Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Bella Of Danville during CMS and state inspections, most recent first.
Failure to provide privacy curtains in shared resident rooms left multiple residents exposed during ADLs and care. An RN provided vital signs and blood glucose in one room while a roommate observed, and a CNA stated there were no privacy curtains or call lights and that she had to use her body as a shield. Residents and roommates reported embarrassment and lack of modesty, while the facility administrator confirmed the curtains were missing after residents were moved from another building.
A facility failed to maintain resident rooms, shower areas, and common spaces in a safe, clean, and homelike condition. A resident room contained a hanging power strip with a cut cord, an extension cord used for an air mattress, and cords left behind after an emergency power event; a community shower room used by residents was dirty and infested with debris and insects; and multiple areas in the building showed unrepaired damage, missing paint, exposed plumbing, and construction materials stored in resident spaces.
Incomplete Fire Watch During Fire Alarm System Impairment: A fire alarm panel showed a Zone 2 open fault and internal ground fault after water damage and a damaged wire affected the system. Staff conducted fire watch for residents in the affected zone, but they did not inspect all rooms as required, including closed rooms in the hallway, even though the fire detection system for that area was unreliable and the panel needed replacement.
A facility failed to ensure several relocated residents had a way to summon staff after storm damage displaced them to new rooms. Multiple residents were observed without call lights, bells, or any temporary call system, and one RN confirmed a resident had no call light or wall connection available. Residents stated they would have to yell for help if they needed assistance, and the facility policy required an accessible call system in residents’ sleeping areas.
The facility failed to maintain infection control logs that tracked infectious organisms, failed to develop and implement a Legionella water management plan that identified risk areas and control measures, and failed to follow EBP and hand hygiene during G-tube medication administration. An LPN administered meds via a G-tube without hand hygiene or a gown for a resident on EBP, and another resident with wounds had no EBP signage or supplies available, while staff stated they were unfamiliar with EBP.
Antibiotic stewardship and infection surveillance logs were incomplete. The facility did not document infectious organisms, signs and symptoms, or antibiotic dose and duration in the infection control logs, and UTI culture sensitivity results were not listed. The IP stated culture results were not always available from the hospital and had to wait for nurse management to provide them, while the ADON confirmed the earlier logs lacked culture sensitivity results for UTIs.
A resident with COPD, emphysema, and a left lower lung cancerous growth had an active order for Anoro Ellipta for SOB, but the inhaler was not available during med pass. An LPN checked emergency stock and found none on hand, and the pharmacy reported a billing issue requiring prior authorization before the medication could be dispensed.
Medication administration errors resulted in an 8% error rate when two residents did not receive ordered meds as prescribed. One resident with COPD and a cancerous lung tissue growth did not receive Anoro Ellipta because the inhaler was unavailable and the pharmacy had a billing/prior authorization issue. Another resident ordered Guaifenesin ER for cough was told the dose was not available, but an LPN later admitted she forgot to return to give it. The DON stated nurses should avoid omissions and follow steps when meds are not available.
Food Served Cold and Unappetizing: Two residents received meals that were cold and not palatable, with one resident reporting an untouched lunch tray was cold when delivered and eggs tasted refrigerated. A test tray later showed hamburger, pasta, peas, and pineapple at low temperatures, with no warming element used on the tray cart, and the kitchen food temp log had missing cook, hold, service, and cold food temperatures. The DON confirmed hall trays had no way to keep food warm and were passed on an open shelf cart.
The facility failed to provide timely follow-through on ordered care for multiple residents. A resident’s sutures were removed weeks after the hospital’s instructions without documented provider notification, another resident returned from the hospital with a leg splint but had no charted orders for the splint or daily skin checks and was later found without it, a resident with a STAT order for breast imaging still had not received the mammogram and ultrasound, and a resident who fell did not receive neuro checks after the first fall and was later sent to the hospital after worsening condition.
A resident’s credit balance and trust fund balance were not returned after discharge. Billing records showed Social Security payments were received after the resident left, creating a $2,120 credit, and an additional trust fund balance of $120.22 remained with no documentation that it was transferred to the resident’s representative or estate. The BOM confirmed the check request was delayed and that no steps had been taken to release the remaining funds.
The facility failed to maintain fall precautions, document falls accurately, notify the MD and family timely, and complete required neuro checks after falls for several residents. A cognitively intact resident with a high fall risk had missing or ineffective interventions, incomplete and late fall documentation, and delayed provider notification, and later sustained an ankle fracture. Other residents had missing ordered fall-prevention devices, absent neuro checks after head injury or unwitnessed falls, and incomplete notification and monitoring after repeated falls.
A resident with a history of falls, recent femur fracture, moderate cognitive impairment, and dependence for ADLs fell while attempting to transfer independently from bed to a wheelchair while wearing slippers, despite a care plan requiring assisted ambulation and fall-prevention measures. A CNA found the resident on the floor, assisted her up, and took her to the nurse’s station without obtaining an RN/LPN assessment and did not report the fall, even though the resident complained of wrist pain. An X‑ray later showed an acute distal radius and ulnar styloid fracture, and the resident returned from the hospital with a soft cast and an order for urgent orthopedic follow‑up. The facility failed to ensure the orthopedic referral was completed: the orthopedic office could not reach the facility using an incorrect phone number, no appointment was scheduled, the transportation aide received no appointment request, and there was no EMR documentation of follow‑up, leaving the resident in a loose, misshapen soft cast until a delayed ortho visit resulted in application of a hard cast.
Two residents’ medical records were not maintained in a complete and accurate manner. For one resident with multiple complex conditions and total dependence for ADLs, the EHR documented that the resident left for a procedure but contained no follow-up notes on the resident’s return, new devices, status, or orders, and several 72-hour readmission entries were left blank until a later NP note about a new infection. For another resident with a history of falls and a left femur fracture, the care plan and fall log reflected multiple falls and fall-prevention interventions, but the EMR lacked any documentation of a fall that resulted in injury or a related physical assessment, even though a subsequent progress note described bruising, swelling, and physician notification.
A resident’s hospice order for concentrated oral morphine was incorrectly transcribed from 0.25 mL PRN to 30 mL PRN on the physician order sheet and MAR, and an RN administered approximately 25–30 mL (about 500 mg) without questioning the unusually large dose or verifying accuracy. The RN also failed to document the controlled substance on the narcotic count sheet. Following administration, the resident became very drowsy, difficult to arouse, and developed shallow, slow respirations with periods of apnea, requiring Narcan and subsequent transfer to the ED. The resident later recalled receiving a much larger-than-usual dose in a medicine cup instead of the usual dropper and reported memory loss for much of the day. A pharmacist and hospice MD confirmed that the dose given was a high morphine dose with potential for severe respiratory depression or death, and the facility’s medication error report noted the error had a high potential for serious adverse reactions.
The facility did not maintain required RN coverage for at least eight consecutive hours on a day during the review period, despite its facility assessment and staffing plan specifying that one RN should be present on each shift in accordance with CMS minimum staffing rules. Review of daily nurse staffing sheets showed a day with no RN coverage for the required duration, and this was confirmed by a regional nurse consultant. During this time, 146 residents were documented as residing in the facility.
The facility failed to prevent sexual abuse by a resident with known sexually inappropriate behaviors and a documented criminal history, resulting in nonconsensual sexual contact with two cognitively impaired residents who lacked capacity to consent. One resident with dementia and multiple comorbidities was found in bed with her incontinence garment unfastened and a resident’s finger inside her vagina, shortly after staff had left her properly covered and fastened; she was observed to be tearful. Another resident with Alzheimer’s disease and prior documented abuse by the same perpetrator was later seen in the dining room when a visitor witnessed the same resident poking his finger into her genital area and intervened. The perpetrating resident’s care plan already identified wandering, inappropriate touching of residents and staff, and high-risk heterosexual behavior, yet he was still able to access and sexually touch these residents, contrary to the facility’s abuse-prevention policies.
