Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bria Of Woodriver during CMS and state inspections, most recent first.
Failure to implement effective fall interventions for a confused, severely cognitively impaired resident with high fall risk, impaired gait and mobility, and prior falls. The resident had four falls, including one that caused a forehead laceration and hospital transfer and another that resulted in a head injury while on anticoagulants. Staff reported only limited initial interventions, and one fall report did not identify any intervention in place.
The facility failed to consistently implement and update fall-prevention interventions for three high-risk residents with cognitive impairment, mobility deficits, and histories of repeated falls. One resident with dementia and severe mobility limitations sustained multiple serious fractures after repeated falls while attempting to stand or ambulate without assist; the only documented new intervention was a brightly colored reminder on the wheelchair, which was later observed not to be in place, and the fall investigation lacked a root cause analysis. Another resident with prior stroke, difficulty walking, and repeated falls had numerous fall-related interventions care planned, including non-skid strips, wheelchair positioning, visual reminders, and a reacher, but surveyors observed that these items and environmental modifications were not present or in use despite multiple documented falls and near-falls. A third resident with multiple comorbidities and severe cognitive impairment fell while attempting to access the bathroom in a wheelchair, reported ankle and hip pain, and yet there was no fall report with root cause analysis or new interventions added to the care plan, contrary to facility policy and staff statements that each fall should trigger investigation and care plan modification.
A resident with a chronic suprapubic catheter and diagnoses including UTI, sepsis, and obstructive/reflux uropathy did not receive catheter care and irrigation as ordered, nor was such care documented on the MAR/TAR. The resident reported that staff cleaned the catheter site only every 2–3 days and complained of penile pain and tenderness during observed catheter care. A provider order required flushing the suprapubic catheter with 60 cc sterile water every 12 hours, but staff interviews showed inconsistent understanding of who performed the irrigation, and there was no documentation that it occurred. Progress notes showed the catheter was changed, the resident was hospitalized and treated for a catheter-associated UTI with urine culture growing Pseudomonas aeruginosa and Enterococcus faecalis, and later remained at high risk for UTI with ongoing symptoms prompting urine collection. The facility’s Foley catheter care policy required daily and PRN catheter care, which was not supported by the records for this resident.
Surveyors found multiple food storage and preparation deficiencies, including produce, eggs, and dry goods stored directly on the floor; raw meat thawing next to ready-to-eat items and fresh vegetables; undated and unlabeled prepared foods, cheese, breadcrumbs, and thickener; and uncovered, opened items exposed to air. A large slab of beef was thawing directly on a cart above an undated container of food. These practices conflicted with the facility’s own policies and the Dietary Manager’s expectations for labeling, dating, separation of raw meat, and maintaining food at least six inches off the floor.
The facility failed to ensure call lights were answered in a timely manner, as multiple cognitively intact and moderately impaired residents who require varying levels of assistance with ADLs reported routinely waiting 30–60 minutes or more for help, particularly with toileting and personal care. Residents described staff being on their phones, unwilling to work, and not responding to call lights, with some residents experiencing incontinence episodes while waiting. The Ombudsman reported numerous complaints and repeated visits about delayed call light response, and Resident Council minutes and grievances over several months documented call lights remaining on for over an hour on all shifts and staff sitting at the desk while call lights and doorbells rang. The DON stated she expected call lights to be answered within 10–15 minutes, and the facility’s policy required calls to be answered as soon as possible.
Surveyors found two Breztri inhalers and one Airsupra inhaler in a medication cart drawer that were partially used but lacked any resident name or date opened. An RN acknowledged she did not know which residents the inhalers belonged to and confirmed that all inhalers should be labeled with the resident’s name and the date opened. The DON stated that all medications, including inhalers, are expected to be labeled in this manner, in line with the facility’s medication storage policy requiring safe, secure, and proper storage per manufacturer or supplier recommendations.
The facility failed to provide physician‑ordered ice cream as part of therapeutic diets for multiple residents with conditions such as dementia, GERD, type 2 DM, dysphagia, and protein‑calorie malnutrition. Several residents had active orders and meal tickets specifying ice cream at lunch and/or dinner, often with super cereal, fortified foods, double portions, and LCS diets, yet surveyors observed meals served without ice cream and residents reported not receiving it for days or weeks, sometimes without any substitute. A tour of the kitchen revealed no ice cream in the freezer, a staff member acknowledged they had run out of ice cream, and the RD stated she had not been informed of the shortage while expecting diet orders to be followed, consistent with facility policy requiring meals to meet residents’ assessed nutritional needs.
An LPN repeatedly failed to follow infection prevention practices during blood glucose monitoring and medication administration for several residents. The LPN did not perform hand hygiene before or after glove use, resident contact, or medication administration, and used the same glucometer on multiple residents without cleaning it between uses. In one instance, the LPN dropped a Lyrica pill on the floor, picked it up, returned it to the medication cup, and administered it to a resident. These actions were inconsistent with facility policies requiring hand hygiene before and after resident contact and invasive procedures, cleaning of glucometers between residents, and wasting medications dropped on the floor.
A resident with a history of cerebral infarction, difficulty walking, and repeated falls, and who required supervision or partial/moderate assistance for mobility and transfers, had an extensive fall-prevention care plan that included non-skid strips by the bed and toilet, a low bed, gripper socks, specific wheelchair positioning, visual reminders not to stand without assist, a "call before you fall" sign, and a reacher. Despite multiple documented falls and near-falls, surveyors observed that these interventions were not in place: non-skid strips were absent, the wheelchair was not left locked by the bed, there was no brightly colored reminder on the wheelchair, no "call before you fall" sign by the bed, and no reacher in the room. Nursing notes described repeated episodes of the resident sliding or transferring to the floor, sometimes with the wheelchair found unlocked, while the facility’s policy and the DON’s statement required that appropriate fall interventions be implemented and care plans updated after each fall.
The facility failed to update and individualize care plans with progressive fall-prevention interventions after multiple falls experienced by three residents with significant mobility impairments, cognitive deficits, and high fall risk. One resident with dementia and severe functional limitations had a serious fall requiring ER transfer, but the fall investigation lacked a root cause analysis and no new interventions were added to the care plan. Another resident with cerebral palsy and documented high fall risk had numerous falls in the bedroom, bathroom, and outdoors, yet no fall investigations or new care plan interventions were documented for any of these events. A third resident with multiple comorbidities and severe cognitive impairment fell while attempting to access the bathroom in a wheelchair, reported pain, and was assessed, but the care plan was not revised with any additional fall interventions despite facility policy and leadership expectations that each fall trigger investigation, root cause analysis, and care plan updates.
A dependent resident with hemiplegia, severe cognitive impairment (BIMS 6), limited ROM, and an ADL self-care deficit requiring staff assistance was observed lying in bed with red liquid staining on her pillow and incontinence pad after spilling a red-colored drink at lunch. Despite the resident reporting that staff had already changed her bedding and later stating staff had not returned, surveyors observed that the soiled pillow and incontinence pad remained unchanged for several hours. The DON reported that ADL care, including bedding changes, is to be provided daily and as needed per the facility’s ADL policy.
A resident with hemiplegia, severe cognitive impairment, malnutrition, limited ROM, and multiple pressure injuries was repeatedly observed lying in bed without ordered pressure-relieving devices in place, including no pillows between knees or under heels and a pressure-relieving boot left off the foot. The resident, unable to reposition independently, reported pain and stated staff had not done anything for her, and was seen in the same position over multiple observations without evidence of turning or repositioning. Records showed documented stage 2 and stage 3 pressure ulcers and DTIs, a care plan requiring assistance with frequent turning and repositioning, and wound NP notes describing multiple wounds and new areas. The wound nurse indicated the resident should have feet elevated and be turned and repositioned as tolerated, while the DON reported residents are turned every 2 hours, and the facility’s pressure injury policy required implementation of standards of practice to prevent or reduce pressure injuries.
A resident with CKD stage 4 and hypokalemia, prescribed Potassium Chloride ER 10 mEq tablets, was found with two large pills and a cup of water left unattended on the bedside table. The resident stated these were her potassium chloride medications that a nurse had left for her and that she planned to take them later. Facility policy required staff to explain the procedure, administer medications, and remain with the resident to ensure the medications were swallowed, but this was not followed, resulting in unsupervised medication administration.
Two residents with documented elopement risk and significant cognitive/psychiatric conditions eloped through the front entrance due to failures in supervision, rounding, and elopement controls. One resident, severely cognitively impaired and care-planned as high elopement risk with a wander guard, left in a wheelchair during the night and was not discovered missing for several hours, later being found miles away. Staff did not consistently perform visual rounds, relied on assumptions and verbal assurances instead of confirming the resident’s presence, and some were unaware of his elopement risk or the existence of an elopement risk binder. Wander guard documentation showed repeated periods when the device was not in place or not available, and staff gave conflicting accounts about its use. The front door alarm was configured so it did not sound at the nurse stations, and several leaders were unaware of this limitation, while residents had access to the door code. Another resident, also care-planned for elopement risk with hallucinations and delusions, exited the same front door and was found across a busy road, demonstrating additional failure to implement care-planned checks and monitoring.
Failure to ensure staff were competent in emergent trach reinsertion led an agency LPN to call EMS when a resident’s trach became dislodged instead of attempting reinsertion. The resident had a trach for respiratory conditions and arrived at the ED via EMS with no trach in place; ED staff were also unable to replace it and transferred the resident for ENT care. A second agency LPN confirmed no RN was present and that neither nurse felt trained or confident to reinsert the trach.
Failure to Reinsert Dislodged Tracheostomy: A resident with a trach was found after an unwitnessed fall with the trach out, and staff sent the resident to the ER without attempting reinsertion. The LPNs stated they were not trained or confident to reinsert the trach and did not know the trach size or where to find it. The resident was later transferred to another hospital and admitted to the ICU for respiratory distress, while the ED documented acute respiratory failure and inability to replace the trach.
Kitchen staff lacked required food handler certification, including 3 cooks and 1 dietary aide. The Dietary Manager said corporate had arranged an in-person class, but no kitchen staff attended, and the DON/AIT could not find one dietary aide’s certificate. One cook said she was told she needed the class but was never told how or when to complete it, and the DON/AIT stated the facility had no policy requiring the certification even though she expected all kitchen employees to have it.
Staff were not adequately trained or competent in providing tracheostomy care, resulting in multiple residents being sent to the hospital for routine trach management, improper CPR performed on a resident with a tracheostomy, and repeated failures to perform necessary interventions. Paramedics and fire department personnel reported frequent non-emergent calls for basic trach care, and staff interviews confirmed a lack of training and comfort with tracheostomy procedures.
