Goldwater Care Peoria Heights

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.”

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to hold Quality Assurance (QA) and Improvement Committee Meetings, which is a requirement to ensure ongoing quality assessment and assurance. The facility's Quality Assurance and Improvement Agenda outlined that various areas, including resident concerns, department reports, and safety issues, should be reviewed at least quarterly. However, upon interview and record review, it was found that there was no documentation of any QA meetings conducted prior to the arrival of the new Administrator in Training in April 2024. The Administrator in Training confirmed the absence of such meetings and held one immediately upon their hire. This deficiency has the potential to affect all 40 residents currently residing in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to monitor infections effectively, which has the potential to affect all 40 residents currently residing in the facility. The facility's Infection Control Surveillance and Monitoring policy, dated April 11, 2022, outlines the responsibilities of the Director of Nursing/Infection Preventionist (DON/ICP) to conduct routine surveillance and monitoring to ensure compliance with infection control practices. This includes investigating and implementing controls to prevent infections, directing correct procedures for infection prevention, and conducting random inspections of clinical records to ensure proper isolation techniques and evaluation of infection-sensitive procedures. However, the facility's Infection Control Monitoring Logs only started in April 2024, indicating a lack of documentation for the period before this date. On October 1, 2024, the current Director of Nursing (V2) stated that they began working at the facility in April 2024 and were unaware of where the previous Director of Nursing (V10) kept documentation of the facility's infections. As a result, there is no documentation available for the period before April 2024, which indicates a failure in maintaining a continuous and comprehensive infection monitoring system. This lack of documentation and monitoring could potentially compromise the facility's ability to manage and prevent infections effectively.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an Antibiotic Stewardship Program, which is essential for optimizing the treatment of infections and reducing adverse events associated with antibiotic use. The program's protocol, dated December 12, 2018, outlines core elements such as leadership commitment, accountability, action, tracking, and reporting. However, as of October 1, 2024, the facility was unable to provide any documentation that antibiotic tracking or infection surveillance had been completed prior to September 2024. This lack of documentation indicates a failure to adhere to the established protocols for monitoring antibiotic use and infection surveillance. During an interview on October 1, 2024, the Director of Nursing (V2) admitted that there was no monitoring of antibiotics or infection surveillance being completed before September 2024. V2 expected that a McGreers Criteria Data Tool Form should have been filled out for every antibiotic ordered to ensure compliance with the Antibiotic Stewardship Protocols. Additionally, V2 had to involve the pharmacy to educate the nursing staff on the concept of Antibiotic Stewardship, highlighting a significant gap in the facility's practices and understanding of the program. This deficiency potentially affects all 40 residents currently residing in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely written notification to the local Office of the State Long-Term Care Ombudsman and the residents or their representatives regarding hospital transfers or discharges. This deficiency was identified for five residents who were reviewed for transfers and hospitalizations. The facility's policy and procedure for transfer and discharge documentation were not followed, as there was no written notification sent to the Ombudsman or documented in the residents' clinical records. Interviews with the Social Service Manager, Director of Nursing, and Administrator confirmed that the facility did not have a practice of notifying the Ombudsman or the residents' representatives in writing about hospital transfers or discharges. The Social Service Manager admitted to never documenting or sending written notifications of hospital transfers to the Ombudsman or the residents' families. The Director of Nursing also confirmed the absence of written notifications in the residents' charts and the lack of any documentation of such notices being sent. The Administrator acknowledged that the facility did not notify the Ombudsman or the residents' representatives in writing, citing the ongoing transition of facility ownership as a reason for the lack of a specific policy on notifying the Ombudsman about hospital transfers or discharges.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a new or updated PASARR Level II for a resident who was reviewed for PASARR screenings. The resident had been admitted with diagnoses including Major Depressive Disorder, Severe Psychotic Symptoms, Bipolar Disorder, Unspecified Psychosis, and Delusional Disorder, and was prescribed medications such as Venlafaxine Hydrochloride and Aripiprazole. The resident's PASARR Level II Screen Outcome indicated that the short-term approval ended on a specific date, and an updated Level I and Level II PASARR was required for continued stay in a Medicaid Certified Nursing Facility. However, the facility did not have an updated PASARR in the resident's medical record, and the Director of Nursing acknowledged the oversight, noting that the PASARR was no longer effective after the specified date and was intended for a short stay.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's prescribed medication, Zolpidem Tartrate, was available, resulting in the resident missing doses on two occasions. The resident, who was on sedative/hypnotic therapy for insomnia, reported not receiving the medication due to an ordering issue, which affected his sleep and anxiety. The Medication Administration Record confirmed the absence of the medication on specific dates, and the Progress Notes indicated that the medication was on order during that time. The Licensed Practical Nurse (LPN) involved was unaware of the availability of the medication in the facility's emergency kit, which contained Zolpidem Tartrate. The Director of Nursing (DON) later discovered the missed doses and identified a communication failure regarding the ordering of medications. The pharmacy required a new signed prescription for the medication, which contributed to the delay in availability.