A facility failed to protect residents from further sexual abuse after an initial allegation when staff did not immediately and effectively separate an alleged male perpetrator from other residents. A visiting family member reported seeing the man in a wheelchair intentionally touch a female resident’s genital area in the dining room and informed a CNA. The CNA told the man to go to his room but then left to remove her coat, leaving him unsupervised. During this time, a housekeeper found him in another female resident’s room, touching her genital area while she lay in bed with her incontinent brief unfastened and bed sheet pulled aside; an LPN removed him and observed his finger inside the resident’s vagina. Facility policy required immediate protection of alleged victims and separation of the alleged perpetrator, and leadership later confirmed that staff were expected to remove and monitor the perpetrator immediately, but this did not occur, resulting in a second sexual assault and an immediate jeopardy finding.
Staff failed to report a new allegation of sexual abuse to the facility Administrator/abuse coordinator as required by policy. A family member observed a resident in a wheelchair intentionally touching another resident’s private area in the dining room and reported this to a CNA, who had previously received abuse reporting training. The Administrator later confirmed he had not been informed of this allegation until notified by surveyors, despite a facility policy requiring immediate reporting of all abuse allegations and a documented history of prior sexual abuse incidents involving the same two residents.
The facility failed to maintain required licensed nurse coverage on multiple shifts, including the absence of an RN for at least 8 consecutive hours on several days and a complete lack of RN and LPN coverage on one overnight shift in one building while LPNs were present in another building. The facility’s own assessment specified that each shift should include an RN and that night shift should include multiple LPNs, yet staffing records and leadership interviews confirmed these requirements were not met for the building housing 54 residents.
The facility did not maintain required RN coverage for at least eight consecutive hours per day, seven days a week, despite its own assessment indicating that staffing should include one RN per shift. Review of nurse staffing records showed multiple days without adequate RN presence, and this was confirmed by the ADON, who reported that nursing management was only on-call on weekends if needed. Resident council minutes over several months documented ongoing concerns about short staffing, during a time when 138 residents were in the facility.
The facility did not submit required final investigation reports to the State Agency within five working days for three cases involving allegations of abuse and misappropriation of property. Although initial reports were made and investigations were started, the process was not completed as mandated by policy and regulation, due to residents recanting allegations or leaving the facility before investigations were finished.
The facility did not thoroughly investigate or document three separate allegations involving physical abuse and misappropriation of property. In each case, either the investigation was not completed or supporting documentation was missing, including situations where a resident recanted an abuse allegation against an LPN, another resident denied abuse by a CNA, and a third resident left AMA after reporting missing money.
A resident with severe cognitive impairment, incontinence, unsteady gait, and high fall risk was found on the floor on one occasion and sitting on the floor mat on another, but staff did not consistently treat the events as falls, report them to the MD and family, or fully investigate them. The resident’s call light was later found out of reach, and staff described ongoing self-transfer attempts and floor-sitting behaviors, while the fall investigation lacked documentation of staff interviews about last observation and toileting before the unwitnessed fall.
A resident with severe cognitive impairment and a history of physical aggression struck another cognitively impaired resident, causing injury. Multiple prior incidents of aggression by the same resident were documented, but there was no consistent evidence that these behaviors were reported to a provider or addressed before the altercation occurred, resulting in a failure to protect residents from abuse.
A resident with dementia, known for a friendly and helpful demeanor and a history of working as a CNA, was not provided with a care plan that reflected their specific activity interests or behavioral patterns. This omission contributed to an incident where the resident startled another, resulting in a physical altercation and injury. Staff interviews confirmed the resident's activity preferences and behaviors, but these were not documented or addressed in the care plan.
Multiple residents with severe cognitive impairment and histories of aggression were involved in physical and verbal altercations, including one incident where a resident sustained a skin tear after being grabbed and another where a resident was struck in the face and subjected to a racial slur. Staff witnessed these events, and care plans documented the residents' behavioral risks, but the facility did not prevent the abuse.
A resident with a wound infection did not receive five consecutive doses of an ordered IV antibiotic, with the first dose delayed by over a day. Facility staff also failed to notify the prescribing provider about the missed doses, contrary to facility expectations.
A resident with severe cognitive impairment and a history of stroke experienced multiple falls from a wheelchair due to inadequate supervision and inconsistent implementation of care plan interventions. Staff provided conflicting accounts regarding who witnessed and responded to the falls, highlighting a lack of clear communication and supervision.
Two residents were involved in an alleged abuse incident, with one resident reportedly touching and kissing another who was severely cognitively impaired. Although the incident was reported internally and investigated by the administrator, it was not reported to the State Agency as required by facility policy.
A resident with a left above-the-knee amputation did not receive a physician-ordered referral to a prosthetic clinic. Although staff were aware of the order and discussed it among the interdisciplinary team, no appointment was made, and the resident did not receive the required service.
The facility did not employ a clinically qualified Director of Food and Nutrition Services, with the person in charge lacking required credentials and only holding a ServSafe certification. The dietician was present only one day per week. Additionally, the facility failed to maintain sanitary dishwashing areas and did not prevent flying insects in food service areas, leading to cross-contamination of dishes used by all residents.
Surveyors found that the facility did not maintain an effective pest control program in the kitchen, resulting in accumulations of decomposed food, soiled surfaces, and the presence of flies and other pests. Flies were observed landing on clean dishes near contaminated drain areas, and pest control reports documented ongoing issues with flies, cockroaches, and spiders. The kitchen prepares food for all residents in the facility.
A resident who was cognitively intact and dependent on staff for care was required to remain in bed for several hours until a wound physician arrived, despite expressing a desire to get up. Staff confirmed that the resident was not allowed out of bed, leading to distress and emotional upset. The DON acknowledged that this prolonged restriction violated the resident's rights to dignity and choice, as outlined in the facility's policy.
A resident's comprehensive assessment was marked as receiving an antibiotic, but review of medical records and order summaries showed no antibiotic was prescribed or administered during the assessment period. The MDS Coordinator confirmed the error, which was inconsistent with facility policy requiring accuracy in assessment documentation.
A resident with necrosis and peripheral vascular disease did not receive wound care in accordance with updated physician orders, as a wound nurse failed to enter new treatment instructions into the system and continued care under outdated orders. During a dressing change, the nurse also did not change gloves between cleaning the wound and applying a new dressing, contrary to professional standards.
A resident with a suprapubic catheter and multiple medical conditions received catheter care from an LPN who failed to change gloves or perform hand hygiene after cleaning a contaminated insertion site, then applied a new dressing with the same gloves. The resident reported that daily site cleaning was not performed as ordered. The DON confirmed that such contamination could lead to infection, and facility policy requiring glove removal and hand hygiene was not followed.
Two residents with severe cognitive impairment were not offered, administered, or documented for Influenza and Pneumococcal vaccinations as required by facility policy. Review of their medical records showed no evidence of consent, administration, or refusal of these vaccines, and the Infection Preventionist confirmed the lack of documentation.
A resident's bathroom ventilation fan remained inoperable despite repeated requests to staff for repairs. The fan had not worked since the resident's admission, and no corrective action was taken by facility staff.
A resident with a history of falls and assessed as a fall risk experienced a preventable fall resulting in a forehead laceration requiring emergency treatment. The facility failed to implement and monitor resident-centered fall interventions, such as ensuring the bed was in a low position and call light accessibility. Staff were unaware of the resident's care plan, leading to inadequate supervision and intervention.
A resident with severe cognitive impairment and a history of elopement exited a facility through a deactivated alarmed door, walking 0.4 miles in cold weather before being found. The facility failed to update the care plan for elopement risks, ensure functional exit alarms, and conduct a post-elopement assessment, leading to significant safety lapses.
The facility failed to maintain a clean and comfortable environment as a resident's disruptive behavior, involving hacking and spitting up mucous, went unaddressed. This behavior, which included throwing tissues on the floor, was observed to affect the dining experience of other residents, leading to complaints. Despite being aware of the issue, the facility did not take action to manage the behavior, resulting in a deficiency.
Two residents reported dissatisfaction with another resident's disruptive behavior, involving hacking and spitting in the dining room, to the staff, including the Assistant Administrator. Despite the facility's grievance policy requiring prompt investigation and resolution, no grievance was filed, and the issue remained unaddressed, as the Assistant Administrator did not recognize it as a grievance-worthy complaint.
The facility failed to provide necessary medications to three residents, resulting in missed doses due to unavailability. One resident did not receive Duloxetine and Lorazepam as ordered, another missed Alendronate-Cholecalciferol due to billing issues, and a third did not receive Aripiprazole because it was not in the backup supply. The facility's policies for handling unavailable medications were not followed, and there was no documentation of physician notification for the missed doses.
