prevention coordinator was. The facility’s agency training documents again did not show training on the abuse policy, reporting procedures, or definitions of abuse, neglect, exploitation, and misappropriation of resident property. The administrator and DON acknowledged that agency staff should be familiar with the abuse prevention policy, but the facility did not have documentation showing the agency nurses had been trained before working in the facility. Record review also showed the facility did not complete the quarterly review process described in its abuse policy. The QAPI binder lacked documented quarterly review of accident reports, incident reports, and safety committee reports to assess for patterns or trends of suspicious bruising, unexplained accidents, or other unusual occurrences that may constitute abuse, neglect, or mistreatment. The administrator confirmed the review process was not being completed, and the regional operations leader and administrator acknowledged that the required tracking and review documentation was not available.
Failure to Train All Staff on QAPI Program
Penalty
Summary
The facility failed to conduct mandatory training for all staff on its Quality Assurance and Performance Improvement (QAPI) program, including the goals and elements of the program. Surveyor interviews found multiple staff members across departments who denied knowing what QAPI was and denied receiving any training on the facility’s QAPI program, including a CNA supervisor, housekeepers, LPNs, agency RN, activity aides, CNAs, an RN, a restorative CNA, the activity director, the infection preventionist, and the DON. One LPN stated knowledge of the term from prior work at another facility but said no training had been provided at this facility. The facility census document showed 170 residents resided in the facility. During interviews, staff repeatedly stated they did not know what QAPI meant or believed it was related to emergency preparedness materials at the nurse’s station. The activity director stated activity staff did not receive QAPI training, and the infection preventionist stated she only brought infection control surveillance and antibiotic stewardship data to monthly meetings and had never been formally trained on QAPI. The DON stated she had never completed all-staff QAPI training and was unsure whether it was a regulatory requirement. At 4:10 PM, the Administrator stated he was responsible for the overall implementation and monitoring of the QAPI program and acknowledged the facility did not have any in-service records for staff QAPI training. The facility’s QAPI policy, dated 1/2024, stated that all employees would participate in ongoing QAPI efforts and that facility-wide training would be conducted to inform everyone in the facility about the QAPI plan through all-staff meetings, department in-services, change-of-shift report time, dialogue, examples, and exercises. The policy also stated the governing body and administration would develop leadership and facility-wide training on QAPI and that the program would be communicated to consultants, contractors, residents, and families.
Medication Storage, Controlled Substance Documentation, and Enteral Feeding Order Communication Failures
Penalty
Summary
The deficiency involves multiple failures in medication storage, labeling, pharmacy services, and documentation, as well as failure to document and communicate a significant change in a resident’s enteral nutrition order. Surveyors observed numerous open insulin vials and pens on multiple medication carts without required open dates or beyond-use dates, including products for residents who had been discharged or were deceased. Several insulin vials and pens had stickers indicating “Do Not Use After” dates that had already passed, yet remained in the active medication drawers. An albuterol inhaler and several insulin products were found on the carts without pharmacy labels or resident names, and 24 loose pills were scattered in the top drawers of one cart. An expired stock bottle of Geri-Dryl liquid allergy relief was also stored with active medications. Staff interviewed on the units acknowledged that these medications were expired, lacked open dates, or were unlabeled and stated they should not be in use. Record review showed that some of the insulin products belonged to residents who had been discharged or had died weeks earlier, and those medications had not been removed from the active supply or returned to the pharmacy. Current physician orders for several residents confirmed ongoing insulin therapy, yet the corresponding insulin vials or pens on the carts were either expired or missing required dating. Pharmacy and facility policies required that multidose injectable vials be dated upon opening, that shortened expiration dates be applied and observed, that all medications be stored in containers with pharmacy labels, and that expired medications be removed from active stock and destroyed. The DON confirmed that insulin should be dated when opened, discarded after the appropriate time frame, and that medications without labels should not be used. Despite these policies, surveyors found expired, undated, unlabeled, and stock medications commingled with active medications on multiple carts. Additional deficiencies were identified in controlled substance documentation and handling. On several medication carts, controlled substance count sheets had multiple missing nurse initials for shift-to-shift counts on various dates. For several residents, the number of controlled medication doses documented as remaining on the monitoring/control records did not match the actual blister card counts, and nurses stated they had administered doses but had not yet signed them out. One resident’s oxycodone blister card had the original pharmacy label name blacked out and the resident’s name handwritten in marker, and the controlled medication was being documented on a handwritten sheet of copy paper instead of an individual controlled substance record. Facility and pharmacy policies required that each controlled dose be recorded at the time of administration on both the MAR and the controlled substance count sheet, that shift counts be completed and signed by oncoming and off-going nurses, and that controlled medications be dispensed with and tracked on individual controlled drug records. The DON stated it was not appropriate to document controlled counts on blank copy paper and that each controlled medication should have a proper count sheet. The deficiency also includes failure to ensure professional standards in documenting and communicating changes in a resident’s diet order. One resident with anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status was care planned as NPO and dependent on enteral feeding for all nutrition needs. The resident previously had an order for continuous tube feeding with 2 CalHN, with a substitution order for Jevity 1.5 if needed, but this feeding order was discontinued. At the time of review, the resident had no active G-tube feeding order, only water flush and medication orders. The dietitian reported that she last saw the resident while on G-tube feeding and hydration therapy and stated she was not notified that the feeding had been stopped. The DON stated that hospice orders should be clarified by the floor nurse, who should verify with the physician, notify the dietitian, and document the order in the record. The LPN who received the order to discontinue feeding stated he simply stopped the feeding, did not document the change in the resident’s record, did not write a progress note, and did not notify the physician or dietitian, despite job descriptions requiring nurses to document nursing care and pertinent data according to facility policies and procedures.
