Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgeway Senior Living during CMS and state inspections, most recent first.
A resident with psychotic disorder, bipolar disorder, recurrent UTIs, and Parkinson’s disease did not receive her monthly Invega Sustenna injection as ordered, even though the medication had been delivered to the facility. Staff also failed to process and administer an antibiotic ordered after an ED visit for a UTI; the RN overlooked the discharge paperwork, the order was not entered, and the pharmacy was never contacted. The resident later exhibited worsening manic and unsafe behaviors and required emergency psychiatric transfer.
A dependent, cognitively impaired resident with multiple diagnoses, including dementia and aphasia, was care planned as totally dependent for bed mobility and requiring a two-person assist for turning and incontinence care. An RN provided peri care alone while the resident was positioned on her side in bed, and when the RN reached for a towel, the bed alarm sounded and the resident rolled out of bed onto the floor. The resident sustained a scalp laceration that required suturing in the emergency room. Staff interviews and records confirmed that the resident could not assist with bed mobility and was always to receive care with two staff present.
A resident admitted with multiple serious conditions, including infective endocarditis, had orders for IV antibiotics to be administered via a PICC line but no corresponding orders for PICC care, such as flushing or dressing changes. Staff, including an RN and the DON, stated that PICC care is usually done routinely and included in batch admission orders, but acknowledged that these orders were not entered for this resident, resulting in IV therapy being provided without documented PICC line maintenance orders.
A resident with multiple serious diagnoses, including infective endocarditis, was ordered IV Vancomycin every 12 hours for infection, but several scheduled doses were not administered and the physician was not notified of these missed doses. An LPN could not clearly explain why the antibiotic was not given on multiple occasions, despite pharmacy records showing more doses delivered than documented as administered on the MAR. A Vancomycin trough was reported as critically low, and a subsequent dose was given before pharmacy recommendations based on that lab were received, with no documented physician notification regarding the missed doses.
Grievance Process Not Made Available or Followed: Residents who regularly attended Resident Council stated they did not know how to file grievances, where forms were kept, or whether complaints could be anonymous. They reported unresolved concerns about food quality, cold meals, lack of incontinence supplies, OTC meds, plastic utensils, and no condiments, and one resident showed a photo of a meal tray with only a plastic spoon. Review found no grievance forms for these issues, and staff gave conflicting information about where forms were available.
A facility failed to assist multiple residents with ADL hygiene needs, including shaving, facial hair removal, and nail care. Residents with dementia, Parkinson’s disease, COPD, diabetes, mobility issues, and other diagnoses were observed with long or unkempt facial hair and long, jagged, or dirty fingernails with black substances under the nails. Staff acknowledged several residents were dependent on assistance for personal hygiene and grooming, including nail care and shaving.
Medication storage and labeling practices were deficient when multiple residents’ opened ophthalmic solutions were found without open or discard dates, including several latanoprost bottles stored together and one bottle kept beyond the 30-day use period. In addition, Norco cards in the locked narcotic box were found opened and re-taped with plastic and paper tape. The DON stated eye drops should be dated for 30 days and unused narcotics should be disposed of with two nurses witnessing the disposal.
A resident with quadriplegia, chronic respiratory failure, and multiple psychiatric diagnoses was kept from using her motorized wheelchair and placed in a manual chair she could not propel. Facility administration directed the PT to change the wheelchair controller to a slower speed before returning it, and the resident and her brother stated no consent was given for the modification. The DON stated staff used the manual chair until the change and safety evaluation were completed, while the resident reported feeling punished and wanting her original controller back.
A resident with Parkinson’s disease, chronic pain, COPD, bipolar disorder, and unsteadiness on feet requested a motorized wheelchair to improve mobility and reduce pain. The PT said he evaluated the resident and made a vendor referral, but was told by supervision/admin not to proceed because the resident would not be allowed to have the power wheelchair. The resident reported the wheelchair had been approved by insurance but delivery was refused by the facility, while the DON said the resident did not need it because the resident could walk with a walker; the resident was observed using a manual wheelchair during the survey.
Failure to monitor and document a physical restraint: A resident with dementia and multiple chronic conditions was observed repeatedly in a wheelchair with a secured lap cushion positioned against her trunk and the wheelchair pushed against a table. Staff said the device was used routinely, but records lacked restraint observations, skin checks, documentation of placement/removal times, and 72-hour response notes. The physician order did not specify release details, and the care plan only noted to provide a lap buddy without restraint-reduction details.
Failure to Report Allegation of Abuse: A resident with quadriplegia, PTSD, MDD, anxiety, and uterine cancer said a CNA was rough during incontinence care and scratched her, causing bleeding. Another CNA was told about the scratch but did not report it, and the allegation was not immediately reported to the abuse coordinator or state agency; the abuse investigation report was filed only after surveyor notification.
A resident with multiple chronic diagnoses and intact cognition was independent with most ADLs and repeatedly stated he wanted discharge to independent or supportive living, but staff were not helping him reach that goal. The discharge plan instead reflected a long-term placement with a 3-year wait for a supportive living option due to an age requirement, even though other independent or supportive living facilities were noted as possible options. The resident was observed ambulating independently and interacting with peers, and an RN stated the resident had been expressing this desire since shortly after admission.
MDS Did Not Accurately Reflect Restraint Use and Oxygen Therapy: The facility failed to accurately document care for two residents in the MDS. One resident with dementia and Alzheimer’s disease was observed using a secured lap cushion attached to a wheelchair, but the MDS indicated no restraint even though staff confirmed it was used as a restraint. Another resident with COPD, emphysema, and dementia had an oxygen order for continuous O2, but the MDS was not updated to reflect the oxygen therapy; staff confirmed the order and use of oxygen.
Failure to off-load a resident’s heels for existing pressure ulcers. A resident with severe cognitive impairment, limited mobility, and incontinence developed facility-acquired unstageable DTI to both heels. The wound physician ordered heel floating, off-loading, and pressure off-loading boots, but staff were observed placing pillows under the heels while the heels still touched the pillows, bed sheet, or mattress. The DON stated the resident’s heels should be off-loaded when recommended, and the care plan did not address the pressure ulcers.
A facility failed to maintain residents’ nutritional status by not consistently monitoring meal intake, not offering meal alternatives, not encouraging intake, and not carrying out RD-recommended supplements and weekly weights for residents with low body weights and poor oral intake. One resident with COPD and DM had significant weight loss and the RD’s MedPass and weekly weight recommendations were not ordered; another resident with dementia and CHF was observed eating poorly and staff did not offer alternatives; a third resident with adult failure to thrive had ongoing weight loss, no nutrition interventions in the care plan, and an unavailable protein shake order despite family concerns.
Oxygen Not Administered as Ordered: A resident with COPD and respiratory failure was observed receiving oxygen above the ordered LPM, another resident with COPD had a continuous oxygen order that was not reflected in the care plan or MDS and was often seen without oxygen, and a third resident was on continuous oxygen at a higher rate than the PRN order specified. Staff confirmed the orders did not match actual oxygen use, and the DON stated oxygen is medication and changes to the rate require a physician order.
Failure to reassess and manage a resident’s pain. A cognitively intact resident with Parkinson’s disease, DM2, COPD, bipolar disorder, and chronic low back/hip pain reported worsening pain with walking, therapy, and leg exercises, but the chart showed no updated pain assessment when symptoms increased and no change in the pain regimen after the resident complained. The resident stated Tylenol was the only pain med available at times, a prior pain med had helped but was discontinued, and the resident had developed a behavior of calling 911 due to unrelieved pain.
Staff failed to follow infection control practices for two residents. An RN provided gastrostomy tube feeding care to a resident on EBP without wearing a gown, removed a glove and handled the resident’s table with a bare hand, then put on a new glove without hand hygiene. In another instance, a CNA entered a resident’s room on contact isolation for Klebsiella without PPE and touched the resident while setting up the meal tray.
A resident with multiple medical and cognitive conditions was found living in a room with raised, uneven floor tiles, a window with rotting wood and a non-functioning crank that allowed cold air to enter, and a malfunctioning refrigerator unable to maintain safe temperatures. These environmental deficiencies were known to maintenance staff for months but were not adequately addressed, and facility leadership was unaware of the ongoing issues, despite policy requirements for preventive maintenance and communication.
A resident with multiple chronic conditions experienced a significant change in condition, including shortness of breath and low oxygen saturation, after being transferred to bed. The LPN assessed the resident and provided oxygen but did not notify the resident's family representative as required by facility policy, and there was no documentation of such notification or escalation to the DON or Medical Director.
