Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evercare Of Collinsville during CMS and state inspections, most recent first.
A resident with chronic sacral and heel pressure ulcers had multiple ordered wound treatments left undocumented on the TAR, and staff did not reposition him promptly when he reported pain from sitting up in his wheelchair. He was observed grimacing, asking to lie down, and using his call light, but a CNA turned off the light and left without helping; he remained up until later that afternoon. The DON stated staff should respond to the resident’s needs immediately and document wound treatments when provided.
A resident’s fall-prevention alarm batteries were not working even though alarm use was identified as an intervention for falls. The resident was later found on the floor near the bathroom with a walker overturned, complained of R arm pain, and was diagnosed with an acute humeral fracture; the record also notes UTI and bradycardia during ER evaluation.
A resident with chronic pain and multiple pain-related diagnoses did not receive ordered Norco doses as prescribed because the medication was unavailable or the new Rx had not been received by the pharmacy. The resident reported severe, ongoing pain, said the medication only made the pain manageable, and stated staff did not ask about pain or offer ice packs. The DON confirmed missed doses, and the pharmacist stated the new Norco dose could not be filled because the script had not been received.
An LPN failed to administer medications according to policy for two residents. One resident with severe cognitive impairment and multiple diagnoses had oral meds crushed, mixed into oatmeal, and left with a CNA, but the resident refused the food and received none of the morning meds. Another resident’s calcium carbonate was left on the bedside table for later instead of being administered and observed by the nurse. Staff interviews and the facility policy stated meds must be given by an LPN and the nurse must remain with the resident until the meds are swallowed.
Survey Results Not Readily Accessible to Residents: The facility failed to make the State Inspection report readily available for residents to read without asking. During a resident council meeting, multiple cognitively intact residents stated they did not know where the survey book was located and could not access the lobby without staff permission because of the door alarm and code. A CNA confirmed residents do not go to the lobby without staff, and the Administrator stated the facility had no policy for the survey book and followed the Guidelines.
Failure to Maintain Required RN Coverage: The facility did not staff an RN for 8 hours per day, 7 days a week across multiple months. Surveyors observed only LPNs on duty, and interviews with the ADON, DON, and Regional Administrator confirmed there were no RNs working or scheduled, aside from one PRN RN who had not worked and one hired RN who had not started. Review of staffing schedules showed minimal RN coverage in one month and none in another, with one RN listed in the following month but not working any shifts.
Failure to Post Daily Nurse Staffing: The facility did not post nurse staffing data daily at the beginning of each shift, and surveyors found no staffing posting anywhere in the building during observation. The RA/DON stated the facility had not been doing the posting, and the DON confirmed this. The only staffing policy available addressed staffing levels and license display, but did not cover RN staffing or daily public posting.
Expired and improperly labeled meds were found in medication rooms and on a med cart. Surveyors found expired Bisacodyl and Acetaminophen suppositories, open multidose Tuberculin vials with no open date, and a discharged resident’s Acetaminophen package still stored in the facility. An LPN also prepared Lispro insulin for a resident and had drawn it up before realizing the date on the box was invalid and discarding it.
Improper Food Storage, Labeling, and Dating: Surveyors observed multiple food items stored improperly in the kitchen, including a case of pears on the floor, opened refrigerated items without dates, and several unlabeled or undated containers of prepared foods and beverages. In the freezer, opened bags of vegetables and chicken were not sealed or dated. The dietary manager stated opened food in the refrigerator and freezer should be labeled and food should not be stored on the floor.
Call lights were not answered in a timely manner for 4 of 24 residents reviewed. Resident council minutes documented repeated concerns that call lights were not being answered and that staff were turning them off. Several cognitively intact residents reported that staff did not respond promptly, sometimes turned off the light without returning, and that residents had to go find help. A CNA and an LPN stated that call lights should be answered within a few minutes and that all staff are responsible for responding.
Failure to provide resident activities: Multiple residents stated there were no activities, that they were bored, and that bingo was the only or main offering. Residents reported the activity person had left and activities were not consistent, with no calendar available to them. Surveyors observed no activities during the investigation, and the administrator stated the listed activities were not occurring because the facility did not currently have an activity person.
Failure to change and date humidified O2 water bottles for residents receiving oxygen therapy. Four residents with diagnoses including COPD, dyspnea, and dependence on O2 were observed with water bottles that were undated or remained dated beyond the expected change interval. MAR-TARs showed scheduled humidifier and tubing changes, and staff stated nurses were responsible for completing and documenting the changes, while the DON expected weekly changes as ordered and reflected on the MAR-TAR.
Failure to provide activities for residents with dementia. A resident with dementia and wandering behaviors stated he was not invited to activities, while other residents with dementia had care plans calling for activity participation and social engagement. Residents reported there were no activities, boredom, and no consistent schedule; staff stated activities were not occurring because the facility did not have an activity person, and no activities were observed during the investigation.
Failure to complete medication regimen review documentation for a resident receiving Sertraline and Buspirone. The resident had diagnoses including paranoid schizophrenia, MDD, and bipolar disorder. Notes to the attending physician/prescriber for GDR consideration were left blank or lacked physician review/signature, and the DON stated the medication reduction notes were not done.
Food Served Cold and Late: The facility failed to ensure meals were served at palatable temperatures for 4 residents reviewed. Resident council minutes documented repeated complaints that food was cold, bland, and overall poor. Cognitively intact residents reported meals were horrible, tasteless, cold, and often delivered late or at inconsistent times, with one resident describing breakfast delays of up to 2 hours.
Infection Prevention and Hand Hygiene Failures: A CNA was observed assisting a resident with feeding and later feeding another resident without performing hand hygiene, and an LPN performed wound care without hand hygiene before, during glove changes, or after care. A CNA also handled soiled linen and a urine-soaked brief during peri-care for a resident on isolation, threw the contaminated items on the floor, and then handled clean items with the same gloves. Facility policy required hand hygiene before and after resident contact, between glove changes, and proper disposal of contaminated linen.
Two residents who required supervision or touch assistance for eating were observed receiving little to no help during meals. One resident with intact cognition sat at the table with covered drinks and an unopened supplement, did not eat for an extended period, and only began drinking and eating after staff prompted them. Another resident with severe cognitive impairment dozed at the table, ate only part of dessert, did not touch the main meal items, and was not given cueing or encouragement until an LPN later intervened. Both residents’ MDSs and care plans identified a need for assistance with ADLs, including feeding.
Medication Administration Error Rate Exceeded: Surveyors observed a 36.84% medication error rate during med pass. An LPN crushed and mixed a resident’s meds into oatmeal, then left the tray with a CNA, resulting in the resident not receiving morning meds when the oatmeal was refused. For another resident, an LPN left calcium carbonate at the bedside for later instead of ensuring it was taken. Staff and the DON stated meds should be administered by the nurse and not left with a CNA or at the bedside.
Insufficient Resident Room Square Footage: Surveyors found that multiple 2-bed rooms did not provide the required 80 square feet per resident bed, with some rooms measuring 75, 76.5, 77.5, or 78.5 square feet per resident bed. Residents were observed in these rooms, and facility records showed a census of 78; the Regional Maintenance staff acknowledged that the facility had multiple rooms with less than the required square footage.
A resident with severe cognitive impairment and a history of frequent falls was not properly monitored or provided with effective fall prevention interventions, resulting in multiple injuries and repeated hospital visits. Staff failed to follow care plan interventions, did not perform regular checks, and left the resident soiled in bed for hours with the call light out of reach. These actions and inactions led to a finding of neglect and Immediate Jeopardy.
A resident with severe cognitive impairment and a history of frequent falls experienced repeated injuries due to the facility's failure to implement and follow individualized fall prevention interventions. Staff did not consistently keep the call light within reach, provide adequate supervision, or update care plans after each fall, resulting in multiple injuries and emergency room visits. Observations also revealed lapses in incontinence care and improper transfer techniques, despite clear facility policies and expectations.