Insufficient RN Staffing on Respiratory Unit Leading to Widespread Late Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on the third-floor respiratory (ventilator) unit to meet resident needs, resulting in widespread late medication administration. The third floor housed 32 residents, all dependent on staff for all or some daily needs, including 16 residents on ventilators, 29 with tracheostomies, 22 with gastrostomy tubes, and 15 with wounds. Facility staffing records from 3/9/26–3/25/26 show that only two licensed nurses were scheduled per shift on this high-acuity respiratory unit, consistent with the facility assessment and staffing plan that identified two licensed nurses per unit and per shift. On the date reviewed, the schedule showed two RNs (one agency) assigned to the third floor, and the DON confirmed there had been a call-off and that one RN came in to cover until the agency nurse arrived. On the morning in question, one RN reported still having several residents left to receive their medications and stated that medications would be late, explaining that the volume of residents with gastrostomy tubes made medication administration time-consuming due to required checks and preparation. This RN stated that medications were late every day on that floor and that a third nurse was needed. A floor manager RN reported being asked to come in temporarily to help until the agency RN arrived and acknowledged that most residents’ medications, scheduled for 9:00 a.m. and due by 10:00 a.m., were not given by the due time; the floor manager passed medications for only two residents and then stayed to help the agency nurse. The agency RN stated that they had just arrived, were receiving report, had 19 residents assigned, and still had 17 residents needing their morning medications after the due time, confirming that these medications would be late. Medication Administration Audit reports for the third floor on the same date showed that 16 of 32 residents received medications late, affecting residents assigned to both RNs. Multiple residents with complex conditions, including respiratory failure, ventilator dependence, tracheostomies, gastrostomy tubes, epilepsy, diabetes, pressure ulcers, quadriplegia, hemiplegia, anoxic brain damage, COPD, and other serious diagnoses, had scheduled morning medications administered from 21 minutes to more than three hours past the scheduled times. The DON acknowledged that medications are expected to be given within one hour before or after the scheduled time, affirmed that administration more than one hour past the scheduled time is a timing medication error requiring physician notification, and nonetheless stated a belief that two nurses were sufficient for the unit. Additional staff who regularly worked on the respiratory unit, including an RN, an LPN, and the Infection Preventionist, reported that there were not enough nurses on the third floor, described the residents as very acute with extensive ventilator, trach, and tube-feeding needs, and stated that the workload made it difficult to do more than pass medications and impeded timely completion of other nursing tasks. These observations and records demonstrate that the facility did not ensure sufficient nursing staff with appropriate competencies to meet the assessed needs of all residents on the respiratory unit, contrary to its own staffing, medication administration, and resident rights policies.
Failure to Protect Resident Dignity During Catheter Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to provide care in a manner that promoted resident dignity by not covering urinary catheter drainage bags for three residents and by performing blood glucose monitoring and insulin administration in the dining room without privacy for two residents. During a lunch observation, an LPN checked blood glucose and administered insulin to one resident while the resident was seated at a table in the dining room with multiple other residents present, and checked another resident’s blood glucose at a dining room table with other residents nearby. The LPN did not ask either resident to go to their room or another private location, and later stated the care should be done in the patient’s room for confidentiality. The DON also stated blood glucose checks should be done in the privacy of the resident’s room and insulin should be administered in the resident’s room or in private. The report also documents that three residents with urinary catheters had drainage bags left uncovered and visible. One resident with paraplegia, protein calorie malnutrition, chronic respiratory failure with hypoxia, anoxic brain injury, neuromuscular dysfunction of the bladder, neurogenic bowel, tracheostomy status, dependence on a ventilator, and dysphasia was observed sleeping in bed with an uncovered urinary drainage bag containing approximately 300 mL of straw-colored urine visible from the hallway. Another resident with quadriplegia, neuromuscular dysfunction of the bladder, chronic pain, and type 2 diabetes mellitus had an uncovered urinary drainage bag hanging from the bed frame with approximately 375 mL of clear amber urine visible. A third resident with quadriplegia, urinary tract infection, urogenital implants, and neuromuscular dysfunction of the bladder had an uncovered urinary drainage bag hanging from the bed frame with approximately 450 mL of dark yellow urine visible. Two of the residents with uncovered drainage bags were cognitively intact and expressed concern about the lack of privacy. One resident stated a desire for a cover so people would not have to look at the bag, and another stated that he would not want to look at someone’s urine in a bag. Staff members confirmed that the bags should have privacy covers, and the DON stated that all residents’ urinary bags were expected to be placed into privacy bags for privacy and HIPAA reasons. The facility policy on Resident Rights states that the facility will provide an environment that maintains dignity and well-being and will provide a safe, clean, comfortable, and homelike environment.
PASRR screening not updated for new mental illness diagnoses
Penalty
Summary
The facility failed to submit a new PASRR Level I screening for two residents after new diagnoses of mental illness were identified, and failed to ensure that two other residents were screened for PASRR Level I as indicated by their prior Level I PASRR outcomes. This affected four residents reviewed for PASRR screening in a sample of 82 residents. For one resident, the admission record documented psychosis with an onset date of 04/16/2024, along with dementia and depression. The resident’s MDS showed a BIMS score of 06, indicating severe cognitive impairment. The record also included active orders for escitalopram for antidepressant use and haloperidol for psychosis. A prior PASRR Level I outcome from 10/02/2023 stated that no Level II was required and that no mental health diagnosis was known or suspected at that time. A psychiatry follow-up note from 04/16/2024 documented bizarre behavior, confusion, refusal of labs and care at times, poor hygiene, abnormal thought processes, poor insight and judgment, and an assessment of psychosis with continued psychiatric management. For another resident, the facility record showed diagnoses including schizoaffective disorder, unspecified psychosis due to a substance or known physiological condition, dementia, psychotic disturbance, mood disturbance, and anxiety. The resident’s PASRR Level I screening dated 09/03/2025 indicated referral for a Level II onsite. Two additional residents had records showing diagnoses such as psychotic disorders, schizophrenia, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition, and their PASRR Level I outcomes also indicated referral for Level II onsite. The Social Services Director stated he was responsible for PASRR Level I screening and that he submits screenings based on the end date of the PASRR, and he stated he was not taught to submit a new Level I screening when there is a new diagnosis of mental illness. He also stated he was not sure who follows up with Maximus to ensure residents receive Level II screening.
Crash Cart Daily Checks Not Completed
Penalty
Summary
The facility failed to ensure that emergency medical equipment stored for use in basic life support was checked daily. Surveyors observed the document titled Crash Cart Check for the 3rd floor and found multiple missing daily crash cart checks for numerous dates in the month reviewed. The facility census showed 35 residents residing on the third floor, and the missing checks applied to the crash cart designated for that floor. During interview, an RN stated that the emergency cart should be checked daily and explained that it should be checked every day to make sure the AED and other equipment are working and present. The DON stated that the facility has one crash cart per floor and that the night nurse is to check the crash carts every night. The facility policy titled Crash Cart and AED stated that crash carts are to be checked daily by the night nurse and department manager, with a checklist used to document that the cart is fully stocked and supplies are not expired, and that the AED is to be checked daily by maintenance.