A resident with multiple chronic conditions became lethargic and required oxygen, but nursing staff did not perform or document a thorough assessment, including vital signs and neurological status, as required by facility policy. The nurse did not seek additional help or notify the physician in a timely manner, and documentation of the resident's condition and interventions was incomplete prior to the resident's emergency transfer and subsequent hospital admission for serious medical issues.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident with cognitive intactness and multiple diagnoses, including congestive heart failure and Parkinson's disease, was found with disheveled hair, overgrown nails, and a wet brief. Despite a care plan addressing her needs, the resident reported being left wet for extended periods, with CNAs observed not attending to her needs. The facility's policy lacked specific guidelines on the frequency of perineal care checks.
A resident with multiple health conditions was left without a working call light for over a day, resulting in delayed assistance while she was wet and unable to call for help. Despite being aware of the issue, the facility did not provide an alternative method for the resident to contact staff, and the call light was not repaired promptly.
The facility failed to follow standardized recipes, resulting in substandard meal quality for residents. Observations revealed that meals did not adhere to prescribed recipes, with residents reporting issues such as overly salty food and unpleasant tastes. The kitchen staff deviated from recipes for items like pizza and strawberry shortcake, leading to meals lacking nutritional value and quality. The dietary manager confirmed the importance of following recipes to ensure proper nutrition and taste.
The facility's kitchen was found to have several deficiencies related to food safety and storage. The walk-in cooler was operating above the safe temperature, and food items were improperly stored, including staff lunches without labels. Staff members were not wearing required hair and beard restraints, and the kitchen lacked a garbage can near the handwashing sink. In dry storage, several food items were expired or improperly labeled. These issues indicate non-compliance with the facility's food safety policies.
The facility failed to maintain the kitchen walk-in cooler at a safe temperature, with readings of 58 and 55 degrees Fahrenheit observed, exceeding the safe range of 41 degrees Fahrenheit or below. Despite this, perishable food items were stored in the cooler, contrary to facility policy, which requires transferring food to another unit if temperatures exceed safe levels. This affected all residents receiving oral nutrition from the facility kitchen.
The facility failed to provide written notification to residents and their families or POA regarding hospital transfers and did not notify the ombudsman. This affected five residents transferred for conditions like acute cystitis, wound infection, sepsis, and respiratory distress. The ADON stated that written documentation was only given to alert residents and the ombudsman was notified only upon discharge, not during hospitalizations.
The facility failed to provide written notification of bed hold policies to residents and/or their POA at the time of hospital discharge. Five residents were transferred for various medical conditions without receiving the required documentation. The ADON admitted that the facility only verbally notified families and lacked a formal bed hold policy.
The facility failed to provide adequate ADL care for five residents dependent on staff for personal hygiene. Observations showed residents with unshaved facial hair, long nails with brown substances, and oily hair. Residents expressed dissatisfaction, indicating staff did not provide necessary assistance. The residents had various medical conditions requiring staff help, but the facility did not meet these needs, as evidenced by their unkempt appearances and reports of inadequate care.
The facility failed to secure medications during administration and did not obtain physician orders for over-the-counter medications, leading to unauthorized storage in residents' rooms. An RN left medications unattended, and several residents had medications without proper orders or assessments. The DON acknowledged the need for assessments and orders for self-administration or bedside storage, which were not followed.
The facility failed to maintain proper temperature logs and storage of food in residents' personal refrigerators, affecting five residents. Observations showed missing temperature logs and thermometers, with some refrigerators containing potentially spoiled food. The DON was unsure of staff responsibilities for temperature checks, later identifying housekeeping as responsible, but they were not consistently performing the task. Facility policies require food to be labeled, dated, and discarded per guidelines, with daily temperature checks recorded.
The facility failed to implement proper infection control practices, affecting all residents. Staff did not use Enhanced Barrier Precautions (EBP) as required, with missing signage and PPE for residents with wounds and catheters. Improper disposal of PPE and inadequate hand hygiene were observed. The facility also lacked updated infection control policies and had missing records for water testing to prevent legionella.
A resident with severe cognitive impairment was fed by a nurse in a demeaning manner, with the nurse standing over her and instructing her to eat in a demeaning tone. The Director of Nursing acknowledged that staff should sit at the same level as residents during feeding to maintain dignity, as per the facility's Resident Rights Statement.
A resident in a LTC facility was unable to reach her call light while sitting in a recliner, as it was attached to her bed across the room. The resident, who has moderately impaired cognition and is dependent on staff for hygiene, expressed frustration about the inaccessibility. The MDS Coordinator and DON confirmed that call lights should be within reach, aligning with the facility's policy to ensure communication means are accessible to residents.
A facility failed to invite a resident to care plan meetings, resulting in the resident being unaware of discharge goals. The Social Services Director confirmed the lack of documentation showing invitations to the resident or family, despite the facility's policy requiring their involvement in the care planning process.
The facility failed to properly monitor blood glucose levels and administer insulin according to physician orders for two residents. An RN administered insulin without aligning with meal times, and an LPN checked a resident's blood glucose while they were eating, contrary to orders. The DON acknowledged the need for pre-meal checks, but some nurses administered insulin with meal trays to avoid hypoglycemia.
A facility failed to implement a physician's order for a resident with dysphagia, leading to the use of a straw despite orders against it. The resident's care plan and physician's orders specified no straws and aspiration precautions, which were not followed by CNAs and an SLP. The facility lacked a policy for implementing physician's orders, as acknowledged by the ADON.
A resident with a history of hemiplegia and hemiparesis following a cerebral infarction did not receive restorative services as recommended. Despite being on programs for bed mobility, dressing, and active range of motion, there was no documentation of these services being provided over the past 30+ days. The resident expressed that he no longer receives therapy and is unable to get out of bed on his own, highlighting a lapse in the facility's adherence to its restorative nursing policy.
The facility failed to properly position catheter drainage bags for three residents during wound and incontinence care, leading to potential urine backflow. One resident's bag was placed above the bladder line, causing backflow, while another's was mishandled during care. A third resident was not switched to a larger collection bag when in bed, risking backflow. Staff acknowledged the improper handling, which could lead to UTIs.
The facility did not post current daily staffing information, affecting all 159 residents. The Daily Staff Posting was outdated, showing a previous date and census. The DON explained that the receptionist updates and posts staffing information after receiving the census email between 9:30 AM and 10:00 AM. However, the receptionist's schedule may cause delays. The facility's policy requires posting staffing data at the start of each shift, as per regulations.
A resident with a complex medical history experienced a slow deterioration due to the facility's failure to identify a change in condition, provide frequent monitoring, and communicate effectively with the physician. The resident was transferred to the hospital in critical condition and later died from septic shock. The facility did not take vital signs after the initial assessment and delayed notifying the physician, leading to a delay in hospital transfer.
The facility failed to conduct the required quarterly Quality Assessment and Assurance (QAA) meetings with the necessary members, impacting all residents. The last QAPI meeting was in December 2023, and subsequent meetings were missed. The April 2024 QA meeting lacked attendance from the Administrator and Medical Director, contrary to the facility's policy requiring their presence.
The facility failed to maintain a safe and sanitary environment in the B-wing hallway, affecting several residents. Observations showed missing ceiling tiles with water dripping from exposed plumbing, saturating the carpet. A malfunctioning air conditioning unit was identified as the cause, with temporary fixes leading to leaks. The Maintenance Director acknowledged the safety concern of water dripping onto an electrical source, but no immediate resolution was provided. The issue persisted for several days, impacting residents and staff.
Missed antipsychotic injection and unprocessed antibiotic order
Penalty
Summary
The facility failed to ensure a resident received a monthly Invega Sustenna injection as ordered and failed to ensure an oral antibiotic ordered after an ED visit was processed and administered. The resident had diagnoses including psychotic disorder with hallucinations, bipolar disorder, recurrent urinary tract infections, and Parkinson’s disease. Her physician orders showed Invega Sustenna 156 mg/mL to be given monthly on the 5th, and her prior MARs showed the injection had been given consistently in earlier months. However, the July MAR did not show the medication as administered, and instead contained a notation for other/see nursing notes on the 5th. Family and staff interviews showed the injection was delivered to the facility on 07/06/2026, but the RN who received it said he did not realize he needed to administer it. The resident’s family member stated the resident did not receive the injection that month and later developed worsening psychiatric symptoms. A late nursing note documented that the resident was calling 911 from the facility, exhibiting manic behavior, agitation, poor judgment, and unsafe behaviors that could not be safely managed in the facility, and she was transferred for emergency psychiatric evaluation and stabilization. The facility also failed to carry out an antibiotic order from the resident’s ED visit for a urinary tract infection. The RN stated he overlooked the discharge paperwork and did not endorse it to the incoming nurse, and the antibiotic order was not entered on the active physician orders. The LPN told the family the resident was receiving antibiotics, but later acknowledged there was no order entered. The physician stated he was not notified of the antibiotic order or asked to clarify the ED orders, and the pharmacist stated the facility never called to fill the prescription. Facility staff and policies indicated medication orders should be processed timely, transcribed promptly, and medications not received and initiated within 24 hours were considered a medication incident.
