Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Goldwater Care Peoria Heights during CMS and state inspections, most recent first.
A cognitively intact resident was not protected from misappropriation of funds when a CNA used his debit card to withdraw cash and returned only part of the money. The resident reported he requested $800 but received $700 back, while bank records showed four ATM withdrawals totaling $800. The administrator confirmed the CNA was terminated for theft/dishonesty, and the receptionist verified the account activity.
Failure to document a resident’s advance directive led to CPR being started when he was found pulseless and apneic. An LPN reported the spouse said the resident was DNR but could not provide paperwork, so staff and EMS performed full resuscitation measures. The resident had significant respiratory diagnoses and was able to communicate his needs, and later records documented him as No CPR / DNAR.
Failure to monitor a resident who smoked and to provide adaptive smoking devices and a smoking apron led to third degree burns on the resident’s fingers. The resident had DM and PVD, had previously been identified as needing assistance, supervision, finger grips, and a smoking apron, yet was treated after sustaining burns while smoking independently. Staff stated independent smokers were not monitored and there was no official list of residents allowed to smoke.
Failure to thoroughly screen a resident before admission led to a resident with documented agitation, combative behavior, and use of mittens being admitted without an in-person assessment. Pre-admission records showed PRN Lorazepam orders and safety measures from the transferring hospital, and the resident later became combative during the initial nursing assessment and was involuntarily discharged for safety reasons. The DON/CNO, admission director, and Administrator stated that clinical review was based on paperwork and that no one laid eyes on the resident before admission.
Delayed assessment and treatment of pressure ulcers. A resident with severe cognitive impairment and multiple serious diagnoses was admitted with skin concerns and moderate pressure ulcer risk, but the initial skin documentation lacked wound measurements, detailed descriptions, and physician notification. Pressure ulcer prevention interventions and treatment orders were not in place until several days later, when the wound nurse documented stage 2 ulcers on both buttocks and a stage 3 ulcer on the coccyx. The resident’s family reported poor turning and repositioning, and the Medical Director stated he was not notified of the wounds on admission.
A resident who was cognitively intact and able to make his own decisions was kept on 1:1 supervision after altercations with other residents, but the facility could not provide a safety assessment or clear reason for continuing the restriction. He told staff he felt embarrassed, isolated, and unable to go anywhere in the facility, while other residents involved in the incidents were not placed on 1:1. Staff were also observed using earbuds and phones while assisting residents with dining and personal care, including feeding residents and providing cares to a resident while phone calls and texting occurred.
A resident with multiple pressure ulcers, including stage 3 and stage 4 wounds, did not receive ordered wound care on multiple occasions, and the TAR lacked documentation or explanation for the missed treatments. The wound clinic noted the resident arrived with incorrect dressings, including telfa instead of ordered mesalt, and the RN stated the wounds were worse and that the facility’s use of the wrong dressings likely contributed to the worsening.
No RN coverage was provided for the required daily hours. Surveyors found that the facility had 53 residents, no policy for RN scheduling, and that the DON was only in the building Monday through Friday. On one day, no RN was on duty and the Daily Assignment showed no RN scheduled for either 12-hour shift. The facility also could not provide the January nursing schedule, and later schedules showed multiple dates with no RN coverage.
Food service staff were observed serving resident meals with a beard net improperly worn or not covering the full beard, despite the facility policy requiring beard nets for employees with facial hair. Staff also stored multiple food items improperly, including undated and unidentified containers, leftover pasta servings past the date on the tray, and an employee lunch kept in the kitchen refrigerator instead of the Employee Break Room. The Dietary Mgr acknowledged several of these items should not have been in the kitchen or should have been discarded.
Facility failed to keep hallway linens covered and failed to maintain a Legionella water management program with testing frequency, protocols, acceptable ranges, documentation, baseline testing, routine flushing, or added monitoring after a water main break. Staff observed exposed linens on a cart while a CNA accessed them, and the IP, maintenance, and VPO stated the facility had no Legionella testing or prevention process in place.
Incomplete antibiotic tracking and delayed infection assessment: The facility did not consistently document antibiotic start and stop dates, the diagnosis being treated, lab/culture results, or the organism identified on infection tracking logs. The IP stated the McGreer assessment was sometimes completed after an antibiotic had already been ordered, and the MD started an antibiotic before obtaining the urinalysis, culture, and McGreer review, which showed no antibiotics were indicated.
Failure to offer and track staff COVID-19 vaccination. The facility did not ensure staff were educated on the COVID-19 vaccine’s benefits, risks, and potential side effects, did not offer the vaccine to staff, and did not track staff vaccination status. The IP/LPN stated she was not monitoring staff COVID-19 vaccinations and had not provided education or vaccine offers to staff.
Surveyors found that a shared bathroom used by several residents, including a resident with a colostomy, was not kept clean, with feces observed on the toilet, floor, and in the sink, as well as food particles on the sink drain guard. One resident with multiple comorbidities got another resident’s feces on his pants when he used the soiled bathroom. Staff, including the Maintenance Director and Housekeeping Director, acknowledged that a resident routinely emptied and cleaned his colostomy bag in the bathroom sink and that housekeeping checks were only verbally directed and not tracked, despite the resident’s care plan calling for daily and PRN ostomy care.
Failure to issue Medicare non-coverage notices: The facility did not ensure NOMNC/ABN notices were given to Medicare Part A beneficiaries or their POA, if applicable, when covered services were ending. During record review, the facility could not produce a NOMNC policy and could not provide notices for several residents discharged from Medicare A covered services; the Administrator confirmed the notices should have been issued but were not.
Failure to Immediately Report Abuse Allegation: A resident who was cognitively intact reported that an agency CNA refused toileting assistance and made an insulting, humiliating remark when the resident requested care before leaving with family. The resident told the DON about the incident, but the DON did not notify the Administrator or initiate the abuse reporting process, and the Administrator was unaware of the allegation until surveyor notification.
Failure to investigate an abuse allegation: A cognitively intact resident who was dependent on staff for toileting and transfers reported that an agency CNA refused care twice and made an inappropriate, insulting remark when the resident asked for help before leaving with family. The DON acknowledged the complaint but did not initiate an investigation, and the Administrator stated the CNA was blocked from the facility without a formal investigation or report to the state agency.
Failure to Notify Family and Ombudsman of Transfers and Discharges: The facility did not notify the local Ombudsman of transfers and discharges and did not notify one resident’s family member of a hospital transfer. A resident with continuous vomiting and blood-like emesis requested ER evaluation and was sent out, but the transfer form showed the resident representative was not notified and was not aware of the clinical situation. The family member later stated they were the only contact person and had not been called about the hospitalization, and the Ombudsman reported not receiving transfer/discharge notifications.
The facility failed to complete PASRR re-screening and/or referral after changes in mental health status for multiple residents. One resident had PTSD added after a PASRR Level II that did not include that diagnosis, another had bipolar disorder documented on the MDS without evidence PASRR was initiated, and a third resident’s short-term PASRR expired without an updated reassessment.
Failure to Implement PASRR Safety Plan for a Resident With Mental Health Findings: The facility did not implement a safety plan identified in a Level II PASRR for a resident with a history of suicidal ideation. The PASRR summary stated a crisis intervention service or plan was needed and that a safety plan should be in place if the resident had thoughts of self-harm, but the medical record contained no safety plan. The contract social service/counselor, Administrator, and President of Operations were unaware of the PASRR results, while the resident denied suicidal statements and later denied suicidal thoughts in counseling notes.
Failure to invite the resident and representative to care plan meetings and to keep the comprehensive care plan updated was identified for two residents. One resident had cognitive impairment and was dependent on staff for ADLs, yet the EMR had no care plan meeting documentation or care plan notes. The family member reported poor communication, no care plan meeting contact for over a year, unresolved roommate noise concerns, and delayed notification of a fall; the MDS coordinator could not locate a care plan meeting record within the past year and confirmed quarterly care plan meetings were expected.
A resident with major depression, DM2, and COPD was not provided activities that matched his stated interests and psychosocial needs. His preferences included reading, music, animals, group activities, fresh air, and religious services, but records showed mostly TV, socializing, and 1:1 entries with limited meaningful engagement. Counseling notes documented boredom, isolation, lack of support, and a desire for prayer or Bible study, while staff were observed not engaging him in activities during 1:1 supervision.
A resident who was severely cognitively impaired and totally dependent on staff was observed with a brief saturated with loose stool, dried stool, and stool leaking during care, with a strong odor of stool and urine in the room. Two residents with Foley catheters also had dignity and hygiene concerns, including a catheter bag left visible from the doorway and no dignity bag in place, despite staff acknowledging that catheters should be kept off the floor and covered for privacy.
A resident with a tracheostomy did not receive aseptic trach care as required by facility policy. An RT donned multiple gloves, suctioned the resident, handled supplies from the resident’s drawers and bed, used one sterile glove while continuing care with the other gloved hand, and did not remove the base layer of gloves or perform hand hygiene during the procedure.
Failure to document PTSD triggers in a resident’s care plan. A resident with dementia, major depressive disorder, and a trauma history related to family suicide was pleasantly confused and unable to answer questions appropriately during survey. Social services documented that loud noises, changes in routine or environment, and male caregivers were triggers, but the care plan did not identify these PTSD triggers. The President of Operations confirmed the care plan was not resident specific.
Improper medication storage was observed for two residents when an LPN was found with two clear medicine cups full of pills in a med cart drawer. The cups contained scheduled AM meds for the residents, even though the facility policy states meds should remain in their original containers and not be transferred by non-pharmacy staff. The Administrator stated meds should not be kept in medicine cups in cart drawers.
The facility failed to protect a resident from abuse by another resident when it did not prevent or adequately manage a resident-to-resident altercation involving willful physical contact. One cognitively intact resident with documented delusions, hallucinations, and a history of verbal and physical aggression grabbed another resident’s beard while the other resident grabbed his shirt, after a verbal confrontation. The incident caused pain to the resident whose beard was pulled, and the Administrator confirmed that willfully pulling another resident’s beard meets the facility’s definition of physical abuse under its abuse prevention policy.
A resident with dementia, cerebrovascular disease, adult failure to thrive, and under hospice care, who was care planned as totally dependent on two staff and requiring a mechanical lift for transfers, experienced a witnessed fall during a shower transfer when a CNA attempted to transfer the resident alone without a mechanical lift. The CNA reported slipping in the shower room, causing the resident’s feet to slide, and then lowering the resident to the floor by grasping the resident’s upper arms. Subsequent documentation noted right shoulder pain and an X-ray with no fracture, and the administrator confirmed that the transfer was not performed according to the resident’s care plan or facility policies requiring a mechanical lift and two-person assist.
Facility leadership failed to provide effective oversight of nursing and daily care, resulting in widespread missed wound treatments, inadequate skin assessments, and poor g-tube care for multiple residents. A resident admitted without pressure injuries developed a stage 3 coccyx ulcer that progressed to a stage IV sacral ulcer with sepsis after delayed and repeatedly missed treatments, while another resident with a stage IV sacral ulcer experienced missed wound care, lack of rectal tube replacement due to missing supplies, prolonged fecal contamination of the wound, and repeated failures to perform ordered g-tube site care and residual checks, culminating in sepsis. Several residents missed numerous doses of critical medications, including anticoagulants, anticonvulsants, antihypertensives, pain meds, and nutritional supplements, often documented as on order or unavailable. Residents also went extended periods without documented showers, and staff reported chronic short staffing, heavy reliance on agency staff, delayed call light response, and management that was frequently absent or behind closed doors. The facility lacked a full-time Activity Director, did not provide daily activities, and had no current activity calendar, while QAPI training, required CNA in-services, and regular QAA meetings were not documented or conducted.
Two residents with severe functional dependence and high risk for skin breakdown did not receive required pressure ulcer prevention and treatment. One resident developed a facility-acquired coccyx ulcer that progressed from stage 3 to stage 4 with tunneling and heavy drainage, while ordered wound dressings were delayed, repeatedly missed, and never incorporated into a care plan. Another resident admitted with a stage IV sacral ulcer and osteomyelitis had multiple missed wound treatments, no documented PRN care, no documented daily skin checks, and no monitoring of a rectal tube ordered to keep stool away from the wound; the rectal tube fell out, was never replaced, and the surgeon was not notified. Staff reported that wound care was often not done due to workload, and leadership and the MD were unaware that ordered treatments, assessments, labs, and rectal tube monitoring were not being completed, contributing to both residents’ wounds worsening and subsequent hospitalizations for sepsis and stage IV decubitus ulcers with osteomyelitis.
A resident with a PEG tube for nutritional support did not receive physician-ordered G-tube site care, residual checks, water flushes, and lab monitoring as required by facility policy and the care plan. Treatment records showed repeated missed G-tube site cleanings, gauze changes, and residual monitoring over multiple months, and ordered daily soap-and-water cleansing was not consistently completed. Medication records also showed missed tube flushes before and after medications. After a rectal tube fell out, the MD’s expectation that a GI surgeon be notified was not carried out, and there was no documentation of replacement or surgeon contact. Over several days, nursing notes documented recurrent vomiting, later diarrhea, and G-tube leakage, with ordered labs never obtained. The G-tube site was later found soaked with feed and leaking continuously, and a family member observed crusted feeding and yellow pus at the site before requesting hospital transfer. The resident was admitted to the hospital with sepsis, with the G-tube site infection identified as one of multiple suspected sources, and the PEG tube was removed due to an abscess and sepsis.