Nursing staff lacked the training and supplies needed to provide proper tracheostomy care, resulting in inadequate airway management for several residents. Two residents with tracheostomies did not receive appropriate ventilation during CPR, as staff attempted to bag over the mouth instead of the tracheostomy tube, and both died. Other residents were sent to the hospital for issues like secretions and tube dislodgement that staff could not manage. EMS and fire department personnel reported frequent calls for basic tracheostomy care that should have been handled by facility staff, and multiple staff members confirmed they had not received training on tracheostomy care or CPR for these residents.
Two residents with tracheostomies who were full code did not receive proper CPR when staff failed to provide ventilation through the tracheostomy during resuscitation. Staff either attempted to ventilate via the mouth or did not provide ventilation at all, citing lack of knowledge and equipment compatibility. Both residents died following these incidents, and staff interviews confirmed unfamiliarity with correct CPR procedures for tracheostomy patients.
A resident with severe cognitive impairment and complex medical needs exhibited significant changes in condition, including dilated pupils, cool skin, and decreased responsiveness, which were observed by two CNAs but not reported to nursing staff. Approximately 15-20 minutes later, the resident was found unresponsive, and CPR was initiated, but the resident was already cold and stiffening. Facility policy required reporting such changes, but the lack of communication between CNAs and licensed staff led to a delay in assessment and intervention.
A resident's medical records were not provided in a timely manner after an attorney's request due to staff turnover, poor communication, and failure to follow established procedures. Multiple attempts by the attorney's office to obtain the records went unaddressed until the issue was escalated, revealing gaps in the facility's process for handling medical record requests.
A resident with severe burns and recent skin grafts did not receive wound care as ordered, including missed dressing changes, lack of required bacitracin ointment, and unsanitary wound care practices. Documentation was incomplete, and staff were unclear on orders, leading to wound infection, increased pain, and hospital readmission for further surgical intervention.
A resident with recent burn and skin graft surgery experienced severe pain and bleeding when a nurse attempted to remove a xeroform dressing from the donor site without pre-medicating or following wound care orders. The resident was not given pain medication prior to the procedure, and the dressing was not supposed to be removed according to the hospital's instructions. Staff interviews confirmed the resident's pain was not managed appropriately during the incident.
A resident with Alzheimer's and Dementia experienced a decline in condition, including refusal of oxygen therapy, reduced meal intake, and weight loss, which was not adequately documented or communicated to medical staff. This led to a delay in treatment and hospitalization for pneumonia and other conditions.
The facility failed to properly identify, assess, and monitor pressure ulcers, and provide physician-prescribed treatment for four residents. One resident developed an unstageable pressure ulcer that went untreated for 23 days, while another developed three pressure ulcers, including an infected sacral ulcer. Inconsistencies in treatment documentation and administration, along with communication issues between staff and the wound nurse practitioner, contributed to these deficiencies.
A facility failed to adhere to its Abuse Policy and Prevention Program when Lorazepam went missing from a non-communicative resident's medication supply. Despite video footage suggesting an agency nurse's involvement, the facility delayed notifying law enforcement, contrary to policy. The Director of Nursing believed an investigation was needed before reporting, leading to a deficiency in handling the incident.
A facility failed to timely report suspected misappropriation of Lorazepam for a non-communicative resident. The medication was discovered missing, and video footage was inconclusive. The DON delayed notifying police, believing an investigation was needed first, contrary to facility policy requiring immediate reporting. The administrator later acknowledged the delay, highlighting a deficiency in policy adherence.
The facility failed to provide timely meals for four residents, leading to grievances and dissatisfaction. One resident experienced a two-hour delay for dinner, while another missed breakfast due to communication issues among kitchen staff. The Director of Nursing and Administrator acknowledged the expectation for timely meal service, but the facility's policy was not followed, resulting in unmet nutritional needs.
A resident with a right hip fracture had surgical staples removed without a physician's order, leading to discomfort when a staple was left in the incision. The DON confirmed the absence of the required order, contrary to facility policy.
A resident with a history of colon resection surgery and a diagnosis of Ulcerative Colitis did not have a colonoscopy scheduled despite a physician's order. The DON cited difficulties in contacting doctors' offices, and the facility lacked a policy on radiology/diagnostic services, contributing to the delay.
Two residents in an LTC facility developed worsening pressure ulcers due to inadequate care and failure to follow care plans. One resident, with multiple health issues, was not provided a low air loss mattress and developed severe ulcers. Another resident, severely cognitively impaired, had inconsistent treatment documentation for pressure ulcers. The facility's policies on skin management were not consistently followed, leading to significant deficiencies in wound care management.
The facility failed to date opened insulin pens for five residents, as observed during a survey. Two LPNs, one an agency nurse and the other new, were unaware of the requirement to date insulin pens upon opening. The DON expected staff to date insulin pens due to their 28-day expiration but was unaware of the undated pens. The facility's policy mandates proper medication storage.
The facility failed to provide food that was palatable, attractive, and at a safe temperature. Residents reported ongoing issues with cold meals, despite forming a special food committee to address these concerns. Observations confirmed delays in meal service and inadequate food temperatures, with only one out of six items meeting the required standards.
The facility failed to follow infection control policies for four residents, leading to deficiencies in infection prevention. Staff did not wear required gowns or perform hand hygiene during wound care and medication administration, increasing the risk of cross-contamination and infection. These actions violated the facility's Enhanced Barrier Precautions policy.
The facility failed to protect residents from resident-to-resident physical abuse, involving incidents where a cognitively impaired resident was hit with a cane by another resident, resulting in a hematoma, and another altercation where hair was grabbed, causing a scratch. These incidents highlight deficiencies in the facility's abuse prevention measures.
A resident with multiple medical conditions and a history of wandering eloped from the facility despite having a wander guard. The resident was found at a nearby apartment building after being reported missing. The facility's policy requires immediate response to door alarms, but staff failed to monitor and respond effectively, allowing the resident to exit unsupervised.
A resident who was always incontinent of urine and frequently incontinent of bowel did not receive timely incontinent care, as observed by surveyors. The resident's care plan required regular checks to keep her clean and dry, but during an observation, her brief was found heavily soiled, and the CNA responsible could not recall the last check. Interviews confirmed that checks were expected every two hours, but this was not followed, leading to the resident's hospitalization with sepsis and dehydration.
A resident reported being scratched and attacked by CNAs, leading to police involvement and one CNA's arrest. However, an earlier complaint about a CNA being rough and rude was not reported or investigated, violating the facility's abuse prevention policy.
A resident reported incidents of abuse by CNAs, including being scratched and attacked, to the administrator. Despite the facility's policy requiring immediate reporting of such allegations, the administrator was not informed by staff or the DON. The facility's policy mandates documentation and reporting of all incidents to the Illinois Department of Public Health, which was not followed in this case.
A long-term care facility failed to provide timely medications for four residents, leading to missed doses of critical drugs like insulin and antihypertensives. The facility's pharmacy was located far away, causing delays, and staff reported issues with access to the automated medication dispensing machine. Residents with serious conditions, including pulmonary hypertension and diabetes, were affected, with one resident requiring emergency evaluation due to discomfort and dehydration.
A resident experienced a delay in receiving pain medication due to a CNA administering it instead of a licensed nurse, violating the facility's medication administration policy. The incident was reported, and the responsible RN, an agency nurse, was not allowed to return.
A resident admitted with serious infections requiring IV antibiotics did not receive the medications as ordered due to delays and unavailability. Tigecycline was not administered despite being available, and Voriconazole could not be obtained. The facility failed to document the reasons for these omissions, resulting in the resident not receiving antibiotics for 48 hours.
A resident in an LTC facility was physically and mentally abused by staff members who forcibly put her to bed against her will, resulting in bruising and fear. Despite her cognitive intactness and medical conditions, including schizophrenia and anxiety, the staff ignored her protests and used a mechanical lift to move her, violating her rights and causing distress.
The facility failed to provide complete incontinent care for a resident with a history of UTIs and other medical conditions. A CNA did not perform hand hygiene and did not clean the resident's right side during care. The resident was later hospitalized with a UTI and other complications, and had a positive urine culture for E. Coli. The facility's incontinence care policy was not followed.
The facility failed to have enough CNAs working to meet the needs of the residents, resulting in a resident being left soaked in urine overnight due to short staffing. Interviews with staff confirmed frequent short staffing on night shifts, and the facility was unable to provide a staffing policy.
A resident was denied her medications, including pain, muscle spasm, heart, and seizure medications, for about three days due to issues with pharmacy delivery and communication. The facility's records showed multiple instances where medications were not given as ordered, and the required steps to resolve these issues were not consistently followed.
The facility failed to install the correct bed rail and obtain consent from the resident or their representative prior to the installation and use of bed rails for four residents. Observations and interviews confirmed that the facility had not been obtaining the necessary consents for bed rail use, despite their policy mandating it.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective fall interventions for a resident who was admitted from assisted living with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, cerebral infarction, muscle wasting and atrophy of both lower legs, weakness, reduced mobility, and abnormal gait and mobility. The resident’s fall risk assessments documented high fall risk scores, and the care plan identified the resident as high risk for falls related to prior falls, impaired balance and gait, psychotropic medication use, incontinence, impaired safety awareness, and glaucoma. The resident’s MDS documented dependence on staff for toileting, hygiene, dressing, and personal hygiene, and the resident was described as confused and severely cognitively impaired. The resident fell four times at the facility. On the first fall, the resident attempted to ambulate to the closet and fell into the door, causing a forehead laceration and bleeding, and 911 was called for hospital evaluation. On another fall, the resident was found on the floor by a CNA with no obvious injuries, and the incident report did not identify an intervention in place. On a separate fall, the resident was found on the floor in her room after falling out of her chair and was again sent out by 911; the report listed confusion, incontinence, non-compliance with safety guidance, gait imbalance, and impaired memory, with frequent rounding and a call-before-you-fall sign noted as interventions. On the fourth fall, the resident fell in the dining room, hit her head, had a large bump to her forehead, was lethargic, and 911 was called because she was on anticoagulants; the report noted she fell forward out of her wheelchair while being taken to her room to lie down. Facility staff stated the resident was confused, a high fall risk on admission, and initially had no interventions in place except reminders not to ambulate alone. Staff also stated the resident was eventually to be kept near the nurses’ station because of falls. The physician stated he would have expected interventions to be in place on admission because the resident had fallen prior to admission and expected the facility to identify and implement effective fall interventions. The facility policy required fall risk evaluation on admission and after each fall, with fall risks identified on the care plan and interventions implemented to minimize fall risk.