Failure to Use Required Two-Person Assist During Peri Care Resulting in Resident Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a dependent resident during incontinence care, resulting in a fall from bed and injury. The resident had diagnoses including conversion disorder with seizures, dementia, aphasia, and dysphagia, and an assessment documented severe cognitive impairment with total dependence on staff for all care, including bed mobility. The care plan for activities of daily living identified the resident as totally dependent for bed mobility, requiring two staff to roll left and right. Despite this, on the afternoon in question, a single RN provided incontinence care while the resident was lying in bed on her right side. The RN reported that the resident’s daughter had requested the resident be cleaned, the daughter then left the room, and the RN proceeded to provide care alone. During the provision of perineal care, the RN had the resident positioned on her right side and reached to the left for a towel while stating she kept a hand on the resident. At that moment, the bed alarm sounded and the resident rolled out of the bed onto the floor. The fall report and staff interviews indicate the resident was totally dependent for movement in bed and was always to be assisted by two staff for care. Following the fall, the RN observed bleeding from a small cut on the back of the resident’s head, immediately assessed the resident, contacted the physician, and the resident was transferred to the emergency room, where a 1-centimeter scalp laceration requiring two staples was documented. The DON’s investigation concluded that the resident rolled off the bed during incontinence care while only one staff member was present, despite the resident’s documented need for two-person assistance for care and bed mobility.
Failure to Obtain PICC Line Care Orders for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to obtain and document provider orders for the care and management of a resident’s PICC (peripherally inserted central catheter) line despite ongoing IV antibiotic therapy. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder, and had admission orders for two IV antibiotics to be administered via the PICC line two to three times daily. However, the admission orders did not include any directives for PICC line care, such as flushing, dressing changes, or other maintenance. Nursing staff, including an RN and the DON, reported that routine PICC line care (flushes, weekly dressing changes, checking for a cap, measuring the line and arm circumference) is normally performed and is supposed to be included in batch orders entered at admission, but acknowledged that these orders were not entered for this resident. This omission resulted in the resident receiving IV medications through a PICC line without corresponding written orders for line care and maintenance, as confirmed by interview and record review.
Missed Vancomycin Doses and Lack of Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV Vancomycin doses were not administered as prescribed and the physician was not notified of the missed doses. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder. The February 2026 MAR shows that Vancomycin 1750 mg/350 ml every 12 hours for infection was not given on multiple scheduled administrations: 2/26 at 9:00 PM, 2/27 at 9:00 PM, 2/28 at 9:00 AM, and 2/28 at 9:00 PM. An LPN stated she did not know why the Vancomycin was not given on those days, speculating that on the admission date it was probably not available, that on one date the resident went to the hospital after calling 911, and that on another date the medication might have been on hold pending blood test results, but she did not provide a clear reason for each missed dose. Laboratory data show that a Vancomycin trough drawn on 2/28/26 was reported as an alert low value of 3.6 (normal 10–20), with the result communicated to facility staff on the same day at 2:52 PM. The facility’s process, as confirmed by staff, was to notify the pharmacy after receiving such results. The next progress note entry, dated 3/1/26 at 3:19 PM, documents a call from the pharmacy with instructions to continue the same Vancomycin dose and obtain additional labs, and staff confirmed that a Vancomycin dose was administered on 3/1/26 at approximately 9:30 AM before the pharmacy’s recommendations based on the 2/28/26 lab were received. Pharmacy packing slips show that a total of 8 Vancomycin doses were delivered between 2/26 and 3/3, while the MARs for February and March 2026 document administration of only 5 doses. Progress notes from 2/27 through 3/1 do not contain any documentation that the physician was notified of the missed Vancomycin doses.
Grievance Process Not Made Available or Followed
Penalty
Summary
The facility failed to follow its grievance policy, failed to ensure residents knew how to file grievances, and failed to make grievance forms readily available. During the annual survey resident meeting on January 13, 2026, eight residents who regularly attended Resident Council, including the Resident Council President, stated they did not know how to file a concern or grievance, did not know where grievance forms were kept, and did not know whether grievances could be filed anonymously. The residents also reported recurring concerns from council meetings that they felt were not resolved or responded to, including food quality, lack of supplies such as incontinence care items, and meal service issues. Specific concerns raised during the meeting included lack of incontinence supplies, the facility being out of OTC acetaminophen, meals served cold, residents being given only plastic utensils, and no condiments being provided when needed. One resident provided a photo showing a meal tray with only a plastic spoon for a salad, hamburger, and French fries. Two residents stated they had been requesting healthier snacks such as fresh fruit and vegetables instead of crackers and cookies, but there had been no change and no response from staff. Review of the concern/grievance forms for the prior 6 months showed no forms completed for these issues. Staff interviews showed conflicting information about access to grievance forms, with one staff member stating forms would be given if requested, another stating they were available only at the reception desk, and the receptionist stating the desk was staffed from 8 AM to 8 PM. The facility policy stated grievances or complaints were to be investigated within 5 working days and the resident or complainant informed of findings and actions taken.
Failure to Provide ADL Hygiene and Nail Care
Penalty
Summary
The facility failed to provide assistance with activities of daily living for residents who were identified as needing help with personal hygiene and nail care. In the sample of 30 residents, 5 of 5 residents reviewed for ADL care—R27, R49, R63, R92, and R133—were observed with long, jagged, dirty, or unkempt fingernails, and several also had long or unshaven facial hair. The report states that these residents had diagnoses including dementia, Parkinson’s disease, COPD, diabetes, cancer, gait and mobility problems, and other conditions, and their MDS assessments and care plans identified varying levels of cognitive impairment and dependence on staff for personal hygiene. R92 was observed in a reclining wheelchair with long, unkempt facial hair and long, jagged fingernails with black substances under some nails; staff stated he required total assistance with grooming, shaving, and nail care. R27 was in bed with long, jagged fingernails with black substances under some nails and stated she needed staff help to trim and clean them; staff acknowledged she was dependent on staff for nail care. R133 was observed with long, curling facial hair on her chin and uneven, jagged fingernails with black substances under the nails; she stated she wanted staff to shave her and clean and trim her fingernails, and the ADON acknowledged she needed assistance with grooming and nail care. R63 was observed in bed with long, unkempt facial hair and stated it would be nice to be shaven; staff stated he needed shaving and was dependent on staff for personal hygiene. R49 was observed eating lunch with long fingernails and black substances under the nails on both hands, and staff stated the CNAs were responsible for cleaning her fingernails during scheduled showers and as needed when dirty. The DON stated that providing assistance with shaving or removal of unwanted facial hair and nail care is part of the facility’s nursing care and service to maintain residents’ hygiene and grooming.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to provide safe medication storage and labeling practices for residents receiving prescription and narcotic medications on one nursing unit. During a medication cart inspection, opened latanoprost ophthalmic solution bottles for multiple residents were found without open or discard dates written on the bottles or boxes. For one resident, two opened bottles of latanoprost were stored together in one box without dates. For another resident, both latanoprost and brimonidine tartrate eye drops were open with no open or discard dates documented. The residents involved had diagnoses including glaucoma, hypertension, vascular dementia, cerebral infarction, multiple sclerosis, transient ischemic attack, and type 2 diabetes mellitus. Additional medication storage concerns were identified with other residents’ eye drops. One resident had two opened bottles of latanoprost stored together in one box without open or discard dates. Another resident had two opened bottles of latanoprost stored together in one box without open or discard dates. For one resident, the latanoprost eye drop box was open and dated with an open date of December 2, 2025, but the medication had not been discarded after 30 days; the nurse stated it should have been disposed of on January 1, 2026. The DON stated that residents’ prescribed eye drops should be dated for 30 days of use upon opening and discarded after 30 days. The inspection also found narcotic medication cards for Norco 5-325 mg in the locked narcotic box that had been opened and re-taped. One card for a resident was re-taped with clear plastic tape, and another resident’s card was re-taped with yellow paper tape. The DON stated that unused narcotic medications should be disposed of with two nurses witnessing the disposal and that nurses should not return unused narcotic medication by applying tape to seal the medication cards. The facility’s Medication Administration Policy stated the cart will be locked when direct visual access is not possible and that no medications may be returned to its original container once removed, and the Medication Labeling Policy required all drug and biological labels to be accurate and complete upon receipt and prior to administration.