Two residents who were dependent on staff for ADLs and toileting hygiene, with frequent bowel and bladder incontinence and significant medical conditions, experienced prolonged waits for call light response and incontinence care, despite facility policies requiring prompt call light response and regular incontinence checks. One resident reported lying in urine and feces for hours and being left on a bedpan for extended periods, causing pain and feelings of embarrassment, shame, and disgust, with staff stating they lacked sufficient staffing to change everyone timely. Another resident was observed with a call light on for an extended time after a CNA said they would return with supplies but did not, and he described multiple episodes of sitting in his own feces for long periods, resulting in burning and soreness of the buttocks and feelings of disgust and “hell.” Staff interviews, including CNAs and LPNs, confirmed frequent complaints about long waits, acknowledged that staff sometimes fail to return after answering call lights, and attributed delays to inadequate staffing, while leadership acknowledged that such wait times were too long.
A resident with a stage IV sacral/coccyx pressure ulcer, tracheostomy, gastrostomy, critical illness myopathy, osteomyelitis, bowel incontinence, and total dependence on staff had a rectal tube ordered for fecal management and wound protection, with instructions to monitor placement and empty contents every shift. The care plan addressed the pressure ulcer but did not include the rectal tube, and the TAR showed no documentation of rectal tube monitoring or assessments over an extended period. After the rectal tube fell out, an MD instructed staff to monitor and contact the surgeon, but there was no documentation that the surgeon was ever notified, and the tube was not replaced due to lack of product availability despite the resident later consenting to reinsertion. The family reported that the rectal tube was never replaced and that stool-soaked wound dressings remained unchanged for hours, and the resident was subsequently hospitalized with sepsis and a stage IV decubitus ulcer with osteomyelitis, while facility clinicians later confirmed the absence of monitoring, replacement, and care planning for the rectal tube.
A resident with multiple pain-related conditions and a scheduled Hydrocodone-Acetaminophen order did not receive one scheduled dose and then missed all subsequent scheduled doses over several days because the medication was unavailable and listed as on order. During this time, staff did not perform comprehensive pain assessments, did not administer PRN pain medications or non-pharmacological interventions, and did not document timely notification to the physician or NP about the lack of medication and ongoing pain complaints. The resident reported severe, excruciating pain, crying out and being unable to move or get comfortable, while staff and leadership acknowledged the resident’s frequent pain complaints, the grievance about being out of pain medication, and the absence of alternative pain management or proper pain assessment in the record.
The facility failed to provide an ongoing daily activities program on day and evening shifts as required by its own policies, which call for four to seven organized activities per day, person-centered psycho/social support, and a mix of group and one-to-one programming. Observations over multiple days showed no activities occurring and no announcements made, while residents reported being very bored, having to find their own activities, and lacking a full-time Activity Director, with only occasional coloring pages and bingo. Staff, including an Ombudsman, LPNs, and the Interim DON, confirmed that no daily, evening, or weekend activities were being offered, that no current activity calendars were posted or distributed, and that a static bulletin board with generic activities was not updated monthly. A Housekeeping Supervisor intermittently filled in for activities but verified that no activities occurred on specific observed days and that there were no planned activities after mid-afternoon or on weekends.
The facility failed to provide sufficient nursing staff to meet residents’ ADL and incontinence care needs, as evidenced by staffing levels that fell below its own facility assessment and repeated reports of inadequate coverage on evening and night shifts. Multiple residents, a family member, and the Ombudsman reported chronic delays in call light response and long periods spent in urine and feces, with one resident describing being left on a bedpan for extended periods and another reporting repeated multi-hour waits for assistance. Staff, including CNAs and an LPN, stated that call lights could go unanswered for an hour or more, that residents were sometimes placed in double disposable briefs to reduce the frequency of changes, and that management instructed them to "make it work" despite short staffing and heavy reliance on agency staff.
Surveyors found that CNAs did not receive the required minimum of 12 hours of annual in‑service training. Facility records showed over 50 residents in care, and the facility’s own assessment tool specified that nurse aide in‑service education must be at least 12 hours per year to ensure ongoing competence. During an interview, the corporate/interim DON acknowledged being unable to provide documentation that any CNA had completed the required annual training hours.
The facility did not hold required Quality Assessment and Assurance (QA&A) Committee meetings with administration and the medical director at least quarterly as required by its QAPI plan and regulations. Documentation showed the last QA meeting occurred in mid-2025, with no evidence of subsequent meetings or prior meeting records. The Corporate President of Operations reported that the Administrator in Training had been informed that QA meetings were to occur monthly and at least quarterly per regulation, but she was unaware that these meetings were not being conducted. At the time of this deficiency, 53 residents were documented as residing in the facility.
The facility did not provide required annual QAPI (Quality Assurance and Performance Improvement) in-service training to its staff. Review of the staff in-service records over more than a year showed no documentation of QAPI training, despite 53 residents residing in the facility during this period. The AIT confirmed that no staff had received the annual QAPI training.
Multiple dependent residents with significant medical conditions, including dementia, metastatic cancer, traumatic brain injury, respiratory failure, and hemiplegia, did not have showers or hygiene care completed and documented as required by facility policy. Care plans and MDS assessments showed these residents were dependent on staff for bathing and personal hygiene, yet electronic records contained no shower entries over extended periods. Cognitively intact residents and family members reported that showers were not provided or were provided only once or twice over several weeks, and staff sometimes stated they did not have time or cited isolation status as a reason not to use the shower room. Observations revealed poor hygiene, including long, thick toenails, visible skin debris on clothing, and long fingernails with orange/yellow crusted material, while a CNA acknowledged nails should be cleaned during showers. The DON and MDS staff confirmed that showers were to be documented electronically, that paper shower sheets were not used, and that there was no documentation of showers for the affected residents.
Surveyors found that the facility failed to ensure multiple physician‑ordered medications were available and administered as prescribed for several residents. One resident with recent fractures and chronic pain missed all scheduled doses of ordered Hydrocodone‑Acetaminophen over several days because the drug was unavailable or on order, while staff did not document timely physician notification or obtain alternatives. Another resident missed numerous doses of anticoagulant, anticonvulsant, antihypertensive, antiepileptic, nutritional supplement, and stimulant medications, with notes indicating the drugs were on order or not available. Additional residents missed multiple doses of ordered Prazosin and Nystatin oral suspension for oral candidiasis under similar circumstances. An NP later documented that a resident had not been receiving ordered Nystatin and stated she had not been informed of the unavailability, and an agency LPN and the ADON reported that missing or on‑order medications were common and that medication administration had not been audited.
A resident with multiple chronic conditions, including HTN, dementia, and DM2, died while on hospice, leaving a significant balance in their facility account. The facility’s own records and emails showed that staff initially identified a smaller refund amount, later determined that over $10,000 was due, and then delayed issuing the refund after an additional payment required adjusting the amount and obtaining preapproval. The BOM acknowledged there was no refund policy, that private pay refunds were not processed timely, and that the refund should have been completed months earlier, resulting in a failure to promptly return the deceased resident’s funds to the representative as required by the facility’s abuse and misappropriation policy and the admission contract.
The facility failed to follow its fall prevention policy by not investigating falls, not revising care plans, and not implementing existing fall interventions for three residents at high risk for falls. One resident with metastatic cancer, TBI, seizures, and gait abnormalities, care planned for assistance and appropriate footwear, had multiple falls and was later observed in a wheelchair barefoot with the call light out of reach while needing the restroom. Another cognitively impaired, high‑fall‑risk resident had an unwitnessed fall with a note referencing nonskid footwear, but no new intervention was added to the care plan, and the resident was later observed in a recliner without a call light on their side of the room. A third resident with tracheostomy, gastrostomy, critical illness myopathy, a stage IV sacral ulcer, diabetes, and a history of falls was found partially out of a low bed with a rectal tube dislodged, yet no fall investigation, care plan revision, or updated fall assessment was documented.
The facility failed to follow its own weight policy and physician orders by not completing ordered daily admission weights for two residents with complex medical conditions, including cancer, CKD, severe protein-calorie malnutrition, tracheostomy, gastrostomy, critical illness myopathy, a stage IV sacral pressure ulcer, and type 2 DM. For one resident, only a single weight was documented despite an order for daily weights for seven days. For the other, only two weights were recorded over an extended period, despite the same daily weight order and ongoing tube feeding. The Assistant DON confirmed that the ordered daily weights for both residents were not completed.
Two residents with complex medical conditions, including TBI, encephalopathy, cardiomyopathy, and intracerebral hemorrhage, did not receive multiple doses of ordered medications such as Vimpat, Keppra, Hydrochlorothiazide, and Enoxaparin, despite facility policies requiring administration and documentation of all prescribed drugs. MARs showed numerous missed or undocumented doses of anticonvulsants, a diuretic, and an anticoagulant over several days, with no explanatory notes. The MDS coordinator confirmed the medications were not given and could not explain the omissions, while the NP acknowledged ongoing problems with medication availability and stated that failure to administer ordered drugs like Lovenox or Keppra is a serious problem.
A resident with a sacral pressure ulcer, diabetes, a tracheostomy with pneumonia risk, enteral feedings, and a leaking g-tube had multiple labs ordered, including CBCs, CMPs, BMP, CRP, hemoglobin A1C, prealbumin, and sedimentation rate, for monitoring various conditions. Despite documented physician orders and NP notes referencing needed lab monitoring and indicating that some ordered labs had not been drawn, the EMR contained no lab results from the facility for the entire stay. The ADON confirmed that no ordered labs were completed at the facility and that only hospital labs were available, contrary to the facility’s assessment stating it would provide clinical laboratory services.
A resident experienced a witnessed fall from a wheelchair, striking the head and later developing swelling and bruising around one eye. Nursing staff notified the physician, and a PA subsequently evaluated the resident, noting headache and vision changes and ordering an orbital x-ray. The medical record shows no evidence that the ordered x-ray was ever completed or that results were obtained, even though the facility’s assessment states it will provide access to diagnostic x-ray services. The resident later had another fall and was sent to the hospital, where a head CT was performed, and the ADON later confirmed the orbital x-ray had not been done.
A facility failed to follow its abuse prevention policy when an LPN did not immediately separate a resident from a visitor after the resident reported mistreatment. The LPN left the resident and visitor alone in the room, and later found the resident's bed soaked, raising further concerns. The administrator confirmed that immediate separation is required in such cases.
A resident reported verbal abuse by a visitor to an LPN, who documented and internally reported the incident, including evidence of possible retaliation. However, the Administrator did not notify the state agency of the abuse allegation within the required timeframe, resulting in a failure to comply with mandated reporting requirements.
The facility did not investigate two separate allegations of verbal abuse reported during Resident Council meetings, including a dietary staff member making a derogatory comment about a resident's weight and a Social Services Director threatening a resident with homelessness. The staff member responsible for Resident Council meetings was not educated on how to handle complaints, and facility leadership confirmed that no abuse investigations were initiated for these incidents.
The facility failed to maintain room temperatures at a safe and comfortable level for 14 residents, with temperatures ranging from 55 to 67 degrees Fahrenheit. The heaters, operated by a boiler system, were not functioning, and residents expressed discomfort due to the cold. The Director of Nursing confirmed the issue, which had persisted since the previous day, during a period of extremely cold weather.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to protect a cognitively intact resident from the wrongful use of his money when a CNA took the resident’s debit card to withdraw cash and did not return all of it. The resident stated that he asked the CNA to withdraw $800 for him, but when the CNA returned, she gave him only $700 and said she had only been able to withdraw $700. The resident later checked his online banking account and saw that $800 had actually been withdrawn from his account. The administrator stated he was informed that the resident was reporting the CNA had stolen $100 from him. He interviewed the resident, who repeated that he had given the CNA his debit card to withdraw $800 and received only $700 back. The administrator also stated that when he reviewed the bank account, he confirmed four separate withdrawals totaling $800, and he determined the CNA had not given the resident all of his money. The CNA’s termination notice documented the separation reason as theft/dishonesty, and the receptionist stated the resident’s account showed four withdrawals of $200 each, totaling $800, plus ATM fees.
Failure to Document Advance Directive Led to CPR Being Initiated
Penalty
Summary
The facility failed to formulate and document a resident’s desired advance directive, resulting in the resident receiving CPR when he did not wish to. The resident had diagnoses including acute respiratory failure with hypoxia, ventilator dependence, tracheostomy status, and gastrostomy tube status, and the medical record documented that he was alert and oriented and able to make his needs known by text message, mouthing words, or gestures. The facility’s advance directive policy required residents to be asked at admission whether they had executed an advance directive and to maintain copies of any advance directive in the clinical record. On the morning of the event, an LPN found the resident pulseless and not breathing. The resident’s spouse was at bedside and told the LPN that the resident was DNR, but she could not provide a signed physician order or other paperwork to support that status. The LPN stated that CPR was started and that facility staff and paramedics provided full life-saving measures, including chest compressions, ventilation, and medications, before the resident was transported to the hospital. The LPN also stated that she searched the electronic medical record and loose hospital paperwork but could not locate any documentation of the resident’s advance directive. The spouse stated that she told staff the resident was DNR and that he would not have wanted CPR or other life-saving measures. She stated that no one asked her for paperwork when he was admitted and that he had been very clear that he did not want CPR. The admission note later documented the resident as No CPR, and the hospital referral packet documented his status as No CPR Full Arrest: Do Not Attempt Resuscitation. A regional nurse coordinator confirmed that the resident should have had a POLST form indicating his wish not to receive life-saving measures if found pulseless and without respirations.