Two residents dependent on staff for ADLs were left in urine and feces for extended periods without timely or complete incontinent care. Staff failed to follow proper hygiene and infection control protocols, including hand hygiene and thorough peri-care, and did not check residents for incontinence as required by facility policy.
Staff failed to perform required hand hygiene before, during, and after providing care to multiple residents, including during incontinent care and G-tube procedures. CNAs and an LPN were observed not sanitizing hands before donning gloves, between glove changes, or after completing care, despite facility policy and staff knowledge of proper infection control practices.
A resident's room window was found to have a hole, allowing flies and outside air to enter due to an inadequately secured plexiglass cover. The issue was not reported through the facility's maintenance work order system, resulting in the deficiency going unaddressed until discovered during a survey. Staff interviews confirmed that the established process for reporting and repairing such issues was not followed.
A facility failed to conduct required background checks on employees with direct resident contact, resulting in a resident with mental health diagnoses experiencing verbal abuse from a staff member. The incident caused the resident significant emotional distress and reluctance to leave their room. The facility could not verify that background checks had been completed for the staff member involved, as required by policy.
The facility did not complete required background checks for several staff members who had direct contact with residents, resulting in a situation where a resident with mental health diagnoses experienced verbal abuse from a staff member. The resident reported significant emotional distress, and the facility's failure to follow its own screening policies affected all residents.
A resident experienced multiple falls, including one where he was unable to reach his call light and had to call 911 for help due to insufficient staff presence. First responders had difficulty locating staff, eventually finding a nurse and another staff member outside, both unaware of the resident's situation. Staffing records showed fewer CNAs than scheduled, and the resident was found on the floor with dried blood, having tried to get attention with a broken coat hanger.
A resident with severe cognitive impairment and a history of repeated falls experienced multiple falls over a two-month period, but the facility did not notify the resident's family of these incidents or any resulting injuries, contrary to facility policy. The family only became aware of an injury after observing it during a visit and asking staff. Staff interviews confirmed that family notification was expected but not consistently performed.
A resident's legal representative, holding power of attorney, submitted a HIPAA-compliant request for medical records after the resident's discharge. The request was received by social services and reportedly forwarded to administration, but the administrator and clinical leadership stated they never saw the form. As a result, the records were not provided within the required timeframe.
The facility did not consistently update individualized care plans or complete fall risk evaluations after multiple residents experienced falls, including unwitnessed incidents and falls occurring outside the facility. Despite documented physical and cognitive impairments, care plans and interventions were not revised as required by facility policy, and staff interviews confirmed these lapses.
Mechanical lifts used for resident transfers were not maintained in safe working order, with staff observed struggling to control malfunctioning equipment and residents expressing fear and discomfort during use. Staff reported ongoing issues with the lifts, including malfunctioning legs and dead batteries, but the facility's reporting and maintenance processes failed to address these problems, resulting in continued use of unsafe equipment.
Surveyors found multiple bathrooms and shower areas with visible mold, strong bleach odors, and unclean conditions, including missing tiles and crumbling walls. Residents and staff confirmed ongoing mold issues, with some residents limiting showers due to unsanitary conditions and staff reporting illness related to mold exposure. Housekeeping efforts to address mold were described as insufficient, and the facility's policy for immediate cleaning was not effectively implemented.
A resident with epilepsy did not receive prescribed anti-seizure medications for several days after staff, acting on concerns about possible double dosing by a family member, obtained an order from a covering nurse practitioner to hold the medications. The situation was not promptly assessed or clarified, and there was no direct communication with the resident's specialists. During this period, the resident experienced a seizure and required emergency treatment. The facility lacked a policy on continuity of care to guide staff in such circumstances.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications due to delays in refilling and lack of availability, resulting in a seizure episode that required emergency room evaluation. Facility records and staff interviews confirmed missed doses, lack of timely reordering, and absence of the medication in the emergency kit, with no documentation explaining the delay.
The facility failed to properly clean dishes and store food, risking foodborne illness for all 55 residents. A cook skipped the rinsing step in the dishwashing process due to a missing stopper, and food items in the refrigerator and freezer were not labeled or dated as per policy.
A facility failed to thoroughly investigate an abuse allegation involving a resident with multiple health conditions. The resident claimed to have been hit by a night CNA, but initial assessments showed no injuries, and camera reviews found no interaction. The administrator admitted to not asking the correct questions during interviews with other residents, leading to an incomplete investigation and a deficiency in handling the abuse allegation.
A resident's care plan failed to address pain management despite documented pain and prescribed medications. The resident reported chronic pain, and the MDS/Care Plan Coordinator acknowledged the oversight, citing frequent hospital discharges as a possible reason. The facility's policy requires comprehensive care planning, including pain management.
The facility failed to meet the required minimum floor space per resident bed, with several two-bed rooms providing less than the mandated 80 square feet per resident. Observations confirmed that 26 residents were affected by this deficiency.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting all 56 residents. Observations and interviews revealed roaches in various areas, and staff reported that the maintenance man responsible for pest control was terminated for not performing his duties. The pest control company recommended monthly services, but financial issues led to a lapse in treatment, exacerbating the infestation.
Missed Pressure Ulcer Treatments and Delayed Repositioning
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident with chronic sacral and right heel pressure ulcers. The resident’s MDS documented that he was cognitively intact and had three pressure ulcers. Physician’s orders directed staff to cleanse the sacral wound with normal saline, apply zinc barrier cream to the periwound as needed, loosely pack the wound bed with Dakin’s moistened gauze, and cover with a dry clean dressing twice daily and as needed; the right heel wound was to be cleansed with normal saline, treated with Dakin’s moistened gauze, and covered with an ABD pad and gauze wrap twice daily and as needed. The TAR showed no documentation that the sacral treatment was administered on multiple day and evening shifts, and no documentation that the right heel treatment was administered on some day and evening shifts. During observation, the resident was transferred to his wheelchair and later stated that his pressure ulcer was hurting from sitting up and that staff told him he had to remain in the wheelchair until at least 3:00 PM because his family wanted him up that long. He was observed grimacing, attempting to reposition himself, and saying he was hurting badly. When he used his call light and a CNA entered, the CNA turned the light off and left without assisting him; the resident again stated he wanted to lie down because he had been sitting up since noon. He remained in the wheelchair until a CNA supervisor and another CNA transferred him to bed later that afternoon. The DON stated she expected staff to respond to the resident’s needs immediately, to lay him down if he complained of increased pressure ulcer pain from sitting up, and that if treatments were administered they should be documented on the TAR. The facility’s wound management policy stated nursing staff would initiate treatment and use interventions for pressure redistribution and wound management.
Fall Prevention Alarm Not Functioning
Penalty
Summary
The facility failed to ensure that R8’s alarm batteries were working, even though alarm function was identified as an intervention for falls. During the review, R8 was one of 5 residents reviewed for accidents in a sample of 67, and the deficiency was tied to the facility’s failure to maintain the fall-prevention intervention as planned. The report states that this failure resulted in R8 falling and fracturing a humerus. R8’s records show an unwitnessed fall in which she was found sitting on her buttocks in front of the bathroom floor door with her walker flipped over in front of her. She was assessed and complained of right arm pain, and an in-house x-ray showed an acute humeral fracture. The incident report also documents that R8 later went to the ER, where she was diagnosed with a UTI and bradycardia, and she stated she was on her way to the bathroom but could not recall why she was on the floor.