Resident denied use of motorized wheelchair and wheelchair modified without consent
Penalty
Summary
The facility failed to honor a resident’s right to dignity, self-determination, communication, and exercise of rights when it prevented R175 from using her motorized wheelchair and modified the wheelchair without obtaining her consent. R175 was admitted with quadriplegia C5-C7 incomplete, chronic respiratory failure, malignant neoplasm of uterus, alcohol abuse, major depressive disorder, anxiety disorder, and PTSD. Her MDS showed she was cognitively intact and required varying levels of assistance with ADLs, including dependence for toileting and transfers. After returning from the hospital, R175 stated staff would not allow her to use her motorized wheelchair and instead placed her in a manual wheelchair, which she could not propel because of left hand spasticity and immobility of her left leg from her spinal cord injury. She stated she was told the facility would not return her motorized wheelchair until the chair was modified to limit it to indoor speed. R175 stated she did not want the modification and wanted her original controller back, but felt pressured to agree so she could regain access to her wheelchair. The physical therapist stated administration instructed him to modify the wheelchair speed before returning it to R175, and he removed the original controller and installed a different one with only one slow speed. The DON stated staff were instructed to use a manual wheelchair until the modification and safety evaluation were completed, and also stated the facility was not allowed to take away a resident’s motorized wheelchair because it would decline the resident’s quality of life. R175’s brother denied giving permission for any change to the wheelchair, and another resident confirmed seeing the wheelchair in the chapel activity room after R175 returned to the facility. The facility policy stated residents are to be treated with kindness, respect, and dignity and assisted in exercising their rights.
Failure to Complete Referral for Requested Motorized Wheelchair
Penalty
Summary
The facility failed to complete the referral process to obtain a motorized wheelchair for a resident who requested it to gain more independence with mobility. The resident had multiple diagnoses including Parkinson’s disease, type 2 diabetes, low back and left hip pain, COPD, bipolar disorder, and unsteadiness on feet. The resident’s MDS showed the resident was cognitively intact and needed assistance with several ADLs, including supervision with oral hygiene, dressing, and transfers. The resident stated that a motorized wheelchair had been ordered by the physician because walking caused increased pain, but it was not delivered because the Social Services Director told the Physical Therapist the resident did not need one. The Physical Therapist stated he had evaluated the resident for power wheelchair use and had made a referral to the vendor, but his supervisor told him administration instructed him not to proceed because the resident would not be allowed to have the power wheelchair. Email correspondence showed the vendor was working with the resident’s healthcare provider to obtain a face-to-face evaluation, and therapy documentation showed wheelchair management training had been provided. The resident reported being forced to walk despite pain and said insurance had approved the power wheelchair, but delivery was being refused by the facility. The DON stated the resident did not need a motorized wheelchair because the resident could walk with a walker to the smoking area, while the resident was observed using a manual wheelchair during the survey. The facility was unable to provide a policy regarding accommodation of resident needs when requested.
Failure to Monitor and Document Use of a Physical Restraint
Penalty
Summary
The facility failed to provide ongoing monitoring and reassessment of a physical restraint, failed to implement restraint-reduction interventions, and used a physical restraint without documentation showing it was medically necessary for one resident. The resident was admitted with multiple diagnoses including intervertebral disc degeneration of the lumbar region, hypercholesterolemia, hypertension, osteoarthritis of the left hip and knee, dementia, chronic embolism and thrombosis, Alzheimer's disease, anxiety disorders, varicose veins, and osteoporosis. The current MDS showed severe cognitive impairment, that the resident was rarely understood, and that she used a manual wheelchair operated by staff, with no physical or verbal behaviors or wandering documented. Survey observations showed the resident seated in a wheelchair with a secured lap cushion on her lap and resting against her trunk while the wheelchair was pushed up against a corner table in the dining room. On multiple observations across several days, the resident remained in the same position, including one instance where she attempted to move the secured lap cushion but was unsuccessful and another where she was sleeping in the wheelchair at the dining room table. Staff interviews indicated the device was used routinely, with one CNA stating the resident must always wear the secured lap cushion because she gets out of her wheelchair, and another CNA stating it was removed only for toileting and at bedtime. An LPN stated staff were not instructed to document the time the device was placed or removed. Record review showed a physician's order dated August 25, 2025 for a lap buddy on the wheelchair every shift, but the order did not note release of the restraint. A signed restraint evaluation dated August 19, 2025 identified the secured lap cushion as both an enabler and restraint and cited sliding out of the wheelchair as the reason for use. There was no documentation of the restraint in progress notes, no evidence of a restraint observation, no documentation of the resident's response for 72 hours after initiation, and no skin assessments related to the restraint. The care plan only stated to provide a lap buddy and did not include details about release, duration, reason, or interventions to reduce restraint use. The facility's Physical Restraint Policy required restraint observations, physician orders defining type, reason, duration, and justification, documentation of the resident's response each shift for 72 hours, temporary release at least every two hours, and care plan details reflecting restraint use and reduction efforts.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the designated abuse coordinator and the state agency. A resident admitted with quadriplegia, chronic post-traumatic stress disorder, recurrent major depressive disorder, anxiety disorder, and uterine cancer stated that some staff were really rough and that a CNA gouged her during incontinence care and made her bleed. The resident reported the incident to several aides, including another CNA, and later said that CNA saw the scratch left from the care the next day. The CNA who was told about the scratch said the resident told her that the other CNA scratched her during incontinence care, but she did not report it to anyone and believed the resident would report it to the DON. The administrator stated that rough handling of a resident would be considered an allegation of abuse and should be reported immediately for investigation, staff removal from the schedule, resident assessment, and notification of the physician and state agency. The facility’s abuse investigation report was filed only after notification by the survey team, rather than immediately after the allegation was reported.
Inadequate discharge planning assessment for a cognitively intact resident seeking more independent living
Penalty
Summary
The facility failed to adequately assess a resident for discharge planning in accordance with its policy. The resident was admitted with diagnoses including radiculopathy, type 2 diabetes, low back pain, benign prostatic hyperplasia without lower tract symptoms, and acquired ichthyosis. The resident's MDS dated December 19, 2025, showed he was cognitively intact and required set up assistance with eating and showering, while being independent with grooming, toileting, dressing, bed mobility, transfers, and ambulation. On January 12, 2026, the resident stated he wanted discharge to independent or supportive living and said staff were not helping him reach that goal. He reported that he only received medications from nurses, was independent in self-care, and even swept his own room. He also stated he needed help obtaining personal items from the facility he transferred from and had made those requests to the Social Services Director without receiving assistance. The discharge plan assessment showed the resident's placement was expected to be long term and that he would have to wait 3 years in the current facility before discharge to a supportive living facility. On January 14, 2026, the Assistant Administrator stated the 3-year wait was due to the resident not meeting the age requirement for the sister supportive living community, though other supportive or independent living facilities could be options. The resident later stated he wanted discharge within 3 months, as soon as it could be arranged, and did not remember discussing a 3-year wait. He said he had always wanted to go to independent or supportive living since admission and questioned why he was still in the facility. During multiple observations, he was seen ambulating independently, interacting with cognitively intact peers, and on January 15, 2026, an RN stated the resident had been expressing his desire for a more independent setting since shortly after admission. The RN also stated the physician had discussed that the current facility was not a good fit for the resident.