Failure to Implement and Maintain Fall-Prevention Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to initiate, implement, and consistently maintain progressive fall-prevention interventions and environmental safeguards for multiple residents identified as high fall risk. For one resident with severe cognitive impairment, reduced mobility, muscle weakness, difficulty walking, dementia, abnormal gait, and a history of repeated falls, the care plan identified high fall risk related to incontinence, weakness, history of falls, glaucoma, confusion, and psychotropic medication use. Despite this, after a serious fall in which the resident attempted to go to the bathroom independently and sustained a right intertrochanteric hip fracture requiring hospital transfer and surgery, the facility’s fall investigation contained only clinical documents (face sheet, physician orders, care plan, MDS sections) and did not include a root cause analysis or new interventions. Later, the same resident experienced additional falls while attempting to stand or ambulate without assistance, including a fall into a medication cart with head impact while on a blood thinner and a subsequent left intertrochanteric hip fracture and a left clavicle fracture, yet the only documented new fall-related intervention in the care plan was a brightly colored reminder on the wheelchair instructing the resident not to stand without assistance. Surveyors observed that this intervention was not consistently implemented. On a later observation date, the resident was again seen attempting to stand from the wheelchair without assistance in front of the nurses’ station, and no brightly colored reminder was present on the wheelchair as documented in the care plan. Staff interviews confirmed that the resident was known to be a high fall risk, frequently tried to get up independently, and required assistance with transfers. The MDS coordinator, DON, and nurse practitioner each stated that after a fall, the facility’s expectation and policy were to investigate the fall, determine a root cause, implement an intervention, and update the care plan after each fall. However, the documentation for this resident’s multiple falls did not show a root cause analysis or a series of progressive, individualized interventions corresponding to each fall event. For a second resident with diagnoses including cerebral infarction, difficulty in walking, and repeated falls, and who required supervision or assistance with bed mobility, transfers, and toileting, the care plan listed numerous specific fall-prevention interventions such as non-skid strips by the bed and toilet, keeping the wheelchair locked by the bed, a brightly colored reminder on the wheelchair not to stand without assist, a “call before you fall” sign by the bed, and provision of a reacher. Nursing notes documented multiple fall or near-fall events, including the resident being found with knees on the floor by the bed, sitting on a floor mat, falling while attempting an unaided transfer from bed to chair, sliding from the wheelchair to the floor, and attempting to transfer from wheelchair to bed with the wheelchair unlocked. Despite these documented events and corresponding care plan interventions, surveyor observation of the resident’s room showed that non-skid strips by the bed and toilet, the wheelchair positioned locked by the bed, the brightly colored reminder on the wheelchair, the “call before you fall” sign by the bed, and the reacher were not present or in use as care planned. For a third resident with multiple comorbidities including type 2 diabetes, weakness, unsteadiness on feet, cognitive communication deficit, acute kidney failure, CKD stage 3, muscle weakness, heart failure, hypertension, anxiety, depression, anemia, and insomnia, the MDS documented severe cognitive impairment for ADLs. The care plan identified the resident as at risk for falls related to frequent falls, impaired safety awareness, impaired balance and gait, and incontinence, with an intervention of frequent rounding during the day. Nursing progress notes recorded that the resident fell while trying to get into the bathroom in a wheelchair, landing on the right side and reporting pain in the right ankle and hip, though no open wounds or bruises were noted and vital signs were within range. Despite this fall, there was no fall report or investigation with root cause analysis, and no new interventions were documented in the care plan to address this specific fall. The fall log listed the fall, but when surveyors requested the fall report and investigation multiple times, the facility provided only a folder containing the POS, care plan, and nurse’s notes, with no additional fall-related analysis or interventions. The facility’s fall policy stated that all resident falls shall be reviewed, the plan of care evaluated and modified as needed, and the care plan updated with a new intervention based on root cause analysis after each fall occurrence, which was not carried out for this resident.
Failure to Provide Ordered Suprapubic Catheter Care and Irrigation Resulting in Catheter-Associated UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered catheter care and irrigation for a resident with a chronic suprapubic catheter, which resulted in a catheter-associated UTI and hospitalization. The resident, who was cognitively intact with a BIMS score of 14 and required partial/moderate assistance with toileting, had diagnoses including UTI, sepsis, and obstructive/reflux uropathy. He reported that staff cleaned his catheter site only every 2–3 days and that he had a recent urine infection. Observation on one date showed a suprapubic catheter draining clear tea-colored urine, and during observed catheter care on another date, the resident complained of penile pain and tenderness around the suprapubic catheter site. The resident’s physician orders included a 1/30/26 order to flush the suprapubic catheter with 60 cc of sterile water every 12 hours. However, there were no additional specific orders for catheter care, and review of the MAR/TAR for January and February 2026 showed no documentation of catheter care or catheter irrigation during that period, despite the order. Staff interviews revealed inconsistent understanding and implementation of the irrigation order: an LPN stated she believed the irrigation was done on evening shift and that she did not perform it on day shift, while the wound nurse stated catheter care should be done every shift. The DON stated that catheter care and irrigation would be documented on the MAR/TAR and that she expected physician orders to be followed. Progress notes documented that the resident’s suprapubic catheter was changed on 1/9/26 and that he was later sent to the hospital on 1/15/26 due to severely elevated blood pressure, returning on 1/17/26 with new and changed orders. A 1/18/26 progress note documented that the resident was on antibiotics for a UTI and had a Foley catheter in place draining yellow urine. A hospitalist history and physical dated 1/22/26 documented a catheter-associated UTI with urine culture showing >100,000 CFU of Pseudomonas aeruginosa and Enterococcus faecalis. Subsequent notes described ongoing monitoring for UTI symptoms, recent treatment with antibiotics for UTI, and episodes of penile pain, loose stools, confusion about day and time, and burning and pain that prompted collection of urine and stool samples. The facility’s Foley catheter care policy, dated 4/2019, required daily and PRN catheter care to promote comfort and cleanliness, which was not reflected in the documentation of care provided to this resident.
Improper Food Storage, Labeling, and Thawing Practices in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and preparation practices that failed to prevent potential contamination of food items. In the walk-in refrigerator, a 50-pound mesh bag of onions and a large box of pasteurized eggs were stored directly on the floor. The eggs were placed next to a box of cupcakes, and a large industrial box of raw meat (chicken or pork) was thawing in the middle of these items. On a metal shelf in the same refrigerator, a large industrial bowl of greens was found without any date or label, and a half-open bag of mozzarella cheese was uncovered, unlabeled, and exposed to the air. A box of raw chicken was thawing and dripping next to a box containing 12 heads of fresh cabbage, with the raw chicken box undated and unlabeled. Additional observations showed a large slab of beef thawing directly on top of a removable metal cart in the storage room, with an undated and unlabeled 4-quart container of a red substance with large noodles stored directly underneath the meat. In the kitchen area, a large container holding an opened 25-pound bag of breadcrumbs was not dated or labeled, and a large industrial container of food thickener was also undated and unlabeled. In the dry storage area, an opened container of oatmeal was sitting directly on the floor and exposed to the air. The Dietary Manager stated that items were expected to be stored at least six inches off the floor, never directly on the floor, that all items should be dated and labeled, and that meat should be stored alone and not near other items to prevent food contamination and possible foodborne illness. Facility policies required food stock to be stored six inches off the floor and leftovers and opened foods to be clearly labeled and dated, and indicated that protein items are to be defrosted on the bottom shelf of the refrigerator.
Ongoing Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were answered in a timely manner for multiple residents, despite a policy directing staff to respond to resident calls as soon as possible. Interviews and record reviews showed that six residents, several of whom were cognitively intact and required assistance with activities of daily living such as toileting, hygiene, dressing, and transfers, reported frequent and prolonged delays in call light response. One resident who uses a wheelchair and needs substantial/maximal assistance stated that call lights are typically unanswered for at least 30 minutes or more and that this concern is repeatedly raised at Resident Council meetings without improvement. Another cognitively intact resident who can perform most tasks independently reported that residents regularly complain that staff are on their phones, do not want to work, and fail to answer call lights. Additional residents with moderate cognitive impairment and functional limitations described waiting long periods for toileting assistance, including one resident who reported feeling embarrassed after wetting the bed because staff did not respond quickly enough to the call light. Another wheelchair-bound resident needing partial to moderate assistance with ADLs stated it was not uncommon to wait about forty minutes, especially at night, for staff to respond. Other residents reported that staff “do not want to work” and that call lights are often unanswered for an hour or more, causing stress when help is needed. The Ombudsman confirmed receiving numerous complaints and making several visits regarding delayed call light response, noting the problem persisted. Resident Council minutes and written grievances over several months documented repeated reports of call lights remaining on for over an hour on all shifts, staff sitting at the desk while call lights and doorbells rang, and concerns that nurses were not assisting CNAs with answering call lights. The DON acknowledged awareness of some complaints and stated an expectation that call lights be answered within 10–15 minutes, while the written policy required answering resident calls as soon as possible.
Unlabeled and Unidentified Inhalers Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage when inspecting the 100 Hall medication cart with an RN, where two Breztri inhalers and one Airsupra inhaler were found in the top right drawer without any resident name or date opened, despite appearing used and having a small number of inhalations remaining. The RN stated she did not know which residents the inhalers belonged to, acknowledged that all inhalers should be labeled with the resident’s name and the date opened, and speculated that the midnight nurse may have placed them in the drawer to determine ownership. The DON later confirmed the expectation that all medications, including inhalers, be labeled with the resident’s name and the date opened, consistent with the facility’s “Medication Storage In The Facility” policy, which requires medications and biologicals to be stored safely, securely, and properly following manufacturer or supplier recommendations. This failure to label and identify the inhalers meant that medications in use were not in accordance with the facility’s policy or accepted professional principles, and the number of residents affected could not be determined because the owners of the inhalers were unknown.
Failure to Provide Physician‑Ordered Ice Cream as Part of Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered therapeutic diet items, specifically ice cream, with meals for multiple residents. Several residents had active physician orders and corresponding meal tickets specifying ice cream at lunch and/or dinner as part of their prescribed diets, often in conjunction with other nutritional interventions such as super cereal, fortified foods, double portions, and low concentrated sweets (LCS) diets. Despite these orders, surveyors observed meal service and reviewed records showing that ice cream was not provided as ordered. One resident with dementia and hypertension, assessed as moderately cognitively impaired and needing setup or clean‑up assistance with eating, had orders for a NAS diet with regular texture, thin liquids, super cereal at breakfast, and vanilla ice cream at lunch and dinner. On two separate lunch observations, this resident’s tray did not include ice cream, and the resident reported that she sometimes received it and sometimes did not. Another resident with GERD, schizoaffective disorder, and dementia, who was severely cognitively impaired and required supervision or touching assistance with eating, had orders for a regular diet with pureed texture, thin liquids, super cereal at breakfast, and ice cream at lunch and dinner. This resident stated she did not receive ice cream with her lunch tray and could not recall the last time she had received it. Additional residents with diagnoses including GERD, hypertension, type 2 diabetes mellitus, dysphagia, and protein‑calorie malnutrition had physician orders and meal tickets specifying ice cream with lunch and/or dinner, sometimes along with double portions, fortified potatoes, fortified pudding, and whole milk. These residents reported not receiving ice cream for several days or weeks and, in some cases, not receiving any substitute item. During a kitchen tour, no ice cream was observed in the freezer. The registered dietitian stated she had not been notified that ice cream was unavailable and expected diet orders to be followed, while another staff member reported the facility had run out of ice cream and had been out for a few days. The DON and nurse practitioner both stated they expected staff to follow physician‑ordered diets, and the facility’s policy on dietary preferences and nutritional requirements stated that residents are to receive nourishing, palatable, well‑balanced meals that meet assessed nutritional needs.