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents had fresh water available between meals for six of seven residents reviewed for hydration. The facility's Hydration policy mandates providing each resident with sufficient fluids to maintain proper hydration, including fresh water and ice at the bedside. However, observations and interviews revealed that residents did not receive fresh ice water every shift. Residents R2, R3, R4, R5, R6, and R7 all reported not having fresh water available in their rooms, and some had to resort to getting tap water themselves. The Director of Nursing confirmed that all residents should have water pitchers at their bedside and receive fresh ice water every shift, which was not being adhered to in practice. R2, R3, R4, R5, R6, and R7 all had physician's orders for thin liquids, with some having additional medical histories such as urinary tract infections and sepsis. Despite these orders, these residents were observed without fresh ice water in their rooms on multiple occasions. Interviews with the residents confirmed the lack of water provision, with some residents expressing frustration and the need to get water themselves. The Director of Nursing verified the absence of water pitchers and fresh water in the rooms of the affected residents, acknowledging the failure to follow the facility's hydration policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure call lights were answered in a timely manner for one of three residents reviewed for call light response time. The Rehab Resident Council Meeting Minutes documented slow call light reaction times on both the 1st and 2nd shifts. A resident reported that call lights sometimes took hours to be answered, particularly during the day shift when aides were busy. An agency nurse confirmed the wait times and mentioned that on one occasion, there was only one aide in the entire building due to staff call-offs. The Director of Nursing acknowledged the issue and stated that filling vacant positions and training CNAs was a priority. Another agency nurse noted that some residents had to wait a long time for assistance after using the restroom because CNAs were occupied with other tasks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure staff provided care by assessing, evaluating, and providing immediate treatment of an acute condition for a resident admitted with multiple serious diagnoses, including sepsis, type two diabetes mellitus, chronic obstructive airway disease, cellulitis, bilateral below the knee amputation, and congestive heart failure. The resident's vital signs were not monitored after a certain date, and there was a lack of documentation regarding the resident's condition, assessments conducted, and physician notifications leading up to the resident's transfer to the hospital. On the day of the incident, the resident complained of being tired, and although initial vital signs were within normal limits, the resident's condition worsened throughout the day, showing signs of lethargy, slurred speech, and low oxygen saturation levels, which were not adequately documented or addressed in a timely manner by the nursing staff. The resident was eventually transferred to the hospital and diagnosed with septic shock, probable urinary tract infection, and cellulitis at the amputation site. The Director of Nursing acknowledged that vital signs should have been monitored more frequently, especially given the resident's history of infections, and that the progress notes lacked necessary documentation of assessments and physician notifications. The failure to properly monitor and document the resident's condition and to notify the physician in a timely manner led to the deficiency identified in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain scheduled physician-prescribed medications from the pharmacy for a resident, resulting in missed doses of critical medications. Specifically, the resident did not receive their scheduled dose of Zolpidem Tartrate 10 mg on one occasion and Atenolol 50 mg on another occasion due to the medications being unavailable. The facility's policy mandates that all medications be given as prescribed and that the attending physician be notified promptly to renew prescription orders to avoid interruptions in the resident's therapeutic regimen. However, this policy was not adhered to in these instances. The resident expressed frustration over the missed doses, stating that they were tired of hearing excuses from the Director of Nursing about the facility running out of medications. The Director of Nursing confirmed that the missed dose of Zolpidem was due to the pharmacy not receiving the signed prescription refill order, and the missed dose of Atenolol was because the pharmacy did not deliver the refill to the facility in time. These lapses indicate a failure in the facility's medication management and communication processes with the pharmacy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide Physical Therapy (PT) and Occupational Therapy (OT) services as ordered by a physician for a resident with bilateral below-knee amputations (BKA). The resident was admitted to the facility with a documented need for PT/OT services to assist with mobility and daily living activities. Despite the physician's order and the resident's care plan indicating the necessity of these services, there is no evidence in the medical record that the resident received any PT/OT evaluations or services since admission. The resident expressed a desire to go home but stated that they had not received the necessary therapy to facilitate this transition, citing insurance issues as a barrier. The Administrator-In-Training acknowledged that the facility did not have therapy services available at the time of the resident's admission, suggesting that the PT/OT order might have been a standardized order rather than a specific plan of care for the resident. The facility's failure to provide the required PT/OT services as per the physician's order and the resident's care plan constitutes a deficiency in meeting the resident's health care needs. The resident's condition, including the need for maximum assistance with transfers and daily tasks, underscores the importance of these rehabilitative services. The lack of therapy services not only contradicts the facility's admission policy but also leaves the resident without the necessary support to improve their functional status and achieve their goal of returning home.