Pain medication not provided as ordered
Penalty
Summary
The facility failed to provide pain medication according to physician orders and failed to effectively treat pain for a resident with chronic pain. The resident’s record documented diagnoses including peripheral vascular disease, bilateral carotid artery stenosis, anxiety, polyneuropathy, dorsalgia, weakness, disease of the spinal cord, chronic pain, spinal stenosis of the cervical region, and spondylolysis of the lumbar region. The care plan identified acute and chronic pain and included interventions such as applying hot or cold packs, determining a satisfactory pain level, establishing a pain management treatment plan, evaluating pain, and monitoring factors that precipitate or aggravate pain. The MDS documented that the resident was cognitively intact, frequently experienced pain, and that the pain interfered with day-to-day activities. The resident’s medication administration notes showed multiple missed or delayed doses of Hydrocodone-Acetaminophen 5-325 mg ordered four times daily for pain because the medication was out of stock, unavailable, or not present in the medication system. Notes documented that the medication was unavailable on multiple occasions, that a new prescription was needed after the dose was increased to 7.5 mg, and that the facility was waiting for the pharmacy to receive the new script. The resident stated that he had severe pain, that the pain medication made the pain manageable but did not eliminate it, and that he had to sit in pain for days because the medication was not available. He also stated that he had not been offered ice packs and that staff did not ask whether he was in pain. During interview, the DON confirmed that the resident had not received the increased Norco dose because the pharmacy had not received a script and verified that the resident had not received the medication as prescribed. The DON also stated that there was no excuse for missed doses because the nurses had access to the medication in the Nexus medication machine and that if a resident missed a pain dose he would be in pain. The pharmacist stated that the pharmacy had not received a script for the 7.5 mg Norco, had requested it from the provider without success, and that the resident’s 5 mg Norco refill was sent only after a refill request was received. The facility’s pain management policy stated that the licensed nurse will administer pain medication as ordered and document it on the MAR.
Medication Administration Errors and Failure to Ensure Residents Swallowed Medications
Penalty
Summary
The facility failed to administer medications according to professional standards for 2 of 4 residents reviewed for medication errors. For one resident with diagnoses including malnutrition, catatonic schizophrenia, anxiety, hypertension, diabetes, depression, dyskinesia, falls, and atrial fibrillation, the record showed multiple medication orders including Depakote Sprinkles, Austedo, haloperidol, carvedilol, furosemide, hyoscyamine, and Xanax, and a physician order allowing medications to be crushed. On observation, an LPN obtained the resident’s medications, crushed all medications except the Depakote capsules, opened the capsules, mixed everything into oatmeal, and placed the oatmeal on the resident’s tray before leaving the room. A CNA then attempted to feed the resident, who refused the oatmeal, and the resident did not receive any of the morning medications. For the same resident, the incident note documented that the prescribed oral medications were crushed and mixed into oatmeal for consumption, but the resident refused breakfast and did not consume the medication mixed with food. The DON later documented that the resident did not receive the morning medications, and the ADON stated that this would contribute to some of the resident’s behaviors. The NP stated she was not aware the resident had not received medications that day and said the resident should be getting all medications as ordered. The resident’s care plan and MDS documented severe cognitive impairment, dependence on staff for all ADLs, and ongoing behavioral concerns. For a second resident with diagnoses including PVD, carotid stenosis, HTN, anxiety, PTSD, depression, and spinal conditions, the record showed an order for calcium carbonate chewable tablets in the morning. During observation, an LPN gave the resident other medications in one cup but left the calcium carbonate in another cup on the bedside table, stating the resident would take it later. Staff interviews and the facility policy stated medications are to be administered by a licensed nurse, the nurse must remain with the resident until the medication is swallowed, and medications are not to be left at bedside. The DON stated nurses should stand by the resident and ensure all medications are taken and should never leave medications with a CNA or at the bedside.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to have the State Inspection report readily available for residents to read without asking. During a resident council meeting, R66, R57, R12, and R15 stated that they did not know where the inspection book was located or that they could look at it. When told the survey book was in the front lobby, they stated they could not go to the lobby without permission. R66 stated that staff do not let residents go to the lobby and that staff must put in the code, adding that if a resident goes through the door and the alarm goes off, staff chase them down like a criminal. R57 stated that staff do not allow residents in the lobby unless they are leaving the facility and that they would not know about anything in the lobby or have access to it. V16, CNA, stated that residents do not go out in the lobby without staff and that staff must let them out to the lobby. R12 stated he did not know where the inspection book was and did not know how to find it. R15, the resident council president, stated that residents do not have access to the lobby without staff permission and help due to the door alarm. The Administrator stated the facility does not have a policy for the survey book and follows the Guidelines.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for eight hours per day, seven days a week during October, November, and December of 2025. On 12/15/25 at 8:30 AM, surveyors observed three Licensed Practical Nurses (LPNs) working in the facility and no RNs on duty. The deficiency was identified through interview, observation, and record review and was stated to have the potential to affect all 78 residents residing in the facility. During interviews on 12/22/25, the Assistant Director of Nursing stated that there were no RNs on the schedule and that she was an LPN. The Regional Administrator/Director of Operations stated that there were no RNs working in the facility. The Director of Nursing stated that the facility did not have any RNs on the schedule except for one PRN nurse who had not worked in a while, and that one RN had been hired but had not started yet. Review of the nurse schedules showed that in October 2025 there were two RNs scheduled with a total of three days worked, November 2025 had no RNs scheduled, and December 2025 had one RN scheduled who had not worked any shifts. The facility also stated it did not have a policy covering RN staffing or the daily posting of staff.
Failure to Post Daily Nurse Staffing
Penalty
Summary
The facility failed to post the nurse staffing data daily at the beginning of each shift. During surveyor observation on 12/15/25 at 8:30 AM, there was no staffing posting found anywhere in the facility, and this same condition was observed each day of the survey. The deficiency was identified through interview, observation, and record review and was noted to affect all 78 residents residing in the facility. On 12/22/25 at 9:15 AM, the Regional Administrator/Director of Operations stated that they had not been doing the staffing posting. At 9:17 AM the same day, the DON stated that they had not been doing that either. The Regional Administrator/Director of Operations also stated that the only staffing policy available did not cover RNs or the daily posting of staff. The facility’s undated staffing policy addressed providing sufficient licensed and unlicensed nursing staff, calculating staffing needs based on census and resident needs, and displaying copies of current licenses, but it did not include a policy for daily staffing postings.
Expired and improperly labeled medications found in medication rooms and on a med cart
Penalty
Summary
Drugs and biologicals were not properly stored, labeled, or discarded in the facility’s medication rooms and medication carts. During inspection of the 200 Hall medication room, surveyors found a clear plastic bag containing R41’s Bisacodyl 10 mg suppositories with an expiration date of 7/31/2025, and an open, partially used multidose vial of Tuberculin with no open date. An LPN verified that the suppositories were expired and should have been removed from use, destroyed, and reordered, and stated that the Tuberculin vial should have had an open date written on the vial or box when first accessed. The Tuberculin package insert stated that a vial entered and in use for 30 days should be discarded. In the 100/300 Hall medication room, surveyors found multiple expired stock medications in the refrigerator, including Bisacodyl 10 mg suppositories with expiration dates of 7/2023 and 8/2024, Acetaminophen 650 mg suppositories with expiration dates of 7/2024, 8/2025, and 9/2025, and another open, partially used multidose vial of Tuberculin with no open date. Surveyors also found R85’s package of Acetaminophen 650 mg suppositories with a discard date of 10/18/2025 and an expiration date of November 2025, even though R85 had been discharged from the facility on 3/26/2025. In addition, an LPN prepared to administer Lispro insulin to R55 and had drawn up the insulin in a syringe; when questioned about the date written on the insulin box, the LPN stated it was the open date, then realized the date predated the facility’s receipt of the insulin and discarded it. Staff interviews reflected that expired medications should be removed and replaced, and the DON stated that nurses should bring expired medications to leadership for disposal.