A resident in the facility did not receive insulin on time, leading to significant medication errors. The resident, who is cognitively intact, reported delays in receiving medications, including insulin, which affected blood sugar levels. The MAR showed that Lispro insulin was scheduled at specific times but was often administered hours late. The DON confirmed that medications should be given within an hour of the scheduled time, as per the facility's policy.
A facility failed to administer medications correctly, resulting in a 12% error rate. An LPN did not give a resident their prescribed Ferrous Sulfate, another resident received the wrong dosage of Breo Ellipta and was not instructed to rinse their mouth, and a third resident missed a dose of Aripiprazole due to unavailability. The facility's policy mandates correct administration according to physician orders.
A resident with multiple diagnoses, including wounds, experienced maggot infestation due to the facility's failure to perform wound dressing changes as ordered. The resident's wounds deteriorated, causing significant pain. The DON acknowledged the unacceptable care, and the wound physician raised concerns about infection.
The facility's ineffective pest control program led to a fly infestation affecting all 141 residents. Despite a policy requiring regular pest control, reports from April to August 2024 did not address flies. Observations revealed numerous fly strips in resident rooms, with one room having over 50 flies on a strip. A resident reported using fly strips for months, and an LPN confirmed widespread use among residents. The Maintenance Director dismissed flies as pests, while the pest control representative identified entry points and breeding sites but was unaware of the issue until the survey. The DON confirmed a resident had maggots in wounds, highlighting the infestation's severity.
The facility failed to provide prescribed low concentrated sweets diets to diabetic residents, serving the same meals to all residents regardless of dietary needs. This oversight was confirmed by staff interviews and could lead to health issues such as elevated blood sugar levels and poor wound healing.
A resident was physically abused by another resident, resulting in facial swelling and fear. The incident occurred after an argument over borrowed money, with staff witnessing aggressive behavior and racial remarks. The facility's abuse prevention policy was not effectively enforced.
Failure to Provide Privacy Curtains in Shared Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for five residents, R14, R15, R16, R17, and R18, which also affected their roommates R19 through R25 in shared rooms. On 6/18/26, surveyors observed that R18 did not have a privacy curtain in his area of the room, and R16 and R17 also did not have privacy curtains in their shared room. R14 and R15 were observed without privacy curtains in their room as well. During care, an RN obtained R18’s vital signs and blood glucose in the room while the roommate was present and observing the care being provided. A CNA stated that R14, R15, R16, R17, and R18 did not have call lights or privacy curtains and that there was no way to provide privacy, although she tried to use her body as a shield. The facility administrator confirmed that these residents did not have privacy curtains and stated they had been moved from the North building to the South building after storm damage, and that the facility should have provided privacy curtains when they were moved. Resident statements reflected the lack of privacy in the rooms. R18 stated, “You learn to lose your modesty in this facility,” and said he would like to have a privacy curtain. R17 stated, “God and everybody sees what goes on over here.” R15 stated it was embarrassing to have to dress and undress in front of others and said she would like a privacy curtain. R22 stated he was tired of seeing R18 in his underwear, and R25 stated she felt sorry for R14 and R15 because they had no way to cover themselves while dressing. The MDSs showed that R14 was severely cognitively impaired and required supervision with toileting, bathing, dressing, bed mobility, and transfers; R15 and R18 were moderately cognitively impaired and required supervision or assistance with multiple ADLs; R16 was moderately cognitively impaired and required supervision or moderate assistance with several ADLs; and R17 was severely cognitively impaired and dependent on staff for complete assistance with multiple ADLs. The facility policy stated that all resident bedrooms would be equipped to assure full visual privacy for each resident, including ceiling-suspended curtains around each bed in non-private bedrooms.
Unsafe and Unclean Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by leaving hazardous electrical equipment and environmental disrepair in resident areas. In one cognitively intact resident’s room, a power strip was hanging from a metal holder beside the bed, the power cord had been cut in half, the detached portion was coiled on the floor, and the resident’s air mattress was plugged into an extension cord connected to the wall outlet. The resident stated the room was a mess because of the broken power strip and cords everywhere and said she had not cut any cords or plugged anything into the extension cords. The Maintenance Director stated the facility had lost power for three days during severe weather and that extension cords had been used temporarily for medical equipment, but maintenance staff forgot to remove the extension cord after commercial power was restored. The facility also left a community shower room in unsanitary condition while residents continued to use it because two of four shower rooms were out of service. Surveyors observed a wet cigarette butt, loose tobacco, dried brown material, wet towels, dead insect carcasses, live gnats, and a strong musty odor in the room. The DON confirmed residents had been showered there earlier that morning and acknowledged it needed cleaning before additional residents used it. In addition, a moderately cognitively impaired resident had a wall with missing paint beneath the light switch, and surveyors repeatedly observed unrepaired environmental concerns throughout the South Building, including boxes of floor tile stored in a dining room that also contained resident beds and mattresses, an unpainted patched drywall section in the dining area, a sink cabinet missing its front panel, and chipped paint near the nurses’ station. The Maintenance Director acknowledged numerous areas needed repair or replacement and said he had a lengthy repair list.
Incomplete Fire Watch During Fire Alarm System Impairment
Penalty
Summary
The facility failed to ensure fire system equipment was functioning properly and failed to complete a thorough fire watch for 10 residents living in Zone 2 of the North Building Dementia Unit. On 6/18/26, the fire alarm annunciator panel behind the front nurses' station displayed "Trouble Fire - Zone 2 Open Fault." Staff began fire watch because Zone 2 was offline and included rooms 4 through 17, but the fire watch did not include rooms 5 through 13. Later observations on 6/23/26 showed a CNA walking the hallway and looking only into rooms with open doors, without touching closed resident room doors for heat, opening closed doors to inspect rooms, or entering the closed hallway beyond the fire doors to inspect rooms 5 through 13, even though those rooms were within the affected fire alarm zone. The Maintenance Director stated water damage beginning on 6/6/26 damaged a fire sensor on 6/10/26 and that a disconnected wire also affected the fire alarm panel. The fire system service coordinator stated the alarm panel showed a Zone 2 open fault and an internal ground fault, and that the panel needed replacement before further troubleshooting could occur; the coordinator also stated the facility should remain on continuous fire watch until the panel was replaced and deficiencies corrected. The facility's fire watch policy required that whenever a significant portion of the fire alarm or sprinkler system is not functioning, the fire watch team observe and inspect every room. The facility's records documented 10 residents in Zone 2, and the fire alarm system remained impaired during the period reviewed.
Residents Left Without Means to Summon Staff
Penalty
Summary
The facility failed to provide an accessible means for five residents to summon staff after they were relocated to rooms in the South Building following storm damage. On observation, R18 was sitting in his wheelchair in his room without a call light assigned to his living space, and there was no temporary call system, portable bell, or other device available. V32 RN searched for a call light and stated that R18 did not have any type of call light or even a wall location where one could be connected. R18 stated he had not been given a call light or bell and said he would have to yell for help if he needed assistance, noting he lived at the end of the hallway and that staff might not hear him. Similar observations were made for R16 and R17, who were also without call lights or any other means of contacting staff, and for R14 and R15, who were observed without call lights or any other means to summon staff. R17 stated he had been moved after storm damage and could try to yell for help if needed, and he shared the room with other residents who were frequently out of the room. R15 stated she and R14 had been placed in the rooms after the severe storm damaged their previous rooms and believed staff should have verified the rooms were decent enough to live in before relocating residents. The facility policy stated the call system would be accessible to residents while in bed or other sleeping accommodations, and V14 stated all residents should have a means to contact staff, with an alternative such as a hand bell if a traditional call light was unavailable.