Improper LAL Mattress Layering and Incorrect Weight Setting
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were not layered with multiple linen layers for four residents, and failed to ensure one resident’s LAL mattress was set at the correct weight setting. The report identifies residents R61, R87, R134, and R191 as being at risk for pressure ulcers, with all four observed on LAL or air loss mattresses with more linen layers than the facility’s stated expectation. The report also documents that R87’s mattress setting did not match the resident’s recorded weight. R134 had diagnoses including pressure ulcer of the right ankle, chronic kidney disease, diabetes mellitus, and dementia, and was unable to be interviewed due to altered mental status. Her Braden Scale score was 12, indicating high risk for pressure ulcers. Her care plan documented that she was on an air mattress with heel protectors, and wound documentation showed a chronic Stage 3 sacral pressure injury and a Stage 3 right lateral ankle pressure injury, both not healed. On observation, R134 was lying on her back on a LAL mattress with a top sheet, incontinence pad, and a quadruple-folded top sheet, creating six linen layers under her body. The wound care nurse stated that the recommended layering on a LAL mattress was one flat sheet and either one pad or one brief. R61 was observed in bed on an air loss mattress with a fitted sheet, bed pad, and incontinence brief. The resident was awake with some confusion and unable to answer questions, and the MDS indicated dependence or substantial/maximal assistance for all ADL needs. The resident had an active wound in the care plan, and the Braden Scale score of 12 indicated a problem with friction and shear. R191, who had dementia and other diagnoses including a prior right femur fracture and muscle weakness, had a BIMS score of 3 and required substantial/maximal assistance for most ADLs. R191 was observed sleeping on an air loss mattress with a fitted sheet, bed pad, and incontinence brief, and wound consultation documented an active wound with a recommendation for a pressure reducing mattress. R87 had morbid obesity, a Stage 3 pressure ulcer, osteomyelitis, and hypertension, and was cognitively intact per MDS. She was observed on a LAL mattress with a flat sheet, incontinent pad, and incontinent brief between her skin and the mattress. The mattress setting was on level 9, which staff described as about 375 lbs, while the resident’s recorded weight was 299.2 lbs. The wound care nurse stated the setting should match the resident’s weight and that the purpose of the setting was to prevent skin breakdown and pressure ulcers.
Respiratory equipment not contained, changed, or dated
Penalty
Summary
The facility failed to ensure respiratory equipment was contained, changed, and dated for residents receiving respiratory care. During observation, R68 had an oxygen sign posted at the door, was seated in the room without using the nasal cannula, and the nasal cannula was not labeled or contained. R68’s nebulizer mask was also not contained and was labeled with a date of 12/22/25. V16 stated she was not responsible for changing and labeling the nasal cannula and nebulizer mask. R68’s record showed diagnoses including pleural effusion and obstructive sleep apnea, with orders for weekly changes of nebulizer tubing and oxygen tubing/humidifier bottle. R8 was observed with a BiPAP mask lying on the bedside dresser and not contained. R8 stated the mask was not put in a bag and that nurses help with it. R8’s record documented diagnoses including COPD, acute and chronic respiratory failure with hypercapnia, and quadriplegia, and the care plan identified difficulty breathing related to COPD, OSA, dependence on oxygen, and chronic respiratory failure. R8 had a physician order for BiPAP at bedtime related to obstructive sleep apnea. R5 was observed in bed with an oxygen trach collar in use, while the humidifier and suction canister had dates of 2/19 and 2/25. When asked about the respiratory equipment, R5 indicated not being sure about when it was changed. R5’s record documented chronic respiratory failure, tracheostomy, dependence on respirator, obstructive sleep apnea, and morbid obesity, with orders to change aerosol tubing, nebulizer tubing, suction canister, and suction tubing on scheduled intervals. R184’s oxygen humidifier was observed in use, undated, and connected to the oxygen concentrator. R184 had dementia and dysphagia, was unable to be interviewed due to altered mental status, and had an order for 2 LPM oxygen with oxygen saturation checks every shift. V7 stated respiratory therapists handle all respiratory equipment, and V2 stated the Respiratory Department is responsible for managing and properly dating the equipment.
Controlled Substance Documentation and Count Sheet Errors
Penalty
Summary
The facility failed to follow its controlled substance documentation policy for multiple residents by not properly documenting medication administration on the controlled substance record and shift-to-shift count sheets. During review of the 2nd floor medication cart side 1, the controlled substances check form had multiple missing nurse initials for several shift counts across multiple dates. When the narcotic count was reviewed, R175’s Pregabalin 75 mg showed a mismatch between the medication monitoring/control record and the blister package, and the LPN stated the dose had not yet been signed out. The same issue was identified for R167’s Clonazepam 1 mg, where the record showed one more tablet remaining than the blister package, and the LPN stated the morning dose had been given but not signed out yet. On the 4th floor medication cart side 1, R100’s controlled medications also showed discrepancies between the medication monitoring/control record and the blister packages. R100 had Lacosamide 200 mg and Clobazam 10 mg, and the counts on the record did not match the tablets remaining in the packages. The controlled substances check form for that cart also had multiple missing nurse initials for shift-to-shift counts on several dates. When questioned, the LPN stated the medications had not been signed out yet and said the count sheet was completed at the end of the shift with the nurses. For R188, the medication blister card for Oxycodone HCl 5 mg had an altered pharmacy label with the resident’s name covered by black marker and handwritten on the card. There was no pharmacy medication monitoring/control record sheet for the medication, and the controlled medication was being documented on a handwritten sheet of copy paper. The RN stated it should have been on a control form and that it should have been changed. The DON stated that controlled medications should be signed out on the controlled record sheet, that the incoming and outgoing nurses are responsible for the shift count sheet, and that blank paper is not acceptable for controlled medication counts.
Late Administration of Scheduled Medications
Penalty
Summary
The facility failed to ensure that five residents remained free from significant medication errors when multiple scheduled medications were administered late on the third floor. On 3/24/26, the RN assigned to the unit stated that medications were going to be given late because there were too many residents to pass medications on time, including residents with gastrostomy tubes who required additional time for placement checks, residual checks, crushing, and flushing. The RN also stated that a third nurse was needed for the floor, and the floor manager and agency RN acknowledged that many residents’ morning medications were already past the scheduled time. Record review showed that R1’s 9:00 a.m. medications were given late, including Levetiracetam at 11:03 a.m., Losartan Potassium at 10:59 a.m., and Carvedilol at 11:12 a.m. R11’s Keppra was given at 1:21 p.m. instead of 9:00 a.m. R12’s Valproic Acid was given at 12:36 p.m. instead of 9:00 a.m. R39’s Metoprolol Tartrate and Keppra were both given at 10:41 a.m. instead of 8:00 a.m. and 9:00 a.m., respectively. R172’s Metoprolol Succinate ER and Amiodarone were both given at 12:28 p.m. and 12:29 p.m. instead of 9:00 a.m. The residents involved had diagnoses including epilepsy, seizures, hypertension, atrial fibrillation, respiratory failure, gastrostomy, tracheostomy, COPD, quadriplegia, and end stage renal disease. The DON stated that medications are due one hour before or one hour after the scheduled time, that medications given more than one hour past the scheduled time are technically timing medication errors, and that physician notification is expected. The facility policy required medications to be administered at the proper time and, if given at a different time, the reason should be documented and the physician notified in a timely manner.