Failure to Follow Hand Hygiene and Glucometer Cleaning Practices During Medication Administration
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during medication administration, specifically related to hand hygiene and glucometer cleaning for multiple residents. On 2/5/26, an LPN (V9) was observed performing blood glucose (accu-check) testing and administering medications without performing hand hygiene before or after glove use, resident contact, or medication administration. V9 conducted an accu-check on R52 after donning gloves, then removed the gloves without hand hygiene and did not clean the glucometer after use. Shortly afterward, V9 used the same, uncleansed glucometer to perform an accu-check on R16, again without hand hygiene before or after glove use and without cleaning the glucometer after use, and then administered medications to R16 without performing hand hygiene. Further observations on the same date showed that V9 entered R69’s room and administered medications without hand hygiene before or after administration, and then entered R75’s room, touched the resident who was complaining of pain and vomiting, and exited without performing hand hygiene. V9 then entered R49’s room, completed an accu-check without hand hygiene before or after glove removal and without cleaning the glucometer before or after use. While preparing R49’s medications, V9 dropped a Lyrica pill on the floor, picked it up, placed it back into the medication cup, and administered it along with the other medications, again without performing hand hygiene before or after administration. The facility’s RN/Infection Control Preventionist (V4) later stated that nurses are expected to perform hand hygiene each time a resident is touched, clean glucometers after each use, and waste any medication dropped on the floor before obtaining a replacement. Facility policies for blood glucose machine cleaning, hand hygiene, and medication administration all documented requirements for cleaning glucometers between residents and performing hand hygiene before and after resident contact, glove use, and invasive procedures such as blood glucose monitoring.
Failure to Implement Fall-Prevention Care Plan Interventions After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement multiple fall-related care plan interventions for a resident identified as high risk for falls. The resident’s EMR documents diagnoses including cerebral infarction, difficulty in walking, and repeated falls, and an MDS showing a BIMS score of 14/15 with needs for supervision or partial/moderate assistance for bed mobility, transfers, and toileting. The resident’s care plan, initiated and updated over several months, includes numerous fall-prevention interventions such as non-skid strips by the bed and toilet, use of a low bed, gripper socks, wheelchair positioning, visual reminders, and provision of a reacher, all intended to address the resident’s fall risk factors of incontinence, impaired balance, history of falls, and psychotropic medications. Despite these planned interventions, surveyor observation on 2/10/26 at 1:13 PM found that several care-planned items were not in place in the resident’s room. Non-skid strips were not present by the bed or toilet, the wheelchair that was to be left locked by the bed was instead across the room, there was no brightly colored reminder on the wheelchair instructing the resident not to stand without assistance, there was no “call before you fall” sign by the bed, and the reacher that had been care planned was not found in the room. These observations directly conflicted with the documented interventions on the resident’s care plan dated between 3/6/25 and 1/27/26. Nursing notes document multiple fall events and near-falls for this resident over the same period, including being found with knees on the floor by the bed, sitting on a floor mat, sliding from the wheelchair to the floor, and attempting or completing unaided transfers between bed and wheelchair. In several of these incidents, the resident admitted to trying to transfer independently or being “stubborn,” and staff documented that the wheelchair was not locked during at least one fall. The facility’s Fall Prevention and Management policy states that all falls are to be reviewed and the care plan updated with new interventions based on root cause analysis after each fall occurrence, and the DON confirmed that care plan interventions should be implemented after determining appropriate fall interventions. However, the documented lack of implementation of multiple existing care plan interventions following these falls led to the cited deficiency.
Failure to Update Care Plans With Progressive Fall Interventions After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to evaluate and revise residents’ comprehensive care plans with progressive, individualized fall-prevention interventions after multiple falls. For one resident with dementia, reduced mobility, muscle weakness, difficulty walking, and a history of repeated falls, the MDS documented severe cognitive impairment and high fall risk, with dependence for transfers. The care plan identified the resident as high risk for falls and listed general risk factors, but after a significant fall that required transfer to the ER, the fall investigation contained only existing records (face sheet, physician orders, care plan, MDS sections) and did not include a root cause analysis or new interventions. The care plan did not reflect any progressive intervention specific to this fall. Another resident with cerebral palsy, unsteadiness of feet, weakness, and abnormalities of gait and mobility was documented as cognitively intact, using a walker and wheelchair, and needing supervision or touching assistance for transfers and ambulation. This resident was assessed as high risk for falls and had a care plan noting high fall risk related to balance and gait problems, cerebral palsy, arthritis, incontinence, psychoactive drug use, history of falls, and noncompliance with fall interventions. Despite multiple documented falls and fall-related events over several months—including sleeping on the floor after rolling out of bed, falls in the bathroom, falls next to the bed, and a fall forward out of a wheelchair while outside with activities—there were no fall investigations or new fall interventions documented in the care plan for any of these incidents. A third resident with multiple diagnoses including type 2 diabetes mellitus, weakness, unsteadiness on feet, cognitive communication deficit, kidney disease, muscle weakness, heart failure, hypertension, anxiety, depression, anemia, and insomnia was documented as severely impaired for cognition and activities of daily living. This resident experienced a fall while attempting to get into the bathroom in a wheelchair, landing on the right side and reporting pain in the right ankle and hip, with vital signs within range and no open wounds or bruises noted. Although the care plan identified the resident as at risk for falls related to frequent falls, impaired safety awareness, impaired balance and gait, and incontinence, and included an intervention of frequent rounding during the day, there were no additional interventions documented in the care plan in response to this fall. Facility leadership and clinical staff stated their expectation and policy that every fall be investigated, a root cause analysis completed, and an intervention implemented and added to the care plan after each fall, which did not occur for these residents.
Failure to Change Soiled Bed Linens for Dependent Resident
Penalty
Summary
Failure to provide adequate ADL care occurred when staff did not change soiled bed linens for a dependent resident who was unable to care for herself. The resident had contractures of the left hand, wrist, elbow, and shoulder, was unable to move her left upper and lower extremities, and could not make significant movements or reposition herself in bed. Her diagnoses included hemiplegia/hemiparesis following cerebral infarction involving the left non-dominant side, muscle weakness, and age-related physical debility. Her MDS documented severe cognitive impairment with a BIMS score of 6, limited ROM in bilateral upper and lower extremities, and dependence on staff for hygiene. Her care plan documented an ADL self-care deficit requiring staff assistance. On the day of the survey, the resident was first observed in bed on her left side. Later that day, she reported that her lunch tray had been delivered, she had eaten, and made a mess. A reddish liquid substance, appearing to be from a red-colored drink, was observed on her pillow and incontinence pad. When asked if staff were going to change her bedding, the resident stated they already had, then touched the incontinence pad and stated it was wet, referring to the red staining. Over two hours later, the resident was again observed in bed on her left side with the same red staining still present on the pillow and incontinence pad, and she stated staff had not been in to change her bedding. The DON stated that ADL care, including bedding changes, is to be provided daily and as needed, and the facility’s ADL policy described a program intended to maintain residents at their maximal level of functioning based on their diagnosis.
Failure to Implement Pressure-Relieving Interventions and Repositioning for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions and a turning/repositioning program for a resident with existing pressure ulcers and significant immobility. On multiple observations, the resident was seen in bed without appropriate pressure-relieving devices in place, despite having known pressure injuries and care plan interventions requiring assistance with turning and repositioning. On 2/5/26, the resident was observed lying on her left side with a heel protector only on the left foot, no pillow between her knees or under her heels, and she appeared very thin. She had contractures and was unable to move her left upper and lower extremities and could not significantly reposition herself in bed. On 2/10/26 at 7:53 AM, the resident was again observed in bed on her back/left side with knees contracted up to her waist, with nothing between her knees or ankles and nothing under her heels; her left ankle was touching the bed and her pressure-relieving boot was on the bed but not on her foot. The resident complained of pain and anxiety and stated that staff had not done anything for her. Subsequent observations at 9:25 AM and 10:36 AM on the same day showed the resident in the same position and conditions, still without pressure-relieving items or interventions in place, and she reported she had not been repositioned and that staff had not done anything for her. Record review showed the resident had diagnoses including hemiplegia/hemiparesis following cerebral infarction involving the left non-dominant side, moderate protein-calorie malnutrition, muscle weakness, age-related physical debility, soft tissue disorders, and skin transplant status. The MDS documented severe cognitive impairment, limited ROM in all extremities, dependence for rolling in bed, and multiple pressure injuries, including a stage 2 ulcer not present on admission, a stage 3 ulcer present on admission, and two DTIs not present on admission, and indicated she was not on a turning/repositioning program. The care plan documented pressure ulcers to the left ankle (stage 3), left medial lower leg (stage 3), left great toe (DTI), and left 4th toe (DTI), with an intervention to assist and encourage frequent turning and repositioning. Progress notes and wound NP documentation detailed multiple wounds and new areas developing over time. The wound nurse stated the resident should have her feet elevated and be turned and repositioned as tolerated, and the DON stated residents are turned and repositioned every 2 hours, while the facility’s pressure injury policy required implementation of standards of practice to prevent or reduce pressure injuries.
Unsupervised Administration of Potassium Chloride Tablets
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered under staff supervision as required by policy for one resident. The resident had chronic kidney disease stage 4 and hypokalemia and was prescribed Potassium Chloride ER 10 mEq tablets, with the care plan indicating medications were to be given as ordered. The resident’s MDS documented that she was cognitively intact for decision making and activities of daily living. During observation on 2/5/2026 at 8:39 AM, surveyors noted a small clear cup of water and two large pills left unattended on the resident’s table. When asked, the resident identified the pills as her potassium chloride medications that the nurse had left for her, stating she planned to take them later. This practice conflicted with the facility’s Medication Administration Policy, which requires staff to explain the procedure, give the medication, and remain with the resident to ensure the medication is swallowed. The facility’s policy, reviewed in 4/2025, specifies that all medications are to be administered safely and appropriately, including remaining with the resident to confirm ingestion. Despite this, the nurse left the potassium chloride tablets at the bedside without supervision, and the resident was not observed taking them at the time of the surveyor’s observation. The combination of the resident’s medical conditions, the standing order for potassium chloride, and the unattended medications on the table demonstrated that the facility did not follow its own medication administration procedures for this resident.