MDS Did Not Accurately Reflect Restraint Use and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected resident use of a restraint for R147. R147 was admitted with multiple diagnoses including dementia and Alzheimer’s disease, and the quarterly MDS dated [DATE] indicated severe cognitive impairment and stated that no restraint was used in Section P. However, on January 12, 2026, R147 was observed in the dining room pushed up to a corner table with a secured lap cushion attached to the wheelchair, and R147 was not able to move the lap cushion. An LPN stated that R147 used the secured lap cushion because she always tried to get up, and a restraint evaluation and consent form had been signed on August 19, 2025. The MDS Coordinator confirmed that R147 was the only resident using a restraint and that the secured lap cushion should have been documented in Section P of the MDS, but it was not selected on the November 04, 2025 assessment. The facility also failed to ensure that R9’s MDS reflected an oxygen order. R9 was admitted with diagnoses including COPD, emphysema, pneumonia, dementia, and other chronic conditions. The physician’s report dated December 30, 2025, documented oxygen at 3 LPM continuous to keep saturation at 90% as needed for shortness of breath, but the most recent MDS dated November 18, 2025, had not been updated to reflect the oxygen order. R9 stated that she used her oxygen concentrator every night, and the concentrator was located beside her bed. An LPN stated that R9 used oxygen when feeling short of breath, and the ADON confirmed that the oxygen order was documented on December 30, 2025 and should have been recorded in the MDS.
Failure to Off-Load Heels for Resident With Pressure Ulcers
Penalty
Summary
The facility failed to off-load the heels of a resident who had facility-acquired pressure ulcers. The resident was admitted with multiple diagnoses including congestive heart failure, abnormal gait and mobility, and dementia, and the MDS showed severe cognitive impairment, substantial to maximal assistance needs for bed mobility and transfers, frequent bowel and bladder incontinence, and risk for pressure ulcer development. The initial wound evaluation documented unstageable deep tissue injuries with intact skin on both heels, with pressure identified as the cause and the wounds present for more than five days. The wound physician recommended floating the heels in bed, off-loading the wounds, and using pressure off-loading boots. Subsequent wound evaluations continued to show unstageable deep tissue injuries to both heels, and the physician again recommended floating the heels in bed and off-loading the wounds. During multiple observations, the resident was found in bed with pillows under the heels, but both heels were still touching the pillows, and at other times the heels were touching the bed sheet or mattress. These observations were made in the presence of the wound nurse and other staff. The DON stated the resident's heels should be off-loaded when recommended for pressure ulcers and noted the resident stayed in bed due to chronic pain, making off-loading important. The DON also stated the resident's current care plan did not address the pressure ulcers. The facility policy stated that when a resident is in bed, every attempt should be made to float the heels off the bed.
Failure to Maintain Nutritional Status Through Inadequate Monitoring and Supplementation
Penalty
Summary
The facility failed to provide adequate care and services to maintain residents’ nutritional status by not consistently monitoring food intake, not offering meal alternatives of similar nutritive value, not encouraging intake at meals, and not ordering or providing nutritional supplements as recommended by the dietitian for residents with low body weights and poor oral intake. This deficiency involved three residents reviewed for nutrition: R18, R49, and R105. R49 had multiple diagnoses including COPD, type 2 diabetes, gait and mobility abnormalities, and lack of coordination. Her weight declined from 135.6 lbs to 107.9 lbs over several months, with the RD documenting significant weight loss and recommending continuation of the current diet, encouragement of intake, 120 mL MedPass BID, and weekly weights. The POS did not show orders for MedPass or weekly weights, and when R49 was weighed in the presence of the surveyor, her weight was 103 lbs. The DON stated the RD’s recommendation was missed and no one followed up to obtain an order. R18, who had dementia with behavioral disturbance, CHF, gait and mobility abnormalities, repeated falls, anxiety disorder, and seizures, was observed not eating lunch on one day and only lightly eating on another. Staff documented that she pushed her tray away or ate only a portion of the meal, and staff stated they did not offer alternatives. Her meal intake reports showed 51–75% intake of lunch meals, while her weight trended down from 123 lbs to 117.1 lbs over about three months. Her active orders included a nutritional supplement three times daily and weekly weights, and her nutritional assessment called for her to consume 75% or more of meals and maintain stable weight. R105 was admitted with adult failure to thrive, CHF, bipolar disorder, dementia with behavioral disturbance, cognitive communication deficit, and hypovolemia. Her care plan did not include dietary or nutrition interventions, and clinical assessments showed no diet or appetite concerns despite later documentation of fluctuating appetite, poor intake concerns, and family reports of serious weight loss. Her weight decreased from 91 lbs to 82.6 lbs in two months, and weekly weights were not documented after admission even though an order had existed earlier. The dietary note stated a protein shake was ordered but not available at the facility, and the RD recommended adding a nutritional supplement once daily. Family members reported concerns about the lack of a plan for her weight loss and communication regarding her nutrition care.
Oxygen Not Administered as Ordered
Penalty
Summary
The facility failed to ensure residents received oxygen as prescribed for 3 of 4 residents reviewed for oxygen administration. The report identified that oxygen orders were not followed as written for residents with respiratory diagnoses, including COPD and chronic respiratory failure, and staff observations showed oxygen delivery settings and use that did not match the physician orders. For one resident with acute and chronic respiratory failure with hypoxia, pneumonia, heart failure, and COPD, the physician order specified oxygen at 7 LPM via nasal cannula every shift. However, the resident was observed receiving 8 to 8.5 LPM on one occasion and 8.5 to 9 LPM on another, and an RN confirmed the oxygen was set above the ordered rate. The RN stated the order should be followed to avoid oxygen overload because the resident had COPD. For another resident, the active summary report showed oxygen 3 LPM continuous to keep saturation at 90% as needed for shortness of breath, but the care plan stated the resident was not currently on oxygen and the MDS did not reflect oxygen use. The resident was observed multiple times without oxygen, and the resident stated oxygen was used only at night because the concentrator was too big to carry. Staff gave conflicting statements about whether oxygen was continuous or only used as needed. For a third resident, the order was for oxygen 2 LPM via nasal cannula PRN for shortness of breath or oxygen saturation below 92% on room air, but the resident was observed on continuous oxygen at 4 to 4.5 LPM via nasal cannula. Staff checked oxygen saturation at 97% but did not adjust the oxygen to match the physician order, and the DON stated oxygen is considered medication and changing or increasing the rate should have a physician order.
Failure to Reassess and Treat Resident Pain
Penalty
Summary
The facility failed to ensure a resident with complaints of pain was reassessed and provided interventions to relieve pain in accordance with facility policy. The resident was admitted with multiple diagnoses including Parkinson’s disease, type 2 diabetes, low back and left hip pain, COPD, bipolar disorder, and unsteadiness on feet. The resident was cognitively intact and required assistance with several ADLs. The care plan initially did not include non-pharmacological pain interventions, and a later care plan noted the resident developed a behavior of calling 911 due to unrelieved pain, with an intervention to see the pain doctor. The resident reported worsening pain during walking, therapy, and leg exercises, and stated that the only prescribed pain medication was Tylenol, which had been unavailable on the units for several days. The resident also reported that a pain doctor had previously prescribed a medication that helped, but it was discontinued and there was no further visit. Record review showed current pain medications included scheduled acetaminophen, Lyrica, and PRN lidocaine patches, with prior tramadol and a brief prednisone trial from the physiatrist. The most recent pain assessment documented no pain, and there was no pain reassessment or modification of the pain regimen when the resident began reporting increased pain. Facility policy required pain assessment whenever pain was suspected or there was a significant change in condition, and required individualized assessment and physician-directed interventions.
Failure to Follow PPE and Hand Hygiene During Isolation and Tube Feeding Care
Penalty
Summary
The facility failed to implement infection control practices during resident care involving enhanced barrier precautions and contact isolation. R92 had diagnoses including oral phase dysphagia and adult failure to thrive and had an active order for bolus tube feeding four times daily. During a gastrostomy tube feeding, the RN entered the room while an EBP sign was posted requiring gloves and gown for high-contact care, including feeding tube device care. The RN administered the feeding, removed a glove, used a bare hand to move the resident’s overbed table, put on a new glove without performing hand hygiene, and continued the tube feeding without wearing a gown. The RN acknowledged she should have worn a gown and performed hand hygiene before donning a new glove. The DON stated that complete PPE and hand hygiene should be used during gastrostomy tube feeding and care to prevent cross contamination and maintain infection control. The facility also failed to follow contact isolation precautions for R74, who had diagnoses including partial paralysis and COPD and had an active order for contact isolation for Klebsiella bacteria. A contact isolation sign and PPE bin were posted outside the resident’s room, but a CNA entered without donning PPE and touched the resident’s hand while delivering and setting up the meal tray. The ADON stated that staff should wear PPE when entering a resident’s room on contact isolation and when having physical contact with the resident while delivering meal trays. The report states that R74 was on contact isolation for ESBL Klebsiella in urine during the cited period.