Failure to Monitor Smoking Resident and Provide Adaptive Smoking Safety Devices
Penalty
Summary
The facility failed to monitor a resident who smoked, failed to provide adaptive smoking materials, and failed to provide a smoking apron for a resident with diabetes mellitus and peripheral vascular disease. The resident’s smoking safety assessment last completed on 4/1/25 identified that he had severe difficulty handling cigarettes, required assistance and supervision while smoking, required a smoking apron, and had burns on his fingers and clothing from not using finger grips. Despite this, no further smoking assessments were completed before the resident’s smoking incident on 5/15/26, when he sustained burns to his right second and third fingers. The resident’s final report documents that on 5/15/26 he had a burn to the right second and third fingers and was treated by the wound doctor with new orders. The wound evaluation described third degree burns with necrotic tissue, including a 3 x 1.3 cm wound on the right third finger and a 4 x 1 cm wound on the right second finger, both estimated to take 4 to 6 months to heal. The resident stated he smoked independently, did not use a smoking apron, had limited feeling in his fingers, and that the burns were from smoking. Staff interviews indicated independent smokers were not monitored and that there was no official list of residents allowed to smoke outside.
Failure to Thoroughly Screen Resident Before Admission
Penalty
Summary
The facility failed to thoroughly screen a resident prior to admission for one resident reviewed for admission, discharge, and transfers. Pre-admission records from the transferring hospital documented that the resident had neurologic reserve Lorazepam for clearly documented seizures or severe agitation, with PRN Lorazepam orders of 0.5 mg every four hours and 2 mg every 15 minutes as needed, and that the resident was using bilateral mittens, full side rails, and a bed alarm. After admission, the resident arrived with mittens on both hands and became combative during the initial nursing assessment, attempting to hit both nurses. The resident was later involuntarily discharged from the facility for safety reasons, with the discharge notice stating that the safety of individuals in the facility was endangered. The resident's wife stated that the facility was aware of the resident's behaviors before admission and that the resident was feisty, irritable, and combative with staff. The Acting DON/CNO stated that the facility had a team of three for admissions and did not always lay eyes on a person before admission, while the admission director stated that the clinical side was reviewed by nursing staff and that she left the clinical decision to the nursing facility. The Administrator stated that she and the prior DON reviewed the resident's paperwork, that RT reviewed residents for the respiratory unit, and that no one laid eyes on the resident prior to admission.
Delayed assessment and treatment of pressure ulcers
Penalty
Summary
The facility failed to ensure timely assessment, physician notification, documentation, and implementation of treatment interventions for pressure ulcers for one resident with severe cognitive impairment and dependence on staff for activities of daily living. The resident had diagnoses including acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, encephalopathy, gastrostomy status, tracheostomy status, and type 1 diabetes. The facility policy required admission skin and pressure ulcer risk assessments, prompt reporting of identified skin conditions, physician notification, and implementation of interventions to address skin breakdown and prevent worsening. On admission, the resident’s record showed a moderate risk for pressure ulcers, but the initial skin documentation did not include wound measurements, detailed descriptions, or physician notification for the skin concerns that were later identified. A skin condition report documented an open pressure ulcer to the right rear thigh, redness to both buttocks, and a recurring rash to the right front thigh, but no measurements or detailed wound descriptions were recorded. The resident’s care plan did not contain pressure ulcer prevention or relieving interventions until several days later, and physician orders for pressure ulcer treatment were not present until that time. A wound note later documented a stage 2 pressure ulcer to the right buttocks, a stage 2 pressure ulcer to the left buttocks, and a stage 3 pressure ulcer to the coccyx, all with drainage, and treatment was initiated with hydrocolloid dressings. Subsequent records showed treatment changes because the dressings were not staying in place, and the physician and responsible party were notified at that time. The resident was later transferred to the hospital for respiratory decline, and hospital records documented an unstageable pressure injury present on admission at the coccyx extending into the sacrum. The resident’s family member stated staff did not notify them about the pressure ulcers until a couple of days after admission and that turning and repositioning were not done well. The DON confirmed treatment was not in place until the wound nurse assessed the resident, and the Medical Director stated he was not notified of the wounds on admission.
Failure to Respect Resident Choice and Dignity During 1:1 Supervision and Care
Penalty
Summary
The facility failed to allow autonomy and freedom of choice and failed to treat one resident equally as compared with others. R28 was admitted with diagnoses including major depression, type II diabetes mellitus, and COPD, and was documented as cognitively intact and able to make his own decisions. During the survey, R28 stated he felt embarrassed by having to have a 1:1 staff escort, described it as having a babysitter, and said he could not go anywhere in the facility because of the 1:1. He also stated that management said they did not know who started either of two altercations with other residents, yet he remained on 1:1 while the other residents were not on 1:1. The record and interviews showed that after an altercation with R35, staff witnessed contact between the two residents, but the facility could not provide a safety assessment or interdisciplinary team documentation explaining why R28 was considered the aggressor or why he remained on 1:1. A later altercation with R40 also resulted in police issuing only R28 a notice to appear in court, and the facility again could not provide a safety risk assessment or reasoning for the continued 1:1. R28 told social services he had no external support, wanted a romantic relationship, felt bored and unstimulated, was not getting along with residents and staff, felt ignored, and was isolated in his room watching TV. The activity director stated that since R28 was placed on 1:1 for behavior issues, he did not really come out as much anymore. The facility also failed to treat residents with dignity and respect during care and feeding. A CNA was observed with an ear bud in while pushing R28 in a wheelchair into the dining room. Another CNA was observed feeding residents in the assisted dining room while typing on a phone with one hand. A CNA providing cares to R2 had her phone ring twice and silenced it twice while with the resident. The administrator stated staff are not to have ear buds or phones out in resident care areas. The facility also had a list of 10 residents who needed assistance eating, and the observations involved residents receiving feeding assistance while staff used personal devices.
Missed Ordered Wound Treatments and Incorrect Dressings for Resident With Multiple Pressure Ulcers
Penalty
Summary
The facility failed to ensure a resident with multiple pressure ulcers received ordered wound treatments, including for a dorsum of the right foot and left heel. R39 was admitted with diagnoses including acute infarction of the spinal cord, paraplegia, neuromuscular dysfunction of the bladder, cauda equina syndrome, and multiple pressure ulcers, including stage 3 and stage 4 ulcers on the buttocks and heels. The facility policy stated that dressings used for healing purposes were to be removed at least weekly or more often per physician orders and that ordered treatments were to be initialed on the electronic TAR. The TAR showed multiple dates in February and March 2026 when the ordered cleansing, mesalt application, gauze, and foam dressing treatments were not documented as administered, with no explanation in the record for the missed treatments. The wound clinic documented that the heel sites were worse than the prior visit and that the resident arrived with incorrect dressings, including telfa dressings instead of the ordered mesalt dressings. The wound clinic RN stated that on two visits all wounds were covered with the wrong dressings or missing the ordered mesalt dressing, and that the wounds had worsened. The resident also stated that staff had used the wrong dressings on the multiple pressure ulcers, and the medical record did not document that the resident refused treatments.
No RN Coverage for Required Daily Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week. The resident roster provided by the Administrator documented 53 residents in the facility, and the facility was unable to provide any document or policy addressing RN scheduling requirements during the survey. On 4/28/26, the VPO stated there was no policy addressing necessary RN coverage for the facility, and stated that until recently the facility had only LPNs scheduled to deliver direct care and staff the facility, with the DON in the facility Monday through Friday and no RN coverage on weekends. On 4/26/26 at 8:15 a.m., there was no RN on duty in the facility, and the Daily Assignment posting verified no RN was scheduled for the day or night 12-hour nursing shifts. An LPN stated there were no RNs currently assigned to work that day, and the DON stated she was an RN and was in the facility eight hours a day Monday through Friday only, with weekend RN coverage not consistent. The facility was unable to provide the January 2026 nursing schedule or Daily Assignment postings for that month, and the schedules provided for February, March, and April 2026 documented multiple dates with no RN coverage.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During meal service, a Dietary Cook/Server was observed filling residents’ breakfast and lunch plates at the steam table without a beard net properly covering his full facial beard; on multiple observations, the beard net was either absent, askew on the chin, or under the chin with the beard exposed. The facility’s Dietary Policies and Procedures Manual stated that beard nets should be used for employees with facial hair, and the Dietary Manager acknowledged that the beard net should have been worn in the kitchen. The facility also failed to properly date, label, and store food items in the kitchen and walk-in refrigerator. Observations included a large undated, unidentified plastic container of thick red liquid, a large personal beverage container with no label or date, six undated and unidentified servings of pasta dish on a tray dated 4/14/26, and an undated restaurant carry-out container of chicken wings with two sauce containers in the kitchen cooler/refrigerator. The Dietary Manager stated the undated tomato soup should have been dated and could not be used, the personal beverage container should not have been in the refrigerator, the pasta salad servings should have been discarded, and the employee lunch should have been stored in the Employee Break Room rather than the kitchen. The facility’s CMS 671 documented 53 residents in the facility.
Infection Prevention and Water Management Deficiencies
Penalty
Summary
The facility failed to keep linens in the hallway covered and failed to maintain an infection prevention and control program related to Legionella and water management. During observation, the linen cart on the [NAME] wing had its cover lifted up and towels, bath blankets, sheets, gowns, bedspreads, pillow cases, briefs, and gloves were exposed. A CNA was observed taking linen from the cart and moving in and out of a resident room without pulling the cover down over the linens, and an LPN later pulled the cover down and stated the linen should be covered any time staff are not standing in front of the cart. The facility also failed to include required elements in its water management program, including the frequency for testing, testing protocols, acceptable ranges, and a system to document testing and corrective actions for Legionella. The facility had no baseline water testing results, no water sample analysis from the health department or town, no testing results or protocols, no heat or chemical water treatment, no adjustment of water temperatures, and no increased monitoring after a water main break. Maintenance stated the facility had not been flushing water pipes, did not have a piping diagram, was unsure which parts of the building had stagnant pipes, and did not have a testing kit or baseline water reports. The IP stated she did not do anything with Legionella surveillance or prevention, and the VPO stated the facility did not have any Legionella testing.
Incomplete antibiotic tracking and delayed infection assessment
Penalty
Summary
The facility failed to track antibiotic start and stop dates, the diagnosis being treated, laboratory and culture results, and the organism identified for antibiotics given to residents. Review of the January through April 2026 infection control tracking showed the log was incomplete and did not include these details. The facility’s Infection Surveillance, Tracking, and QA Reporting policy required monitoring infections, reviewing laboratory and microbiology reports, determining whether McGreer’s criteria were met, tracking physician antibiotic prescribing practices, and completing an infection tracking log for all residents with infection and/or treated with antibiotics. The facility also failed to use its infection assessment tool before administering antibiotics. The facility’s Antibiotic Stewardship Program stated that McGreer’s criteria were used to determine whether an infection met criteria for antibiotic treatment and that clinical assessment and antibiotic selection should be reviewed for new antibiotic starts. The IP stated there had been no infection control tracking log until she took over the role in December 2025, and she verified the tracking form was not complete with the required information. She also stated the McGreer assessment should be completed before an antibiotic is started, but that it was sometimes completed after the antibiotic had already been ordered. The MD had started a resident on an antibiotic before obtaining the urinalysis, culture, and McGreer assessment, which indicated no antibiotics were needed.
Failure to Offer and Track Staff COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure staff members were offered the COVID-19 vaccine, to track staff COVID-19 vaccination status, and to provide staff education on the benefits, risks, and potential side effects of the COVID-19 vaccine. The facility’s COVID-19 Vaccination Guidelines state that when the vaccine is available, each staff member is to be offered the vaccine unless contraindicated or already immunized, staff are to receive education before the vaccine is offered, and the facility is to maintain documentation of staff education, vaccine offers, and vaccination status. During interview, the IP/LPN stated she was not sure what vaccinations were offered to staff, could not provide documentation showing staff COVID-19 vaccination monitoring, and later stated she was not tracking staff COVID-19 vaccinations, did not offer education, and did not offer the vaccine to staff. The facility’s CMS 671 documented that 53 residents resided in the facility.
Failure to Maintain Clean Shared Bathroom for Residents with Ostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and safe bathroom environment for multiple residents who shared the same bathroom. One resident with hypertension, acute kidney failure, diabetes, and heart failure reportedly got another resident’s feces on his pants while using the shared bathroom, which had feces on the floor and toilet when he could not wait to use it. A roommate reported that the prior roommate, who has a colostomy bag, cleaned the colostomy bag in the bathroom. During observation, surveyors noted feces splattered on the toilet and in the sink, as well as undigested food particles on the sink drain guard in this shared bathroom. Facility staff, including the Maintenance Director and Housekeeping Director, acknowledged that the resident with the colostomy bag routinely empties and cleans the colostomy bag in the bathroom sink, resulting in feces being left on the floor, toilet, and sink. The Housekeeping Director stated she had verbally instructed housekeeping staff to check this bathroom several times a day but confirmed there was no tracking system to indicate how often it was checked or cleaned. The resident with the colostomy bag confirmed that he empties and cleans his colostomy bag himself and sometimes receives staff help, and his care plan included an intervention for daily and as-needed ostomy care. The DON confirmed that four residents shared this bathroom where these conditions were observed.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure the Advance Beneficiary Notice (ABN) CMS-10055 form was issued to Medicare Part A beneficiaries to notify the resident and/or the resident's Power of Attorney, if applicable, of the date Medicare Part A covered services would end for four of six residents reviewed for ABN compliance in a sample of 48. The facility was unable to provide a NOMNC/Notice of Medicare Non-Coverage or Resident Beneficiary Notice policy. During record review and interviews, the Administrator provided a list of residents discharged from Medicare A covered services in the past six months due to expiring Medicare A coverage, including R4, R13, R30, R59, and R65. When surveyors requested NOMNC notices for residents including R14, R30, and R59, the facility initially provided documentation for R13 only and stated there were no NOMNC/Beneficiary Notices for R4 and R59. Later, NOMNC notices were provided for R59 only, and the facility stated there were no NOMNC notices for R14 or R30. The Administrator ultimately verified that NOMNC notices should have been provided for residents discharged from Medicare A covered services, including R4, R14, R30, and R65, and that this had not been done.