Improper Food Storage, Labeling, and Dating
Penalty
Summary
The facility failed to properly store, label, and date opened food items in the kitchen and food storage areas. During the initial tour of the kitchen, a case of diced pears was observed in a box on the floor of the dry storage room. In the walk-in refrigerator, an opened carton of traditional scrambled egg mix had no date showing when it was opened. Also observed were two clear containers with green lids containing noodle in broth that were not labeled or dated, a metal container with cooked cereal that was unlabeled and undated, a metal container of sliced tomatoes covered with clear wrap that was unlabeled and undated, and a metal container of sliced onions covered with clear wrap that was unlabeled and undated. Additional observations in the walk-in freezer included a box with a plastic bag of mixed vegetables on a shelf with the bag open, and a box labeled white fully cooked diced chicken 3/8 inch containing a plastic bag of chicken that had been opened, not sealed, and not dated. An opened bottle of thick and easy thickened orange juice was also observed with no date on the container. The dietary manager stated that all opened food in the freezer and refrigerator should be labeled and that food should not be stored on the floor. The facility policy stated food should be stored and prepared in a clean, safe, sanitary manner, stored at least 6 inches from the floor, and that all food not in original containers should be labeled and dated.
Call lights not answered timely
Penalty
Summary
The facility failed to answer resident call lights in a timely manner for 4 of 24 residents reviewed for call lights in a sample of 67. Resident Council Minutes from May 21, July 16, and October 15, 2025 documented concerns that call lights were not being answered promptly and that staff were turning off call lights. The facility’s call light policy stated that resident call lights would be answered in a timely manner, all staff should assist in answering call lights, nursing staff should respond to the call system and promptly cancel the light when entering the room, and requests should be answered in a courteous and professional manner. During interviews on 12/17/2025, R66 stated staff do not answer call lights and are nowhere to be found, describing the situation as horrible; R66’s Fall Risk Evaluation documented that R66 was alert and oriented x3. R57 stated staff do not answer call lights timely, if they answer them at all, and that the resident must go find someone for help; R57’s MDS documented cognitive intactness. R12 stated staff do not answer call lights timely and are either wrapped in blankets asleep or sitting in the TV room; R12’s MDS documented cognitive intactness. R15, the resident council president, stated staff do not answer call lights timely and sometimes come into the room, turn the light off, and never return; R15’s MDS documented cognitive intactness. On 12/18/2025, a CNA stated it is everyone’s responsibility to answer a call light and that it should be answered within about 3 minutes, while an LPN stated it should not take longer than 5 minutes and that older staff do turn the call lights off.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide activities for 5 of 5 residents reviewed for activities in a sample of 67. On 12/16/2025, one resident stated there were no activities and described the only offering as bingo, saying there was no activity person and that he was bored out of his mind. During a resident council meeting on 12/17/2025, four residents stated they did not have any activities at the facility and said they were bored and had nothing to do. Additional interviews on 12/17/2025 showed that one resident stated there were no activities and nothing to do, and said boredom led residents to do their own thing. Another resident stated there was nothing to do around the facility and said that since the activity person got sick and quit, there had not been any activities, and that a replacement did not stay long. A third resident stated he was bored and that there were no activities at all, and a fourth resident stated bingo had been cut out and that since the activity person left, there had not been consistent activities or a calendar with activities on it. During the investigation from 12/15/2025 to 12/18/2025, no activities were observed. Although a December activity calendar was observed on the hall wall on 12/18/2025, the administrator stated the activities listed were usually done in the dining room but were not occurring because the facility did not currently have an activity person.
Failure to Change and Date Humidified Oxygen Water Bottles
Penalty
Summary
The facility failed to change and date humidified oxygen water bottles for 4 of 4 residents reviewed for respiratory care. The residents involved were receiving oxygen therapy for conditions including COPD, dyspnea, dependence on oxygen, and shortness of breath. Record review showed each resident had physician orders and care plan interventions for oxygen therapy and humidification, with scheduled changes for oxygen tubing and humidified water bottles at set intervals. For one resident with COPD, asthma, and shortness of breath, the humidified water bottle in the room was dated 11/24/25 on 12/15/25 and remained dated the same on 12/17/25. For another resident with COPD and CHF-related shortness of breath, the humidified water bottle was observed undated on 12/15/25 and again on 12/17/25. A third resident with COPD and multiple chronic conditions was observed on oxygen with an undated humidified water bottle on 12/15/25 and again on 12/17/25; a nebulizer was also observed on the table with the mask sitting on it and not in a bag. A fourth resident with dyspnea and dependence on oxygen had a humidified water bottle dated 11/29/25 on both observations, 12/15/25 and 12/17/25. Staff interviews confirmed nurses were responsible for changing oxygen cannulas and water bottles and that the task should appear on the MAR-TAR when due. One LPN stated the bottles and cannulas are changed every Sunday and PRN, while another stated she checks and changes them as they appear on the MAR-TAR. The DON stated she would expect nurses to change the oxygen water bottles weekly as indicated on the MAR-TAR and not just sign them off as completed. The facility’s oxygen administration policy required oxygen tubing, humidifiers, masks, and cannulas to be changed weekly and stored in a plastic bag when not in use.
Failure to Provide Activities for Residents with Dementia
Penalty
Summary
The facility failed to provide activities for 4 of 4 residents reviewed for treatment and services for dementia residents. R16’s record documented dementia with anxiety, and the care plan identified the resident as an elopement risk/wanderer with interventions that included offering pleasant diversions, structured activities, food, conversation, television, and books. However, on observation R16 was sitting in the room with head down and stated that he was not invited to any activities but would go if there were any. R1, R25, and R34 also had diagnoses of dementia, including severe dementia with psychotic disturbances for R1 and dementia with psychotic disturbances for R34, and each care plan included interventions involving the activities coordinator and encouraging participation in activities or social situations. During the investigation, residents in council meetings stated that there were no activities at the facility, that they were bored, and that there was nothing to do. One resident stated that since the activity person got sick and quit there had not been any activities, and another stated that bingo had been cut out and there was no consistent activity schedule or calendar. From 12/15/2025 to 12/18/2025, no activities were observed. Although an activity calendar was posted, staff stated that activities were usually held in the dining room but were not occurring because the facility did not currently have an activity person and was recruiting and hiring.
Failure to Complete Medication Regimen Review Documentation
Penalty
Summary
The facility failed to complete a medication review for 1 of 1 resident reviewed for medications, R8. R8 had physician orders for Sertraline 100 mg daily and Buspirone 10 mg daily, and the face sheet listed diagnoses of paranoid schizophrenia, major depressive disorder, and bipolar disorder, current episode manic without psychotic features. The resident’s note to attending physician/prescriber dated and printed 7/26/2025 documented consideration of a gradual dose reduction for Buspirone 10 mg daily, but it did not document physician review or signature. A second note to attending physician/prescriber dated and printed 8/27/25 documented consideration of a gradual dose reduction for Sertraline 100 mg daily, but the sheet was blank and also failed to document physician review or signature. On 12/17/2025 at 11:44 AM, the DON stated that by looking at the blank note to attending physician for consideration of medication reduction, they were not done. The facility policy on Medication Regiment Review states that the consultant pharmacist incorporates federally mandated standards of care and that recommendations are acted upon and documented by facility staff and/or the prescriber, with the physician either accepting and acting upon the suggestion or rejecting it with an explanation.