Failure to Maintain Safe and Comfortable Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident with multiple diagnoses, including Parkinson's disease, bipolar disorder, paranoid schizophrenia, unspecified dementia, hypertension, and chronic diastolic heart failure. The resident was noted to have impaired cognition, impaired mobility, poor safety awareness, and an increased risk of falls. During observation, two floor tiles in the resident's room were found to be raised and uneven, creating an unstable surface that contributed to the instability of furniture, including a television stand. The Maintenance Director acknowledged awareness of the uneven tiles and stated they should have been repaired earlier. Additionally, the window in the resident's room had rotting wood, peeling paint, and a non-functioning crank, resulting in a gap that allowed cold air to enter the room. The window had been in this condition for several months, and work orders submitted to address the issue were either marked as completed without full resolution or left incomplete. The room temperature was measured at 67°F, and the in-room refrigerator provided by the facility was found to be malfunctioning, with an internal temperature of 48°F, water accumulation in the freezer, and moisture along the interior edges. Staff confirmed the refrigerator was unable to maintain appropriate temperature. The Assistant Administrator was unaware of the issues with the floor, window, or refrigerator, and acknowledged these conditions posed a safety concern. The facility's Safety Policy requires preventive inspections, maintenance, and a system for communicating and addressing repair needs, but these procedures were not effectively implemented in this case.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding prompt notification of a resident's representative after a significant change in the resident's condition. A resident with multiple diagnoses, including type 2 diabetes, congestive heart failure, gout, chronic kidney disease, and morbid obesity, experienced shortness of breath and a drop in oxygen saturation to 87% after being transferred to bed with the assistance of four staff members. The LPN on duty assessed the resident and applied oxygen via nasal cannula but did not notify the resident's family representative of this change in condition, as required by facility policy. Documentation in the resident's electronic medical record and progress notes did not indicate that the family representative was informed, nor was there evidence that the physician or the Medical Director or DON were contacted when the physician did not respond. The DON later confirmed that the family representative had not been notified and that the LPN stated it had not occurred to her to do so. The facility's policy specifically requires prompt notification and documentation of such events, which was not followed in this instance.
Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to follow its policy and perform a timely assessment on a resident who exhibited a change in condition. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, chronic kidney disease, and morbid obesity, was noted to be lethargic and required oxygen after a drop in oxygen saturation. Nursing staff did not complete or document a thorough assessment, including vital signs and neurological status, when the resident's condition changed. The nurse on duty did not seek assistance from other nurses, did not call an internal code, and only called 911 after the resident became barely responsive. Documentation of vital signs and the use of oxygen was incomplete, with the last recorded vital signs taken hours before the emergency transfer and delayed progress notes regarding oxygen administration. The facility's policy required staff to assess and document vital signs, neurological status, and changes in level of consciousness when a resident experiences an acute change in condition. Staff were also expected to notify the physician and monitor the resident's progress. In this case, the nurse did not collect or report the necessary information to the physician, and there was a lack of monitoring and documentation as required by facility policy. The resident was ultimately transferred to the hospital, where they were diagnosed with hypothermia, septic shock, thrombocytopenia, and hypernatremia.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident, identified as R9, who was reviewed for activities of daily living. On multiple occasions, R9 was observed with disheveled hair, overgrown nails with brownish debris, and a wet disposable brief. R9 reported that she had been left wet for almost an hour and had experienced a previous incident where no perineal care was provided, leaving her wet for an entire shift. R9 also mentioned that her call light was not functioning, requiring her to wait for staff to check on her or to call out for assistance. Despite the care plan addressing R9's needs appropriately, the CNAs were observed sitting in the dining hall and not attending to R9's needs. The CNAs stated they check on residents every 1-2 hours, but R9 remained in a wet brief for an extended period. The Director of Nursing confirmed that staff are expected to check on residents every 1-2 hours, especially those who are frequently wet. The facility's policy for ADL care, revised in 2008, does not specify the frequency for checking and providing perineal care, contributing to the deficiency in care provided to R9.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to ensure that a resident's call light was in working condition, resulting in the resident not receiving timely assistance. On January 21, 2025, a resident was observed lying in a bariatric bed with a wet disposable brief, bedsheet, and blanket. The resident, who was alert and oriented, reported that her call light had been broken since the previous day, and she had been wet for almost an hour without assistance. The resident had no alternative method to call for help, and the call light was confirmed to be non-functional by two CNAs the following day. The resident, who was admitted with diagnoses including congestive heart failure, Parkinson's disease, bipolar disorder, and anxiety, required moderate assistance with upper body functions and was totally dependent for lower body functions. Despite the facility's policy requiring daily checks of call lights by CNAs and maintenance personnel, the issue was not addressed promptly. The Director of Nursing stated that call lights must be answered as soon as they are noticed, but the resident's call light was not repaired until a work order was placed on January 22, 2025, leaving the resident without an alternative method to call for help in the interim.
Failure to Follow Standardized Recipes in Meal Preparation
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature, as evidenced by the failure to follow standardized recipes. Observations and interviews revealed that residents receiving regular diets, both regular and pureed textures, were served meals that did not adhere to the prescribed recipes. For instance, a resident reported that the food was consistently salty, leading her to rely on canned soup brought by her family. Another resident described the food as horrible and opted for simple sandwiches instead of the menu items. A third resident found a long black hair on her lunch tray and described the food as having an unpleasant taste, refusing to eat it. Further investigation showed that the kitchen staff did not follow the recipes for several menu items, including pizza, pureed pizza, strawberry shortcake, and side salad with dressing. The cook used red peppers instead of the specified green peppers and did not measure the vegetables as required. The strawberry shortcake was served with pound cake and half a strawberry instead of the specified biscuit and full portion of strawberries. The side salad lacked the required tomatoes and shredded cheese, consisting only of bagged lettuce. The dietary manager confirmed that recipes are designed to ensure nutritional value and quality, emphasizing the importance of following them. The facility's policy mandates the use of standardized recipes for all menu items, but this was not adhered to, resulting in substandard meal quality for the residents.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and storage protocols, as observed during a survey of the kitchen. The walk-in cooler was found to have a temperature of 58 degrees Fahrenheit, which is above the safe storage temperature of 41 degrees Fahrenheit. Despite being informed of the elevated temperature, food items such as bread and various vegetables were still stored in the cooler. Additionally, staff lunches were improperly stored in the walk-in cooler without labels or dates, contrary to facility policy. During the kitchen tour, it was noted that staff members, including the Dietary Manager and a Dietary Aide, were not wearing required hair and beard restraints while working in food preparation areas. This lack of compliance with the facility's policy on hair restraints poses a risk of cross-contamination. Furthermore, the kitchen lacked a garbage can near the handwashing sink, which is necessary for proper hygiene practices. In the dry storage area, several food items were found to be improperly stored or expired. An opened carton of Au Gratin potatoes was not sealed, and five boxes of muffin mix and two cartons of rainbow sprinkles were past their expiration dates. An opened bag of cake mix was also found without a label or date. These findings indicate a failure to follow the facility's policies on labeling, dating, and discarding expired food items, which are essential for maintaining food safety and preventing foodborne illnesses among residents.