Infection Control Logs, Legionella Plan, and Enhanced Barrier Precautions Deficiencies
Penalty
Summary
The facility failed to maintain infection control logs that identified infectious organisms to monitor for trends. The Infection Surveillance policy stated that surveillance is the core of the infection prevention and control program and that pathogens are included as part of surveillance and monitoring. However, the January through March 2026 infection control logs did not include surveillance or monitoring of infectious organisms for urinary tract infections to identify trends or patterns, and the May 2026 infection control log did not document infectious organisms. The organism column was either blank or only listed the general infection, such as pneumonia or urinary tract infection. The former IP stated she did not complete infection control logs during part of April and did not identify trends in infections, and the current IP confirmed the May 2026 log did not document infectious organisms. The facility also failed to develop and implement a Legionella water management plan that included identified risk areas and control measures. The facility’s water management plan stated that cold water is heated to approximately 145 F and tempered to 100 F-110 F at resident and staff handwashing stations, but it did not identify other Legionella risk areas or control measures. Separate facility documents identified sinks, showers, and water heaters as risk areas, and floor plans showed multiple hot water heaters located throughout the buildings, including in hallways and resident room closets. The maintenance director stated he tempered water at faucets, was unsure how many hot water heater tanks the facility had, had not changed the water fountain filter since November 2025, and had no documentation of other Legionella control measures. Random hot water heater tanks viewed with maintenance staff did not have gauges or thermostats to identify stored water temperature, and one gauge was set at approximately 130 F. The facility further failed to follow Enhanced Barrier Precautions and failed to perform proper hand hygiene when administering medications via G-tube for two residents. One resident with a G-tube, dysphagia, and cancer diagnoses had EBP signage posted, but an LPN administered medications via the G-tube without performing hand hygiene and without wearing a gown. The LPN stated he should have worn a gown and performed hand hygiene and admitted he had not been following those practices. Another resident with diagnoses including peripheral vascular disease, right below-knee amputation, bacteremia, and type 2 diabetes with foot ulcer had wounds and was identified by the IP as needing EBP, but there was no EBP signage outside the room and no gloves, gowns, or masks available. An LPN stated she had never heard of EBP at the facility, and the resident’s care plan did not address EBP even though the facility’s EBP policy stated an order for EBP would be obtained and initiated for residents with wounds, including diabetic foot ulcers.
Antibiotic Stewardship and Infection Surveillance Logs Incomplete
Penalty
Summary
The facility failed to follow its antibiotic stewardship policy to ensure appropriate prescribing of antibiotics. The Infection Surveillance policy revised in June 2026 states that pathogens and signs and symptoms of infections are to be included in surveillance and monitoring, and the Antibiotic Prescribing Practices policy dated June 2026 states that laboratory testing is to be reviewed to determine whether an antibiotic is indicated or whether adjustments are needed, using CDC guidance, McGeer criteria, and Loeb Minimum Criteria to define infections and determine if antibiotics are needed. The policy also states that all antibiotic orders should include a specific dose, duration, and indication for use. The January-March 2026 Infection Control Logs did not include surveillance or monitoring of infectious organisms for urinary tract infections to identify trends or patterns, and the May 2026 Infection Control Log did not document infectious organisms. The organism column was left blank or listed only the general infection, such as pneumonia or urinary tract infection. The logs also did not document antibiotic dose and duration or signs and symptoms of infections. The former IP was on vacation for the latter half of April and did not complete infection control logs during that time, and the current IP stated the May 2026 log did not document infectious organisms, signs or symptoms, or antibiotic dose and duration. The IP also stated culture results were not always available from the hospital and had to wait for nurse management to provide them, while the ADON confirmed the January-March 2026 logs did not list culture sensitivity results for urinary tract infections.
Medication Not Available for Resident With COPD
Penalty
Summary
The facility failed to ensure that a prescribed medication was readily available for administration for one resident. The resident had diagnoses including COPD, emphysema, and cancerous tissue growth in the left lower lung, and the care plan documented altered respiratory status related to COPD and emphysema with interventions that included administering prescribed medications, inhalers, and nebulizer treatments and monitoring the resident for effectiveness. The resident had an active physician order for Anoro Ellipta inhalation aerosol powder 62.5-25 mcg, 1 mg inhaled orally once daily for shortness of breath. During medication administration, an LPN observed that the resident's Anoro Ellipta inhaler was not available and stated it would need to be reordered, then checked the emergency medication supply and later stated there was no Anoro Ellipta inhaler available in the facility. The LPN reported that the pharmacy said there was a billing issue requiring prior authorization before the medication could be dispensed. The DON stated that nurses should avoid medication omissions, administer available medications, check overflow stock, notify the physician for further orders if the medication is not available, contact the pharmacy to clarify availability, and notify the resident or representative, and stated the LPN should have followed those steps and obtained guidance from the physician.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors resulted in an 8% medication error rate after the facility failed to administer physician-ordered medications for two of five residents reviewed. One resident had diagnoses including COPD and a cancerous tissue growth in the lower left lung, and had an active order for Anoro Ellipta inhalation aerosol powder once daily for shortness of breath. On 6/1/26, the LPN stated the medication was not available and needed to be reordered, then later stated there was no inhaler in the facility because the pharmacy reported a billing issue requiring prior authorization before it could be dispensed. A second resident had an active order for Guaifenesin ER 600 mg every 12 hours for cough for seven days. During medication administration on 6/2/26, an LPN told the resident the medication was not included because the correct dose was not available and said she would return with it when available, but later stated she forgot to return to administer it. The DON stated nurses should avoid medication omissions and should administer available medications, check overflow stock, notify the physician for further orders, contact the pharmacy to clarify availability, and notify the resident or resident's representative when medications are not available. The facility's Pharmacy Services policy states medications are to be acquired, received, dispensed, and administered in a timely manner as ordered.
Food Served Cold and Unappetizing
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for two residents reviewed for Dietary Services. On 5/12/26, dietary staff were observed plating lunch from the steam table between 12:05 PM and 12:20 PM, and no food holding temperatures were observed being checked during that time. Later that day, one resident was found in bed with an untouched lunch tray on the bedside table and stated the food was cold when placed there and that the resident did not like the taste of it. The resident also stated the food is generally cold and the eggs taste like they came straight out of the refrigerator. On 5/13/26, a test tray was plated on a regular covered plate and placed on a serving tray without a warming element. Food temperatures were taken after the last hall tray was served, and the hamburger meat measured 115 degrees F, pasta noodles 97.5 degrees F, peas 96 degrees F, and pineapple 50 degrees F. The meal was described as not palatable, with cold and slimy pasta, peas that did not taste like butter as listed on the menu, hard pineapple chunks, and an unappetizing aroma. The kitchen food temperature log also showed several meals without documented cook, hold, or service temperatures, including no temperatures for cold food items and no temperatures documented for the breakfast meal on 5/13/26. The Assistant Dietary Manager stated there had been only one complaint about the food, from one resident who said kitchen staff did not know how to cook, and the DON confirmed hall trays had no element to keep food warm and were passed on an open shelf cart.
Failure to Provide Timely Follow-Through on Orders and Change-in-Condition Care
Penalty
Summary
The facility failed to provide timely care and follow-through for residents with changes in condition and ordered treatments. R8 was sent to the hospital after an unwitnessed fall with a bleeding forehead laceration and returned with sutures, with discharge instructions to remove the sutures in five days. The sutures were not removed until several weeks later, and the record contained no documentation of physician or NP notification or an order authorizing the delayed removal. R3, who was documented as cognitively intact, returned from the hospital with a left leg splint after a fracture. The hospital discharge paperwork stated the splint was to be worn as directed by the healthcare provider, removed only with approval, and the skin around it checked daily. When surveyed, R3 was found without the splint, with bruising and swelling around the left ankle, and reported that the x-ray technician had removed the splint the prior night and no one knew how to put it back on. Facility staff and the DON confirmed there were no physician orders in the chart for the splint or skin checks, and the DON stated the facility had no policy regarding splints, casts, braces, or other devices. R13 had a documented left breast mass with a STAT order for a diagnostic bilateral mammogram and targeted left breast ultrasound. The mass was described as golf-ball sized, mobile, and tender, and the referral was sent to scheduling and leadership. Despite repeated attempts and reported authorization and referral issues, the imaging had not been completed by the time of survey, and there was no documented follow-up in the medical record regarding the delay. R4 experienced an unwitnessed fall and later another fall, but no neurological checks were initiated after the first fall, and the responsible party was not called until later. The resident later developed fever, was warm to touch, had unclear speech, and was sent to the hospital at the family member’s request, where the resident was admitted with UTI and sepsis.