Failure to Immediately Report Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was immediately reported to the Administrator or designated official and to the state agency for one resident, R46, who was reviewed for abuse. The facility’s Abuse Prevention and Reporting Policy required all staff to immediately report any allegation, suspicion, or observation of abuse, including verbal abuse or conduct causing humiliation, intimidation, or distress, to the Administrator or designated authority. R46 was admitted to the facility and was documented as cognitively intact on one MDS, with a later MDS showing cognition not assessed and dependence on staff for toileting and transfers. R46 stated that over the weekend an agency CNA, V19, refused twice to assist with toileting before R46 left the facility with family and then made an insulting statement, telling R46, “they should have left your ass in the bed, and someone could have got you up and ready right before you left.” R46 reported the interaction was upsetting and inappropriate and stated she told the DON, V2, on 4/26/26. V2 acknowledged that R46 told her a staff member was not nice and that R46 requested V19 not return because of attitude problems and rudeness, but V2 did not report the allegation to the Administrator or initiate the facility’s abuse reporting process. The Administrator later stated she had not been made aware of the allegation until the surveyor notified her.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse was thoroughly investigated and that appropriate actions were taken to prevent further potential abuse for one resident who was cognitively intact and dependent on staff for toileting and transfers. The resident reported that an agency CNA refused twice to assist with toileting before the resident left the facility with family and made an inappropriate statement, telling the resident, "they should have left your ass in the bed, and someone could have got you up and ready right before you left." The resident said the interaction was upsetting and reported it to the DON, who apologized but did not initiate an investigation. The DON later acknowledged she did not investigate the allegation, and the Administrator stated the CNA was blocked from working in the facility without a formal investigation and that the abuse allegation should have been investigated and reported to the state agency.
Failure to Notify Family and Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the local Ombudsman of transfers and discharges and failed to notify one resident’s family member of a transfer to the hospital. The deficiency involved 3 residents reviewed for transfers and discharges and was identified through interview and record review. The facility’s Physician-Family Notification-Change of Condition policy, dated 11/13/2018, states that medical care problems are to be communicated to the attending physician or authorized designee and the family/responsible party in a timely, efficient, and effective manner. For R23, nurse’s notes dated 1/3/2026 at 11:52 PM document continuous vomiting episodes, with the resident stating the vomitus tasted like blood and requesting to be sent to the ER for evaluation. The SNF/NF to Hospital Transfer Form dated 1/3/2026 documents that R23 was sent to the ER, but the form also indicates the resident representative was not notified of the transfer and was not aware of the clinical situation. On 4/29/2026, R23’s family member stated that they were the only contact person and usually received calls from the nurses when something happened, but did not get called about the January hospitalization and learned about it from R23. On 4/28/2026, the Ombudsman stated she was not getting notified of transfers or discharges from the facility, and on 4/29/2026 the Administrator confirmed the facility could not provide documentation that the Ombudsman had been notified. The facility census dated 4/26/2026 showed 53 residents in the facility.
PASRR Re-screening and Referral Not Completed After Mental Health Changes
Penalty
Summary
The facility failed to ensure PASRR Level I/II re-screening and/or referral was completed after significant changes in mental health status for residents reviewed for PASRR. The facility’s PASRR policy stated it would coordinate with the state PASRR authority, complete Level I screenings annually and with significant changes in status, and report changes to the appropriate state authority so residents receive necessary services. For one resident, a PASRR Level II outcome documented bipolar disorder and dementia with Alzheimer’s disease, but PTSD was later added to the medical diagnosis list and also appeared on MDS assessments; the Administrator stated no PASRR Level II had been completed and that a new PASRR should have been initiated when PTSD was added. For another resident, the admission record showed bipolar disorder, the MDS later documented an active bipolar disorder diagnosis, and the VPO stated the MDS coordinator would typically notify Social Services to initiate PASRR when a new mental health diagnosis is confirmed, but there was no record this occurred. For a third resident, the PASRR Level II was approved for short term without specialized services, the approval had expired, and the facility could not provide an updated PASRR; the VPO confirmed the PASRR was expired and the resident should have been reassessed.
Failure to Implement PASRR Safety Plan for Resident With Mental Health Findings
Penalty
Summary
The facility failed to implement a safety plan identified on R28’s Level II PASRR for mental health needs. The facility’s PASRR policy states that the PASARR level II determination and evaluation report are to be included in the resident’s assessment and comprehensive care plan, and that the facility will care plan and provide the specialized services indicated in the level II determination under the direction of qualified personnel. However, R28’s Illinois PASRR Summary of Findings documented that a crisis intervention service or plan was needed and that a safety plan should be in place if the resident had thoughts of self-harm and needed support. R28’s medical record did not contain any information related to a safety plan. Counseling notes beginning on 3/9/2026 documented the start of therapy, and subsequent counseling notes documented denial of suicidal thoughts by R28. On 4/27/2026, the contract social service/counselor stated he was not aware of the PASRR level II results or any history of suicidal ideation for R28. On the same date, the Administrator and President of Operations denied knowledge of the PASRR level II results indicating a history of suicidal ideations. R28 denied making suicidal statements and stated, "I do not believe in suicide, it is a sin. I said I wish the good Lord would go ahead and take me. But I would never pretend to know better than the Lord."
Failure to Invite Resident and Representative to Care Plan Meetings and Update Care Plan
Penalty
Summary
The facility failed to ensure that the resident and representative were invited to participate in care plan meetings and failed to review and revise the comprehensive care plan on an ongoing basis for two residents, including R11. The facility’s Comprehensive Care Plan policy stated the interdisciplinary team was responsible for reviewing and revising the care plan after each assessment, including quarterly reviews, and that residents and/or representatives were to be invited to participate at least quarterly in person, by phone, or by video conference. R11 was admitted to the facility and the MDS documented cognitive impairment and dependence on staff for activities of daily living. R11’s electronic medical record did not contain documentation of a care plan meeting or care plan notes. R11’s family member stated communication with the facility was very difficult, calls often went unanswered, and he had not been contacted for a care plan meeting in over one year. The family member also reported concerns about a roommate turning the television volume up loudly, which bothered R11, and stated those concerns had been voiced to staff but not resolved. The family member further stated he was not notified of a recent fall and learned of it days later from the resident. The MDS coordinator stated she was unable to locate documentation of a care plan meeting for R11 within the past year and confirmed care plan meetings should be held quarterly and as needed with changes, with the resident and representative invited.
Failure to Provide Activities Aligned With Resident Needs and Preferences
Penalty
Summary
The facility failed to provide activities to meet the needs of one resident who had diagnoses including major depression, Type II diabetes mellitus, and COPD. The resident’s activity preference interview identified important interests such as reading newspapers and magazines, listening to music, being around animals, doing things with groups of people, participating in favorite activities, going outside for fresh air, and taking part in religious services or practices. The resident’s PASRR Level II also documented that attending groups may provide support and reduce isolation, that he does not like to be alone, and that he needs a structured environment with structured socialization activities to diminish tendencies toward isolation and withdrawal. The resident’s care plan documented that he was partially dependent on staff for emotional, intellectual, physical, and social needs and that he should be provided a program of activities that is of interest and empowers him by encouraging choice, self-expression, and responsibility. However, the facility could not provide activity participation records prior to February 2026, and the records that were available showed repeated documentation of movie/TV, socializing, and 1:1 entries, with some days left blank in March. The resident was also documented as participating in a special event and bingo on limited occasions, but the records did not show meaningful participation aligned with his stated interests. Counseling notes documented that the resident had no external social support, wanted a romantic relationship, felt bored and unstimulated, was not getting along with other residents and staff, was anxious, and was upset that he could not go to church. He repeatedly stated that he was bored, ignored, and not getting enough attention, and said he would love to pray or do a bible study. The Activity Director stated the facility only had Catholic services in house and did not know whether the receptionist who prayed with residents had ever met with this resident. Throughout the survey, the resident was not observed in activities or being invited to participate, and staff assigned to his 1:1 were mostly observed sitting outside his room on their phones or talking to other staff rather than engaging him in games, socialization, or prayer.
Incontinence and Catheter Care Deficiencies
Penalty
Summary
Appropriate incontinence care was not provided for one resident who was severely cognitively impaired, nonverbal, and totally dependent on staff for all ADLs. The resident’s care plan directed staff to change the resident after each incontinent episode to prevent skin breakdown and infections, but during observation the resident’s brief was saturated with loose stool, contained dried stool, and stool was leaking from the brief during care. The resident’s room also had a strong, foul odor of stool and urine, and the brief contained an incontinence insert. Catheter care and dignity were not maintained for two residents with Foley catheters. One resident had an order for a Foley catheter for urinary retention, and a nurse stated catheters should be off the floor. Another resident was observed in bed with a catheter on the side of the bed with no dignity bag over it, and the catheter bag and amber-colored urine were clearly visible from the doorway. The nurse verified that the resident’s catheter should have had a dignity bag over the top for privacy.
Aseptic Technique Not Used During Tracheostomy Care
Penalty
Summary
The facility failed to perform tracheostomy care using aseptic technique for one resident with a tracheostomy. The facility’s Tracheostomy Care policy stated that residents with tracheostomies are to receive routine care to maintain a patent airway and that aseptic technique is to be used during dressing changes until the tracheostomy is healed and a physician order is obtained for tracheostomy care. During observation, the respiratory therapist donned a gown and multiple gloves at the doorway, entered the room, suctioned the resident’s mouth and around the outside of the tracheostomy stoma, and then opened the resident’s drawers to remove supplies and place them on the bed. The therapist opened the sterile tracheostomy care package and placed one sterile glove on one hand while continuing care with the other gloved hand, including turning the suction machine on and feeding the catheter into the tracheostomy multiple times. The therapist then removed the dressing behind the tracheostomy plate, used both hands on and off to wipe around the stoma with a cotton applicator, placed the new dressing behind the tracheostomy plate, discarded used supplies on the bed, and adjusted the resident’s clothing and covers. The therapist later stated that double gloving was normal practice and confirmed that she did not remove the base layer of gloves and perform hand hygiene during the tracheostomy care.
Failure to Document PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to identify PTSD triggers for one resident who had a documented trauma history. The resident was admitted with diagnoses including adult failure to thrive, unspecified dementia with behavioral disturbance, and major depressive disorder. During the survey, the resident was pleasantly confused and did not answer questions appropriately. The Social Service lookback summary documented that the resident had lost her husband, nephew, and son, that her husband committed suicide, and that she did not want male caregivers in her room alone. It also documented that loud noises, changes in her living environment or routine, and male caregivers made her uncomfortable. The resident’s current care plan documented trauma history due to family suicide, but the care plan did not identify the resident’s PTSD triggers. The care plan interventions listed were to determine medical necessity for medical procedures involving trauma triggers, determine the resident’s coping mechanism, and ensure the resident’s safety and the safety of others. On interview, the President of Operations confirmed that the resident’s PTSD triggers were not documented on her care plan and that the care plan was not resident specific.
Improper Medication Storage in Cart Drawer
Penalty
Summary
The facility failed to store medications in a safe manner for two residents, R30 and R58, during observation, interview, and record review. The facility’s Medication Storage policy dated 7/2/2019 states medications and biologicals should be stored in the containers in which they were originally received and that no transfers between containers are to be performed by non-Pharmacy personnel. On 4/26/2026 at 8:30 AM, the top drawer in the [NAME] medication cart contained two clear medication cups with writing on the sides, each full of pills. An LPN stated the cups contained R30 and R58’s scheduled 8:00 AM medications. R30’s MAR listed Calcium Carbonate 1500 mg, Folic Acid 1 mg, and Cephalexin 500 mg, and R58’s MAR listed Amlodipine 10 mg, Aspirin 81 mg, Cholecalciferol 1000 Units, Folic Acid 1 mg, Carvedilol 25 mg, Furosemide 80 mg, and Hydralazine 100 mg. The facility’s medication cart list identified both residents’ medications as stored on the [NAME] cart, and the Administrator stated that no medications should be in medicine cups in the drawers of medication carts and that they should be administered when prepared.