Medication carts contained expired, unlabeled, and improperly stored medications
Penalty
Summary
The facility failed to follow its medication storage and labeling policies by leaving expired insulin, unlabeled insulin, an unlabeled inhaler, expired stock medication, and loose pills in medication carts on the 2nd and 4th floors. During observation of the 2nd floor medication cart, multiple insulin vials and pens were found in the top right drawer with no open date or expiration date, including medications for residents who had been discharged or had died, and an albuterol inhaler was present without a pharmacy label or resident name. Twenty-four loose pills were also scattered in the cart drawers. Staff acknowledged that the pills should be discarded, that insulin should be dated when opened, and that medications without labels should not be used. Record review showed that several of the insulin products found in the carts belonged to residents who were no longer in the facility, including residents who had been discharged or deceased, yet the medications remained in the active medication carts and had not been returned to the pharmacy. The report also identified expired insulin for multiple current residents, including vials and pens with open dates or handwritten expiration dates that had passed. On the 4th floor, additional insulin vials and pens were found without open dates, without pharmacy labels, or with dates showing they were expired. One Lantus vial had the resident’s name handwritten on it, but no pharmacy label and no open or expiration date. The 4th floor medication cart also contained an altered controlled medication blister card for oxycodone, with the pharmacy label name covered by black marker and the resident’s name handwritten on the card. There was no pharmacy medication monitoring/control record sheet for the medication, and it was being documented on a handwritten sheet of copy paper. Staff stated that it should have been on a control form. The DON stated that insulin should be dated when opened, expired insulin should be discarded, medications without labels should not be used, loose pills in carts are not acceptable, and expired stock medication should be discarded, but these conditions were still observed in the carts during the survey.
Failure to Follow POLST Regarding Artificial Nutrition and Hydration
Penalty
Summary
The facility failed to follow a resident’s advance directive, specifically the Illinois POLST form, regarding the provision of artificial nutrition and hydration. The resident, who had anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, a stage 4 sacral pressure ulcer, tracheostomy and gastrostomy status, and a history of sudden cardiac arrest, was cognitively severely impaired and dependent on staff for all ADLs. The POLST form directed that artificial nutrition and hydration be provided by any means, including new or existing surgically placed tubes. The resident’s care plan documented NPO status with enteral feeding for all nutrition needs, with interventions to adjust tube feeding as needed and monitor tolerance, weight, labs, skin, and hydration. However, record review showed that the resident had no active G-tube feeding orders, only water flushes and medications, and that a prior continuous tube feeding order had been discontinued on a specified date. During observations on two separate days, the resident was seen in bed, unresponsive to questions, with a G-tube plunger at the bedside but no feeding pump or feeding infusing. When questioned, an RN stated she was unsure of the feeding orders and later reported that hospice had discontinued the feeding. The resident’s family member/POA reported being told by hospice that feeding could not be restarted because the resident was at end of life and, lacking clinical experience, accepted this explanation, although she stated she wanted the resident to continue receiving feeding. The DON stated she was unaware that the feeding had been discontinued and affirmed that the facility should follow the POLST. The physician acknowledged knowing that hospice had stopped the feeding due to aspiration risk and that the resident’s wife was said to be okay with it, and further stated that if G-tube feeding is discontinued, the POLST should be readdressed and a new one obtained. The facility’s advance directive/DNR policy states that residents have the right to determine in advance what life-sustaining treatment will be provided, including artificial hydration and nutrition, and that such directions enable staff to know how to treat residents in advance of an emergency.
Call Light Not Within Reach or Usable for Resident With Quadriplegia
Penalty
Summary
The facility failed to ensure that resident R183’s call light was readily accessible and within reach, and failed to ensure the resident could effectively use the call system. R183 was admitted on 3/19/26 with diagnoses including quadriplegia, chronic pain, muscle spasm, neuromuscular dysfunction of the bladder, and Type 2 diabetes mellitus. The resident’s BIMS on 3/25/26 was 14, indicating cognitive intactness. The care plan documented that R183 required a blow call light due to quadriplegia and that the call light should be within reach, properly placed, and functioning during rounds and care. On 3/23/26, R183 was observed lying in bed with a pressure-sensitive call light positioned at the upper right corner of the bed and out of immediate reach. R183 stated the light could not be reached and that staff expected the resident to use a chin to press it, but the resident said this was not possible and that the resident had been yelling for staff when help was needed. The resident’s family member stated staff had been told on 3/20/26 that the resident could not use the pressure-sensitive light and that staff said they would get a blow-into call light. An LPN later stated maintenance was getting the resident the call light that could be blown into, and the DON stated the resident should have a call light the resident had the ability to use.
Resident Identifying Information Posted in View of Others
Penalty
Summary
The facility failed to protect resident information when a birthday sign was posted by a resident’s door that displayed the resident’s full name and date of birth. During observation on 03/23/2026, the sign was seen in full view, and an LPN, an RN, and Central Supply staff all stated that it was a HIPAA violation because anyone could see the resident’s personal information. The resident involved, R21, had diagnoses including psychosis, dementia, and depression, and the most recent MDS documented a BIMS score of 06, indicating severely impaired mental status. During interviews, the Activity Director stated that the Activities Department posted birthday flyers by residents’ doors at the end of each month and that the flyers included the resident’s full name and full date of birth. She stated she had been doing this since November or December 2025 and did not know the policy, though she later acknowledged it was a HIPAA violation. The Social Services Director and the DON also stated that a resident’s full name and date of birth should not be in full view of other residents and visitors, and both identified the practice as a HIPAA violation.
MDS Not Coded Accurately for Mitt Restraints
Penalty
Summary
The facility failed to code MDS assessments accurately for one resident. The resident’s face sheet documented multiple diagnoses, including nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcers, convulsions, tracheostomy/gastrostomy dependence, ventilator dependence, osteoarthritis, depression, and hypertension. The physician orders included mitts to both hands related to pulling at the trach, and the MAR documented that mitt restraints were removed every shift. However, the 2/13/2026 MDS did not identify any restraint use and coded limb and other restraints as not used during the lookback period, despite the resident being rarely/never understood and having short- and long-term memory problems. On 3/24/2026, the MDS nurse confirmed the resident used mitt restraints and agreed the MDS was miscoded. The nurse reviewed the physician orders and MAR and stated the mitt restraints should have been coded. The nurse also stated that accurate MDS coding is important because it helps guide the resident’s plan of care. Review of the care plan showed no plan was developed to address the resident’s restraint use. The RAI guidance in the record stated that hand mitts/mittens are included as limb restraints when they meet the definition of a physical restraint and must be identified when used during the lookback period.