Failure to Return Resident Funds After Discharge
Penalty
Summary
The facility failed to return a resident’s credit balance and trust fund balance after discharge. The resident’s census documents show billing stopped on 10/20/25, and the record identifies Medicaid as the payor source. The resident’s family stated that at least two Social Security monthly benefits were remitted after the resident discharged, first to the hospital and then to another skilled nursing facility, and that the subsequent nursing facility billed the resident’s estate. The resident’s statements showed a credit of $2,120 from two payments of $1,060 made in November and December 2025, and a check request form dated 5/20/26 requested reimbursement of that amount to the facility where the resident resided after hospitalization. The resident’s statement dated 3/2/26-5/1/26 also showed a balance of $120.22 as of 5/1/26, and there was no documentation that this balance was transferred to the resident’s family representative or estate. The Business Office Manager reviewed the billing and trust fund statements and confirmed the resident had an active trust fund balance. The Business Office Manager stated the check request was not submitted timely, that there were no prior check request forms, and that no steps had been taken to release the remaining trust fund balance to the resident’s representative or estate.
Failure to follow fall precautions, document falls, and complete required post-fall monitoring
Penalty
Summary
The facility failed to implement and maintain fall interventions after resident falls with injury, accurately assess and document falls, timely notify the physician and family of falls, and complete neurological assessments after a fall with a head injury for four residents reviewed for falls. These failures were identified during observation, interview, and record review and included residents R3, R4, R10, and R8. The report states these failures resulted in R3 sustaining an acute nondisplaced fracture at the medial and posterior malleoli. R3 was documented as cognitively intact and at high risk for falls due to epilepsy, tremor, neuropathy, and osteoarthritis. The care plan included interventions such as keeping the wheelchair locked and positioned next to the bed, providing a reacher, applying anti-rollbacks, and keeping the call light within reach. On observation, R3’s wheelchair brakes and anti-rollbacks were not effective for R3’s use, the call light was not within reach, the bed was not in the lowest position, and R3 did not have a reacher available. The record also showed falls on multiple dates, but there was no documentation addressing one fall, and another fall note was completed late. Staff interviews confirmed the missing documentation and that the physician was not called or texted about the fall and assessment, with notification reportedly sent by fax instead. The facility’s own policies required physician and family notification, incident documentation within 24 hours, and review and update of the care plan after a fall. R10 was identified as moderately cognitively impaired and at high risk for falls related to unawareness of safety needs and pain. The care plan called for a scoop mattress and bolsters on the bed, but when R10 was observed after a fall, the call light was within reach and non-skid footwear was on, yet no bolsters or scoop mattress were present. The DON confirmed the mattress was not a scoop mattress and there were no bolsters on the bed, stating the bed may not have been moved after the resident changed rooms. R8 had a prior unwitnessed fall from a wheelchair with a forehead laceration requiring emergency room treatment and sutures. The care plan included an anti-roll back device as a fall prevention intervention, but later observation showed no anti-roll back device on the wheelchair, and the DON verified it was not present. After R8 returned from the emergency room with a negative CT scan, neurological checks were not completed, and the medical record contained no physician notification or order for neuro checks. R4, who was moderately cognitively impaired, had two unwitnessed falls documented on the same day; no neurological checks were initiated after the first fall, and the responsible party was not called after that fall. Later documentation noted the resident was warm to touch, speech was not clear, and the resident was sent to the hospital at the family member’s request, with the hospital diagnosing urinary tract infection with sepsis.
Failure to Assess Fall and Follow Orthopedic Follow-Up Orders After Wrist Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and appropriately assess an acute change in condition following a fall, and failure to follow physician orders for post-fracture care. The resident had diagnoses including UTI, left femur fracture surgical aftercare, repeated falls, moderate cognitive impairment, and dependence on staff for ADLs, and was care planned as high risk for falls with a recent femur fracture. The care plan specified ambulation with assistance and a walker, left leg weight bearing as tolerated, and fall-prevention interventions such as a scoop mattress, non-skid strips by the bed, and non-skid socks to replace slippers. Despite this, the resident’s roommate reported that the resident got out of bed unassisted, attempted to walk to a wheelchair located by the bathroom door, and slipped and fell while wearing slippers. Following this fall, the CNA who responded found the resident seated on the floor on her buttocks with both palms on the ground, wearing a t‑shirt, brief, socks, and slippers. The CNA assisted the resident from the floor and transported her to the nurse’s station but did not have a nurse assess the resident at the time of the fall and did not report the fall to nursing staff. The roommate stated the resident complained of wrist pain after the fall, and the DON later confirmed that the CNA got the resident up from the floor without a nurse assessment and failed to communicate the fall, resulting in the wrist injury going unnoticed until the evening of the next day. A subsequent radiology report documented an acute distal radius (Colles’) fracture and ulnar styloid fracture, and the resident returned from the hospital with a soft cast and a referral to orthopedic surgery. The facility also failed to follow through on the physician’s order and referral for orthopedic follow-up. The After Visit Summary from the hospital documented that the resident was to schedule a follow-up appointment with orthopedic surgery as soon as possible. The orthopedic office reported that no appointment was scheduled and that their referral was closed after unsuccessful attempts to contact the facility using an inaccurate phone number. The transportation aide stated there had been no request or information regarding the need for an orthopedic appointment until weeks later, and that the original order was written during off hours when the nurse should have placed the information in the transportation box. The DON stated there was no documentation in the EMR about the resident going to a follow-up appointment and that the facility did not have a policy on following physician orders, despite the RN job description requiring nurses to transcribe and carry out physician orders as written. During observation, the resident was seen with a soft cast that was very loose and misshapen until a later date when a hard cast was finally applied after a delayed orthopedic evaluation.
Incomplete and Missing Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents in accordance with its own policies and accepted professional standards. For one resident with multiple complex diagnoses including CVA, epilepsy, vascular dementia, obstructive uropathy, severe protein malnutrition, anxiety, and autonomic nervous system disorder, the care plan documented total dependence for ADLs, severe cognitive impairment, seizure disorder, aphasia, and risk for skin breakdown. The EHR progress note recorded that this resident was out of the facility for a procedure on 4/9/26, but there was no subsequent documentation of the resident’s return, any new medical devices, status, or new orders associated with the procedure. The progress notes also contained five blank 72-hour readmission entries, and the next documented entry was not until 4/20/26 by a nurse practitioner regarding a new infection. The DON confirmed there were blank entries and no follow-up progress notes documenting the resident’s return from the appointment or clinical changes. For another resident admitted with diagnoses including UTI, left femur fracture surgical aftercare, and repeated falls, the undated care plan documented high fall risk with a recent fracture, multiple fall-prevention interventions, ambulation with assistance and walker with left leg weight bearing as tolerated, dependence on staff for ADLs, risk for skin alterations, and moderate cognitive impairment and weakness. The facility’s fall log showed this resident had falls on 2/6/26 and 3/26/26. However, the resident’s EMR did not contain documentation of the 3/26/26 fall, the incident that caused the injury, or any physical assessment related to that event. A progress note the following day documented bruising and swelling to the left wrist, physician notification, and diagnostic testing, but there was no corresponding incident documentation in the EMR. The DON confirmed the absence of documentation of the 3/26/26 fall, despite facility policies requiring that each medical record accurately represent the resident’s experiences and that incidents and accidents be documented within 24 hours.