Food Served Cold and Late
Penalty
Summary
The facility failed to ensure food was served at palatable temperatures for 4 of 4 residents reviewed for meal services, identified as R2, R15, R28, and R57. Resident Council Minutes from June, August, September, and October 2025 documented repeated concerns that the food was cold, bland, and overall poor. The facility's Food Preparation: Teste-Tasting policy stated that food items would not be served unless palatable and pleasing to the eye, and the Food & Beverage Temperature Control policy stated that food temperatures are maintained during serving times so residents receive safe food served at acceptable temperatures. R2, R28, R15, and R57 were each documented in their MDS as cognitively intact. During interviews, R2 stated the food was horrible, cold, sometimes done and sometimes not, and that meals came at different times, sometimes late or not at all. R28 stated the food was cold and delivered late. R15 stated the food was horrible, tasteless, and cold, with breakfast starting at 7 AM but delays up to 2 hours, resulting in food arriving around 9:30 AM and being cold. R57 stated the food was cold and late more often than not and looked and tasted horrible.
Infection Prevention and Hand Hygiene Failures
Penalty
Summary
The facility failed to perform appropriate hand hygiene during resident care, failed to maintain proper infection control practices during wound care, and failed to properly dispose of contaminated linen. During lunch observation, a CNA assisted a resident with feeding, left the resident at the table to assist other residents and handle lunch trays, then returned to continue feeding without hand hygiene being observed before, during, or after the assistance. Another resident was observed on contact isolation for ESBL/UTI, and a CNA performing peri-care wore gown, mask, and gloves but threw soiled linen and a urine-soaked brief onto the floor before placing them in the isolation container, while also handling clean items in the room with the same soiled gloves. A wound care observation showed an LPN entering a resident’s room with supplies, donning gloves without hand hygiene, and cleaning multiple reddened areas with glove changes between areas but without hand hygiene before, during glove changes, or after the care was completed. The resident receiving this care had wound-related skin issues, and the record noted treatment with zinc oxide ointment and anti-fungal cream. In addition, another resident who was dependent on staff for eating was observed being fed by a CNA, who picked up utensils and fed the resident without sanitizing hands before the feeding and again later after resting hands on her lap. The facility’s hand hygiene policy stated hand hygiene should be performed before and after direct contact, after contact with body fluids or wound dressings, when moving from contaminated to clean body sites, before glove placement, and after glove removal. The infection prevention policy stated standard precautions are to be used for all residents and that linens soiled with blood, body fluids, secretions, and excretions are not to be placed on the floor or other resident equipment. Staff interviews reflected expectations for hand hygiene before and after resident care, between glove changes, and during feeding assistance, as well as proper disposal of contaminated linen.
Failure to Assist Residents With Eating During Meals
Penalty
Summary
The facility failed to provide assistance with eating for 2 of 8 residents reviewed for help with eating. One resident was observed seated sideways in a regular chair at the dining table with a meal tray in front of them, including pasta with peas and chicken, cooked carrots, cake, water, orange drink, and an unopened Mighty Shake. For several minutes, the resident did not take a bite, and the drinks remained covered with plastic. The resident later removed the plastic from the orange drink and sipped it, then took a bite of casserole after an LPN encouraged eating. The resident’s MDS documented cognitive intactness with a BIMS of 15 and need for supervision or touch assistance for eating, and the care plan identified risk for self-care deficit including feeding with intervention to provide assistance with ADLs as needed. The second resident had severe cognitive impairment with a BIMS of 6 and also required supervision or touching assistance for eating per the MDS. During the meal, the resident ate only part of the cake, drank half of a beverage, and did not touch the casserole or carrots. The resident was observed dozing at the table and struggling to manage the cake and fork without cueing or encouragement to eat. A CNA briefly asked if the resident needed anything but did not encourage eating, and later an LPN entered and encouraged the resident to eat. The resident’s care plan also identified risk for self-care deficit including feeding and directed staff to provide assistance with ADLs as needed.
Medication Administration Error Rate Exceeded
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent during medication administration observations. Surveyors observed 14 errors during 38 opportunities for error, resulting in a 36.84 percent medication error rate. The deficiency involved two residents, including one resident with severe cognitive impairment, dependence on staff for all ADLs, and diagnoses including catatonic schizophrenia, anxiety, hypertension, diabetes, malnutrition, dyskinesia, falls, and depression, and another resident who was cognitively intact and required supervision or touching assistance for ADLs and transfers. For the resident with severe cognitive impairment, an LPN obtained the resident’s medications, crushed all medications except Depakote sprinkles, opened the Depakote capsules, mixed the medications into oatmeal, and placed the oatmeal on the resident’s breakfast tray in the room where a CNA was assisting with breakfast. The LPN then left the room. The CNA attempted multiple times to feed the resident the oatmeal without knowing medications were in it, and the resident refused to eat it. Later that morning, the CNA stated the resident did not eat any oatmeal and did not receive any morning medications. The ADON stated this would contribute to some of the resident’s behaviors, and the NP stated the resident should have been getting all medications as ordered. For the second resident, the LPN gave medications in one cup and left the resident’s calcium carbonate tablets in another cup on the bedside table, stating the resident would take them when he wanted to. Other nurses and the DON stated they would remain with the resident to ensure medications were taken and would not leave medications with a CNA or at the bedside. The facility’s medication administration policy stated medications are to be administered by a licensed nurse, not left at bedside, and the nurse must remain with the resident until the medicine is actually swallowed.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide at least 80 square feet of floor space per resident bed for 53 of 78 residents reviewed for room size. Surveyors found that the facility had 30 two-bed resident rooms that provided only 75 square feet per resident bed, with rooms measuring 12 feet by 12 feet 6 inches. These rooms were all certified for Medicare and Medicaid and included multiple numbered rooms, with one room now used as a family visiting room and telephone room for residents and another now used as a storage room. Surveyors also found 8 two-bed resident rooms that provided only 77.5 square feet per resident bed, measuring 12 feet 1 inch by 12 feet 6 inches with an additional 10-inch by 72-inch offset, and 3 two-bed resident rooms that provided only 76.5 square feet per resident bed, measuring 12 feet by 12 feet 6 inches with an additional 10-inch by 48-inch offset; one of these rooms was now the Break Room and another was now the Activity Room. In addition, 2 two-bed rooms provided only 78.5 square feet per resident bed and measured 15 feet by 10 feet 6 inches. During observation from 12/15/2025 through 12/17/2025, residents were observed in the rooms that did not meet the 80-square-foot requirement. Form CMS 671 dated 12/15/25 documented a census of 78, and on 12/15/2025 at 9:25 AM, the Regional Maintenance staff stated that the facility had multiple rooms with less than the required square footage.
Failure to Prevent Neglect and Address Fall Risks
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including schizophrenia, malnutrition, and a history of frequent falls, was not adequately monitored or provided with appropriate interventions to prevent neglect and injury. Despite being identified as a high fall risk and having a care plan that documented numerous falls, staff repeatedly failed to implement or update fall prevention interventions after each incident. The resident experienced multiple falls, some resulting in injuries that required emergency room visits, yet new or effective interventions were often not put in place, and fall risk assessments were missing after several incidents. In addition to the failure to address fall risks, staff did not consistently follow existing care plan interventions such as frequent toileting, ensuring the call light was within reach, and performing regular checks. The resident was observed on several occasions lying in bed for extended periods, saturated in urine and feces, with the call light out of reach and the door closed, making the resident not visible to staff. Staff members were seen opening the door, looking in, and leaving without providing care or cleaning the resident, even after being aware of the resident's condition. The resident remained soiled for at least five hours, and staff failed to respond to his needs despite clear evidence of incontinence and discomfort. Interviews with staff and medical professionals confirmed that the standard of care was not met, as the resident was left unattended and in an unhygienic state, and interventions to prevent falls and address incontinence were not followed. The facility's own policies defined such actions as neglect, including inadequate provision of care, poor hygiene, and leaving someone unattended who needs supervision. The repeated lack of appropriate response and disregard for the resident's care, comfort, and safety led to the identification of neglect and the declaration of Immediate Jeopardy.