Failure to Maintain Safe Temperature in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to maintain the kitchen walk-in cooler in a safe operating condition, affecting all residents receiving oral nutrition and foods prepared in the facility kitchen. During a kitchen tour, the walk-in cooler was observed to have a temperature of 58 degrees Fahrenheit, which is above the safe temperature range for food storage. The Dietary Manager confirmed that the cooler's temperature should be below 41 degrees Fahrenheit to prevent the growth of pathogens and bacteria. Despite this, food items such as bread, tomatoes, potatoes, onions, cabbage, and spinach were found stored in the cooler, with packaging indicating they should be kept between 33-38 degrees Fahrenheit. The facility's policy on refrigerator and freezer temperatures requires that all cold storage units maintain a temperature of 41 degrees Fahrenheit or below. If temperatures exceed this range, the policy mandates that food be transferred to another unit and the affected unit be locked out. However, the walk-in cooler continued to operate at unsafe temperatures, as confirmed by the Maintenance Director's infrared thermometer reading of 55 degrees Fahrenheit. This failure to adhere to established guidelines and procedures for food storage compromised the safety and quality of food provided to residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their families or Power of Attorney (POA) regarding the reasons for hospital transfers, as well as failing to notify the ombudsman of these transfers. This deficiency was identified in five residents who were transferred to the hospital for various medical conditions, including acute cystitis, wound infection, sepsis, acute on chronic abdominal pain, and acute chronic respiratory distress. The facility's Assistant Director of Nursing (ADON) admitted that written documentation of the bed hold policy was only provided to alert residents and that the ombudsman was only notified upon discharge from the facility, not during hospitalizations. The report highlights specific instances where residents were transferred to the hospital without proper written notification to their families or the ombudsman. For example, one resident was sent to the hospital due to elevated blood pressure and jerking movements, another for a wound infection requiring possible debridement, and another for respiratory distress. In each case, the facility failed to provide the necessary written documentation to the resident's family or representative, and the ombudsman was not informed of the hospital transfers, which is a requirement for compliance.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of bed hold policies to residents and/or their Power of Attorney (POA) at the time of discharge to the hospital. This deficiency was observed in five residents who were transferred to the hospital for various medical conditions, including acute cystitis, wound infection, sepsis, acute on chronic abdominal pain, and acute chronic respiratory distress. In each case, there was no documentation in the medical records indicating that the residents or their representatives were informed in writing about the bed hold policy, which is a requirement. The Assistant Director of Nursing (ADON) acknowledged that the facility only verbally notified residents' families of hospital transfers and did not provide written documentation of the bed hold policy. The facility's existing policy stated that a bed hold agreement should be provided to residents or their representatives at the time of transfer, but this was not adhered to. The facility also lacked a formal bed hold policy, further contributing to the deficiency.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate ADL care for five residents who are dependent on staff for personal hygiene. Observations revealed that residents had unshaved facial hair, long and jagged nails with brown substances underneath, and oily hair. These residents expressed dissatisfaction with their personal hygiene care, indicating that staff did not provide necessary assistance. For instance, one resident with multiple sclerosis and quadriplegia was observed with facial hair and stated that she was unaware of it because staff never offered her a mirror or assistance with shaving. Another resident with severe cognitive impairment and mobility issues reported that staff only shaved her once a month, which caused her discomfort. The residents involved had various medical conditions, including multiple sclerosis, osteoarthritis, parkinsonism, type 2 diabetes, Alzheimer's, dementia, chronic obstructive pulmonary disease, and hemiplegia. Their care plans indicated a need for staff assistance with personal hygiene due to their physical and cognitive limitations. Despite these documented needs, the facility did not provide the necessary care, as evidenced by the residents' unkempt appearances and their reports of inadequate assistance. The Director of Nursing acknowledged that personal nail care and hair washing should be provided as needed, but the facility was unable to provide an ADL policy, highlighting a gap in ensuring residents' rights to a dignified existence and quality of life.
Medication Security and Physician Order Deficiencies
Penalty
Summary
The facility failed to secure medications properly during administration and did not obtain physician orders for over-the-counter medications, leading to medications being stored in residents' rooms without authorization. In one instance, an agency RN left a medication cup with nine unlabeled pills on a resident's dresser while retrieving equipment, leaving the medication unsecured. The resident, who had multiple diagnoses including chronic kidney disease and schizoaffective disorder, had moderately impaired cognition, increasing the risk of medication mishandling. Another resident was found with a bottle of eye drops and a cup containing unlabeled pills, which the resident identified as ibuprofen for foot pain. The resident's medical record did not include a physician order for ibuprofen or permission to store medications in the room. Similarly, other residents were found with various medications, such as inhalers and eye drops, on their bedside tables without proper orders or assessments to self-administer or store medications at the bedside. Additionally, a medication cart was left unattended in a hallway with a cup of unlabeled pills, posing a risk of accidental ingestion by other residents. The Director of Nursing acknowledged that residents need an assessment and physician order to self-administer or store medications at the bedside, and that medications should not be left unattended. The facility's policy on medication storage was not followed, as evidenced by the lack of orders and assessments for residents to self-medicate or store medications in their rooms.
Failure to Maintain Proper Food Storage and Temperature Logs
Penalty
Summary
The facility failed to maintain proper temperature logs, storage, and labeling of food items in residents' personal refrigerators, affecting five residents. Observations revealed that several personal refrigerators lacked temperature logs and thermometers, with some containing potentially spoiled food items. For instance, one refrigerator contained liquid ice cream and sherbet, while another had an uncovered and unlabeled bowl of salad. Additionally, one refrigerator showed a temperature of 42°F, which is above the recommended range. The Director of Nursing (DON) acknowledged that temperatures should be checked and recorded daily, but was unsure which staff was responsible for this task. It was later discovered that housekeeping staff were supposed to manage the residents' personal refrigerators, but they were either not performing the task or doing so inconsistently. The facility's policy requires food to be labeled, dated, and discarded according to safe storage guidelines, and the temperature of refrigerators and freezers outside the kitchen to be checked daily and recorded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, affecting all 159 residents. Several instances were observed where Enhanced Barrier Precautions (EBP) were not implemented as required. For instance, a resident with a stage 4 sacral ulcer and an indwelling catheter did not have EBP signage or PPE outside her room. Staff members, including a Wound Care Coordinator and a CNA, were observed providing wound care and handling the resident's urinary catheter with only gloves, without using gowns or other necessary protective equipment. This occurred despite a physician's order for EBP isolation due to the resident's wounds and catheter. Another resident with cellulitis and venous insufficiency also lacked EBP signage and PPE outside his room. A registered nurse provided wound care without wearing a gown, and there was no physician order for EBP for this resident. Similarly, a resident with a PICC line and multiple infections did not have precaution signage or PPE outside her room. A registered nurse assisted with incontinence care without wearing a gown, despite a physician's order for EBP being issued during the survey. The facility's infection control practices were further compromised by improper disposal of contaminated PPE. A red garbage container meant for disposing of PPE was placed outside a resident's room instead of inside, contrary to the facility's policy. Additionally, hand hygiene practices were not followed, as staff members failed to change gloves and clean their hands between tasks, such as wound care and incontinence care. The facility also lacked updated infection control policies, including those related to COVID-19, and there were missing records for water testing to prevent legionella growth.
Failure to Provide Dignified Care During Feeding
Penalty
Summary
The facility failed to provide care with dignity to a resident, identified as R139, who was observed being fed by a nurse, V9, in a demeaning manner. During the observation, V9 stood over R139 and repeatedly instructed her to eat in a demeaning tone. R139 is an elderly female with severe cognitive impairment and requires substantial assistance for eating, as indicated in her Minimum Data Set (MDS) assessments. The Director of Nursing, V2, acknowledged that staff should not stand over residents while feeding them, as it compromises their dignity. The facility's Resident Rights Statement emphasizes the right of residents to a dignified existence and care that enhances their quality of life and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were accessible to dependent residents, specifically affecting one resident in the sample. During an observation, a resident was found sitting in a recliner chair in her room with the call light attached to her bed, which was by the window, while she was sitting closer to the door. The resident expressed frustration about not being able to reach the call light from her position, stating that she needed it for assistance. The MDS Coordinator confirmed that the call light should be within reach of residents at all times. The resident's MDS indicated moderately impaired cognition and dependence on staff for toileting and personal hygiene, with a care plan noting a risk for falls and the need to call for assistance. The Director of Nursing also acknowledged that call lights should be easily accessible to residents in their rooms. The facility's policy states that call lights should be within easy reach to meet residents' needs.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite a resident to care plan meetings, which is a requirement for developing and maintaining a comprehensive care plan. This deficiency was identified for one resident, who expressed a desire to know what was needed to be discharged home but was unaware of the care plan meetings. The resident reported never being informed about the goals or invited to participate in these meetings. The Social Services Director confirmed that there was no documentation or progress notes indicating that the resident or their family had been invited to the care plan meetings. The facility's policy requires the involvement of the resident and their family in the care planning process, but this was not adhered to in this case, as evidenced by the resident's Care Plan Meeting Attendance forms showing no attendance by the resident or family at any meetings.
Improper Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to obtain residents' blood glucose levels appropriately and did not follow physician orders for administering insulin, affecting two residents. For one resident, an agency RN checked the blood glucose level and administered insulin based on a sliding scale, but the timing was inconsistent with meal times, as the resident had breakfast hours earlier and lunch trays were served later. The RN was unaware of the meal schedule, which is crucial for accurate insulin administration. Another resident's blood glucose was checked by an LPN while the resident was already eating, which is contrary to the physician's order to check blood sugar before meals. Insulin was administered based on this reading. The DON confirmed that blood glucose checks should be done before meals to ensure accurate readings, but some nurses were administering insulin when they saw meal trays to prevent hypoglycemia, indicating a lack of adherence to proper procedures.