Failure to Supervise and Prevent Elopement of Two At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents, both of whom had identified elopement risk and/or cognitive or psychiatric conditions. One resident (R2) had multiple diagnoses including dementia with agitation, schizophrenia, major depressive disorder, aphasia, chronic respiratory failure, facial weakness after stroke, and unsteadiness on feet. His MDS documented severe cognitive impairment and need for assistance with transfers and supervision or touching assistance for wheelchair mobility. R2’s care plans repeatedly identified him as high risk for elopement and falls, with interventions including use of a wander guard, monitoring of its function and placement every shift, replacement every 90 days, redirection from exits, and assistance with ADLs. Multiple elopement risk assessments over many months rated him as high risk. On the night of his elopement, R2 exited through the front door around 2:05 AM in his wheelchair. Facility video and external agency camera footage showed him leaving the front lobby, moving toward a neighboring assisted living facility, remaining in that area for a period, then traveling along the road and out of camera view. Staff on duty did not identify him as missing until approximately 8:00 AM, despite expectations from leadership and multiple staff interviews that residents should be rounded on and visually seen at least every two hours to confirm safety. Night staff, including the assigned CNA and LPN, reported they did not lay eyes on R2 for extended periods, relied on verbal assurances rather than direct observation, and in one case mistook his roommate for him during rounds. Staff also reported they were not informed that R2 was at risk for elopement, were unaware of an elopement risk binder, and did not initiate a head count or elopement process when they could not locate him. R2 was ultimately located by police approximately 4.4 miles away from the facility in his wheelchair. The report also documents systemic issues with the facility’s elopement prevention systems and door alarms. Although R2’s care plan required a wander guard, multiple medication administration notes in the weeks before and after the elopement documented that his wander guard was not in place or not available on several dates, and staff noted he frequently removed it. Leadership and staff gave conflicting accounts about whether R2 had a wander guard the night of the elopement and whether he was considered an elopement risk. The front lobby door alarm did not sound at the nurse’s stations like other exits, and several key staff, including the DON, HR, and RNC, were unaware that the front door alarm could not be heard from the nursing stations. The maintenance director confirmed that the front and north doors were set differently due to high traffic and that the front door alarm only sounded locally at the door. Staff interviews further showed inconsistent knowledge of elopement risk identification, reliance on residents knowing door codes, and lack of clear rounding policy at the time, all contributing to the failure to supervise and prevent R2’s elopement. A second resident (R4) was also identified as at risk for elopement due to delusions and stated intent to leave, with care plan interventions including 1:1 as needed, 15–30 minute checks as needed, and use and monitoring of a wander guard. R4 eloped through the front door and was found across a busy two-lane road approximately 500 feet from the facility entrance. The report attributes both residents’ elopements to the facility’s failure to ensure the environment was free from accident hazards and to provide adequate supervision, including failure to consistently implement care-planned elopement interventions, failure to ensure functioning and properly monitored wander guards, and failure to maintain an effective door alarm system that alerted nursing staff when at-risk residents approached or exited through the front door.
Failure to Ensure Competent Emergent Trach Reinsertion
Penalty
Summary
The facility failed to ensure staff were knowledgeable and competent to provide emergent tracheostomy reinsertion for one resident with a trach. The resident had been admitted for rehabilitation with diagnoses including acute respiratory failure, COPD, pneumonia, atrial fibrillation, weakness, and a tracheostomy, and the nursing admission assessment documented that the resident had a size 6 trach and was receiving oxygen humidification at 28%. During the night shift, the resident’s trach was found out of place. A late entry nursing note documented that the resident’s trach was out and that, because no RN was on duty, the resident was sent to the emergency room. The note did not document any attempt to reinsert the trach or the resident’s vital signs, including oxygen saturation, at that time. The agency LPN who documented the event stated she assessed the resident after being told the resident had fallen out of bed and that the trach was out, saw a head laceration, and used nursing judgment to call EMS for transport. She stated she did not attempt reinsertion because she had not been in-serviced on how to do it and did not feel comfortable or confident doing so. A second agency LPN stated she also worked that night shift and confirmed that no RN was in the building. She stated she did not attempt to reinsert the trach because she had not been in-serviced on trach reinsertion and did not feel comfortable or confident attempting it. She also stated she told the first LPN that trach reinsertion was not within LPN scope of practice. The hospital ED paperwork documented that the resident arrived via EMS with no trach in place, that the trach site had no patency, and that staff were unable to replace the trach there, resulting in transfer to a larger hospital for ENT replacement.
Failure to Reinsert Dislodged Tracheostomy
Penalty
Summary
The facility failed to provide necessary emergent respiratory care for a resident with a tracheostomy when the resident was found on the floor after an unwitnessed fall and the trach was discovered to be out. The resident had been admitted for rehabilitation and had multiple respiratory and cardiac diagnoses, including acute respiratory failure with hypoxia, COPD, trach dependence, pneumonia, sepsis, hypoxemia, left ventricular failure, pulmonary embolus, and congestive heart failure. The nursing note documented that the resident had a small forehead laceration and that the trach was out, but there was no documentation that staff attempted to reinsert the trach or documented the resident’s oxygen saturation at that time. The LPN who assessed the resident stated she called EMS because there was no RN on duty and she did not feel comfortable or confident reinserting the trach. She stated she had not been in-serviced on trach reinsertion, did not know the resident’s trach size, and did not know where to find that information or whether a backup trach kit was available. Another LPN stated she was not assigned to the resident and also said trach reinsertion was not within her scope of practice and that she had not been in-serviced on how to do it. The resident’s POA reported that the resident was transferred to the hospital, then transferred again because the first hospital did not have proper staff to reinsert the trach, and the resident was admitted to the ICU for respiratory distress. The ED record documented acute respiratory failure with hypoxia and hypercapnia, that the trach was not present, that the trach site had no patency, and that staff were unable to replace the trach. The facility’s DON stated that when a trach is dislodged she expected the nurse to reinsert it and document the attempts, but the ADON later stated the facility’s trach care policy and skills checklist did not include trach reinsertion instructions and that no staff had been in-serviced on trach reinsertion.
Kitchen Staff Lacked Required Food Handler Certification
Penalty
Summary
The facility failed to ensure kitchen employees had food handler certification for 4 staff members, including 3 cooks and 1 dietary aide. During interview, the Dietary Manager stated she had started in the role about 2 months earlier and was aware that multiple kitchen staff had not completed the food handler certification class. She reported corporate had arranged an in-person class for all kitchen staff in August 2025, but no kitchen staff attended. The Dietary Aide stated he thought he had taken the required certification but was not sure, and the DON/AIT later stated she could not find his food handler certificate. Record review and interviews showed the affected kitchen staff included a dietary aide and cooks whose employee census entries listed hire dates of 5/1/2025, 5/3/2025, and 10/14/2025. One cook stated her initial hire date was 9/9/2024 and that a former dietary manager told her on 9/25/2025 that she needed to take the food handlers class, but she was not told how or when to complete it. The Dietary Manager later stated that 2 cooks and 1 dietary aide were taking the class that day, and the DON/AIT stated 3 kitchen staff were taking the certification online that day and would not work until it was completed. The DON/AIT also stated the facility did not have a policy requiring kitchen employees to complete the food handler certification course, although she expected all kitchen employees to have it completed.
Failure to Ensure Competent Tracheostomy Care by Qualified Staff
Penalty
Summary
The facility failed to ensure that staff were educated and competent in providing necessary care and services for residents with tracheostomies, as required by each resident's written plan of care. Multiple residents with tracheostomies experienced repeated episodes where staff were unable to perform routine tracheostomy care, such as suctioning, cleaning, and tube changes. In several cases, residents were sent to the hospital for issues that should have been managed within the facility, including removal of mucus plugs, tracheostomy replacement, and management of secretions. Documentation revealed that staff did not perform suctioning when residents exhibited symptoms such as secretions or emesis from the tracheostomy, and there was a lack of documentation of interventions to prevent repeated tracheostomy dislodgement in one resident. One resident was found unresponsive, and staff performed CPR incorrectly by bagging the resident's mouth instead of the tracheostomy, as they were unaware of the correct procedure. Staff interviews confirmed that neither the LPNs nor CNAs had received training on tracheostomy care or emergency response for residents with tracheostomies. The local fire department and paramedics reported frequent calls to the facility for non-emergent tracheostomy issues, such as suctioning and cleaning, which they considered routine care that should be managed by facility staff. In several instances, emergency responders found that the facility lacked necessary equipment, such as suction tips, and that staff were not using available equipment properly. The deficiency was further evidenced by staff statements indicating a lack of formal or routine training on tracheostomy care, with some staff expressing discomfort and lack of knowledge in providing such care. The facility's own documentation and job descriptions required staff to remain current in facility policies and procedures, including specialized care needs such as tracheostomy care. Despite this, the facility assessment indicated that tracheostomy care was a service provided, yet staff were not adequately prepared to deliver this care, resulting in repeated hospital transfers and, in one case, a resident death.
Removal Plan
- Tracheostomy in-service was completed
- All nurses, including agency nurses, were educated
Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
Nursing staff failed to provide safe and appropriate respiratory care for residents with tracheostomies, as evidenced by a lack of knowledge, skills, and necessary supplies. Multiple staff members, including RNs, LPNs, and CNAs, reported not having received training on tracheostomy care or CPR for residents with tracheostomies. During emergencies, staff were unable to properly ventilate residents with tracheostomies, as they did not know how to use the bag-valve-mask (BVM) with a tracheostomy tube and instead attempted to ventilate via the mouth, which is not appropriate for these residents. In several cases, staff were unable to suction or replace tracheostomy tubes due to lack of training or proper equipment, resulting in inadequate airway management. Two residents with tracheostomies, both full code, experienced respiratory distress and required CPR. In both cases, staff did not provide ventilation through the tracheostomy tube during resuscitation efforts, and only performed chest compressions or attempted to bag over the mouth. There were multiple reports of staff not having the correct tubing or not knowing how to attach the BVM to the tracheostomy. Both residents died in the facility, with death certificates pending. Other residents with tracheostomies were sent to the hospital for issues such as secretions, mucus plugs, or tracheostomy tube dislodgement, which could not be managed by facility staff due to lack of training or supplies. Emergency medical services and local fire department personnel reported frequent calls to the facility for non-emergent tracheostomy care needs, such as suctioning or cleaning, which should have been managed by facility staff. In several instances, EMS had to use their own equipment to suction residents, as the facility lacked necessary supplies like suction tips. Staff interviews confirmed that there was no routine or formal training on tracheostomy care, and some staff expressed discomfort or lack of proficiency in caring for residents with tracheostomies. The facility's own policy required routine tracheostomy care and suctioning as needed, but this was not consistently provided.