Removal Plan
- R2 was provided with 1:1 sitter.
- DON/ADON completed skin assessment on R2 with no negative outcomes noted.
- Administrator, DON & ADON were in-serviced by the RNC on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Administrator in-serviced all department heads on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Department managers in-serviced department staff members on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Staff will not work until in-serviced on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- DON/ADON/Department Manager will in-service any future agency employees on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- The DON/ADON/Licensed staff completed skin assessment on residents requiring incontinent care.
- A quality assurance tool was implemented: DON/ADON/CNA Supervisor will conduct audits on residents requiring incontinent care and completed in timely manner.
- A quality assurance tool was implemented for SSD (Social Service Director) or designee to conduct resident interviews to ensure there are no concerns related to Abuse/Neglect.
- The DON/ADON will complete audit review during daily morning clinical meeting to ensure compliance.
- Audit tool will also include review of new/re-admit fall risk assessments for resident high risk to ensure prevention measure are in place.
- Root cause analysis completed for neglect related to coordination of care provided to residents.
Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to provide effective fall prevention and adequate supervision for a resident with a documented history of frequent falls and severe cognitive impairment. This resident experienced 50 falls over an eight-month period, many resulting in injuries such as hematomas, lacerations, and head injuries, some of which required emergency room visits. Despite being identified as a high fall risk and having multiple interventions listed in the care plan, staff did not consistently implement or update these interventions after each fall, and several falls were not addressed in the care plan at all. Additionally, fall risk assessments were not completed after every incident as required by facility policy. Observations and interviews revealed that staff often failed to keep the resident's call light within reach, did not maintain the resident in visible areas for supervision, and did not follow specific care plan interventions such as increased toileting rounds or ensuring environmental safety (e.g., removing nightstands, keeping doors open for visual checks). On multiple occasions, the resident was found lying on the floor or in bed with saturated linens, indicating a lack of timely assistance with activities of daily living and incontinence care. Staff were observed opening the resident's door to check if he was breathing but did not provide further care or ensure his safety, and transfers were performed without the use of gait belts or proper technique, increasing the risk of falls and injury. Interviews with facility leadership and clinical staff confirmed that there was an expectation for staff to follow all care plan interventions and maintain resident safety, but these expectations were not met. The facility's own policies required prompt response to resident needs, regular fall risk assessments, and implementation of individualized interventions, none of which were consistently followed. The failure to implement and monitor effective fall prevention strategies and provide adequate supervision directly resulted in repeated injuries and placed the resident in Immediate Jeopardy.
Removal Plan
- A fall risk assessment was completed for R2 and placed on 1:1 supervision.
- 1:1 sitters were in-serviced on 1:1 expectation related to coordination of care for R2.
- IDT team reviewed R2 falls to ensure that appropriate current interventions are in place.
- Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.
- In-service front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions.
- In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed.
- An initial audit will be completed of all falls to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective.
- Initial audit completed of fall risk assessments to ensure that appropriate prevention interventions are in place and care plans are reflecting those interventions.
- A quality assurance tool was implemented: An audit will be completed during clinical meeting to ensure that any fall has a root cause analysis, progressive intervention, and care plan is updated.
- A root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting.
- Review of the Fall Prevention Policy.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. One resident with severe cognitive impairment and multiple diagnoses, including schizophrenia and diabetes, was observed lying in bed for several hours in saturated sheets with urine and feces. Despite staff entering the room multiple times, the resident was not cleaned or checked for incontinence, and the door was repeatedly closed without intervention. The resident confirmed not being cleaned or checked during this period, and staff acknowledged not having time to provide care due to staffing issues. When incontinent care was eventually provided, staff failed to follow proper infection control and hygiene protocols. Hand hygiene was not performed before or after glove changes, and soiled gloves were used to handle clean supplies. The resident's peri-care was incomplete, as the penis and testicles were not cleaned, and soiled clothing was not promptly removed. The process lacked the use of a gait belt for safe transfer, and contaminated gloves were used to search for clean clothing, further breaching infection control standards. A second resident, cognitively intact but dependent on staff for toileting, also received incomplete peri-care. During observed care, staff failed to retract the foreskin to clean the entire penis and did not dry the resident after cleaning. The facility's own policies require residents to be checked for incontinence at least every two hours and for complete peri-care to be provided, including proper hand hygiene and cleaning techniques. Interviews with staff and the DON confirmed expectations for timely and thorough care, which were not met in these instances.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care for three out of four residents reviewed for infection control. In multiple observed instances, staff members, including CNAs and an LPN, did not perform hand hygiene before donning gloves, between glove changes, or after completing resident care and leaving the room. These lapses occurred during the provision of incontinent care and gastrostomy tube (G-tube) care. One resident with severe cognitive impairment and total dependence for activities of daily living was observed receiving incontinent care from two CNAs who donned gloves without prior hand hygiene, changed gloves multiple times without hand hygiene between changes, and left the room without performing hand hygiene. Another resident, also dependent on staff for ADLs and with a history of bowel and bladder incontinence, received peri-care from CNAs who failed to perform hand hygiene before care, between glove changes, and after care. Additionally, an LPN providing G-tube care to a resident did not perform hand hygiene before donning PPE, between tasks, or after doffing PPE and leaving the room. Interviews with facility staff, including the Director of Nursing and CNAs, confirmed the expectation that hand hygiene should be performed before and after resident care, as well as between glove changes. Facility policies also require hand hygiene at these critical points. However, direct observations and record reviews demonstrated that these protocols were not consistently followed during the care of residents with complex medical needs and high dependency.
Failure to Maintain Resident Room Window in Safe and Homelike Condition
Penalty
Summary
A deficiency was identified when a resident's room window was found to have a hole, allowing flies to enter the room. The resident's daughter reported the issue and took temporary measures by taping the hole and using a fly swatter. The Maintenance Director was unaware of the problem, stating that he typically addresses work orders the same day they are submitted, but no work order had been received for this issue. Upon inspection, the window was found to be inadequately covered with a piece of plexiglass that was not properly secured, leaving visible gaps and allowing outside air to enter the room. The plexiglass was attached with only one screw and loose duct tape, which was no longer effective, resulting in the wind blowing the plexiglass inward. Staff interviews revealed that the process for reporting maintenance issues involves filling out a work order and notifying maintenance, but in this case, the process was not followed, and the deficiency went unaddressed until it was observed during the survey. The facility's policy emphasizes the importance of maintaining a safe, clean, and homelike environment, but the failure to promptly identify and repair the window compromised these standards for the resident involved.
Failure to Conduct Employee Background Checks and Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse by not performing required background check screenings on current employees who have direct contact with residents. This lapse in screening had the potential to affect all 79 residents in the facility. Specifically, a resident with diagnoses of Bipolar Disorder, Depression, and Anxiety experienced verbal abuse from a staff member. The resident reported that a kitchen staff member used inappropriate language, stating he was going to 'whoop' the resident's ass after the resident complained about cold food. The incident left the resident feeling fear, anger, embarrassment, and a reluctance to leave his room while the staff member was employed. The facility's investigation into the incident was inconclusive, as there were no witnesses and the resident could not recall specific details or the exact date of the event. The staff member in question was suspended immediately and later terminated for safety reasons. During the investigation, it was discovered that the facility could not locate or verify the completion of the staff member's background checks. The administrator acknowledged responsibility for ensuring background checks are completed upon hire, as required by the facility's abuse prevention policy, but was unable to confirm that this had been done for the staff member involved.