Failure to Prevent Resident-to-Resident Physical Abuse During Altercation
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when it did not prevent or adequately manage a resident-to-resident altercation that met the facility’s own definition of physical abuse. The facility’s Abuse Prevention and Reporting policy, revised 10/24/22, prohibits abuse, including physical abuse such as hitting, slapping, pinching, kicking, and controlling behavior, and specifies that resident-to-resident altercations involving willful actions resulting in physical injury, mental anguish, or pain must be reported. One resident (R2), who was cognitively intact with documented delusions, hallucinations, and frequent verbal and physical behaviors, had a care plan noting a history of making inappropriate comments and gestures toward female staff and residents, and a history of being physically and verbally aggressive, whether provoked or unprovoked. Despite this known history, R2 was involved in an altercation with another resident (R1) in which R2 willfully grabbed R1’s beard while R1 grabbed R2’s shirt. According to the facility’s Final Abuse Investigation Form dated 2/22/2026, a former employee observed the two residents making physical contact, with R2’s hand on R1’s beard and R1 holding R2’s shirt, and intervened to separate them. R2 later stated he and R1 did not like each other and described an incident where R1 got in his way, they yelled at each other, and he grabbed R1’s beard while R1 grabbed his shirt. R1 reported that R2 reached out, grabbed his beard, and cursed at him, and that the beard pulling was very painful. The Administrator confirmed that, under the facility’s policy, a resident willfully pulling another resident’s beard is considered abuse. The incident, involving willful physical contact causing pain between residents with a known history of behavioral issues, demonstrates the facility’s failure to ensure that R1 was free from abuse by another resident as required by its policy and regulatory standards.
Improper Manual Transfer Leads to Fall During Shower
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and transfer policies during a staff-assisted transfer, resulting in a witnessed fall for one resident. The facility’s Fall Prevention Program Policy requires assessment of fall risk, implementation of appropriate safety interventions, use of mechanical lifting devices for residents needing a two-person assist, and communication of these needs to direct care staff. The Transfers-Manual Gait Belt and Mechanical Lift Policy further specifies that mechanical lifting devices must be used for any resident needing a two-person assist or who cannot be transferred safely, and that direct care staff will be trained in their use. Despite these policies, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone in the shower room without using a mechanical lift, contrary to the resident’s care plan and facility policy. The resident involved had multiple significant diagnoses, including cerebrovascular disease, major depressive disorder, senile degeneration of the brain, dementia, adult failure to thrive, and was under hospice care. The resident’s current care plan documented total dependence on two staff members for bed mobility, dressing, grooming, bathing, positioning, and transfers using a mechanical lift with two staff. On the date of the incident, the CNA reported that while in the shower room, her foot slipped during the transfer, the resident’s feet slid, and she grasped the resident’s upper arms and lowered the resident to a seated position on the floor. A witnessed fall report and nursing notes documented that the resident was lowered to the floor during this transfer, later complained of right shoulder pain, and an X-ray was obtained, which was negative for fracture. The administrator confirmed that the resident was supposed to be transferred with a mechanical lift and two-person assistance and that the CNA had improperly transferred the resident alone.
Systemic Administrative and Clinical Failures Leading to Missed Care, Worsening Wounds, and Medication Errors
Penalty
Summary
The deficiency involves a failure of facility administration and nursing leadership to provide adequate oversight of wound care, medication administration, treatment administration, quality assurance, and basic activities of daily living. The Administrator-in-Training did not hold a temporary license and had been functioning in the role since July 2025 under a regional VP of Operations who was not present in the building daily. The DON role was filled on an interim basis, and staff reported that management kept office doors closed, was not consistently present in the building, and did not effectively address staffing or care problems. The facility did not have a full-time Activity Director, and activities were not provided daily, with no activity calendar posted and no planned activities after 4:00 PM or on weekends. Multiple residents experienced missed or delayed wound care, skin assessments, and gastrostomy tube (g-tube) care. One resident was admitted without pressure ulcers and later developed a stage 3 coccyx ulcer for which treatment was delayed 24 hours and then missed 16 times, ultimately progressing to a stage IV sacral ulcer with concern for osteomyelitis and hospitalization for severe sepsis. Another resident with a pre-existing stage IV sacral ulcer was hospitalized for sepsis related to the wound and osteomyelitis, returned to the facility, and then had multiple missed wound treatments. This same resident’s rectal tube was accidentally removed and not replaced due to lack of supplies, leaving the sacral wound exposed to fecal matter for extended periods, and g-tube site care and residual checks were repeatedly not completed, with subsequent hospitalization for sepsis with suspected sources including g-tube site infection and the stage IV sacral wound. Medication administration was not reliably carried out as ordered. One resident missed 18 scheduled doses of significant medications, including anticoagulants, anticonvulsants, antihypertensives, nutritional supplements, and stimulants, with documentation indicating medications were on order or not available. Another resident did not receive any scheduled doses of ordered Norco over several days, and additional residents missed multiple doses of anticonvulsants, antihypertensives, and anticoagulant injections. The facility nurse practitioner reported awareness of problems with medication availability. Documentation and oversight of showers and basic hygiene were also deficient, as several residents had no evidence of receiving showers over a two-month period, and the interim DON confirmed that no one was overseeing whether showers were completed and documented. Staff interviews and observations further demonstrated systemic failures in supervision and quality assurance. CNAs and nurses reported chronic short staffing, heavy reliance on agency staff, delayed call light response, missed pain medications, and wound treatments not being done daily. Staff stated that management told them not to disclose issues to surveyors and that concerns about staffing and care were not addressed. The wound nurse/infection preventionist reported not being educated on the wound process, not having wound logs when starting in December 2025, and not being delegated responsibility for monitoring MARs and TARs until early February 2026. The medical director stated that continuity of care was affected by staff and management changes and that he had not been informed of widespread missing treatments, medications, and care concerns. The facility lacked documentation of annual QAPI training for staff, required CNA in-service hours, and quarterly QAA meetings, with leadership confirming that QAA meetings had not been held since July 2025.
Removal Plan
- V2 (Interim DON) and V4 (ADON/Wound Nurse) in-serviced all licensed nurses on Physician Orders—Entering and Processing and Documentation in the Health Record, including the Physician Orders—Entering and Processing policy; orders are entered into the EMR by V2 and V4.
- V2 and V4 in-serviced all licensed nurses on Pressure Injury and Skin Condition Assessment and Documentation—Electronic Health Record policy (entries must be timely, accurate, relevant, and complete by V2 or V1).
- V2 and V4 in-serviced all staff on Change of Condition and Physician-Family Notification, including the Physician-Family Notification—Change in Condition policy.
- V2 and V4 in-serviced all staff on Comprehensive Care Plan/Baseline Care Plan, including the Baseline Care Plan.
- V2 and V4 in-serviced all staff on admission of residents, including the Admission of Resident Care Plan.
- V2 and V4 in-serviced all staff on the Resident/Admission–Readmission Checklist, including the admission checklist.
- V2 and V4 in-serviced the IDT on Comprehensive Care Plan, including the Comprehensive Care Plan.
- V2 and V4 in-serviced all staff on Infection Prevention and Control Program, including the Infection Prevention and Control Program policy.
- Initiated a facility audit to identify all residents with pressure ulcers, including completing wound assessments, contacting the physician and wound nurse, reassessing wounds in 24 hours, and obtaining consents to see the wound physician; 56 residents were assessed.
- V2 and V4 in-serviced staff on Pressure Injury and Skin Condition Assessment and implemented a process requiring the direct care nurse to review the TAR prior to providing wound care.
- V2 and V4 in-serviced staff on Pressure Ulcer Prevention and multiple related policies (Med Error/Adverse Drug Reaction, Physician Orders—Entering and Processing, Documentation—Health Record, Comprehensive Care Plan/Baseline Care Plan) and implemented a process to train staff on pressure ulcer prevention/worsening prevention interventions (review care plan before care; follow skin policy; weekly skin assessments; follow physician orders; identify residents dependent for repositioning; dietary/clinical follow meal ticket/orders for diet/supplements; review MAR/TAR prior to med pass and wound care; skin assessments on return from hospital; open risk management for skin breakdown and notify wound nurse/DON).
- V2 and V4 in-serviced all staff on Pressure Injury and Skin Condition Assessment and Skin Condition Assessment and Monitoring Pressure and Non-Pressure, including the Pressure Injury and Skin Condition Assessment policy.
- V2 and V4 in-serviced all nurses and CNAs on Pressure Ulcer Prevention, including the Pressure Ulcer Prevention policy.
- Began a facility-wide audit of all residents’ wound care plans and updated wound care plans.
- Completed a facility-wide review/audit of residents with wounds for needed changes and updated the physician; produced a wound report.
- Educated all licensed nurses on the complete Gastrostomy Tube—Feeding and Care policy (by V2, V3, and V4).
- Completed a facility-wide audit of all residents with gastrostomy tubes to ensure stoma site treatment orders, tube feeding orders in EHR, residual checks on MAR, monitoring/notification for GI symptoms, documentation of stoma abnormalities and physician notification, and care plan review/updates on TAR by the nurse (V2/designee).
- V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Management Policy.
- V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Assessment Policy.
- V3 and V4 in-serviced all licensed nurses on Medication Administration General Guidelines.
- V3 and V46 in-serviced all licensed nurses and CNAs on the Resident Rounds Policy and procedure.
- V3 and V46 in-serviced all clinical staff on the Bathing—Shower and Tub Policy.
- V3 and V4 in-serviced all staff on the Incontinence Care Policy and Procedures.
- V1 (AIT) in-serviced V25 (Housekeeping Supervisor) on the Activities Program Policy.
- V1 (AIT) in-serviced all staff on the Residents Rights and Dignity Policy.
- V14 (Corporate President of Operations) in-serviced facility leadership on the facility Quality Assurance Performance Improvement (QAPI) Program Procedure.
- V14 in-serviced facility leadership on the Program of Angel Round to ensure leadership availability to residents, families, and staff.
- V14 in-serviced facility leadership on ensuring oversight and implementing policies for wound care, medication administration, treatment administration, quality assurance measures, and basic ADL resident care, including review of job descriptions.
- V14 re-oriented V1 (AIT) on Administrator duties for the facility.
- Held an impromptu meeting with the medical director and interdisciplinary team to discuss the deficiency and facility action plan.
- Performed an audit on one resident per day to ensure residents with pressure injuries have wound prevention orders in EMR and that wound assessments are completed upon admission/re-admission or weekly per policy.
- Performed an audit on one resident per day to ensure treatments were performed and initialed/dated per policy.
- Performed an audit on one resident per day to ensure care plans are revised timely and interventions are linked to the Kardex; treatments are charted and signed off in PCC.
- Performed an audit on one resident per day to ensure wound physician progress notes are reviewed and the Physician Order Sheet is updated (treatments, labs, supplements, pressure-relieving devices) prior to the next scheduled wound care.
- Performed an audit on one resident per day to ensure weekly skin assessments are completed by the responsible nurse.
- Performed an audit on one resident per day (five days per week) to ensure nurses review the TAR prior to performing wound care procedures.
- Performed an audit on one resident per week to ensure the Dietary Department provides the correct diet/supplements.
- Performed an audit on one resident per day to ensure Infection Prevention Guidelines are followed when performing wound care.
- Performed an audit on one new admission per day to ensure all required equipment and supplies are obtained and in the facility.
- Completed the missed administration report and medication administration report daily to ensure MAR accuracy and completeness per policy/procedure.
- Completed a daily audit to ensure residents with gastrostomy tubes have stoma site treatment orders, TAR sign-off for completion, tube feeding orders in EHR, residual checks on MAR, physician notification/documentation for GI symptoms, and documentation/notification for stoma abnormalities.
- Planned to monitor all residents’ MARs daily to ensure residents are not going without medication (including visibility of medications documented as on hold).
Failure to Provide Ordered Pressure Ulcer Care and Monitoring for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and treat pressure ulcers, prevent a facility-acquired pressure ulcer, prevent existing ulcers from worsening, administer wound treatments as ordered, and develop and implement appropriate pressure-relieving interventions and care plans for two residents. One resident was admitted with severe cognitive impairment, was bedbound, nonverbal, and fully dependent for all ADLs, with a Braden score of 9 indicating very high risk for pressure ulcers. Despite this, the resident’s care plan did not include a problem or interventions related to pressure ulcer risk or prevention. The facility’s own policies required skin inspections, Braden risk assessments, weekly wound assessments, prompt notification of the physician and representative at the earliest sign of skin problems, and care plan revisions when skin integrity was altered, but these were not followed. For the first resident, the skin condition report initially documented no wounds, but on a later date a wound to the coccyx was identified by a CNA and evaluated by the wound nurse, who described an open area with moderate serous drainage and scarring. A treatment order for medicated dressing and gauze twice daily was placed, but the treatment administration record showed delays in starting the treatment and multiple missed or undocumented treatments on several dates, even after the order was changed to every shift due to drainage. The wound nurse later stated the wound was getting worse, needed debridement, and that there was still no care plan for the wound, acknowledging it was her responsibility to add one when the wound was identified. Progress notes documented that the wound progressed from a stage 3 to a stage 4 ulcer with deep tunneling, purulent, odorous drainage and concerns for infection, and nursing notes described copious dark yellow drainage and worsening of the coccyx wound before the resident was sent to the hospital. For the second resident, who was originally admitted with a stage IV coccyx pressure ulcer, tracheostomy status, gastrostomy status, critical illness myopathy, osteomyelitis, and dependence on staff for all ADLs and mobility, the care plan documented the presence of a pressure ulcer and the need for a pressure-relieving/reducing mattress and treatments as ordered. Physician orders included use of a rectal tube to protect the wound from stool contamination and specific wound care regimens, including wound vac and later wet-to-dry dressings twice daily and PRN, as well as sodium hypochlorite solution every 12 hours. Treatment administration records showed multiple missed scheduled wound treatments, no PRN wound treatments documented, and numerous missed sodium hypochlorite applications. There was no documentation of site monitoring or assessments for the rectal tube and no daily nursing skin checks in the electronic record. The rectal tube fell out and, although the physician ordered monitoring and follow-up with the surgeon, the surgeon was not notified, the rectal tube was not replaced, and there was no documentation that the gastric surgeon was contacted. The NP documented that the rectal tube had come out on two occasions, that replacement tubes were out of stock, and that the family wanted it reordered, but the tube remained unavailable. The resident’s family reported observing stool-soaked wound dressings remaining in place for over four hours before being changed. Nursing notes also documented orders for labs and imaging related to a leaking G-tube, but the electronic record contained no laboratory results for the entire admission. Staff interviews confirmed that wound care was often not completed on night shift due to workload, that missed treatments meant they were not done, that nurses were not consistently assessing skin daily, and that the DON and medical director were unaware that ordered wound treatments, skin assessments, labs, and rectal tube monitoring were not being completed.