Significant Morphine Overdose Due to Transcription Error and Failure to Question High Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an opioid analgesic order was inaccurately transcribed and an abnormally large dose was administered without verification. Hospice orders for the resident dated 3/5/26 specified Morphine Sulfate (concentrate) oral solution 100 mg per 5 mL, with a dose of 0.25 mL by mouth every two hours as needed for moderate pain or air hunger. However, the physician order sheet for March 2026 documented the same medication and concentration but with a dose of 30 mL by mouth every two hours as needed, which represented a 100-fold increase over the prescribed dose. This incorrect dose was also reflected on the resident’s Medication Administration Record (MAR), indicating that the transcription error carried through to the record used for medication administration. On 3/10/26, the RN responsible for the resident’s care administered approximately 25–30 mL of Morphine Sulfate orally, consistent with the incorrectly transcribed order rather than the original hospice order of 0.25 mL. The RN later stated that the order had been transcribed incorrectly into the physician orders and MAR and acknowledged that she should have verified the order and questioned the unusually large dose. She also confirmed that she failed to document the administered dose on the corresponding narcotic count sheet, contrary to facility policy requiring controlled substances to be recorded on the designated usage form and controlled drug record. The facility’s policies required nurses to follow the six rights of medication administration, compare the medication source with the MAR, and refer to drug reference material if unfamiliar with a medication, but these safeguards were not effectively applied in this instance. Following the administration of the overdose, the resident initially went about her normal routine but later became very difficult to arouse. When a hospice CNA arrived around midday to provide care, the resident was sleeping, responded in a very quiet whisper that she was in pain, and was difficult to awaken. The CNA reported the situation to the RN, who then realized she had given the wrong dose earlier that morning and had no additional morphine available. The CNA and hospice staff observed that the resident was very drowsy, hard to wake, and had shallow, slow respirations that required placing a hand on the resident’s chest to count breaths. A hospice RN later documented a respiratory rate of eight breaths per minute, and a hospice LPN that evening noted periods of apnea, a respiratory rate of ten, eye-rolling, and brief unresponsiveness, leading to the decision to transfer the resident to the emergency room for evaluation of the morphine overdose. The resident later reported that the dose she received that morning was much larger than normal, that she usually received the medication in a small dropper under her tongue rather than in a medicine cup, and that she had no memory of events between breakfast and being told she was going to the hospital, describing the day as a blank and stating she was glad to still be alive. The facility’s pharmacist and hospice medical doctor confirmed that the dose administered, approximately 500 mg of oral morphine, was a high dose and that an overdose of concentrated oral morphine could result in shallow breathing, decreased respirations, impaired cognition, and potentially death. The facility’s medication error report documented that there was a transcription error with the morphine order, that the dose was supposed to be 0.25 mL orally every two hours as needed but was transcribed as 30 mL orally every two hours as needed, and that the administering nurse did not question the order and administered 30 mL of morphine sulfate. The report further documented that the error could have endangered the resident and had a high potential for adverse reactions up to and including death. The DON confirmed that the RN did not verify the inaccurate dose or question the abnormally large dose, which led to the administration of approximately 25 mL (500 mg) of oral morphine sulfate and resulted in the morphine overdose for the resident.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty providing services for at least eight consecutive hours a day, seven days a week, as required. The Facility Assessment Tool for the period 07/2025 through 04/2026 documented a staffing plan for licensed nurses that referenced the facility assessment and CMS minimum staffing rule and further specified that staffing should include one RN on each shift. However, review of the Daily Nurse Staffing Sheets from 2/26/2026 through 3/31/2026 showed that there was no RN coverage for at least eight consecutive hours on 3/1/2026. On 4/1/2026 at 11:54 a.m., the Regional Nurse Consultant confirmed that the facility did not have RN coverage for eight consecutive hours on that date. The facility’s Midnight Census Report dated 3/20/2026 documented that 146 residents resided in the facility during this period. This deficiency is based on interview and record review and reflects noncompliance with the requirement to have an RN on duty for at least eight consecutive hours each day, seven days a week, despite the facility’s own assessment and staffing plan indicating that one RN should be present on each shift.
Failure to Prevent Sexual Abuse by Resident With Known Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with known sexually inappropriate behaviors. One resident with Alzheimer’s disease, prior transient ischemic attacks, altered mental status, muscle weakness, difficulty walking, and a documented risk for abuse had previously been identified as an alleged victim of sexual abuse by the same perpetrating resident, who had touched her breasts in past incidents. This prior incident was serious enough to have been cited on a previous CMS Form 2567, and the resident’s care plan had been revised to reflect her status as an alleged victim of abuse. Despite this history and the resident’s inability to formulate relevant responses to questions, the facility did not prevent further sexual contact from occurring. Another resident with dementia, depression, pseudobulbar affect, reduced mobility, anxiety, lack of coordination, bipolar disorder, and a care plan indicating risk of abuse was also involved. This resident’s diagnoses list later included confirmed adult sexual abuse. On the day of the incident, a housekeeper observed that this resident, who resided alone, had a second wheelchair in her room. Upon entering, the housekeeper saw the perpetrating resident with his hand in the resident’s diaper area while the resident lay on the bed without a diaper. A CNA who had provided care 15–20 minutes earlier reported that at that earlier time the resident’s undergarment had been fastened and she was covered with a sheet, but when she returned after the report, the sheet was pulled aside, the undergarment was unfastened exposing the genital area, and the resident was tearful. A nurse who responded to the report stated she observed the perpetrating resident’s finger inside the resident’s vagina. The perpetrating resident had a documented history of sexually inappropriate behavior and criminal offenses. His care plan noted that he wandered aimlessly throughout the facility, inappropriately touched other residents and staff, and made inappropriate comments. His diagnoses included high-risk heterosexual behavior, schizoaffective disorder bipolar type, and moderate vascular dementia with agitation. During an interview, he admitted to touching a woman’s vagina in her room and stated he believed she wanted him to touch her. A family member of another resident reported witnessing this same resident poking his finger into the private area of the first cognitively impaired resident while both were in wheelchairs in the dining room and intervened by moving his wheelchair. Facility leadership, including the DON and Administrator, confirmed that the two victim residents did not have the cognitive capacity to consent to sexual activity. The facility’s own policies defined sexual abuse as any nonconsensual sexual contact of any kind with a resident, including unwanted touching of the perineal area and all types of sexual assault, and committed the facility to implement policies to prevent all types of abuse. Despite these policies and the known history and care plan information, the facility did not prevent the resident with known sexual behaviors from making sexual contact with the two cognitively impaired residents.
Removal Plan
- R5 was placed on one-to-one continuous supervision.
- R5 was assessed by an emergency room provider, Social Services V4, and a psychotherapy provider.
- R4 received a head-to-toe nursing assessment by Registered Nurse V22.
- R6 received physician notification and medical evaluation by Nurse Practitioner V9.
- R5 received physician notification and medical evaluation by Nurse Practitioner V9.
- R5 received a psychosocial assessment and emotional support by Social Services V4.
- R4 received a psychosocial assessment and emotional support by Social Services V4.
- R6 received a psychosocial assessment and emotional support by Social Services V4.
- Families/responsible parties for R5 and R6 were notified by Social Services V4.
- R4's family/responsible party was notified by Social Services V4.
- Law enforcement and state reporting requirements were completed for R5 and R6 by Administrator V1.
- Law enforcement and state reporting requirements were completed for R4 and R5 by Administrator V1.
- R6 was transferred to the hospital for evaluation and relocated to the south building upon return.
- A facility-wide resident assessment for abuse risk was conducted by Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3.
- All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, Assistant Director of Nursing V3, and Social Services V4.
- The Abuse Prevention Policy was reviewed by Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 to ensure inclusion of defined staff response steps and immediate Director of Nursing and Administrator notification.
Failure to Separate Alleged Perpetrator After Initial Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to separate an alleged perpetrator of sexual abuse from other residents after an initial allegation, resulting in a second sexual assault. A family member visiting a resident in the dining room reported witnessing a male resident in a wheelchair intentionally poking his finger into the private area of a female resident who was also in a wheelchair. The family member stated she had to move the male resident’s wheelchair to stop the contact and then informed a CNA when the CNA entered the dining room. The family member reported that, because both residents were in wheelchairs, the contact could not have been accidental and she believed the act was intentional. After receiving the report from the family member, the CNA stated she directed the alleged perpetrator to go down the hall to his room and then left the area to remove her coat. During this time, the male resident was not supervised. While the CNA was away, a housekeeper observed the same male resident in a female resident’s room, with the female resident lying in bed and the male resident touching her in her diaper area; the housekeeper clarified that the female resident was not wearing her diaper. The housekeeper reported this to the CNA and an LPN. When the CNA arrived at the second resident’s room after this report, she observed that the LPN was already removing the male resident from the room and that the female resident’s bed sheet was pulled to the side, her incontinent undergarment was unfastened exposing her genital area, and she was tearful. The LPN who responded to the second incident stated she observed the female resident in bed with her bed sheet pulled to the side, her incontinent undergarment unfastened, and the male resident’s finger inside the female resident’s vagina. The facility’s Abuse, Neglect and Exploitation policy required immediate steps to protect alleged victims, including room and staffing changes to protect residents from an alleged perpetrator, and mandated that staff respond immediately to protect alleged victims. The administrator stated he expected staff to take steps to prevent further abuse, including immediately removing the resident from the incident and not contacting him until the situation was under control, and confirmed that facility policy required staff to remove the perpetrator from the incident. Despite prior abuse prevention in-service training for the involved staff, the male resident was left unsupervised after the first allegation and was able to access and sexually assault another resident, leading to a determination of immediate jeopardy.