Failure to Complete Staff Background Checks Leads to Resident Distress
Penalty
Summary
The facility failed to ensure a safe environment free from actual and potential abuse by not performing required background check screenings on current employees who had direct contact with residents. This lapse affected all 79 residents in the facility, as several staff members, including kitchen, housekeeping, maintenance, and nursing staff, were found to have worked without completed background checks or healthcare worker registry verifications. The administrator acknowledged that background checks were not completed for multiple employees, some of whom had direct access to residents, and that the issue stemmed from a lapse in service by the background check provider due to nonpayment, which was not followed up on by facility leadership. One resident, who has diagnoses of Bipolar Disorder, Depression, and Anxiety, reported experiencing verbal abuse from a kitchen staff member. The resident stated that the staff member used inappropriate language, which caused the resident to feel fear, anger, embarrassment, and reluctance to leave their room while the staff member was employed. The incident was reported and investigated, but the facility was unable to substantiate the allegation due to lack of corroborating evidence and the possibility of a misunderstanding in a noisy environment. However, the resident maintained that the incident occurred and described significant emotional distress as a result. Interviews and record reviews revealed that the facility's policies required background checks and registry verifications to be completed prior to employment, but these procedures were not followed. The administrator admitted responsibility for ensuring these checks were completed and confirmed that several staff members had worked without the required screenings. The medical director emphasized the importance of timely background checks to protect vulnerable residents, and the facility's own policies outlined a zero-tolerance approach to abuse, neglect, and misappropriation of property, which was not upheld in practice.
Removal Plan
- Administrator was in-serviced by the VP of clinical services on background checks and the need to run prior to staff member working.
- Administrator will in-service department heads on ensuring that staff will not work without background check being completed.
- All staff members that are currently on the working schedule have had a background check completed and are eligible to work in a skilled facility.
- Initial audit completed for all current employees, that a background check has been completed.
- Review of current policy and procedure to reflect current practices.
- No staff will work before having a background check.
- A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to first working day. Administrator and department manager.
- Root Cause Analysis Completed for background checks.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Response to Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff, including both CNAs and nurses, to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. During facility tours, staffing levels were observed to be as low as 2 CNAs and 2 nurses, and later 5 CNAs and 3 nurses, for 81 residents. Residents reported inadequate staffing, with one resident stating that increased use of agency staff indicated a need for more permanent staff. Another resident described multiple falls, including an incident where he was unable to reach his call light after falling, crawled to the hallway without finding staff, and ultimately called 911 for assistance. First responders, including fire and police personnel, reported difficulty locating staff upon arrival, eventually finding a nurse and another staff member outside smoking, both unaware of the resident's situation. Documentation showed that on the day of the incident, scheduled staffing was not met, with fewer CNAs present than planned. The resident involved in the fall was found on the floor with dried blood on his hands, face, and head, and had been attempting to get staff attention with a broken coat hanger. The nurse on duty reported last checking on the resident approximately 45 minutes before first responders arrived but did not enter the room. The facility's staffing policy requires sufficient licensed and unlicensed staff to maintain residents' well-being, but records and staff interviews confirmed that staffing levels were inadequate at the time of the incident.
Failure to Notify Family of Resident Falls
Penalty
Summary
The facility failed to notify a resident's family member of multiple falls experienced by the resident, despite facility policy requiring notification of the physician and responsible party after such incidents. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 6, and multiple diagnoses including catatonic schizophrenia, anxiety disorder, repeated falls, hypertension, major depressive disorder, and type II diabetes. Progress notes documented several falls over a two-month period, but there was no documentation that the family was informed of these events or any resulting injuries. The resident's family member confirmed that they had not been notified of recent falls and only learned of an injury after observing a cut above the resident's eye during a visit and inquiring with nursing staff. Interviews with facility staff indicated that the expectation was to notify families and physicians after a fall, but this was not consistently done for this resident.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide medical records to a resident's legal representative as required. The resident, who had diagnoses including metabolic encephalopathy, epilepsy, vascular dementia, and major depressive disorder, was moderately cognitively impaired at the time of discharge. After discharge, the resident's daughter, who held power of attorney, completed and submitted a HIPAA-compliant authorization form requesting access to the resident's medical records. The form, which specified that the facility must act within 30 days, was handed to a social services staff member, who stated she placed it on the administrator's desk and notified her. Despite this, the administrator and the Vice President of Clinical Services both stated they had never seen the request form and were unaware of its submission. The social services staff member confirmed receiving the form and taking steps to forward it, but no further action was taken, and the records were not provided to the resident's legal representative. This lack of follow-through resulted in the facility's failure to meet the regulatory requirement to provide timely access to resident records.
Failure to Update Care Plans and Complete Fall Risk Evaluations After Resident Falls
Penalty
Summary
The facility failed to implement and/or revise individualized care plans and complete fall risk evaluations for three out of five residents reviewed for accident hazards and supervision. One resident experienced multiple unwitnessed falls over a period of time, including incidents resulting in a hematoma, yet the care plan was not updated with new interventions after several of these falls. The resident's records indicated significant physical impairments, including lower extremity impairment, wheelchair use, and dependence on staff for transfers and toileting, but interventions remained largely unchanged despite repeated incidents. Another resident, with diagnoses including chronic obstructive pulmonary disease and mental health disorders, was identified as at risk for falls in prior evaluations but did not have a current care plan reflecting this risk. After a witnessed fall and an episode of unsteady gait possibly related to alcohol consumption, no new fall risk evaluation was completed. The resident reported frequent outdoor walks and described a recent incident where she tripped outside the facility, but there was no evidence of updated assessment or intervention following this event. A third resident, who was moderately cognitively impaired and required assistance with mobility, was documented as a high fall risk in a previous evaluation, but her care plan did not reflect this status. Family members and staff interviews confirmed that this resident had experienced falls both inside and outside the facility, with at least one incident observed by a family member and reported to emergency services. Staff acknowledged that fall risk care plans and evaluations should be updated after falls, but this was not consistently done. The facility's own policy required post-fall evaluations and care plan updates, which were not followed in these cases.
Mechanical Lifts Not Maintained in Safe Working Condition
Penalty
Summary
The facility failed to maintain mechanical lifts in safe working condition for four residents who required their use. Multiple CNAs reported and were observed struggling to maneuver a mechanical lift whose right leg would swing out unexpectedly without the use of controls, requiring staff to physically kick it back into place. The issue had been ongoing for several weeks, with the word "BAD" written on the malfunctioning leg to indicate its condition. Staff also reported that the lift sometimes failed to move up or down, possibly due to a short circuit, and that the other available lift had similar issues. Residents who depended on the lifts expressed fear and discomfort during transfers, with one resident stating she sometimes could not get out of bed for days due to lift problems, dead batteries, or lack of slings and staff. Despite these ongoing issues, the facility's process for reporting and addressing equipment problems was ineffective. CNAs stated they had notified maintenance, but the administrator was unaware of any work orders for the lifts and had not received reports of the problems. The facility's policy required routine maintenance checks by nursing and maintenance staff to ensure equipment remained in good working order, but this was not followed, resulting in continued use of unsafe equipment and inadequate communication regarding equipment failures.
Failure to Maintain Sanitary and Comfortable Environment Due to Mold and Poor Bathroom Conditions
Penalty
Summary
The facility failed to provide a sanitary and comfortable environment for residents, as evidenced by multiple observations of mold, strong bleach odors, and unclean conditions in several bathrooms and shower areas. Surveyors observed black and green fuzzy substances, identified as mold by staff, on tiles, baseboards, and walls in both men's and women's bathrooms across different hallways. In some areas, tiles were missing and walls were crumbling, and there were strong bleach odors that caused discomfort to surveyors. Toilets were found unflushed, and residents reported infrequent cleaning and persistent mold issues, with some stating they only shower once a week due to the unsanitary conditions. Interviews with residents and staff confirmed ongoing problems with mold, with residents expressing concerns about the cleanliness and odor of the shower rooms. Staff members, including a CNA and the housekeeping supervisor, acknowledged the presence of mold and described efforts to clean it with bleach and water, though the issue was described as longstanding. The facility's policy requires immediate cleaning of mold and mildew with appropriate cleaners, but the observations and interviews indicate that these measures have not been effective in maintaining a sanitary environment.