Removal Plan
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all licensed nurses on Physician Orders—Entering and Processing, and Documentation in the Health Record (including the Physician Orders—Entering and Processing policy).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all licensed nurses on Pressure Injury and Skin Condition Assessment (including the Electronic Health Record policy).
- Conducted a facility audit to identify all residents with pressure ulcers, including completing wound assessments, contacting the physician, contacting the wound nurse, reassessing the wound in 24 hours, and obtaining consents to see the wound physician.
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced staff on Pressure Injury and Skin Condition Assessment (including the Pressure Injury and Skin Condition Assessment policy) and developed a process requiring the direct care nurse to review the Treatment Administration Record prior to providing wound care.
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced staff on Pressure Ulcer Prevention and Med Error/Adverse Drug Reaction, Physician Orders—Entering and Processing, Documentation—Health Record, and Comprehensive Care Plan/Baseline Care Plan (including related policies) and implemented a process to ensure staff are trained to develop and provide interventions to prevent pressure areas and prevent pressure ulcers from worsening, including: educating staff to review the care plan before care; educating nurses on the facility skin policy; educating nurses on weekly skin assessments; educating nurses on following physician orders; educating staff on residents with pressure ulcers who are dependent on staff for repositioning; educating clinical and dietary staff to follow physician orders and meal tickets to ensure correct diet and supplements; educating nurses on following physician orders and reviewing the MAR/TAR prior to medication pass and wound care; educating nurses on conducting skin assessments upon return from hospital; educating nurses to open risk management for skin breakdown and notify the wound nurse and DON.
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Pressure Injury and Skin Condition Assessment and Skin Condition Assessment and Monitoring—Pressure and Non-Pressure (including the Pressure Injury and Skin Condition Assessment policy).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all nurses and certified nursing assistants on Pressure Ulcer Prevention (including the Pressure Ulcer Prevention policy).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Change of Condition and Physician-Family Notification (including the Physician-Family Notification—Change in Condition policy).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Comprehensive Care Plan/Baseline Care Plan (including the Baseline Care Plan).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on admission of residents (including the admission of Resident Care Plan).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on the admission of Resident/Admission-readmission Checklist (including the admission checklist).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced the IDT on Comprehensive Care Plan (including the Comprehensive Care Plan).
- V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse in-serviced all staff on Infection Prevention and Control Program (including the Infection Prevention and Control Program policy).
- V14/Vice President of Operations in-serviced administration on ensuring all new admissions (referrals) equipment and supplies are obtained prior to admission.
- Held a QAPI meeting with the medical director and IDT to discuss deficiencies and facility action plans.
- Conducted a facility-wide audit for all residents’ wound care plans.
- Conducted a facility-wide audit of residents with wounds to identify any changes needed and updated the physician.
- Planned to conduct audits seven days per week for six weeks for all residents with pressure injuries.
Failure to Provide Ordered PEG Tube Care Leading to Infection and Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered gastrostomy (G-tube/PEG) care, including cleansing, laboratory monitoring, flushes, residual checks, and tube insertion site assessments, for a resident receiving nutritional support via an internal PEG tube. The facility’s own Gastrostomy Tube – Feeding and Care policy required measurement of gastric residuals as ordered, observation for nausea, vomiting, diarrhea, abdominal distention or cramping, and immediate reporting and treatment of skin irritation or infection at the stoma site, including cleansing with soap and water or antiseptic and thorough drying. The resident’s care plan documented dependence on tube feeding and water flushes, the need to check tube placement and gastric residuals per facility protocol, and to obtain and monitor labs as ordered and report results to the physician. The resident’s physician orders included G-tube site care to cleanse and apply split gauze every shift for infection control and to check residuals before medications and feedings, with instructions to hold feeding and medications and notify the physician if residuals were greater than 100 ml. This residual order was not initiated until five days after admission. Treatment Administration Records showed that G-tube site cleaning and gauze changes were missed on multiple occasions across several months, including missed cares on specific shifts and repeated failures to perform scheduled residual monitoring prior to feedings and medication administration. Additional orders to cleanse the G-tube insertion site daily with soap and water during ADL care were also not consistently completed, with several scheduled soap and water cleansings not done. Medication Administration Records documented that ordered water flushes of the G-tube before, between, and after medications were not completed on at least two documented shifts. Progress notes showed that after the resident’s rectal tube fell out, the medical director’s expectation that the gastrointestinal surgeon be notified was not carried out, and there was no documentation that the rectal tube was replaced or that the surgeon was contacted. Over a period of days, nursing notes documented repeated episodes of vomiting and later diarrhea, as well as G-tube leakage, with orders for CBC, BMP, and KUB imaging; however, no CBC or BMP were drawn or resulted at the facility. When the G-tube leakage worsened, staff documented that the resident’s tube drain and gown were soaked with feed and that the G-tube site was continuously leaking. The resident’s family member reported finding the resident’s abdomen covered with crusted feeding and yellow pus under the gauze at the G-tube site and requested hospital transfer. The resident was admitted to the hospital with fever, abdominal pain, diarrhea, nausea, vomiting, toxic appearance, and a diagnosis of sepsis from multiple suspected sources, including a G-tube site infection with pus-filled drainage, and the G-tube was removed in the hospital due to an abscess and sepsis. An ER physician stated that improper G-tube care, including lack of cleansing and flushes, can lead to infection at the site and that dislodged feeding into the abdominal cavity is also a risk factor.
Removal Plan
- All licensed nurses were educated on the facility's complete Gastrostomy Tube - Feeding and Care policy by the Director of Nursing, MDS coordinator, and Assistant Director of Nursing/Wound Nurse.
- All licensed nurses were educated on the facility's Physician Orders - Entering and Processing policy (including when receiving, entering, and confirming physician/prescriber orders in the EMR) by the Director of Nursing and Assistant Director of Nursing/Wound Nurse.
- All licensed nurses were educated on the facility's Documentation - Electronic Health Record policy (timely, accurate, relevant, complete entries) by the Director of Nursing/designee or Administrator.
- All licensed nurses were educated on the facility's Skin Condition Assessment & Monitoring - Pressure and Non-Pressure policy by the Director of Nursing/designee or Administrator.
- All licensed and certified nursing assistants were educated on the facility's Physician-Family Notification - Change in Condition policy by the Director of Nursing/designee or Administrator.
- An impromptu QAPI meeting was held with the medical director and IDT team to discuss the deficiency and facility action plan.
- The facility completed a facility-wide audit of all residents with gastrostomy tubes to verify: stoma site treatment orders are in place; tube feeding orders are in the EHR; residual checks are on the MAR prior to flushes/medications/bolus feeding or starting a new bottle through the feeding pump; signs/symptoms of intolerance are documented with physician notification; any stoma site skin abnormalities are characterized, documented, and physician notified; care plans are reviewed/updated and interventions are in place and reflected on the TAR.
- The facility will conduct audits 7 days per week for 6 weeks to ensure for residents with gastrostomy tubes: stoma site treatment orders are in place and TAR is signed off; tube feeding orders are in the EHR; residual checks are on the MAR prior to flushes/medications/bolus feeding or starting a new bottle through the feeding pump; signs/symptoms of intolerance are documented with physician notification; any stoma site skin abnormalities are characterized, documented, and physician notified; and a QA tool is completed daily for 6 weeks by the Director of Nursing or designee to verify compliance.
Failure to Respond Promptly to Call Lights and Provide Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity and timely care by not responding promptly to call lights and not providing timely incontinence care. Facility policies on dignity, incontinence care, and call light response require that residents be treated with respect, checked for incontinence approximately every two hours, and that call lights be answered promptly by all staff. Despite these policies, the Ombudsman and a resident council representative reported ongoing complaints over multiple resident council meetings about long call light wait times and residents having to sit in urine and feces for extended periods, particularly on second and third shifts when staffing was reportedly short. One resident, a cognitively intact female with multiple medical conditions including periprosthetic fracture, diabetes, osteoporosis, and muscle wasting, was dependent on staff for ADLs and toileting hygiene and frequently incontinent of bowel and bladder. Her care plan required dependent assistance and use of a mechanical lift with two staff for transfers. She reported lying in urine and feces for hours before staff answered her call light, sometimes waiting more than two and a half hours to be cleaned after an incontinence episode. She also stated that when staff placed her on a bedpan, they often did not return for up to two hours, leaving her sitting on the bedpan in pain. She described feeling embarrassed, ashamed, humiliated, and disgusted, and reported that staff repeatedly told her they did not have enough staff to change everyone timely. Nursing staff and an occupational therapist corroborated that she had to wait extended periods, especially on nights, due to staffing. Another resident, a male with a history of intracerebral hemorrhage, acute kidney failure, muscle wasting, hypertension, and other conditions, was dependent on staff for ADLs, required substantial to maximum assistance with toileting hygiene and transfers, and was occasionally incontinent of bladder and frequently incontinent of bowel. During one observation period, his call light remained on for at least 30–40 minutes. He stated that a CNA had come in about 25 minutes earlier, was told he was wet and had defecated, said she would get washcloths and return, but never came back, leaving him lying in his own feces. He reported that this happened frequently, describing his feelings as disgusted and like “hell,” and recounted a prior episode where he turned on his call light after soiling himself and waited approximately three hours before staff responded, during which his buttocks were burning and sore. CNAs acknowledged that his call light had been on for a long time, that staff sometimes answer call lights and then fail to return, and that limited staffing and competing tasks made it hard to respond to all residents timely. The corporate interim DON stated that call lights should be answered as soon as possible and that 30–45 minutes was too long for a call light to go unanswered.
Failure to Monitor and Replace Rectal Tube for Resident With Stage IV Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and replace a fecal management system (rectal tube) and to include it in the care plan for a resident with a stage IV sacral/coccyx pressure ulcer. Facility policy for management of fecal incontinence with a flexible seal required effective diversion and containment of liquid and semi-liquid stool, frequent observation of the device for obstruction, and physician notification for specified adverse events. The resident was admitted with a stage IV coccyx pressure ulcer, tracheostomy status, gastrostomy status, critical illness myopathy, osteomyelitis of the vertebra and sacral region, bowel incontinence, and dependence on staff for all ADLs and mobility. The care plan addressed the pressure ulcer and skin breakdown prevention but did not include any plan of care for the rectal tube. Physician orders directed staff to monitor placement and empty the contents of the rectal tube every shift for wound care beginning in November, but the Treatment Administration Record from November through mid-January contained no documentation of rectal tube placement checks, assessments, or bowel content monitoring. A nursing progress note documented that the rectal tube fell out on January 1 and that the MD instructed staff to monitor and call the surgeon; the nurse was unable to locate the surgeon’s number and notified the DON, with no further documentation that the surgeon was ever contacted. Subsequent progress notes by the nurse practitioner indicated that the rectal tube had come out on two occasions, that there was no replacement tube at the bedside, and that previous attempts to reorder the product were unsuccessful because it was out of stock. The notes also documented that the resident initially declined reinsertion but later consented after discussion that the rectal tube could help keep the wound from contamination; however, the tube was never reinserted due to lack of availability. During this period, there was no documentation that the gastric surgeon was notified of the rectal tube removal or that the rectal tube was replaced. The resident’s family reported that the rectal tube was never replaced after it came out the second time and described observing stool-soaked wound dressings remaining in place for over four hours before being changed. The resident was later admitted to the hospital with fever, abdominal pain, diarrhea, nausea, vomiting, and an ill and toxic appearance, and was diagnosed with sepsis with contributing sources including a stage IV decubitus ulcer with concerns for osteomyelitis. The facility medical director, emergency room physician, nurse practitioner, DON, and wound nurse confirmed that the rectal tube had been intended to keep the sacral pressure ulcer clean, that it was not monitored or documented as ordered, that it was not replaced when unavailable from the supplier, that the surgeon was not notified, and that the rectal tube was not included in the resident’s care plan or daily assessments.