Removal Plan
- R5 was placed on one-to-one continuous supervision pending full investigation.
- R5 was assessed by an emergency room physician.
- R5 was assessed by Social Services V4.
- A psychiatric evaluation was requested by Assistant Director of Nursing V3 and completed by Psychotherapist V49.
- R6 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
- R4 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
- Families and responsible parties of R5 and R6 were notified by Social Services V4.
- R4's family/responsible party was notified by Social Services V4.
- Law enforcement and required state agencies were notified per mandatory reporting requirements by Administrator V1.
- A room change was completed to ensure separation of R5 and R6, and R6 was later moved to the south building upon return from emergency room evaluation.
- All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, and Assistant Director of Nursing V3.
- Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 reviewed the Abuse Prevention Policy to ensure inclusion of a clear step-by-step response protocol following any allegation, mandatory immediate separation of the alleged perpetrator, and immediate notification of the Administrator and Director of Nursing.
- A facility-wide risk assessment for abuse involving Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3 was completed.
Failure to Report Allegation of Sexual Abuse to Administrator
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving one resident (R5) allegedly touching another resident (R4) to the Administrator/abuse coordinator as required by facility policy. The Administrator (V1) stated he is the abuse coordinator and that all staff are trained to report all allegations of abuse to him, but he confirmed he had no active investigation regarding an allegation of sexual abuse involving R5 touching R4 until the surveyor informed him on 2/5/26. The facility’s abuse policy dated 10/1/25 requires all alleged violations to be reported to the Administrator immediately, but not more than two hours if the allegation involves abuse or bodily harm. Training records dated 8/29/25 show that the CNA (V13) had received abuse prevention and reporting training. Interview and record review showed that on 2/2/26, a family member (V21) witnessed R5 in a wheelchair intentionally poking a finger into the private area of R4, who was also in a wheelchair, in the dining room. V21 reported this incident to CNA V13 at the time and stated she had to move R5’s wheelchair to prevent further inappropriate contact. Despite this report, V1 did not receive any report of this allegation from staff. The record also documents a prior allegation on 5/7/25 that R5 had touched R4’s breasts, and a previous CMS-2567 dated 4/17/24 citing an incident in which R5 (then R205) was identified as the perpetrator of sexual abuse toward R4 (then R206) by touching her breasts. These prior documented incidents further establish that R5 had a known history of sexually inappropriate contact toward R4, yet the new allegation reported to staff on 2/2/26 was not reported to the Administrator as required.
Insufficient RN and LPN Coverage on Multiple Shifts
Penalty
Summary
The facility failed to ensure sufficient licensed nursing staff were present for each shift in each building, including required RN coverage, affecting the South Building where 54 residents resided. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses (RNs and LPNs) should follow the facility assessment and CMS minimum staffing rule and specified that staffing should include one RN on each shift and three LPNs on the night shift. Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least 8 consecutive hours on four separate days (1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026). On 1/17/2026, the same records documented that there were no RNs or LPNs working the 11 p.m. to 7 a.m. shift in the South Building, while two LPNs were working the night shift in the North Building. The Assistant DON confirmed the lack of RN coverage for at least 8 consecutive hours on the identified dates and stated that nursing management staff are on-call on weekends if needed. The DON reported being notified by the Administrator at 8 p.m. on 1/17/2026 that there was no nursing coverage for the 11 p.m. to 7 a.m. shift in the South Building and stated that the DON personally worked from 3 a.m. to 5 a.m. during that shift.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least eight consecutive hours a day, seven days a week, as required. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses, including RNs, should follow the facility assessment and CMS minimum staffing rule and further specified that staffing should include one RN per shift. However, review of the Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least eight consecutive hours on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026. On 1/21/2026 at 9:16 a.m., the Assistant Director of Nursing confirmed that there was no RN coverage for eight consecutive hours on those dates and stated that nursing management staff are on-call on weekends if needed. Resident Council Meeting Minutes from October, November, and December 2025 documented short staffing and staffing concerns, and the facility’s Midnight Census Report dated 1/15/2026 showed that 138 residents resided in the facility during this period. No specific resident medical histories or conditions were described in the report, but the deficiency was identified as having the potential to affect all 138 residents currently residing in the facility.
Failure to Submit Final Investigation Reports for Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to submit the results of investigations into allegations of abuse and misappropriation of resident property to the State Agency within five working days, as required by federal and state regulations. Specifically, for three residents who made allegations—two of physical abuse and one of misappropriation of property—initial reports were sent to the Illinois Department of Public Health, but the final investigation reports were not submitted. The Director of Nursing confirmed that no five-day final reports were sent for these cases. The previous administrator explained that in two cases, the residents recanted their allegations or clarified that no abuse occurred, and in the third case, the resident left the facility against medical advice before the investigation was completed, leading to the omission of the required final reports. Facility policy and federal regulations mandate that all allegations of abuse, neglect, or misappropriation must be promptly investigated and the results reported to the appropriate authorities within specified timeframes. Documentation reviewed showed that initial reports were made for each incident, but the process was not completed as required. The failure to submit final investigation reports occurred despite the facility's written policies outlining the obligation to report and investigate such incidents thoroughly and within the required timeframe.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse and misappropriation of resident property were thoroughly investigated for three residents. The Director of Nursing was unable to locate investigation files for allegations of physical abuse and misappropriation of property involving three residents, and could not confirm that thorough investigations were conducted due to the absence of supporting documentation. The previous administrator acknowledged being informed of the allegations but did not complete final reports or thorough investigations for any of the cases. In one instance, after a resident recanted an allegation of physical abuse against an LPN, no final report or investigation was completed. In another case, after a resident stated that a CNA was not abusive, the investigation was not completed or reported. For the third resident, who alleged misappropriation of property and subsequently left the facility against medical advice, no investigation was completed.
Failure to Identify, Report, and Investigate Resident Falls
Penalty
Summary
The facility failed to identify, report, and investigate a fall for a resident with severe cognitive impairment, incontinence, unsteady gait, and a documented high fall risk. The resident’s care plan identified a history of falls, weakness, and a behavior of liking to sit on the floor, with interventions including increased observation, frequent toileting, call light use, and a call-don’t-fall sign in the room. On 9/5/25, an RN found the resident sitting on his bottom on the floor next to his chair in his room. The resident denied falling and said he was trying to clean the wall. He was assessed with no injuries, returned to his wheelchair, and taken to activities, but the event was not documented on the fall log and there was no documentation that the family or physician was notified or that the event was investigated with new interventions developed. The facility also failed to fully investigate an unwitnessed fall on 10/5/25. Around 5:00 AM, a CNA heard a sound and found the resident on the floor mat next to his bed, appearing to have slid down from the bed. The resident was assessed, denied hitting his head, and later developed a large hematoma and skin tear on his right forearm, which led to hospital transfer because he was on aspirin. The fall investigation file did not include documentation that staff were interviewed to determine when the resident was last observed or toileted before the fall. The interdisciplinary team later identified the root cause as attempting to self-transfer to get up for the day, and the only documented intervention was adding the resident to the early morning get up list. During later observations and interviews, the resident was still found with his call light out of reach, and staff stated he continued to try to self-transfer and had behaviors of putting himself on the floor. Staff also stated the resident should have a call light within reach and that if a resident is found on the floor without a witnessed intentional placement, it should be considered a fall. The facility’s policy stated that unless there is evidence otherwise, a resident found on the floor should be considered a fall, and that staff and the physician should provide input to develop and implement a resident-centered fall prevention plan and re-evaluate interventions when falls recur.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On 6/2/25, a certified nursing assistant (CNA) witnessed one resident physically striking another with a closed fist, resulting in a skin tear and bruising. The resident who was struck had severe cognitive impairment and was unable to provide detailed information about the incident. The aggressor also had severe cognitive impairment, a history of delusions, physical aggression, and was receiving psychiatric services and antipsychotic medication, which had recently been reduced. Prior to the incident, there were multiple documented episodes of physical and verbal aggression by the aggressor toward both staff and other residents, including swinging at residents and physically assaulting staff during care. These behaviors were noted in nursing and medication administration records. Despite these documented behaviors, there was no evidence that the physical aggression incidents were consistently reported to a physician or provider prior to the altercation. Staff interviews revealed uncertainty about whether such behaviors were communicated to psychiatric providers, and documentation of these reports was lacking. The facility's policy states that residents have the right to be free from abuse, including abuse from other residents, but the failure to report and address escalating behaviors contributed to the incident of resident-to-resident abuse.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement person-centered activities and interventions for a resident diagnosed with dementia. Specifically, the care plan for a resident with severe cognitive impairment did not identify individualized activities of interest or account for the resident's history of working as a CNA, friendly personality, or tendency to enter other residents' personal space. Despite staff interviews confirming that the resident enjoyed helping others, participating in crafts, going outside, and engaging in activities such as manicures and music, these preferences and behaviors were not reflected in the care plan prior to a documented incident. An incident occurred in which the resident, known for patting and rubbing other residents in a non-aggressive manner, startled another resident by patting him on the head. This led to the second resident, who was drowsy and leaning forward, reacting by striking the first resident, resulting in a skin tear. Staff confirmed that the resident had a pattern of getting into others' personal space and that not all residents liked to be touched. The lack of individualized, person-centered interventions and failure to address the resident's specific behaviors and preferences in the care plan contributed to the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple altercations involving three residents with severe cognitive impairments and histories of behavioral issues. In one incident, a resident with dementia and violent behavior attempted to touch another resident's watch, resulting in the second resident, who also has dementia and a history of physical aggression, grabbing the first resident's wrist and causing a skin tear. Both residents were identified as being at moderate risk for abuse, and their care plans documented behavioral problems and tendencies toward aggression. In a separate incident, another resident with dementia and a history of aggressive behaviors attempted to move a wheelchair occupied by a resident with dementia and agitation. This led to a physical altercation where the resident in the wheelchair swung her arms, and the other resident responded by striking her in the face. The altercation escalated further when the resident who was struck used a racial slur. These events demonstrate that the facility did not adequately prevent or intervene in resident-to-resident abuse, despite documented risks and behavioral histories.