Failure to Update PASRR Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not coordinated for one resident. The resident had diagnoses including schizoaffective disorder, anxiety disorder, dementia with behavioral disturbance, and bipolar disorder, and the comprehensive assessment documented moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. The resident was admitted to the facility and had physician orders for risperidone 0.5 mg daily for psychotic behavior and risperidone 3 mg at bedtime for psychotic behavior. The only PASRR-related document in the record was a nursing facility placement screening dated 02/18/2014 noting bipolar disorder, and the report states the resident had not received the updated Level I PASRR screening while in the nursing facility. The facility also did not provide a PASRR policy when requested.
Failure to care plan mitt restraint use
Penalty
Summary
The facility failed to revise one resident’s care plan after mitt restraints were initiated. The resident had multiple diagnoses including nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcers, convulsions, tracheostomy/gastrostomy dependence, ventilator dependence, osteoarthritis, depression, and hypertension. The physician orders included mitt restraints to both hands related to pulling at the trach, with instructions to remove the mitts and monitor the hands for skin issues. The resident’s MDS documented that the resident was rarely or never understood and had short- and long-term memory problems. On observation, the resident was seen lying in bed with bilateral mitt restraints on the hands, and a CNA confirmed the restraints were in place but was unsure why they were being used. An agency RN also confirmed the mitt restraints were applied and stated it was her first time in the facility and first time assigned to the resident. On a later observation, the resident was seen without mitt restraints while family members were at the bedside. The family members stated they had not been informed before the restraints were started and said they had repeatedly complained that the resident was not receiving proper treatment and that staff did not know how to care for the resident. Record review and staff interviews confirmed the restraint use was not care planned. An RN stated the restraint process should be described in the resident’s care plan and reviewed the chart, confirming the restraints were not care planned. The MDS nurse reviewed the resident’s MDS, physician orders, and MAR and confirmed the mitt restraints were used but not coded on the MDS, and that the MDS was miscoded. The MDS nurse also confirmed no care plan had been developed to address the restraint use, despite the requirement that restraint use be included in the plan of care.
Failure to Implement Fall-Prevention Care Plan Intervention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident assessed as high risk for falls. The resident is an adult male with medical diagnoses including acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, and a BIMS score of 10/15. A fall assessment dated 5-17-2025 scored the resident at 15, indicating high fall risk. The resident’s care plan dated 7-3-2025 included an intervention to keep the bed in the lowest position. However, nursing notes dated 12-25-2025 documented that the resident’s bed was left in an elevated position, and the nurse observed the resident lying on his left side, after which he was sent emergently to a local hospital for evaluation. During interviews, the DON stated that on 12-25-2025 at 5:50 AM, the resident was observed on the floor after the bed had been left in a high position, and that the care plan required the bed to be in a low position due to the resident’s high fall risk. The DON reported not knowing who left the bed in the high position and stated an expectation that nursing staff implement care plan interventions. The Restorative Nurse confirmed that staff are responsible for implementing care plan interventions and did not know why the bed was left high. The Administrator also stated an expectation that nursing staff follow and implement the care plan to ensure the resident’s safety. The facility’s Comprehensive Care Plan policy dated 3-2025 states that the comprehensive care plan should drive the care and services provided for the resident.
Failure to Ensure Effective Nurse-to-Nurse Handoff Communication During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective nurse-to-nurse communication and documentation during resident transfers to an acute care hospital, contrary to professional nursing standards and facility policy. For one resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest, the record for a transfer for a GI bleed showed no documentation of a report being called to the hospital. The Hospital Transfer Form completed by the DON left blank the section for documenting to whom report was called, and the DON stated she did not call the hospital but only helped fill out forms. When requested, the facility could not provide any documentation or other evidence that a nurse-to-nurse report or verbal handoff occurred for that transfer. For the same resident’s later transfer for tachycardia and seizure-like activity, the RN who initiated the transfer stated she believed she had called report to the receiving hospital but could not recall to whom she gave report, and there was no documentation in the medical record of a nurse-to-nurse report or verbal handoff. The RN documented notifying the family and giving information to paramedics, including face sheets and physician orders, but did not document communication with the hospital. The resident had a hospice consent signed several days prior to this transfer, but the SBAR form completed by the RN did not indicate that the resident was on hospice and did not document any communication to the hospital. The facility was unable to provide evidence that a verbal handoff or nurse-to-nurse report was completed at the time of this transfer. A second resident with end stage renal disease, dialysis dependence, acute pulmonary edema, heart failure, hypoxemia, anemia in chronic kidney disease, type 2 diabetes, and peripheral vascular disease was transferred to the hospital on two occasions without documented nurse-to-nurse communication. For one transfer, the hospital transfer sheet completed by an RN did not document who received report at the hospital, and there were no nurse progress notes or other nursing documentation regarding handoff or hospital transfer. For a later transfer, initiated when the resident called 911 stating he did not feel well, the LPN documented that the resident was escorted to the emergency room and that a message was left for the next of kin, but the hospital transfer sheet did not document to whom report was called. The LPN stated she typically did not call the hospital when the resident self-initiated 911 calls, relied on paramedics and the hospital’s prior familiarity with the resident, and did not send physician orders in those situations. The DON described an expectation that nurses obtain physician orders, complete transfer and SBAR forms, notify family, call and give report to the hospital nurse, send a face sheet and physician orders, and document these actions in progress notes, which was not demonstrated in these cases.
Failure to Complete Fall Documentation and Post-Fall Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy for two high fall-risk residents by not completing required fall risk evaluations and post-fall assessments, and by failing to document at least one fall event. One resident, a male with acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, had multiple fall risk assessments with scores greater than 10, indicating high risk for falls. His fall risk scores included 15, 13, 25, 25, and 23 on various dates. A progress note documented that he rolled out of bed and was sent to a local hospital for evaluation, but there were no fall or pain assessments completed after this fall, despite the facility policy requiring a fall risk evaluation after each fall. The second resident, a male with hemiplegia, hemiparesis, diabetes, vascular dementia with anxiety, and tracheostomy, also had multiple fall risk assessments with scores greater than 10, indicating high risk for falls, including scores of 14, 22, 24, and 22. A progress note documented that he was found sitting on his buttocks on a floor mat next to the bed and was sent to a local hospital for evaluation. The DON stated there was no completed fall report for this fall and no documented post-fall assessments for falls on two separate dates. The restorative nurse confirmed that the nurse documented the resident on the floor but did not complete a fall report, risk management, or fall assessment. The Administrator and DON both stated their expectation that staff complete risk management, fall assessments, and required documentation after every fall, consistent with the facility’s Fall Prevention and Management policy, which requires a fall risk evaluation on admission, readmission, quarterly, and after each fall, and completion of a fall incident report in the risk management portal.