Removal Plan
- Tracheostomy in-service was completed and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift.
Failure to Provide Proper CPR for Residents with Tracheostomies
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for two residents with tracheostomies who were full code status. In both cases, staff did not provide adequate respiratory ventilation through the residents' primary airway, the tracheostomy, during resuscitation efforts. Instead, staff attempted to provide ventilation via the mouth or did not provide ventilation at all, despite the presence of bag valve masks (BVMs) in the room, which were not compatible with the tracheostomy or staff did not know how to use them properly. For the first resident, who had chronic obstructive pulmonary disease, asthma, and a tracheostomy, staff initiated CPR after the resident was found unresponsive and cyanotic. However, they were unable to attach the BVM to the tracheostomy and instead covered the tracheostomy with a gloved hand and attempted to bag via the mouth, ultimately providing only chest compressions without ventilation. For the second resident, who had anoxic brain damage, paraplegia, respiratory failure, and a tracheostomy, staff also failed to ventilate through the tracheostomy. Staff attempted to bag via the mouth, not realizing the need to ventilate through the tracheostomy, and were unfamiliar with the correct procedure and equipment. Interviews with staff revealed a lack of knowledge and training regarding CPR for residents with tracheostomies, as well as issues with equipment availability and compatibility. The facility's own policies required that residents with tracheostomies receive care to maintain a patent airway and that CPR be performed per BLS guidelines, but these were not followed. Both residents died following these events, and the failures were confirmed through interviews, record reviews, and observations by surveyors.
Removal Plan
- Staff were inserviced on performing CPR on residents with tracheostomies
- CPR Policy was reviewed
- CPR equipment was verified as available in the Facility
- CPR audits were initiated
- QAPI Meeting was held
Failure to Report Change in Condition Leads to Delayed Response and Resident Death
Penalty
Summary
A deficiency occurred when staff failed to report a resident's significant change in condition to nursing staff for timely assessment and intervention. The resident, who had a history of anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status, was noted by two CNAs to have dilated pupils, cool skin, decreased responsiveness, and increased muscle stiffness during care. Despite these notable changes from the resident's baseline, neither CNA informed the nurse on duty about the observations. Approximately 15-20 minutes after the initial observations, one of the CNAs returned to check on the resident and found the individual unresponsive. The CNA then notified the nurse, who arrived after a short delay, and CPR was initiated. Multiple staff members, including a paramedic and other CNAs, later confirmed that the resident was cold to the touch and already stiffening during resuscitation efforts, indicating a significant lapse in timely recognition and response to the change in condition. Interviews with staff, including the DON and Medical Director, confirmed that facility policy requires staff to report any change in a resident's condition to a nurse, and if the assigned nurse is unavailable, to another available nurse. However, the CNAs involved did not communicate the observed changes, and the facility's policy did not specifically address communication protocols between nurse aides and licensed nursing staff. This failure to report and respond to the resident's change in condition resulted in a delay in assessment and intervention.
Removal Plan
- Clinical and agency staff were in-serviced on timely assessments
- Notification of Change Policy was reviewed
- QAPI meeting was held
- 24 hour reports were reviewed for change in condition
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident's medical records as required, specifically for one resident whose records were requested by an attorney. The process for handling medical record requests was disrupted when the staff member responsible for medical records was terminated, and the responsibility was transferred to the Business Office Manager, who was coordinating with the Regional Medical Records person. There was confusion and lack of communication regarding the receipt and processing of the request, with the Administrator and other staff members unaware of the outstanding request until much later. Documentation shows that the attorney's office made multiple attempts to request the records, including sending faxes, making phone calls, and mailing the request. The facility's fax numbers and process for handling requests contributed to the delay, as one fax number went directly to a copier/fax machine and was not monitored as closely as the secure fax/email. The previous medical records staff member indicated that she had started processing the request but was terminated before completion, and the request was not properly handed off or tracked. The facility's own policies require that all medical record requests be given to the Administrator and outline steps for processing such requests, including verification of authority and notification of costs. However, these procedures were not followed, resulting in a significant delay in providing the requested records. The deficiency was identified through interviews, record reviews, and documentation of the multiple attempts made by the attorney's office to obtain the records.
Failure to Follow Wound Care Orders Resulting in Resident Harm
Penalty
Summary
The facility failed to follow written wound care orders for a resident who was admitted with third-degree burns on the right foot, type 2 diabetes, and recent surgical aftercare. Upon admission, the resident's hospital discharge summary and care plan included specific instructions for wound care, including the use of bacitracin and xeroform dressings, daily washing, and dressing changes. However, documentation and interviews revealed that these orders were not consistently followed. The Treatment Administration Record (TAR) showed no wound care was signed off for two consecutive days, and there was no PRN order for wound care in the TAR. Staff interviews indicated confusion about the wound care orders, with some nurses expressing discomfort or lack of familiarity with the severity of the wounds, and others admitting to not performing wound care as required. The resident and family members reported that wound care was rarely performed, dressings were not changed or washed as ordered, and wound care was sometimes conducted in unsanitary conditions, such as on the floor of the resident's room. The wound care nurse admitted to removing a dressing that was supposed to remain in place and to not having the required bacitracin ointment available, substituting A&D ointment without notifying the provider or obtaining new orders. Communication lapses were evident, as the facility did not inform the hospital or the Director of Nursing about the lack of bacitracin, and the wound care nurse did not consistently document wound care in the TAR, instead making late entries in progress notes due to computer issues. As a result of these failures, the resident's wounds declined, leading to infection, increased pain, and ultimately hospital readmission for wound cellulitis and additional surgical intervention. Laboratory results showed elevated white blood cell counts, and wound cultures were positive for multiple organisms. The resident, his family, and clinical staff all described a pattern of missed or improperly performed wound care, lack of adherence to physician orders, and inadequate documentation, which directly contributed to the resident's deteriorating condition and need for further hospitalization.
Failure to Provide Safe and Appropriate Pain Management During Wound Care
Penalty
Summary
A resident with a history of third-degree burns to the right foot, type 2 diabetes mellitus, and recent skin graft surgery was admitted to the facility with specific wound care and pain management orders. The resident's care plan included interventions to provide treatment as ordered, and physician orders were in place for acetaminophen and oxycodone to be administered as needed for pain. Upon admission, the resident's wound care orders from the hospital specified that the xeroform dressing on the donor site (left thigh) should be left in place, washed daily, and not removed until healed. Despite these orders, a wound care nurse attempted to remove the xeroform dressing from the resident's thigh, causing the resident to experience severe pain and bleeding. The nurse did not pre-medicate the resident prior to the dressing removal attempt, and only stopped after the resident expressed extreme pain and refused further care. The nurse later discovered the correct wound care instructions, which indicated the dressing should not have been removed. Documentation and interviews confirm that the resident was not provided adequate pain management before the procedure, and the wound care was not performed according to the physician's orders. The resident reported significant distress, stating that the dressing was removed without proper pain control, resulting in severe pain and bleeding. Staff interviews corroborated that the resident was in extreme pain during the dressing removal and that pain medication was only administered after the incident. The facility's pain management policy emphasizes the importance of addressing pain as reported by the resident, but this was not followed in this instance, leading to unnecessary suffering.
Failure to Monitor and Document Resident's Decline
Penalty
Summary
The facility failed to assess, monitor, and treat a change in condition for a resident, leading to a delay in treatment and subsequent hospitalization. The resident, who had Alzheimer's Disease and Dementia, was admitted with a history of influenza and was on oxygen therapy, which she frequently refused. Despite her refusal to use supplemental oxygen and a noticeable decline in her condition, including reduced meal intake and weight loss, there was a lack of documentation and communication regarding her deteriorating state. The resident's vital signs showed concerning changes, such as low blood pressure and oxygen saturation, yet there were no nursing notes or assessments documenting these changes or any notification to the physician. Staff interviews revealed that the resident was not eating well, appeared sluggish, and was not her usual self, but these observations were not adequately documented or communicated to the medical team. The resident was eventually sent to the hospital with altered mental status, hypotension, and dehydration, where she was diagnosed with pneumonia, acute on chronic hypoxic respiratory failure, and other conditions. The facility's policies required notification of the physician for significant changes in a resident's condition and documentation of any unusual events or changes. However, these protocols were not followed, as evidenced by the lack of documentation and communication regarding the resident's decline. The Director of Nurses acknowledged the oversight in monitoring the resident's weight loss and meal intake, and the Medical Nurse Practitioner confirmed that they were not informed of the resident's decline, which contributed to the delay in addressing her medical needs.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to properly identify, assess, and monitor pressure ulcers, and provide the physician-prescribed treatment for four residents. One resident developed a pressure ulcer of unknown stage while at the facility and did not receive treatment for 23 days, during which time it became unstageable. Another resident developed three pressure ulcers while at the facility, including a sacral pressure ulcer that became infected. The facility's records failed to document necessary assessments and treatments, and there were inconsistencies in the treatment administration records. For one resident, the facility's records did not document a Braden Scale assessment before a certain date, and there was a lack of documentation regarding the monitoring, assessment, or treatment of a pressure ulcer for several weeks. The resident's treatment administration record showed that the resident refused dressing changes multiple times, and there were discrepancies between the treatment recommendations and the documented orders. Another resident's records failed to document an admission assessment, and there were inconsistencies in the documentation of skin conditions and pressure ulcers. The facility's staff did not consistently follow the prescribed treatment orders, and there were instances where treatments were not administered as ordered. The facility's policy required that pressure injuries be evaluated and documented weekly, but this was not consistently done. Additionally, there were communication issues between the wound nurse practitioner and the facility staff, leading to delays in implementing treatment recommendations. The facility's failure to adhere to its own policies and procedures contributed to the deficiencies in pressure ulcer care.
Failure to Timely Report Drug Diversion Incident
Penalty
Summary
The facility failed to adhere to its Abuse Policy and Prevention Program concerning a case of drug diversion involving a resident who was unable to communicate due to impaired cognition. The incident involved the disappearance of Lorazepam, a medication provided by hospice, which was scheduled to be administered every six hours. The medication was last administered at 6 AM by the midnight nurse, and it was discovered missing during the evening shift on January 10th. The facility's policy required an immediate investigation and notification to local law enforcement if there was a reasonable suspicion of a crime, but this was not done in a timely manner. The Director of Nursing (DON) and the Administrator reviewed video footage, which was inconclusive in identifying the individual responsible for the medication's disappearance. However, the footage showed an agency nurse spending an unusual amount of time with the narcotic box open and going in and out of a hospice resident's room. Despite these observations, the facility delayed notifying the police, as the DON believed she needed to complete her investigation before contacting law enforcement. This delay was contrary to the facility's policy, which required immediate reporting of suspected crimes. The incident report was eventually filed with the local police department, but not until several days after the medication was confirmed missing. The police report indicated that the facility had narrowed down the suspect to one nurse and had video footage of the incident. The delay in reporting the incident to law enforcement was acknowledged by the Administrator, who stated that the notification should have been completed more promptly. The facility's failure to adhere to its policy resulted in a deficiency in handling the drug diversion incident appropriately.