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medications as ordered by the physician for six residents, resulting in a 22 percent medication error rate. The facility's Medication Administration policy requires medications to be prepared and administered within one hour of the designated time or as ordered. However, several instances were observed where medications were either not available or administered late. For example, a registered nurse informed a resident that his Fluticasone nasal spray was not available, and another resident did not receive his Cranberry tablet as it was not in stock. Additionally, blood sugar tests and insulin administration for two residents were delayed, and several other medications were reported as out of stock for different residents. The facility's staff acknowledged the issues with medication availability and timeliness. A registered nurse admitted to running late with blood sugar tests and insulin administration, and another nurse confirmed that several medications were not in stock. The facility administrator verified that there have been ongoing issues with receiving medications in a timely manner. These failures to administer medications as ordered contributed to the high medication error rate observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure physician-ordered wound treatments and dressing changes were performed as ordered for a resident (R1). R1 was admitted to the facility with multiple pressure ulcers and other complex medical conditions. Despite the physician's orders for specific wound care treatments, the facility did not consistently follow these orders, leading to the worsening of R1's wounds. The facility also failed to procure the necessary antimicrobial foam dressings as prescribed, opting instead for less effective alternatives due to cost concerns. This lack of adherence to the prescribed treatment plan resulted in R1's wounds becoming infected and necessitated hospitalization for further wound care. Interviews with various staff members, including the Ombudsman, wound clinic nurse, and wound doctor, revealed that R1's wounds were often not dressed correctly or in a timely manner. The wound clinic nurse noted that the facility was informed about the need for specific dressings, but the facility did not follow through with the orders. The wound doctor confirmed that R1's wounds had worsened due to the incorrect dressings and lack of proper wound care. Additionally, R1 reported that the facility's staffing issues contributed to the inconsistent dressing changes, further exacerbating the condition of the wounds. Documentation from the facility's records corroborated these findings, showing multiple instances where the correct dressings were not applied, and wound care was not performed as ordered. The Treatment Administration Record (TAR) indicated missed dressing changes on several dates, and nursing notes highlighted the deterioration of R1's wounds over time. Ultimately, the failure to provide appropriate wound care and follow physician orders led to R1's hospitalization for severe wound infections and probable sepsis.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate staffing to meet the needs of its residents, resulting in significant delays in care and unmet needs. Multiple residents reported not receiving timely assistance with getting out of bed, being dressed, and receiving breakfast. One resident mentioned not being changed from the night shift until late in the morning, while another resident reported waiting hours to be changed after being incontinent. The facility's staffing policy was not adhered to, and the facility assessment did not include specific staffing requirements based on the resident population and census. On the day of the complaint, there were significant discrepancies between the required and actual staffing hours, with only a fraction of the needed hours being covered. The facility relied heavily on agency staff, and there were instances where only one CNA was available for the entire building. The management team, including the Administrator in Training (AIT), had to work the floor due to the staffing shortage. The lack of sufficient staff led to residents waiting for hours to receive care, including being changed and getting their meals. Interviews with residents, family members, and staff highlighted the ongoing staffing issues. Residents expressed frustration and discomfort due to the delays in care, and staff members confirmed the chronic understaffing. The facility's new Resident Care Coordinator, who started on the day of the complaint, described the situation as chaotic, with many residents still in bed and call lights unanswered. The Regional Director of Operations admitted to being unaware of the specific staffing requirements needed to care for the residents, further indicating systemic issues in staffing management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a comprehensive facility-wide assessment to determine the necessary staffing requirements to care for its resident population and census. The assessment, dated [DATE], documented an average daily census of 55 residents but did not include specific staffing requirements. On 3/20/24, the Resident Care Coordinator/Licensed Practical Nurse (LPN) stated that she took over staffing on 3/11/24 but was not shown how to determine staffing needs or given any tools to use. She was instructed to staff six Certified Nursing Assistants (CNAs) on days, five CNAs on evenings, and four CNAs on nights. On 3/21/24, the Administrator in Training admitted to not knowing if there was a Facility Assessment that documented staffing requirements. The Regional Director of Operations also stated on 3/21/24 that she was unaware the Facility Assessment needed to specify the number of staff required, believing that documenting staffing based on a Staffing Calculator was sufficient. The Long-Term Care Facility Application for Medicare and Medicaid dated 3/21/24 confirmed that 55 residents reside in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate incontinent care for four residents, leading to prolonged periods of discomfort and potential health risks. On multiple occasions, residents were left in soiled or wet conditions for extended periods, as documented by interviews with residents and ombudsmen. For instance, one resident reported not being changed since the night shift, despite having the call light on for a long time. Another resident was found with an engorged disposable brief, indicating a significant delay in care. The facility had only one CNA available during the day shift, which contributed to the delays in providing necessary care. The medical records of the affected residents reveal that they have complex medical conditions requiring diligent care. One resident, who is paraplegic and has multiple pressure ulcers, reported that not being changed promptly exacerbates his condition. Another resident, who is occasionally incontinent, stated that staff take a long time to respond to call lights. A third resident, who is always incontinent of urine and frequently of bowel, mentioned that they often lay in feces for hours due to inadequate staffing. Interviews with staff members corroborate the residents' complaints. CNAs reported that they often find residents soaked or soiled when they come to work in the morning and that residents are not being toileted and changed as needed. The facility's policies on perineal cleansing and CNA duties emphasize the importance of timely and adequate incontinent care to prevent irritation, infection, and to maintain residents' self-esteem. However, the facility's failure to adhere to these policies has resulted in significant deficiencies in the care provided to its residents.