Failure to Integrate and Communicate Hospice Status in Resident Care and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and integrate hospice services into a resident’s plan of care after hospice enrollment. A male resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest had a hospice consent signed on 12/27/25 initiating hospice services. Despite this, review of the resident’s most current physician order sheet (POS) showed no physician orders for hospice, and the resident’s face sheet contained no indication of hospice status. The facility was unable to provide documentation demonstrating that hospice enrollment was incorporated into the resident’s active orders or clearly communicated to nursing staff responsible for the resident’s care. On 01/02/26, the resident experienced a change in condition characterized by a heart rate between 130–150 and seizure-like movements or activity. The RN on duty, working through an agency, notified the manager on duty, contacted the MD, obtained a telehealth consultation, and received an order to send the resident out via 911. The resident was transported to the hospital by EMTs. The RN documented that three copies of the face sheet and the physician orders were printed and given to the paramedics. The RN later stated she did not know the resident was on hospice at the time of transfer and indicated that hospice status would have been important to communicate to the hospital. Review of the SNF to Hospital Transfer Form for the 01/02/26 transfer showed that report was called in to the ER, but there was no indication on the form that the resident was on hospice. The DON stated that if a resident is on hospice, this should be reflected in the POS and on the face sheet, and that once hospice consent is signed, social services should enter the hospice order into the POS and usually inform the nurse on the unit. The facility’s hospice policy requires a documented communication process between the facility and hospice provider and specifies that the facility must immediately notify hospice of a need to transfer the resident. CMS regulations cited in the report require the facility to coordinate hospice services with the hospice provider and ensure hospice care is integrated into the resident’s plan of care, which did not occur in this case.
Failure to Honor 24-Hour Visitation Rights and Improper Enforcement of Visiting Hours
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to receive visitors of their choosing at the time of their choosing, as required by resident rights regulations and the facility’s own visitation policy. The facility maintained and enforced fixed visiting hours, generally from either 8 a.m. or 10 a.m. until 8 p.m., and staff reported that visitors were expected to leave after 8 p.m. Staff, including CNAs and LPNs, consistently described visiting hours ending at 8 p.m., and one LPN stated that no one was allowed after 8 p.m. except for hospice or critically ill patients. The DON stated that, for the sake of residents and to have some normalcy, the facility had visiting hours and that overnight stays required approval from the administrator or DON, usually for hospice, new admissions, or family comfort. Two residents who were nonverbal and fully dependent on staff for care were directly affected by this practice. One resident, an older adult admitted in March 2025 with anoxic brain damage, acute and chronic respiratory failure, severe protein-calorie malnutrition, a stage 4 sacral pressure ulcer, tracheostomy status, anemia, and gastrostomy status, was unable to self-advocate. The resident’s family member reported typically visiting around 5:45–6 p.m. and stated that on one evening staff told her at 8 p.m. that visiting hours were over and it was time for her to leave. She reported refusing to leave until the resident’s tube feeding was turned back on, and stated that being asked to leave at 8 p.m. was consistent with how visiting hours had “always been.” Another resident, an older adult admitted in November 2025 with anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, was also nonverbal and fully dependent on staff. This resident’s family member reported that at 8 p.m. “on the dot” staff came and told her she had to leave because visiting hours were over, even though she was waiting for staff to come and clean the resident. She identified the LPN who told her to leave as the nurse working that evening. The family member also stated that the roommate’s wife had no objection to her presence and had even shared her phone number. No documentation was found to show that the visitation limits imposed on these residents’ visitors were based on individualized clinical need, resident preference, safety concerns, or the rights of others. The facility’s written visitation guidelines, last reviewed in September 2025, stated that residents have the right to receive visitors 24 hours a day and that open visitation is permitted at all times, with only “quiet hours” between 8 p.m. and 8 a.m., and that any restrictions must be reasonable, temporary, least restrictive, explained, and documented.
Failure to Provide Ordered Enteral Nutrition and Accurately Document Tube Feeding Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to maintain adequate nutrition independently received enteral nutrition as ordered and that accurate records of daily enteral intake were maintained. Three nonverbal, fully dependent residents with gastrostomy tubes and significant medical conditions, including anoxic brain damage, respiratory failure, severe protein-calorie malnutrition, tracheostomy status, and pressure ulcers, were affected. For one resident, the spouse reported that the feeding tube pump was off when she arrived around 6:00 PM, despite orders for continuous tube feeding from 2:00 PM to 11:00 AM. Nursing documentation and an incident narrative confirmed that the feeding tube had been turned off for several hours, resulting in missed scheduled tube feeding, and that the issue was brought to staff attention by the spouse. The telehealth physician note further documented that the spouse was upset that feeds were not running between 2:00 PM and 6:00 PM and that feeds were only started once the notification was made. The same resident’s family member reported that this problem had occurred multiple times over a period of weeks, including around Thanksgiving and Christmas, stating that the resident had not been fed for 6 to 8 hours on separate occasions. The family member also reported another recent visit when the pump was beeping and displayed “INACTIVE,” and the nurse present, identified as agency staff, could not explain why the feeding was not running. A CNA stated that when he goes in to provide care, the feeding is often paused and the nurse is notified to turn it back on. At the time of surveyor observation, the resident’s feeding pump was running at the ordered rate of 50 mL/hr with a labeled start time of 6:00 AM, but the amount of formula remaining in the container and the total volume displayed on the pump did not match what should have infused based on the documented start time and rate. For the second resident, who was also nonverbal and fully dependent with diagnoses including respiratory failure, hemiplegia, severe protein-calorie malnutrition, anoxic brain damage, tracheostomy status, and gastrostomy status, the physician’s order specified Jevity 1.5 at 80 mL/hr continuous for 20 hours, on at 2:00 PM and off at 10:00 AM or until 1600 mL was infused, with water flushes every 6 hours. During surveyor observation, the feeding pump was running at 80 mL/hr, but the feeding container lacked a start time label, and approximately 900 mL remained in a 1000 mL container when, based on the ordered rate and start time, only about 100 mL should have remained. The total fed volume on the pump (209 mL) also did not correspond to the actual volume in the container, and the absence of a start time made it unclear when the feeding had been started or whether it had been running continuously as ordered. For the third resident, who was nonverbal, fully dependent, and had diagnoses including anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, the physician’s order specified Vital 1.5 at 70 mL/hr continuous for 21 hours, on at 2:00 PM and off at 11:00 AM, with a total daily volume of 1470 mL and water flushes every 6 hours. Surveyors observed the feeding pump running at 70 mL/hr with a labeled start time of 3:00 AM, and approximately 600 mL remaining in a 900 mL container. Based on the ordered rate and the labeled start time, the container should have contained about 480 mL, but the observed volume did not match this calculation. The total fed volume displayed on the pump was 2836 mL, which exceeded the ordered daily volume of 1470 mL and did not correspond to the labeled start time. The DON acknowledged that staff may not have reset the pump when hanging a new bottle and confirmed that nurses should reset the machine at that time. Across all three residents, review of the medical records showed no documentation of when tube feedings were interrupted, stopped, or restarted, and there was no accurate record of the total daily volume of tube feeding delivered. The DON stated that there was no flow sheet to track bottle changes and that documentation was limited to the MAR, which for one resident showed tube feedings as administered but without times for when feedings were started or total volume received. The facility’s own tube feeding guideline required that the pump be cleared at the end of each shift and that tube feeding delivered be documented, but the observed discrepancies between ordered rates, labeled start times, pump volumes, and actual formula remaining, along with missing documentation of interruptions and total intake, demonstrate that these procedures were not followed for the residents reviewed.