Delayed Reporting of Suspected Medication Misappropriation
Penalty
Summary
The facility failed to inform local law enforcement in a timely manner regarding the suspected misappropriation of a narcotic medication, Lorazepam, for a resident who was unable to communicate due to impaired cognition. The incident was initially identified on January 11, 2025, when it was discovered that a card of Lorazepam was missing. The medication was last administered at 6 AM by the midnight nurse, and upon further investigation, it was found that a card was missing from the narcotics count. The facility's Director of Nursing (DON) and other staff reviewed video footage, which was inconclusive, and attempted to locate the missing medication without success. The facility's policy required immediate reporting to local law enforcement when there was a reasonable suspicion of a crime. However, the DON delayed notifying the police until January 15, 2025, as she believed she needed to complete her investigation first. The facility's administrator later clarified that the policy was to report incidents of suspected crime immediately, regardless of the completion of an internal investigation. The delay in reporting was acknowledged by the administrator, who stated that the notification to the police should have been completed more timely. The facility's abuse policy and prevention program outlined the requirement to contact local law enforcement when there is a reasonable suspicion of a crime, especially if it involves serious bodily harm. In this case, although the resident did not suffer a negative outcome, the failure to report the suspected misappropriation of medication in a timely manner constituted a deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Provide Timely Meals
Penalty
Summary
The facility failed to provide three meals daily at regular times for four residents, as required by their policy. Resident 6, who was admitted with hemiplegia and hemiparesis, reported a significant delay in receiving dinner, which took over two hours to be served. This incident was documented in a grievance, highlighting the issue of staff being on their phones instead of attending to meal service. Resident 7, diagnosed with moderate protein calorie malnutrition and oral dysphagia, also reported that meals were consistently late, creating uncertainty about meal times. Resident 8, with protein calorie malnutrition and ileostomy status, filed a grievance after not receiving breakfast despite being present in the dining hall, indicating a lack of communication among kitchen staff. Resident 10, with chronic obstructive pulmonary disease and chronic kidney disease, similarly reported that meals were always late. The Director of Nursing and the Administrator both acknowledged the expectation for residents to receive three meals a day served on time, as per the facility's policy. The policy specifies that meals should be served at regular times comparable to normal mealtimes in the community, with breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:30 PM. However, the grievances and resident statements indicate a failure to adhere to these scheduled meal times, resulting in dissatisfaction and unmet nutritional needs for the residents involved.
Failure to Obtain Physician's Order for Staple Removal
Penalty
Summary
The facility failed to obtain a physician's order for the removal of surgical staples from a resident's right hip incision. The resident, who was admitted with a diagnosis of right hip fracture, had staples removed from the incision site without a documented physician's order in the medical record. A nurse's progress note indicated that staples were removed and steri-strips applied, but later documentation revealed that a staple was left in the incision, causing discomfort to the resident. The Director of Nurses confirmed the absence of a physician's order for the staple removal and stated that staff are expected to have such an order before performing the procedure. The facility's policy requires physician orders to be followed as written, and any questions about the order should be clarified with the physician.
Failure to Schedule Colonoscopy for Resident
Penalty
Summary
The facility failed to schedule a colonoscopy for a resident, identified as R2, despite a physician's order dated 9/10/24. R2, who has a diagnosis of Ulcerative Colitis and a history of colon resection surgery, was sent to the hospital with a bowel obstruction that was cleared before returning to the facility. R2 expressed concern about not having had a colonoscopy in 5 or 6 years, which was confirmed by his Power of Attorney (POA), who emphasized the importance of the procedure given R2's medical history. The Director of Nurses (DON) acknowledged difficulties in scheduling the colonoscopy due to unreturned calls from doctors' offices. Despite being aware of the POA's concerns, the appointment had not been made. The facility's administrator confirmed the absence of a policy on radiology/diagnostic services, which may have contributed to the delay in scheduling the necessary procedure for R2.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and provide appropriate care for residents at risk or already suffering from pressure ulcers. For Resident 1, who had multiple health conditions including diabetes, dementia, and impaired mobility, the facility did not implement the necessary interventions as outlined in the care plan. Despite being at risk for pressure ulcers, Resident 1 was observed on a regular mattress instead of a low air loss mattress, which was part of the care plan. The resident developed a stage 2 pressure ulcer on the left heel, which worsened to an unstageable ulcer, and a new stage 3 ulcer on the right buttock, along with a deep tissue injury on the coccyx. The facility staff failed to document these new ulcers and did not obtain treatment orders promptly. Resident 2, who was severely cognitively impaired and dependent on staff for mobility, also suffered from inadequate pressure ulcer care. The resident developed an unstageable pressure ulcer on the coccyx and a deep tissue injury on the right heel. The facility's treatment administration records showed that prescribed treatments were not consistently documented as completed. Additionally, there was confusion regarding the diagnosis of a Kennedy ulcer, which was not confirmed by the physician or nurse practitioner. The facility's policies on skin management and pressure injury treatment were not followed consistently. The staff failed to implement prevention protocols, such as regular turning and repositioning of residents, and did not ensure that treatment orders were obtained and documented for new skin impairments. These lapses in care and documentation contributed to the worsening of pressure ulcers in both residents, highlighting significant deficiencies in the facility's wound care management.
Failure to Date Opened Insulin Pens
Penalty
Summary
The facility failed to ensure that opened medications were labeled with open dates for five residents, as observed during a survey. On the specified date, an LPN was observed with a medication cart containing insulin pens for three residents, none of which were labeled with the date they were opened. The LPN, who was an agency nurse, stated she was unaware that insulin pens needed to be dated upon opening and did not know when the pens were initially opened. Another LPN, who was new, was also observed with a medication cart containing an undated insulin pen for a different resident. She similarly stated she was unaware of the requirement to date insulin pens upon opening. The Director of Nurses (DON) expressed that all staff are expected to date insulin pens when opened, as they expire after 28 days, but was not aware of the undated pens in the medication carts. The facility's policy requires medications to be stored safely and properly, following manufacturer recommendations.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Observations during meal times revealed that food was served on Styrofoam plates without proper insulation, leading to cold meals. Residents, including those who were cognitively intact and those with moderate cognitive impairment, consistently reported dissatisfaction with the temperature and quality of the food. Complaints were made during resident council meetings and through a special food committee, but no improvements were noted over a period of at least six months. During a breakfast service, it was observed that trays were not distributed promptly, resulting in further cooling of the food. Additionally, the kitchen ran out of bowls, causing a delay in meal service. A sample tray taken after the last tray was distributed showed that the food was not visually appealing, with a gray and yellowish hue, and lacked flavor. Temperature checks revealed that only one out of six food items was within the acceptable temperature range, with others being significantly below the required 135°F. The facility's policies on food preparation and dining services were not adhered to, as evidenced by the repeated complaints and observations of cold food. Meeting minutes from the food committee indicated ongoing issues with food temperatures, but no documentation was available for recent months. Staff interviews corroborated the residents' complaints, highlighting a persistent problem with food quality and service that had not been addressed effectively by the facility.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control policies and guidelines for four residents, leading to deficiencies in infection prevention and control. For Resident 54, multiple staff members, including CNAs and a wound nurse, entered the resident's room, which was under enhanced precautions, without wearing the required gowns. During wound care, the wound nurse did not change gloves or perform hand hygiene after removing old dressings, increasing the risk of cross-contamination. Resident 20 experienced a similar issue when a wound nurse did not wash her hands or apply disinfectant between changing gloves while treating open and bleeding wounds. This lack of proper hand hygiene before donning new gloves posed a risk of infection. Additionally, Resident 58's wound care was compromised when the wound nurse failed to change gloves or perform hand hygiene between cleansing different pressure ulcers, despite the resident having a diagnosis of osteomyelitis in one of the wounds. For Resident 65, an LPN administered medication via a g-tube without performing hand hygiene or wearing a gown, as required by the facility's Enhanced Barrier Precautions policy. The LPN mistakenly believed that only the resident's roommate required precautions. The facility's policy mandates the use of gowns and gloves during high-contact resident care activities, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, as evidenced by incidents involving three residents. One resident, who is severely cognitively impaired and diagnosed with Alzheimer's Disease, Schizoaffective Disorder, and Psychosis, was involved in an altercation with another resident. This altercation resulted in the cognitively intact resident hitting the impaired resident on the head with a cane, causing a hematoma. The incident was reported to the Director of Nursing, and the police were called, but no report was generated. The facility's abuse policy defines physical abuse as the infliction of injury that requires medical attention, which occurred in this case. Another incident involved a moderately cognitively impaired resident with diagnoses of Schizoaffective Disorder, Depression, Schizophrenia, and Major Depression Disorder. This resident was involved in an argument with the severely cognitively impaired resident over belongings, leading to a physical altercation where hair was grabbed, and a scratch was inflicted. The facility's failure to prevent these incidents and protect the residents from harm highlights a deficiency in their abuse prevention and intervention measures.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R71, who was at high risk for elopement due to multiple medical conditions, including chronic ischemic heart disease, cognitive communication deficit, and anxiety disorder. R71 was known to be exit-seeking and had a history of wandering, as documented in the care plan and physician order sheet. Despite having a wander guard in place, R71 managed to leave the facility on at least two occasions, as confirmed by staff interviews and video footage reviewed by the facility administrator. On one occasion, R71 was found at an apartment building next to the facility after being reported missing by staff. The wander guard alarm was supposed to alert staff when R71 approached the doors, but it was noted that the resident was able to exit the building by hanging on the access door, which opened after 15 seconds. Staff were not immediately aware of R71's absence, and it was only after a search and a call from 911 that the resident was located and returned to the facility. The facility's policy on elopement and unsafe wandering prevention emphasizes the importance of securing the environment and responding immediately to door alarms. However, the report indicates that the staff did not effectively monitor or respond to the alarms, allowing R71 to elope. The failure to ensure adequate supervision and secure the environment contributed to the resident's ability to leave the facility unsupervised.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident, identified as R54, who was always incontinent of urine and frequently incontinent of bowel. The resident's care plan aimed to keep her clean, dry, and odor-free, with interventions to provide incontinence care when needed. However, during an observation on September 11, 2024, it was noted that the resident's incontinent brief was heavily soiled with yellow urine, and the pad underneath was also stained. A CNA, V13, who was responsible for the resident's care, could not recall the last time the resident was checked, indicating a lapse in the two-hourly checks that were supposed to be conducted as per facility policy. Interviews with other CNAs and the Director of Nursing confirmed that incontinence checks were expected to be performed every two hours. Additionally, the resident's son reported finding his mother wet on previous occasions and mentioned that she had been hospitalized with sepsis and dehydration. The facility's policy on incontinence care, dated September 2023, emphasized the importance of keeping residents dry, comfortable, and odor-free to prevent skin breakdown, which was not adhered to in this instance.