Failure to Administer Ordered Opioid and Assess Pain Resulting in Unrelieved Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate pain management for a resident with multiple pain-related diagnoses, including age-related osteoporosis, fibromyalgia, complex regional pain syndrome of the upper limb, a periprosthetic fracture around a prosthetic left knee joint, and an unspecified fracture of the lower end of the left femur. The resident had a physician’s order for Hydrocodone-Acetaminophen 5-325 mg, one tablet every six hours for pain management, and a care plan identifying potential for pain related to recent fracture, recent surgery, and fibromyalgia, with approaches to administer medications as ordered, assess for signs of pain, and notify the physician if pain medications were ineffective. The facility’s own Pain Management and Pain Assessment policies required pain assessments at admission and with condition changes, use of pain assessment tools, documentation of pain assessment and monitoring, and administration of medications as prescribed. Despite these orders and policies, the resident’s scheduled Hydrocodone-Acetaminophen dose was not administered on one evening, and then all 12 scheduled doses over the following several days were not given. Medication administration records and order administration notes documented that the medication was unavailable in the cart and then listed as “on order,” and a health status note indicated the prescription had been faxed to the physician and a refill was awaited. During this period, there was no documentation of any PRN pain medications being given, no non-pharmacological pain-relieving interventions, and no comprehensive pain assessments, even though the resident was not receiving the prescribed opioid. The electronic medical record lacked evidence of physician notification regarding the missed doses, the unavailability of the medication, or the resident’s ongoing pain during the time the medication was not administered. Interviews corroborated that the resident experienced severe, unrelieved pain and that staff were aware of her complaints. The resident reported being in severe pain, crying out, unable to move or get comfortable, and being told by staff that there was nothing they could do while her pain medication was out and awaiting a signed prescription. An LPN stated the resident was not receiving her pain medications as she should have and frequently complained of left leg pain, and was not aware of any other pain-relieving interventions during the time the Hydrocodone-Acetaminophen was unavailable. The administrator-in-training acknowledged the resident had filed a grievance about being out of pain medication and being in pain, and stated the facility was waiting for the prescription to be filled and that the resident should not have gone without her pain medication. The facility medical director and nurse practitioner both stated they expected to be notified if there were issues obtaining the resident’s pain medication so that alternative pain relief could be ordered, and the corporate/interim DON verified that all scheduled doses were missed over several days with no PRN pain medications or interventions and no documented physician notification. Other staff, including an occupational therapist and another LPN, confirmed the resident complained of pain frequently, and the MDS coordinator confirmed that no electronic pain assessment had been completed during the resident’s stay, despite policy requirements.
Failure to Provide Ongoing Daily Activities Program for All Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing, daily program of activities on day and evening shifts as required by its own Activities Program and Facility Assessment Tool. The written Activities Program, dated 11/7/19, requires identification and involvement of each resident in activities designed to appeal to their interests and enhance physical, mental, and psychosocial well-being, including a minimum of four to seven organized activities daily, a mix of group and one-to-one programs, and documentation of attendance and participation. The Facility Assessment Tool, dated 11/1/25, further calls for person-centered psycho/social/spiritual support, culturally competent care, and opportunities for social activities and life enrichment. Despite these written expectations, the January activity calendar contained no scheduled evening or weekend activities. On two consecutive days of observation (1/26/26 and 1/27/26) from 9:15 AM to 3:00 PM, residents were not observed participating in any activities, and no announcements about activities were made. Staff interviews corroborated the lack of programming: an Ombudsman reported that during resident council, residents stated they were very bored, that activities were not being held, no calendar was posted or distributed to rooms, and residents had to find their own things to do. An LPN stated the facility was not providing activities during the day or evening, and that alert residents complained they had to “do their own things” or smoke outside more frequently due to boredom and that they never got to have a movie night. Another LPN working 6:00 AM to 6:00 PM confirmed that no activities were offered that day and that residents were again complaining. Further observations and interviews on 1/28/26 showed systemic issues with activity planning and communication. Multiple residents in the activity room stated that activities were not held every day and that there was no full-time Activity Director, noting that they sometimes only had coloring pages and bingo. A tour with the Interim DON revealed no printed January 2026 activity calendars posted in resident rooms or around the facility. In the activity room, a bulletin board displayed small numbered pieces of paper labeled 1 through 31 with activities listed, but these did not indicate dates or the month and were confirmed by the Interim DON and Housekeeping Supervisor to remain the same each month without being changed. The Housekeeping Supervisor reported she occasionally filled in to perform activities because there was no Activity Director or activity staff, verified that no activities were done on 1/26/26 and 1/27/26, and stated there were no planned activities after 4:00 PM or on weekends.
Insufficient Staffing Leading to Prolonged Call Light Delays and Inadequate Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to respond to call lights in a timely manner, as required by its own facility assessment and policies. The Facility Assessment Tool specified that all residents required assistance with activities of daily living and that the facility would staff an average of five CNAs on day shift, five on evening shift, and three on night shift, totaling 104 CNA direct care hours daily. Staffing data submitted by corporate leadership showed that on multiple dates the facility provided only 73.5 to 80.25 CNA hours, below the assessed need. CNAs and an LPN reported that staffing on evening and night shifts was often as low as two to three CNAs, and at times only one CNA and one nurse on nights, with heavy reliance on agency staff whom they described as less efficient. Residents, family, and the Ombudsman reported repeated problems with long call light response times and unmet care needs. Resident council minutes documented ongoing complaints about long waits for staff, problems with passing ice water, and poor customer service when answering call lights and following through on requests. The Ombudsman stated that residents complain about call light waiting times at every council meeting, and a resident council leader reported that for the last four meetings residents complained about call lights not being answered timely and having to sit in urine and feces for long periods, particularly on second and third shifts. During one observation period, a resident’s call light remained on for over 30 minutes without response. Individual residents and staff described specific instances of inadequate care linked to low staffing. One resident’s guardian reported having to prompt staff to turn and clean the resident, stating that turning sometimes occurred only every three to five hours and that staff placed two disposable briefs on the resident so they would not have to change the resident as often; this resident was observed wearing two briefs. Another resident reported lying in urine and feces for hours when call lights were not answered, being left on a bedpan for up to two hours, and being told staff could not get the resident out of bed because it required two staff and there were not enough staff. A different resident reported repeatedly sitting in urine and feces for extended periods, including one episode where the call light was activated mid-afternoon and not answered for about three hours, and stated that staff frequently said there was not enough staff and that the resident would have to wait. CNAs corroborated that call lights could go unanswered for an hour or longer, that residents were placed in double briefs to reduce the frequency of changes, and that when they reported short staffing, management told them to “make it work.”
Failure to Provide and Document Required Annual In‑Service Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 12 hours of mandatory in‑service training per year. The Daily Census Report dated 1/26/26 documented that 53 residents resided in the facility, and the Facility Assessment Tool dated 11/1/25 specified that staff training, education, and competencies for nurse aides must include in‑service training sufficient to ensure continuing competence, with a minimum of 12 hours annually. During an interview on 1/29/26 at 10:30 AM, the Corporate/Interim Director of Nursing (V2) stated that they could not provide documentation showing that any CNAs had received 12 hours of training in the past year. These findings show that the facility did not maintain evidence that CNAs met the mandated annual in‑service training requirement, affecting all CNAs and having the potential to impact all 53 residents residing in the facility.
Failure to Hold Required Quarterly QA&A Committee Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QA&A) Committee met at least quarterly with required members, including facility administration and the medical director, as outlined in its QAPI plan dated 1/2/26. The QAPI plan specified that the QA&A Committee was responsible for meeting at a minimum on a quarterly basis, coordinating and evaluating QAPI activities, developing and implementing plans of action to correct identified quality deficiencies, and regularly reviewing and analyzing collected data, including data from drug regimen reviews. Record review showed that the most recent QA meeting sign-in sheet documented a QA meeting in July 2025, with no subsequent meetings held. During an interview on 2/10/26 at 11:15 AM, the Corporate President of Operations stated that the facility had not conducted a QA meeting since July 2025 and that there were no records available to show when meetings were held prior to that date. She reported that when the Administrator in Training started in July 2025, the administrator was informed that QA meetings were to be held monthly per facility suggestion and quarterly per regulatory requirements, but she was unaware that these meetings were not being conducted. The facility’s daily census report dated 1/26/26 documented that 53 residents resided in the facility at the time of the deficiency.
Failure to Provide Annual QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure all staff received annual Quality Assurance and Performance Improvement (QAPI) in-service training as required by its QAPI program. A review of the facility’s Daily Census Report dated 1/26/26 showed that 53 residents resided in the facility at that time. Review of the facility’s List of Staff In-services, covering the period from 1/6/25 through 2/3/26, showed no documentation that facility staff received annual QAPI training. In an interview on 2/4/26 at 10:14 AM, the Administrator-in-Training confirmed that no staff had received the annual QAPI training.
Failure to Provide and Document Scheduled Showers and Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document scheduled showers and hygiene assistance for multiple dependent residents, contrary to its Bathing-Shower and Tub Bath Policy and Nail Care Policy. The bathing policy requires that residents be offered a shower, tub bath, or bed/sponge bath at least once per week or according to preference, and the nail care policy requires nail assessment and cleaning during bathing. For one cognitively intact resident with dementia, fibromyalgia, osteoporosis, and mobility deficits, the care plan and MDS documented dependence on staff for showering and bathing, yet the medical record showed no showers over nearly two months. This resident reported never receiving a shower during the stay and stated that staff said they did not have time when showers were requested. The Corporate Interim DON confirmed there was no shower documentation and that shower sheets were no longer used. Another resident with heart failure, anoxic brain damage, chronic respiratory failure with hypercapnia, and COPD was documented as bedfast and dependent on staff for all ADLs, including showers. The medical record contained no documentation of showers, and a nursing note recorded a family complaint that the resident was not receiving showers. The note indicated the resident had not been assigned a shower day in the system and that hygiene was reportedly maintained with bed baths while the resident was on isolation precautions and unable to use the community shower room. The family member stated the resident went without a shower for two to three weeks and believed bed baths were not being done based on the resident’s appearance. The MDS Coordinator later verified there was no documentation of showers for this resident. A similar lack of documentation occurred for another resident with diffuse traumatic brain injury, tracheostomy status, and acute respiratory failure, whose care plan and MDS showed total dependence for ADLs and personal hygiene. A family member reported that this resident was supposed to receive two showers per week but had only one shower in a month and one shower in the prior three to four weeks, and the MDS Coordinator confirmed no shower documentation. Additional residents with ADL self-care deficits and dependence on staff for hygiene also lacked documented showers or baths over extended periods. One resident with metastatic lung and brain cancer, failure to thrive, muscle wasting, and gait abnormalities was care planned to receive substantial/maximal assistance for hygiene and bathing, yet the electronic record showed no showers or baths since admission. The resident’s family reported only two showers over several weeks and stated the resident was not wiped down daily; observation showed long, thick toenails, a shirt with white skin flakes and debris, and discolored fingernails. Another resident with dementia, requiring assistance for bathing, dressing, grooming, and nail care, had no documented showers for at least two months; observations on two dates showed long fingernails with orange/yellow crusted debris, and a CNA acknowledged the nails were dirty and should be cleaned during showers. A further resident with hemiplegia and total dependence on staff for all care and hygiene also had no documented showers for at least two months. The DON confirmed there was no documentation of showers for these six residents and stated that CNAs were expected to document showers electronically, with no paper shower sheets in use.
Failure to Provide and Administer Ordered Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician‑ordered medications were available and administered as prescribed for multiple residents, despite policies requiring timely receipt and accurate records of medication orders and administration. Facility policies state that medications must be received from the pharmacy on a timely basis, administered in accordance with prescriber orders, and that any withheld or unavailable doses must be documented with explanatory notes and physician notification if three consecutive doses of a vital medication are missed. RN and LPN job descriptions require them to prepare and administer medications as ordered by physicians, and the Ombudsman Residents’ Rights Booklet states that the facility must provide services to keep residents’ physical and mental health at their highest practicable levels. One cognitively intact female resident with multiple diagnoses including a recent periprosthetic fracture, left femur fracture, fibromyalgia, osteoporosis, and diabetes had a care plan for potential pain related to recent fracture, surgery, and fibromyalgia, with interventions to administer medications as ordered and assess for pain. She had a physician order for Hydrocodone‑Acetaminophen 5‑325 mg every six hours for pain. Her MAR shows that the scheduled dose on one evening was not administered, and subsequent notes by an LPN document that the medication was unavailable in the cart and then on order. From that evening through several days, all 12 scheduled doses of Hydrocodone‑Acetaminophen were not administered, with repeated documentation that the medication was on order or unavailable. A health status note indicates the prescription was faxed to the physician and the facility was awaiting refill. The resident reported being in severe pain, crying out, and being told by staff that she was out of pain medication and that a script needed to be signed. The interim DON confirmed that all scheduled doses during that period were missed and that there was no documentation of nursing staff notifying a physician to obtain same‑day delivery or an alternative order. Another resident’s MAR for an entire month shows 18 missed scheduled doses of multiple physician‑ordered medications, including an anticoagulant, nutritional wound supplement, anticonvulsants, antihypertensive, antiepileptic, and stimulant. These missed doses were left blank or referenced nursing notes that documented the medications as on order or not available. A third resident with an order for Prazosin 1 mg by mouth every evening for antihypertensive treatment did not receive six of nine scheduled doses over several days, with follow‑up notes again stating the medication was on order and awaiting pharmacy. A fourth resident diagnosed with oral candidiasis had an order for Nystatin oral suspension to be swabbed in the mouth four times daily; the MAR shows that 21 of 27 scheduled doses over several days were not administered, with notes indicating the medication was on order or not available. A progress note by the nurse practitioner documents that the resident had not been receiving the Nystatin and that the facility was still waiting on the pharmacy, and the nurse practitioner later stated she had not been notified that the ordered Nystatin could not be obtained. An agency LPN reported that medications are often missing or on order and that many carts have medications that are out, and the assistant DON confirmed that several residents had not been receiving scheduled medications and that no one had been auditing medication administration prior to the survey. Overall, the survey findings show repeated instances where scheduled medications, including pain medication, anticoagulants, antihypertensives, anticonvulsants, antiepileptics, nutritional supplements, stimulants, and antifungal therapy, were not administered as ordered because medications were unavailable or on order. Documentation frequently noted that medications were on order or not available, but there was no evidence of timely physician notification or effective follow‑through to prevent gaps in administration, despite facility policies requiring such actions. These inactions and failures in ordering, receiving, and administering medications led to multiple residents not receiving their prescribed treatments over extended periods.