Failure to Monitor and Respond to Critical Potassium Levels
Penalty
Summary
A resident with multiple complex medical diagnoses, including chronic obstructive pulmonary disease, hypertension, heart disease, and aortic aneurysms, was admitted to the facility and was being treated for hypokalemia (low potassium). The resident's potassium levels were monitored through laboratory testing, which revealed several critically low values. Orders were given for potassium supplementation, but there was inconsistent documentation regarding the administration of these supplements and a lack of timely repeat laboratory monitoring to assess the effectiveness of the interventions. Despite ongoing potassium supplementation, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice. Subsequently, a laboratory result indicated a critically high potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The nurse who reviewed this result documented that the lab was relayed to the nurse practitioner via phone and that they were awaiting a response. However, there was no further documentation of any actions taken, no confirmation that the provider was made aware of the critical value, and no evidence of nursing assessment or clinical intervention. The nurse did not initiate emergent medical care or escalate the situation as required by facility policy, and the critical lab result was cleared in the electronic medical record, preventing further follow-up by subsequent staff. Interviews with facility staff revealed that the nurse failed to follow established protocols for reporting and acting upon critical laboratory values, including contacting the provider, medical director, or telehealth services when a response was not received. The facility's policy required that critical lab results be communicated to a licensed practitioner within one hour and that escalation procedures be followed if the provider could not be reached. The lack of timely intervention and failure to act upon the critically abnormal potassium level resulted in the resident not receiving necessary medical intervention. Four days after the critical lab result, the resident was found unresponsive and subsequently expired in the facility.
Removal Plan
- The DON checked and verified all residents with time sensitive critical medication, recognizing therapeutic laboratory level, conducting routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- All Nurses staff were provided with education by the DON/Designee. The training included ensuring time sensitive critical medication have therapeutic laboratory level, have routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- The Medical Director, Administrator and DON reviewed the facility's policies which include Policy of Critical Lab Result Reporting, Critical Medications Requiring Laboratory Monitoring.
- New hires will be in-serviced by the DON, ADON or Designee. All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. The staff members will also be provided with the same educational materials.
- The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. The Administrator/DON will send the same training materials to the staffing agency. Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first.
- The DON/ADON/designee will conduct audits to identify any potential concerns related to this plan of removal.
- The DON/ADON/Designee will also conduct staff (nurses and agency) interview, with at least five employees, to gauge knowledge retention and determine if additional training is required.
- During the weekends, the assigned Nursing Supervisor/Designee will conduct the audit, ensuring time sensitive critical medication, recognizing therapeutic laboratory level, conduct routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the clinical leadership which includes the DON, ADON, MDS, IP, Restorative, and the Administrator/Designee.
- Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, DON and Designee will monitor completion of this plan of removal.
Failure to Communicate Critical Lab Result Leads to Resident Death
Penalty
Summary
A facility failed to ensure that laboratory results, specifically a critical potassium level, were communicated to the ordering provider in accordance with its policy and procedures. One resident, an elderly female with multiple cardiac and vascular comorbidities, had a laboratory result indicating a critically elevated potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The result was reviewed by an LPN, who documented that the lab was relayed to the nurse practitioner via phone and that a response was awaited. However, there was no further documentation of actions taken, confirmation that the provider was made aware, or evidence of nursing assessment or clinical intervention in response to the critical value. Interviews with facility staff revealed that the LPN may have attempted to notify the provider by text or voicemail but did not receive a response and subsequently cleared the lab notification in the electronic medical record. This action prevented other staff from seeing the critical result. The LPN did not escalate the issue to the medical director or telehealth, as required by facility policy, nor did she initiate emergent care or further monitoring. Other nurses and leadership confirmed that the expectation was for critical labs to be communicated immediately and for escalation if the provider could not be reached, especially for life-threatening values such as a potassium of 8.4 mEq/L. The resident was found unresponsive in the facility four days after the critical lab result was obtained and subsequently expired. The death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required that critical lab results be communicated to a licensed practitioner within one hour, with repeated attempts and escalation to the medical director if necessary. The failure to follow these procedures resulted in the deficiency and was cited as Immediate Jeopardy.
Removal Plan
- DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call; in-services are ongoing. V4 termed.
- DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation; in-service is ongoing.
- DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order.
- The Medical Director was made aware and in agreement with the abatement and an in-service was conducted with her Nurse practitioner regarding critical labs.