Failure to Investigate Resident's Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse for a resident who reported incidents involving Certified Nursing Assistants (CNAs). On a specific date, the resident stated that she had been scratched on the back with a call light by one CNA and attacked by another. She reported these incidents to the administrator, who then involved the police, resulting in one CNA being jailed. However, a progress note from an earlier date documented the resident's complaint about a night CNA being rough and rude, but no further action or investigation was recorded. The facility's policy mandates that any incident, allegation, or suspicion of abuse, neglect, or mistreatment must be reported immediately to the administrator or a designated individual in their absence. Despite this policy, the administrator was not informed of the resident's earlier complaint, and no investigation was initiated at that time. This oversight indicates a failure to adhere to the facility's abuse prevention and reporting protocols, as the staff did not report the resident's allegations as required.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R73, who was part of a sample of 40 residents reviewed for abuse. On a specific date, R73 reported to the administrator that she had experienced incidents with some CNAs, including being scratched on the back with a call light and being attacked by another CNA. Despite R73's alert and oriented status, as documented in her Minimum Data Set, the facility did not report the allegation of abuse as required by their policy. The facility's policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a designated individual in their absence. However, the administrator stated that neither the staff nor the Director of Nursing informed her of R73's allegations. The facility's policy also requires that all incidents be documented and reported to the Illinois Department of Public Health within specified timeframes, depending on the severity of the incident. In this case, the failure to report the allegation of abuse was a violation of the facility's abuse prevention policy.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to provide routine medications in a timely manner for four residents, resulting in missed doses of critical medications such as insulin, antihypertensives, and anticoagulants. Resident 1, who was admitted with multiple serious conditions including pulmonary hypertension and congestive heart failure, did not receive several prescribed medications on a specific date due to the facility's pharmacy being located 274 miles away. The nurse's notes indicated that the medications were not available upon the resident's arrival. Resident 2, admitted with conditions such as thoracic aortic aneurysm and major depressive disorder, also missed several doses of important medications over two days. The nurse's notes documented that the medications were awaiting delivery from the pharmacy, and the resident was eventually sent to the emergency department for evaluation due to complaints of discomfort and dehydration. Similarly, Resident 3 did not receive a medication for excessive secretions, and the pharmacist noted issues with the prescription fill due to either diagnosis or insurance problems. Resident 4, with a complex medical history including cerebral infarction and diabetes, did not receive multiple medications due to awaiting pharmacy delivery. The facility's staff, including a nurse practitioner and the director of nursing, acknowledged the issues with medication availability, citing problems with pharmacy location and access to the automated medication dispensing machine. Agency nurses reported not having access to the dispensing machine, which further contributed to the delay in medication administration.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide a competent licensed nurse to administer medication to a resident, leading to a deficiency in medication administration. A resident, who was cognitively intact, had a care plan in place for pain management, which included administering Acetaminophen as needed. On a specific date, the resident requested pain medication at 2:30 AM, but it was not administered until 5:30 AM by a CNA, who was not licensed to give medications. The resident reported the incident to the day shift nurse, and it was noted that the medication was not properly documented in the Medication Administration Record by the responsible RN. The Director of Nursing and the Administrator were informed of the incident, and the CNA admitted to administering the medication. The RN involved was an agency nurse, and the facility decided not to allow her to return. The facility's policy on medication administration requires that all medications be administered by licensed personnel, which was not followed in this case, leading to the deficiency.
Failure to Administer IV Medications as Ordered
Penalty
Summary
The facility failed to administer intravenous (IV) medications as ordered for one resident, identified as R2, who was admitted with serious infections requiring specific IV antibiotics. Upon admission, R2 had orders for Tigecycline and Voriconazole to be administered every 12 hours. However, there was a delay in obtaining these medications from the pharmacy. The facility's progress notes indicate that the pharmacy was contacted about the IV antibiotics, and it was communicated that one of the antibiotics would not be available until the following day. Additionally, the pharmacy later informed the facility that they could not provide Voriconazole due to its hazardous nature and their inability to mix it. Despite receiving Tigecycline from the pharmacy on the evening of June 13, 2024, the facility did not administer the medication as ordered, and there was no documentation explaining the omission. The Director of Nursing acknowledged that the Tigecycline should have been administered since it was available. Consequently, R2 did not receive any antibiotics for 48 hours after leaving the hospital, which was confirmed by the medical assistant for the infectious disease doctor. The facility's medication administration policy requires documentation and notification if medications are not given as ordered, which was not adhered to in this case.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to prevent employee-to-resident abuse, resulting in a resident, R2, experiencing both physical and mental abuse. R2 was found with bruising under both eyes and on her left forearm, and she reported feeling scared and unsafe in the facility. The incident occurred when R2 was in her wheelchair and was not ready to go to bed due to pain in her feet and not needing much sleep. Despite her protests, two staff members, identified as V12, an LPN, and V15, a CNA, forcibly put her to bed using a mechanical lift, during which R2 was yelled at and physically handled, causing her distress and injury. R2's medical history includes diagnoses such as osteoarthritis, schizophrenia, bipolar disorder, generalized anxiety disorder, and insomnia, among others. She is cognitively intact, as indicated by her BIMS score of 15. The incident was reported to another LPN, V13, who documented R2's account of the abuse, including being yelled at and physically pulled by her wrists, resulting in a bruise and a small cut. The police were notified, and an investigation was initiated, confirming the abuse allegations. The facility's investigation corroborated R2's claims, with evidence including camera footage showing V12 and V15 entering R2's room with a sit-to-stand lift. Despite R2's resistance and her expressed desire not to go to bed, the staff members forced her into bed, violating her rights. The facility's abuse policy affirms residents' rights to be free from abuse, yet this incident highlights a significant failure in protecting those rights.
Failure to Provide Complete Incontinent Care Leading to UTI
Penalty
Summary
The facility failed to provide complete incontinent care to prevent urinary tract infections (UTIs) for a resident with a history of UTIs and other medical conditions. During an observation, a CNA did not perform hand hygiene after changing gloves and did not clean the resident's right side during incontinent care. The resident's care plan indicated a need for total assistance with toileting, and the facility's policy required cleaning from front to back, which was not followed. The resident was later admitted to the hospital with a UTI, altered mental status, and other conditions, and had a positive urine culture for E. Coli. The resident's medical records documented multiple hospital admissions related to UTIs and other complications, including acute metabolic encephalopathy, seizure, sepsis, fecal impaction, and hypoxemia. The Director of Nurses acknowledged that staff should complete incontinent care for any incontinent resident. The facility's incontinence care policy emphasized the importance of keeping residents dry, comfortable, and odor-free, and required proper perineal cleaning, which was not adhered to in this case.
Inadequate CNA Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to have enough CNAs working to meet the needs of the residents, as evidenced by the experience of one resident (R3). On the night of 4/29/24, R3, who is continent of bowel and bladder if assisted by staff, was unable to reach her call light or cell phone and was not checked on by staff throughout the night. As a result, R3 was left soaked in urine until she managed to call the facility around 5:00 AM. The CNA who responded, V7, confirmed that they were short-staffed and busy. R3 experienced chafing from lying in urine all night, although it had cleared up by the time of the interview. R3's cognitive status was confirmed to be intact with a BIMS score of 15. Interviews with staff members, including an LPN and multiple CNAs, corroborated the issue of short staffing, particularly on night shifts due to call-offs. The facility's Director of Nurses (DON) stated that they use a staffing grid based on census and attempt to cover shifts with their own staff or agency CNAs when someone calls off. However, the CNA schedule documented only three CNAs working on several nights, including the night of 4/29/24. The facility was unable to provide a staffing policy, further highlighting the deficiency in meeting the required staffing levels to ensure resident care.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for one resident (R3). R3 reported that she was denied her medication and experienced a delay in receiving her prescriptions, which she had been getting delivered to her home before moving to the facility. The resident was without her medications, including pain medication, muscle spasm medication, heart medications, and seizure medications, for about three days. The resident's Medication Administration Records (MAR) for March, April, and May 2024 documented multiple instances where medications were not given, including Trileptal, Amlodipine, Atorvastatin, Jardiance, Lamictal, Lisinopril, Coreg, Metformin, Baclofen, and Venlafaxine. Progress notes indicated ongoing issues with medication delivery from the pharmacy and communication problems between the facility and the pharmacy. The Director of Nursing (DON) stated that when a medication is not available, the nurse is supposed to call the pharmacy to resolve the issue. However, the documentation showed that medications were frequently not given or not available, and the reasons were not always clearly documented. The facility's Medication Administration policy requires that if a medication is ordered but not present, the nurse should check for misplacement, call the pharmacy, and obtain it from a contingency or convenience box if available. If the physician's order cannot be followed, the physician should be notified, and a note should be made in the resident's record. These steps were not consistently followed, leading to the deficiency in medication administration for R3.
Failure to Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to install the correct bed rail and obtain consent from the resident or their representative prior to the installation and use of bed rails for four residents. Observations revealed that residents had bed rails installed without documented consent. For instance, one resident with a diagnosis of weakness and hemiparesis was observed using a bed rail without prior consent. Another resident with a cerebral vascular accident diagnosis had a grab bar installed without consent. Similar deficiencies were noted for two other residents who had bed rails installed without documented consent, despite their medical conditions requiring such assistance for bed mobility and transfers. Interviews with the facility staff, including the administrator and the MDS/restorative nurse, confirmed that the facility had not been obtaining the necessary consents for bed rail use. The facility's policy on bed rails, dated October 2021, mandates that all residents be assessed for bed rail use upon admission and significant change, and that consent should be obtained. However, this procedure was not followed, leading to the deficiency. The administrator acknowledged the oversight and mentioned that they were now in the process of obtaining the required consents.
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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.
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Nursing homes near Wood River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nexus At Alton | 2.5 mi | ★★★★★ | 19 | 0 |
| Alton Memorial Rehab & Therapy | 4.4 mi | ★★★★★ | 9 | 0 |
| La Bella Of Alton | 5.1 mi | ★★★★★ | 3 | 0 |
| Estates Of Spanish Lake, The | 8 mi | ★★★★★ | 0 | 0 |
| Evercare At University | 8.1 mi | ★★★★★ | 5 | 1 |
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