Failure to Timely Refund Deceased Resident’s Funds
Penalty
Summary
The facility failed to timely refund resident funds to a deceased resident’s representative, resulting in a deficiency related to misappropriation of resident property. The facility’s abuse policy prohibits exploitation and misappropriation of resident money and defines misappropriation as wrongful temporary or permanent use of a resident’s belongings or money without consent. The resident involved was a 96-year-old with essential hypertension, age-related cognitive decline, type 2 diabetes mellitus, and dementia, who had been admitted with these diagnoses and later died while on hospice services. The admission contract specified that any monies remaining after discharge would be returned to the resident after the facility received all payments from third-party payor sources, and that funds of a deceased resident would be released upon receipt of appropriate estate documentation. After the resident’s death, internal emails between the HR/Business Office Manager and the Corporate Bookkeeper documented that the resident’s family member was concerned about receiving a refund and that an initial refund amount of $1,940 was identified. A later statement showed a balance of $10,465, and a subsequent email from the Corporate Bookkeeper confirmed a total refund amount of $10,465 with no other anticipated charges. Interviews revealed that the refund request had to be adjusted after an additional payment was received, and that the facility fell behind on processing the revised request and required preapproval due to the higher amount. The Business Office Manager acknowledged that refunds, particularly for private pay, were not processed timely, that there was no policy on refunds, and that the refund should have been completed months earlier, while another administrator indicated that refunds typically take 30 to 45 days to be issued.
Failure to Investigate Falls, Update Care Plans, and Implement Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention Program policy by not adequately investigating falls, not updating care plans with new interventions after falls, and not implementing existing fall interventions for multiple residents. The facility’s policy requires assessment of individual fall risk, implementation of appropriate interventions, notification of the physician and family, and care plan updates that address each fall with revised interventions as appropriate. Despite this, three residents with known fall risks experienced falls without proper follow-up, care plan revisions, or consistent implementation of basic safety measures such as call light access and appropriate footwear. One resident with metastatic lung cancer with brain involvement, history of TBI, seizures, malnutrition, and gait abnormalities was care planned as needing substantial/maximal assistance with toileting, transferring, and sitting, and was identified as at risk for falls. The care plan included interventions such as ensuring the call light was within reach and that the resident wore appropriate footwear when up. Nursing notes documented four falls within a three‑week period, including a witnessed fall from a wheelchair. During observation, this resident was found sitting in a wheelchair with bare feet on the floor, without socks or footwear, and the call light was across the room by the bed, not within reach, while the resident stated he needed to use the restroom and wanted his nurse. Another resident was identified on the care plan as high risk for falls due to cognitive impairment, confusion, incontinence, use of assistive devices, impaired judgment, decreased muscle coordination, history of falls, and medication side effects, with an intervention for call light within reach and prompt response. Nursing notes documented an unwitnessed fall and referenced a new intervention for nonskid footwear, but the current care plan did not show any new intervention added after that fall. Observation later showed this resident sitting in a recliner without a call light within reach and with no call light on that side of the room, which was confirmed by a CNA who stated the resident did not have a call light and should have one. A third resident with tracheostomy, gastrostomy, critical illness myopathy, a stage IV sacral pressure ulcer, type 2 diabetes, and a history of falls had a care plan stating the need for a low bed and floor mats, but after being found partially out of bed with the bed low, buttocks and legs on the floor, and a rectal tube pulled out, there was no documented fall investigation, no care plan revisions, and no updated fall assessment in the electronic record.
Failure to Complete Physician-Ordered Admission Weights for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete physician-ordered daily admission weights for two residents, contrary to its own Weights policy requiring residents to be weighed on admission and at least monthly, or as ordered by the physician or care plan. The policy also allows for more frequent weights, such as weekly or bi-weekly, for residents at nutritional risk. One resident was admitted with multiple serious diagnoses, including lung cancer, brain cancer, chronic kidney disease, failure to thrive, muscle wasting and atrophy, and severe protein-calorie malnutrition. The Medication Administration Record shows a physician order beginning on 12/4/25 for height and weight upon admission and then daily for seven days, but only a single weight was documented on 12/4/25 with no additional weights recorded for the remainder of the month. Another resident had diagnoses including tracheostomy status, gastrostomy status, critical illness myopathy, a stage IV sacral pressure ulcer, and type 2 diabetes, and was receiving tube feeding with Osmolyte 1.5 at a specified rate and duration each day. The care plan directed staff to follow physician orders for current feeding orders and to obtain and monitor labs and diagnostics as ordered. The Physician Order Summary documented an order starting on 11/20/25 for height and weight upon admission and then daily for seven days. However, the Weights and Vitals summary shows this resident was weighed only on 11/21/25 and then not again until 12/31/25, and a nutrition progress note dated 12/29/25 recorded the last weight as 11/21/25. The Assistant DON confirmed that both residents did not have their ordered daily weights completed after admission.
Failure to Administer and Document Critical Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite policies requiring medications to be administered as prescribed and properly documented. The facility’s Medication Administration General Guidelines Policy states that medications must be given according to prescriber orders, and any withheld, refused, unavailable, or untimely doses must be circled on the MAR with an explanatory note and physician notification if three consecutive doses of a vital medication are missed. RN and LPN job descriptions require them to prepare and administer medications as ordered by the physician, and the Ombudsman Residents’ Rights Booklet states that the facility must provide services to keep residents’ physical and mental health at their highest practical levels. For one resident with acute respiratory failure with hypoxia, tracheostomy status, gastrostomy status, encephalopathy, traumatic brain injury, and dilated cardiomyopathy with recent cardiac arrest, the care plan documented the need for anti‑seizure and cardiovascular medications as ordered. The December MAR showed multiple undocumented doses of Vimpat 100 mg via G‑tube, ordered twice daily, that were not recorded as given on several specified dates and times. The same MAR showed multiple undocumented doses of Keppra 750 mg via G‑tube, ordered every 12 hours, that were not recorded as given on several specified dates and times. Additionally, Hydrochlorothiazide 25 mg via G‑tube, ordered once daily for dilated cardiomyopathy, was not documented as given on multiple specified dates. The MDS Coordinator verified that this resident did not receive Vimpat, Keppra, and Hydrochlorothiazide as ordered and could not explain why. For another resident with diffuse traumatic brain injury, tracheostomy status, essential hypertension, and acute respiratory failure, the care plan documented that the resident was on anticoagulant therapy for clot prevention, with an intervention to administer anticoagulant medications as ordered. The January MAR documented an order for Enoxaparin 30 mg/0.3 mL subcutaneously twice daily, starting on a specified date and discontinued on a later date, related to nontraumatic intracerebral hemorrhage in the brain stem. The MAR showed that multiple scheduled doses on several specified dates and times were not given. The facility nurse practitioner stated she had heard there were problems with medications not being available and that any time medication is not given as ordered it is a problem, specifically noting that missing medications such as Lovenox or Keppra could result in a serious issue. The MDS Coordinator confirmed that this resident did not receive Enoxaparin as ordered and stated the resident absolutely should have been getting what the doctor ordered, without knowing why the doses were missed.
Failure to Complete and Process Ordered Laboratory Tests
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered laboratory tests were completed and processed for a resident who required ongoing lab monitoring. The facility’s Facility Assessment stated that the facility would employ or contract staff to provide clinical laboratory services. For one resident with a sacral pressure ulcer, diabetes, a tracheostomy with pneumonia risk, enteral feedings, and a leaking gastrostomy tube, multiple labs were ordered over several weeks, including CBCs, CMPs, BMP, CRP, hemoglobin A1C, prealbumin, and sedimentation rate. These orders were documented on the Physician Order Summary across several dates for various clinical indications, such as monitoring a stage 4 pressure ulcer, diabetes, tracheostomy-related pneumonia risk, enteral feedings, and g-tube leakage. Progress notes by the facility nurse practitioner documented that the last available labs were from a prior hospitalization, including a CMP and CBC from the hospital, and specifically noted that an A1C and weekly CBC/CMP ordered for certain dates were not drawn and needed follow-up and reordering. Despite these orders and notations, the resident’s electronic medical record contained no documentation of any lab results being completed or received during either of the resident’s stays at the facility. The Assistant DON confirmed that there were no lab results for the ordered CBC and BMP related to the g-tube leakage and stated that no labs were completed at the facility during the resident’s stay, only at the hospital.
Failure to Complete Ordered Orbital X-Ray After Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an ordered orbital x-ray was completed for a resident following a fall with head impact. The facility’s Facility Assessment dated 11/1/25 states that the facility will employ or contract staff to provide clinical laboratory and diagnostic x-ray services. Nursing progress notes document that the resident had a witnessed fall in the hallway, during which the resident, who was wheeling himself in a wheelchair, scooted out of the chair and hit his head. The following day, nursing notes recorded slight swelling and a bruised right eye, and the night shift nurse notified the facility Medical Director. On 12/31/25, a physician’s assistant evaluated the resident for a fall follow-up and documented a positive review of systems for headache and vision changes, with a plan for an orbital x-ray. Despite this order, the resident’s electronic medical record contains no documentation that the orbital x-ray was ever completed or that any results were obtained. Subsequent nursing notes show that the resident later experienced another fall and was sent to a local emergency room, where a head CT was performed. On 2/10/26, the ADON confirmed that the resident did not receive the ordered orbital x-ray during the time the resident remained in the facility and stated that the x-ray should have been completed.
Failure to Separate Resident from Visitor After Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy when it did not immediately separate a visitor from a resident after an alleged altercation was reported. An LPN reported that in the early morning hours, a resident approached the nurse's station crying and stated that a visitor, who was a family member of another resident, was being mean to her. The LPN went to the resident's room and found the visitor cursing at the resident. The LPN informed the visitor that visiting hours were over and asked her to leave, but left the room before confirming the visitor had actually exited, leaving the resident and visitor alone together for several minutes. Shortly after, the resident again approached the nurse's station in distress, reporting that her bed was soaked. Upon investigation, the LPN found the resident's bed completely drenched and took photographs, suspecting the incident was not self-inflicted. The LPN acknowledged that she should have ensured the resident and visitor were separated immediately after the initial report of the altercation. The facility's administrator confirmed that policy requires immediate separation of the alleged perpetrator and victim in such situations, and the facility's abuse prevention policy mandates immediate protection of residents involved in possible abuse, including separation from accused individuals not employed by the facility.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of visitor-to-resident verbal abuse to the state agency as required. On the early morning of 12/3/25, a resident (R2) reported to an LPN (V7) that her roommate's daughter (V6) was being verbally abusive, including swearing and making derogatory remarks. The LPN intervened, asked the visitor to leave, and documented the incident, including taking photos of a subsequent event where the resident's bed was found soaked with liquid. The LPN reported the incident to the facility's Abuse Coordinator (V1) via text message later that morning. Despite the internal report, the Administrator (V1) did not notify the state agency of the alleged abuse within the required two-hour timeframe, citing a chaotic morning as the reason for the oversight. The facility's own policy mandates immediate reporting, but as of 12/5/25, there was no documentation that the incident had been reported to the Illinois Department of Public Health. The deficiency centers on the failure to timely report the abuse allegation to the appropriate authorities as required by both regulation and facility policy.
Failure to Investigate Alleged Verbal Abuse Documented in Resident Council
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents out of five reviewed for abuse in a sample of ten. According to the facility's Abuse Prevention and Reporting policy, all staff are required to report any incident, action, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property immediately to the administrator or a designated individual. The policy defines abuse broadly, including verbal and mental abuse, and outlines specific examples such as mocking, insulting, threatening, or isolating residents. Despite these clear requirements, the facility did not initiate investigations into two separate allegations of verbal abuse that were documented in the Resident Council meeting minutes. One incident involved a dietary staff member telling a resident, "no you are too fat" when the resident requested a snack. Another incident involved the Social Services Director asking a resident if he would like to be homeless and stating that he would be put in a shelter. The Activity Director, who was responsible for conducting Resident Council meetings and recording the minutes, stated she had never been educated on how to handle concerns or complaints raised during these meetings. Both the Administrator and the Regional Director confirmed that no abuse investigations were conducted for either of the verbal abuse allegations documented in the Resident Council meeting minutes.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures at a safe and comfortable level of 71 degrees Fahrenheit or higher for 14 out of 15 residents reviewed. During a tour conducted by the Director of Nursing, it was observed that the room temperatures ranged from 55 to 67 degrees Fahrenheit, which is below the required range of 71-80 degrees Fahrenheit as per the facility's Code White-Extreme Weather policy. The heaters in the affected rooms were not operational, and the residents expressed discomfort due to the cold temperatures. The residents reported feeling cold, with some wearing additional clothing such as stocking caps, gloves, and coats to keep warm. The Director of Nursing confirmed that the heaters, which are operated by a boiler system, had not been functioning since the previous day. The local weather conditions during this period were extremely cold, with temperatures dropping as low as 14 degrees Fahrenheit, exacerbating the discomfort experienced by the residents.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Peoria Heights | 0.3 mi | — | 23 | 0 |
| Lutheran Hillside Village | 1.1 mi | ★★★★★ | 1 | 0 |
| Accolade Healthcare Of Peoria | 1.4 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Skylines | 2 mi | ★★★★★ | 0 | 0 |
| Loft Rehab Of Peoria, The | 2.7 mi | ★★★★★ | 5 | 0 |
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