Failure to Implement Physician's Order for Aspiration Precautions
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with dysphagia, chronic obstructive pulmonary disease, and dementia. The resident, identified as R77, had a physician's order dated 6/28/23 that specified no straws every shift and aspiration precautions due to her condition. Despite this, on 12/10/24, a CNA provided R77 with a cup of water containing a straw, contrary to the physician's order and the resident's care plan. Additionally, on 12/12/24, another CNA placed a straw on R77's lunch tray, which was then taken by the SLP who conducted a bedside swallow study and confirmed that R77 should not use straws. The facility's failure to adhere to the physician's order was further highlighted by the absence of a policy for following or implementing such orders. The Assistant Director of Nursing acknowledged that staff should follow all physician's orders, including those for no straws and aspiration precautions. The resident's care plan, updated on 11/20/24, reiterated the need for aspiration precautions and no straws, aligning with the SLP's evaluation from 12/12/24 to 12/25/24, which also recommended no straw use.
Failure to Provide Restorative Services to Resident
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R128, as recommended by the ADL Restorative Assessment. R128 is a male resident with a history of hemiplegia and hemiparesis following a cerebral infarction, affecting his right dominant side, along with aphasia, dysphagia, and repeated falls. The resident's MDS indicated impairments on one side of both upper and lower extremities, and he uses a wheelchair for mobility. During an interview, R128 communicated that he no longer receives physical, occupational, or speech therapy, and he does not receive any restorative therapy, despite having weak right arm and leg due to his stroke. The Director of Nursing (DON) confirmed that R128 was on three restorative programs: bed mobility, dressing, and active range of motion for upper and lower extremities. However, there was no documentation to show that these programs had been carried out over the past 30+ days. The resident's care plan, last revised in March, outlined interventions for his deficits, including a bed mobility program and active range of motion exercises, but these were not documented as being implemented. The facility's policy on restorative nursing programs emphasizes the importance of assessing and implementing appropriate nursing measures to achieve maximum independence, but this was not adhered to in R128's case.
Improper Positioning of Catheter Bags Leads to Potential Backflow
Penalty
Summary
The facility failed to properly position the indwelling catheter drainage bags for three residents during wound care and incontinence care, leading to potential backflow of urine. For one resident, the catheter drainage bag was observed hanging on the armrest of a motorized wheelchair above the bladder line, causing backflow of urine. During wound care, the same resident's catheter bag was placed on the bed, again resulting in backflow. This resident had a history of urinary tract infections (UTIs) and was recently on antibiotics for a UTI. The facility's policy requires that the urinary drainage bag be positioned lower than the bladder to prevent backflow. Another resident's catheter bag was similarly mishandled during wound care, being lifted above the bladder level and placed on the bed, contrary to the facility's policy. This resident also had a history of UTIs. Additionally, a third resident, who was supposed to switch from a leg bag to a larger urine collection bag when in bed, was not provided with the appropriate bag, risking backflow due to the lack of gravity with the leg bag. The facility's staff, including the Director of Nursing and Assistant Director of Nursing, acknowledged the improper handling of catheter bags and the potential for backflow, which could lead to UTIs.
Failure to Post Current Daily Staffing Information
Penalty
Summary
The facility failed to post the current daily staffing information, affecting all 159 residents. On December 10, 2024, at 10:36 AM, the Daily Staff Posting at the reception desk displayed a date of December 9, 2024, with a census of 160, indicating outdated information. The Director of Nursing (DON) explained that the admission staff emails the current census between 9:30 AM and 10:00 AM to the front desk, herself, and all managers. The receptionist is responsible for updating the staffing information and posting it after receiving the email. However, the receptionist's work schedule from 8:00 AM to 1:30 PM suggests a delay in posting the updated information. The facility's policy, dated August 2008, requires posting the number of nursing personnel responsible for direct care at the beginning of each shift, as mandated by state and federal regulations.
Failure to Identify Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to identify a change in condition for a resident, R2, who experienced a slow deterioration from the morning until she was transferred to the hospital in critical condition. The failure began when an LPN did not recognize R2's change in condition, did not complete an assessment, obtain vital signs, or notify R2's physician. This oversight continued with another LPN who did not provide frequent monitoring, failed to provide accurate information to the physician, and delayed transferring R2 to the hospital. As a result, R2 was transferred to the hospital in critical condition and later died from septic shock. R2 had a medical history that included COPD, heart failure, peripheral vascular disease, insomnia, atrial fibrillations, major depressive disorder, anemia, a non-pressure chronic ulcer to the left foot, dementia, and osteoarthritis. On the day of the incident, R2 was noted to be confused, experiencing diarrhea, and unable to perform her usual self-care activities. Despite these changes, there were no vital signs taken after the initial assessment in the morning, and the physician was not notified of R2's deteriorating condition. The facility's failure to monitor R2's condition and communicate effectively with the physician led to a delay in transferring her to the hospital. The ambulance report indicated that R2 was in a lethargic state, with low oxygen saturation and critically low blood pressure upon arrival. The lack of timely intervention and accurate communication contributed to the severity of R2's condition, ultimately resulting in her death from septic shock.
Removal Plan
- V19 and V28 were in-serviced and educated on identification of a change in condition and continued monitoring. In-service/Education included: to ensure that assessments, monitoring and documentation is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner.
- Initiated in-service and education to nurses including agency nurses on identification of a change in condition and continued monitoring, documentation of assessments, and monitoring is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner.
- The Director of Nursing and MDS Coordinator in-serviced nurses on Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition. V19 and V28 were already in-serviced and educated. Anyone who had not been in-serviced will be in-serviced in person or over the phone prior to their next shift by DON or designee prior to their next shift in this facility. This in-servicing includes nurses on FMLA & PRN and agency nurses. All new hires will be in-serviced during their orientation on the Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition.
- DON or designee will audit all residents with a change of condition daily to ensure that all residents with a change of condition were properly assessed, monitored, and documented on, MD was notified with accurate information and transferred in a timely manner.
- QAPI Committee have met and discussed the measures that were put in place to ensure that deficient practice does not occur. Medical Director is in agreement of the measures that were put in place and has approved it.
Failure to Conduct Required QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met quarterly with the required members, affecting all residents in the facility. The facility's data sheet indicated there were 163 residents at the time of the survey. During an interview and record review, it was found that the last Quality Assurance and Performance Improvement (QAPI) meeting was held in December 2023, and the subsequent meetings that should have occurred in March/April 2024 and June/July 2024 did not take place. The Director of Nursing (DON) acknowledged that the facility was behind on these meetings, citing a busy period following their annual survey in January and the development of a Plan of Correction (POC) as contributing factors. The monthly QA meeting held in April 2024 was attended by various staff members, including the Restorative, MDS Coordinator, Infection Control Preventionist, and others, but notably absent were the Administrator and Medical Director. The facility's policy requires the Administrator to serve as the Chairperson of the QAA committee, and the committee is expected to meet monthly to address quality measures, improvement processes, and survey findings. The absence of key members and the failure to hold the required meetings indicate a lapse in the facility's adherence to its quality assurance policy.
Unsafe and Unsanitary Conditions in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents in the B-wing hallway, affecting seven residents. Observations revealed missing ceiling tiles with water steadily dripping from exposed plumbing and air ducts, saturating the carpet and creating a sloshing sound when walked upon. A large trash can and personal care basins were placed to catch the water, but the area remained wet, and a light fixture in an adjacent tile was saturated with water. The issue was reportedly due to a malfunctioning air conditioning unit, which had been temporarily fixed by running water on the condenser, leading to the leak. The Maintenance Assistant and Director confirmed the air conditioning unit needed replacement, and a contractor had been called but could not fix the unit immediately. The Maintenance Director acknowledged the safety concern of water dripping onto an electrical source, although the Maintenance Assistant initially dismissed it. The facility had not provided a policy for Building Maintenance and Repair when requested by the surveyor. The situation had persisted since the previous Monday, with residents and staff having to navigate the wet area, raising concerns about safety and sanitation.
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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 Bensenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Of Elmhurst, The | 1.4 mi | ★★★★★ | 6 | 1 |
| Avenora Elmhurst | 2.5 mi | ★★★★★ | 25 | 0 |
| Citadel At Casa Scalabrini | 2.7 mi | ★★★★★ | 0 | 0 |
| Landmark Of Itasca Rehabilitation And Nursing Cent | 3.9 mi | ★★★★★ | 26 | 2 |
| Asbury Court Nursing & Rehab | 5.2 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.