Failure to Ensure Timely Assessment and Continuity of Care for Resident with Epilepsy
Penalty
Summary
A deficiency occurred when a resident with a known history of epilepsy and complex partial seizures did not receive prescribed anti-seizure medications for four days. The resident's medication orders included Lacosamide and Levetiracetam, both critical for seizure control, which were held from 3/14 to 3/17 following an order from a covering nurse practitioner. This order was based on staff concerns that the resident's daughter may have been providing additional, possibly duplicative, medication doses during a leave of absence, though there was no clear evidence or identification of the medication in question. The decision to hold the medications was made without timely assessment or clarification of the situation, and there was a lack of direct communication with the resident's specialists. The covering nurse practitioner, who was not the resident's regular provider, acted on incomplete information provided by staff, who themselves were uncertain about what medication may have been given by the family. The regular nurse practitioner was on vacation, and upon return, noted that the hold order was based on a possible risk of double dosing, but there was no follow-up or assessment to confirm this before stopping essential medications. During the period when the anti-seizure medications were held, the resident experienced a seizure and required emergency hospital treatment. Hospital records confirmed that the seizure medications had been stopped for several days per facility staff orders. Interviews with facility staff and pharmacy consultants indicated that the lack of timely review and assessment of the medication regimen contributed to the resident's adverse event. The facility did not have a policy on continuity of care to guide staff actions in such situations.
Failure to Administer Anti-Seizure Medications as Ordered
Penalty
Summary
A resident with a history of epilepsy and complex partial seizures did not receive multiple doses of prescribed anti-convulsant medications, specifically oxcarbazepine and lacosamide, as ordered by the physician. The medication administration records showed missed doses of oxcarbazepine on two occasions and missed doses of lacosamide over several days. Documentation indicated that the medications were not available in the facility, and pharmacy records confirmed delays in refilling the prescriptions. The facility's controlled drug receipt and disposition forms corroborated that the resident ran out of lacosamide and did not receive it for several days. During this period without medication, the resident experienced a seizure episode in bed, which lasted 2.5 minutes and included clonic activity and emesis. The resident was found in a post-ictal state, displaying confusion, combativeness, and inability to respond appropriately. Emergency medical services were called, and the resident was sent to the hospital for evaluation and treatment. Interviews with facility staff and pharmacy personnel confirmed that the resident was sub-therapeutic for at least one day and that missing anti-seizure medication in such a case is considered a significant medication error. The facility's policies required that controlled substances be reordered when a four-day supply remained, and that emergency pharmacy services be available 24 hours a day. However, the resident's medication was not reordered in a timely manner, and the emergency kit did not contain the necessary anti-seizure medication. Staff interviews revealed uncertainty about how or if the medication was obtained during the period it was unavailable, and there was no documentation explaining the delay in refilling the medication.
Improper Dishwashing and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper cleaning of dishes and appropriate storage of food, which could potentially lead to foodborne illness affecting all 55 residents. During an observation, a cook was seen washing food residue from a dish in the far-right compartment of a three-compartment sink, then dipping the dish directly into the sanitizing solution in the far-left compartment without rinsing it in between. The middle sink compartment, which should have been used for rinsing, was empty. The cook admitted that the usual process is to wash, rinse, and sanitize dishes, but due to the lack of a stopper for the middle sink, she skipped the rinsing step. Additionally, the facility did not adhere to its policy regarding food storage. In the walk-in refrigerator, containers labeled Super Cereal and Meat Salad were found without a 'Use By' date, despite being dated 11/3/24 and 11/5/24, respectively. In the walk-in freezer, opened and resealed bags of biscuit dough and breadsticks were not labeled or dated upon opening. The dietary manager confirmed that food should be discarded after seven days, aligning with the facility's policy that requires items in refrigerators and freezers to be covered, labeled, and dated with a system to track when to discard perishable foods.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with a history of schizophrenia, depression, anxiety, diabetes, sleep apnea, COPD, and morbid obesity. The incident was reported when the resident claimed to have been hit and scratched by a night CNA. Initial assessments by nursing staff found no signs of injury, and a review of facility cameras showed no interaction between the resident and the accused CNA. Despite this, the facility's investigation was incomplete as the administrator acknowledged not asking the correct abuse-related questions during interviews with other residents. The facility's documentation noted minimal swelling on the resident's face, but the investigation did not substantiate the abuse claim. The resident's statements were inconsistent, and during a police interview, the resident was unresponsive or provided unrelated answers. The facility's abuse prevention policy requires interviews with other residents who have regular contact with the accused, but the administrator admitted to not following this procedure correctly. Consequently, the investigation was deemed insufficient, leading to a deficiency in handling the abuse allegation.
Failure to Address Pain Management in Resident Care Plan
Penalty
Summary
The facility failed to address pain management in the care plan of a resident, identified as R3, who was part of a sample of 43 residents reviewed. Despite the resident being alert and experiencing occasional pain, as documented in the Minimum Data Set (MDS), the care plan dated June 4, 2024, did not include any interventions for pain management. The resident's Physician's Order Sheet from November 2024 listed several pain medications, indicating a need for pain management, yet the care plan lacked any mention of this issue. During an interview on November 13, 2024, the resident reported chronic pain in her legs, knees, and ankles, with a pain level of 6 out of 10. The MDS/Care Plan Coordinator acknowledged that the resident's pain should have been addressed in the care plan with both pharmacological and non-pharmacological interventions. The coordinator was unsure why the pain was not included, suggesting that the resident's multiple hospital discharges over the past six months might have contributed to the oversight. The facility's Comprehensive Care Planning Policy emphasizes the importance of addressing all resident needs, including pain management, in the care plan.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum floor space per resident bed, as mandated by regulations. Specifically, the facility has 30 two-bed resident rooms that only provide 75 square feet per resident bed, falling short of the 80 square feet requirement. These rooms measure 12 feet by 12 feet six inches and are certified for Medicare and Medicaid. Additionally, there are 8 two-bed resident rooms providing 77.5 square feet per resident bed, 3 two-bed resident rooms providing 76.5 square feet per resident bed, and 2 two-bed rooms providing 78.5 square feet per resident bed. These measurements were confirmed through historical data and current room measurements. During observations conducted from November 12 to November 15, 2024, it was noted that 26 out of 55 residents were housed in rooms that did not meet the 80 square feet per resident bed requirement. The facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated November 12, 2024, documents the facility's census as 55. The deficiency affects a significant portion of the resident population, as these rooms are integral to the facility's accommodation of its residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a roach infestation that affected all 56 residents. Observations and interviews revealed that roaches were present in various areas, including the 300-hall, dining room, and individual resident rooms. Staff and residents reported seeing roaches scatter when lights were turned on, indicating a significant infestation problem. The facility's maintenance man, who was responsible for pest control, was terminated for not performing his duties, which contributed to the worsening situation. The pest control company had identified roach activity as early as February and recommended monthly services, but the facility did not follow through due to financial issues. The pest control service was put on hold, and the company was not called back until June. During their visit in June, the pest control technician found roach activity in the kitchen and other areas, confirming the ongoing infestation. The facility's policy required monthly preventative treatments, but this was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 888 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Collinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Au Well Care Home, Inc | 3.3 mi | — | 0 | 0 |
| La Bella Of Caseyville | 3.4 mi | ★★★★★ | 4 | 0 |
| Manor Court Of Maryville | 5.4 mi | ★★★★★ | 0 | 0 |
| Evercare At Stearns | 6.9 mi | ★★★★★ | 11 | 0 |
| Meridian Village Care Center | 7 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.