Failure to Monitor and Respond to Potassium Supplementation
Penalty
Summary
A resident with multiple significant medical diagnoses, including chronic obstructive pulmonary disease, hypertension, and heart disease, was admitted to the facility and treated for hypokalemia (low potassium). The resident initially had a potassium level of 3.0 mEq/L, which was flagged as abnormal, and was prescribed a one-time dose of potassium. However, there was no documentation that this dose was administered, nor was there any evidence of follow-up laboratory orders or monitoring after this intervention. Subsequent labs showed a critically low potassium level of 2.0 mEq/L, prompting a new order for potassium supplementation over three days and a repeat basic metabolic panel (BMP) the following morning. Despite these interventions, there was a lack of consistent documentation and follow-up regarding the administration of potassium and the monitoring of potassium levels. The resident continued to receive potassium supplementation, with orders entered incorrectly, resulting in the resident receiving potassium for a longer duration than intended. The medication administration record showed that the resident received 34 doses of potassium over an extended period, rather than the intended three days. During this time, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels, nor was there ongoing assessment for the continued need for potassium supplementation. Repeat potassium levels were not obtained until 13 days after the initial critical low value, at which point the resident was found to have a critically high potassium level of 8.4 mEq/L. Upon discovery of the critically elevated potassium level, there was no documentation of nursing assessment, clinical intervention, or initiation of emergent medical care. The nurse who reviewed the lab result documented relaying the information to the nurse practitioner but did not document any further actions or confirmation that the provider was made aware of the critical value. The resident was found unresponsive in the facility four days after the critically high potassium result was obtained, and the death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required ongoing laboratory monitoring and prompt reporting of critical values for medications like potassium, but these procedures were not followed in this case.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to follow standard infection prevention and control protocols during the provision of morning care for two residents. The CNA was observed assisting one resident with a bed bath, using gloved hands to wash the resident and then using the same soiled gloves to handle the resident's personal items, such as a phone, and to touch various surfaces in the room, including pillows that had been on the floor and the door knobs. The CNA also used the same soiled gloves to pick up clean linen from the hallway linen cart and to handle clean clothing and apply lotion to the resident, without performing any hand hygiene or changing gloves throughout the entire care episode. The CNA continued to use the same soiled gloves to handle soiled linens, which were placed on the bare floor, and to interact with the roommate's belongings and bed linens. At no point during the observed care did the CNA remove the soiled gloves or perform hand hygiene, despite moving between different residents' belongings and clean and soiled items. The CNA acknowledged after the observation that gloves should have been changed and hand hygiene performed, and that soiled linens should have been contained in plastic bags rather than placed on the floor. Interviews with the Infection Control Nurse and the Director of Nursing confirmed that facility policy requires staff to perform hand hygiene before and after resident contact, change gloves between tasks, and avoid touching clean linen carts or moving between residents with soiled gloves. The facility's infection control policies, reviewed and current, specify these requirements for all staff to prevent the spread of infection. The observed failure to adhere to these protocols affected the two residents involved and had the potential to impact all residents on the floor.
Failure to Follow Discharge and AMA Policies for Resident Leaving Facility
Penalty
Summary
The facility failed to follow its discharge and Against Medical Advice (AMA) policies when discharging a resident who left the facility without proper documentation or preparation. The resident, who had multiple medical diagnoses including epilepsy, dysphagia, anxiety disorder, and depression, was cognitively intact but required staff supervision or assistance for all activities of daily living. Despite the resident expressing a desire to leave and being denied a community pass due to not following curfew rules, the facility did not ensure that the discharge process was properly documented or that the resident was adequately prepared for a safe transition. There was no evidence that the resident or their responsible party was educated on the risks of leaving AMA, nor was there documentation that the attending physician was notified and given the opportunity to educate the resident as required by policy. The facility was unable to provide a signed AMA form or documentation that the form was presented and refused, as outlined in their procedures. Additionally, the resident left without his medications or personal belongings, which were instead packed and sent to storage. Attempts to contact the resident after discharge were unsuccessful, and the facility did not know the resident's current location or condition. Interviews with staff confirmed that the required steps for AMA discharge, including documentation of education, physician notification, and proper completion of forms, were not followed. The lack of adherence to policy resulted in the resident being discharged to an unknown location without assurance of safety or continuity of care.
Failure to assess and communicate resident respiratory decline
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident with COPD, hypertensive heart disease with heart failure, and peripheral vascular disease. The resident’s care plan directed staff to observe for changes in breathing pattern and monitor vital signs and lung sounds, and the physician orders included oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation between 90% and 96%, with oxygen saturation checks every shift. The resident’s record showed oxygen saturation readings ranging from 95% to 98% before the change in condition. During the change in condition, a nurse observed the resident breathing heavily and found the oxygen saturation at 81% after the nasal cannula had been off; the cannula was then applied and the oxygen saturation increased to 91%. The resident was sent out by 911, but the documentation did not include the resident’s oxygen flow rate, respirations, blood pressure, pulse, temperature, or lung sounds being reported to the doctor. The nurse later stated she did not know how long the cannula had been off, did not know the ordered oxygen flow rate, and could not recall whether vital signs were obtained before transfer. The nurse also stated she reacted by calling 911 and did not recall where the vital signs were documented. Surveyor review found no SBAR form for the resident’s change in condition, and the progress note for the event did not include vital signs other than oxygen saturation. The DON stated staff should complete an assessment and notify the doctor, including a head-to-toe assessment and vital signs, and confirmed no SBAR was seen. The Medical Director stated staff would be expected to obtain oxygen saturation, heart rate, blood pressure, and other assessments such as alertness, diaphoresis, accessory muscle use, and lung sounds for respiratory distress. The resident was later reported to have been intubated in the ambulance, admitted to the ICU with shortness of breath and hypotension, and then expired.
Broken Shower Chair and Unsecured Shower Room Door
Penalty
Summary
The facility failed to follow its policy procedures for maintaining equipment, failed to ensure staff reported and documented maintenance issues with broken equipment, and failed to ensure broken equipment was not in use. A shower chair on the 4th floor was reportedly cracked before a resident used it, but staff did not remove it from service or notify maintenance. The resident later lost balance while attempting to transfer to the shower chair and fell to the floor. The resident also reported feeling violated when another resident entered the community bathroom while she was showering, stating she had told the other resident not to enter and that this had happened more than once. Surveyor observation and interviews also found the 4th floor North tub/shower room door did not latch, and the metal strike plate was dangling from the door. A CNA stated the shower room used to have a lock but it had been removed, and privacy was maintained only by closing the curtain and redirecting anyone who knocked. The Maintenance Director stated the normal process was for staff to submit a work order for repair or removal of broken equipment, but he said maintenance did not know the shower chair was cracked until it broke and that the issue was a failure in communication. He also stated the facility did not have a policy for maintaining equipment, and documentation of door inspections was not provided.
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Illustrative
What surveyors actually found near you
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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 Elmwood Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl Of Montclare, The | 1 mi | ★★★★★ | 14 | 0 |
| Berkeley Nursing & Rehab Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Gottlieb Memorial Hospital | 1.9 mi | ★★★★★ | 2 | 0 |
| Oak Park Oasis | 2.5 mi | ★★★★★ | 3 | 0 |
| Central Nursing Home | 2.8 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.