Failure to Administer Ordered IV Antibiotic and Notify Provider
Penalty
Summary
Facility staff failed to administer five consecutive doses of an ordered intravenous antibiotic (Unasyn, 1.5 grams every eight hours) to a resident with a history of wound infection and a current diagnosis of cutaneous abscess of the buttock. The resident was scheduled to begin antibiotic treatment on the morning of 4/19/2025, but did not receive the first dose until 4:00PM on 4/20/2025, as documented in the medication administration record. Additionally, staff did not notify the resident's wound care medical provider about the missed doses, as confirmed by a handwritten note and staff interview. The facility's assistant administrator reported that staff are expected to contact the prescribing provider within a day's time if unable to provide an ordered medication. These actions and inactions resulted in the resident not receiving timely antibiotic therapy as ordered, and the medical provider was not informed of the missed doses.
Failure to Supervise High-Risk Resident Resulting in Multiple Falls
Penalty
Summary
The facility failed to provide effective supervision to prevent falls for a resident with severe cognitive impairment, a history of stroke, and Alzheimer's disease. The resident, who was dependent on staff for mobility and transfers, experienced multiple falls from their wheelchair in their room. Despite being identified as high risk for falls and having care plan interventions in place, such as placing the resident in bed after meals and frequent checks, the resident continued to experience falls, including unwitnessed incidents. Documentation indicated that staff were to keep the resident in a common area or under monitoring when in the wheelchair, but these interventions were not consistently implemented. There was confusion and inconsistency among staff regarding who witnessed the resident's falls and who assisted after the incidents. Multiple staff members, including the DON, CNAs, and MDS Coordinator, provided conflicting accounts about their presence and actions during the falls. This lack of clear supervision and communication contributed to the resident's repeated falls, demonstrating a failure to ensure the area was free from accident hazards and that adequate supervision was provided.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one of whom was severely cognitively impaired and dependent on staff for most activities of daily living, while the other was cognitively intact and able to self-propel in a wheelchair. According to the facility's abuse summary report, a certified nurse aide reported to the administrator that the cognitively intact resident had put his hand on the inner thighs of the cognitively impaired resident and kissed her on the side of her neck. The aide immediately removed the resident from the area, and the administrator subsequently reviewed camera footage and interviewed staff and other residents present at the time of the incident. Despite the facility's policy requiring that any allegation of abuse be reported to the State Agency unless it can be immediately refuted, the administrator did not report the incident to the State Agency. The administrator acknowledged that an investigation was initiated but confirmed that no report was made to the required authorities, as stipulated by facility policy. This failure to report the allegation constituted a deficiency in the facility's abuse reporting procedures.
Failure to Arrange Physician-Ordered Prosthetic Clinic Referral
Penalty
Summary
The facility failed to follow a physician's order to arrange a referral to a prosthetic clinic for a resident with a pre-existing left above-the-knee amputation. The resident, who was cognitively intact and required supervision with daily activities, had a physician order documented for a prosthetic clinic referral. Nursing progress notes confirmed the order, but there was no documentation of an appointment being made. Multiple staff members, including the Social Service Director, Physical Therapy Assistant, and Transportation Director, were aware of the referral but did not ensure the appointment was scheduled. The Social Service Director informed the Interdisciplinary Team, but no follow-up occurred, and the Transportation Director was told not to make the appointment. The Nurse Practitioner who wrote the order expected it to be carried out, and the facility administrator confirmed that staff are expected to follow provider orders, although there was no formal policy in place. The lack of action resulted in the resident not receiving the necessary referral to the prosthetic clinic as ordered by the physician.
Lack of Qualified Food Service Director and Sanitation Failures
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, as required by federal and state regulations. The individual identified as the full-time manager of the food service, V10, was observed supervising dietary operations but did not possess the necessary credentials such as being a certified dietary manager, a dietician, or having an associate's or higher degree in food service management or hospitality. V10 only completed a one-day ServSafe food service sanitation course, which did not include clinical nutrition instruction, and held a Certified Food Protection Manager certificate, not a Certified Dietary Manager or equivalent. V10 confirmed not meeting the Illinois standards for a food service or dietary manager and reported that the facility dietician only worked one day per week. Additionally, during the survey period, the facility failed to maintain sanitary conditions in the dishwashing areas and did not prevent or exclude flying insects from the food service areas, resulting in direct cross-contamination of resident dishes. The food prepared in the kitchen was available to all 146 residents in the facility, potentially exposing all residents to the effects of these deficiencies.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain an effective pest control program in the kitchen and food service areas, resulting in the presence of flying insects and unsanitary conditions. On multiple occasions, accumulations of decomposed food were found under the kitchen dishwasher drainboards, on surrounding walls, floors, and plumbing surfaces. The dishwasher drain pipe discharged into a floor-level trough that was soiled with food debris and emitted a fetid odor. Containers beneath the dishwasher and three-basin sink were partially filled with dirty water and food debris, and winged insects resembling fruit flies were seen flying around these areas. The disposal basin attached to the dishwasher, which was designed to empty into a food grinder/disposal, was instead draining into a metal pan in the floor trough, further contributing to the accumulation of food debris and the presence of flies. Pest control reports documented ongoing issues, including fly problems, potential harborage, and sightings of German cockroaches and spiders in the kitchen. Despite recommendations to clean the affected areas, conditions persisted, with flies observed landing on food contact surfaces of clean resident dishes stored near the contaminated drain trough and sewer pipe. The kitchen prepares food for all residents in the facility, and at the time of the survey, 146 residents resided in the facility.
Resident Rights Not Honored During Wound Care Scheduling
Penalty
Summary
A resident with multiple medical diagnoses, including muscle wasting, morbid obesity, end stage renal disease, and moderate protein calorie malnutrition, was documented as cognitively intact and dependent on staff for most activities of daily living. The resident's care plan instructed staff to provide opportunities for choice during care. However, on the day in question, the resident expressed a desire to get out of bed but was told by staff that he had to remain in bed until the wound physician arrived, which could be several hours. The resident became visibly upset and teary-eyed, stating he could not get up by himself and staff would not assist him. Staff interviews confirmed that the resident was not allowed to get up until seen by the wound physician, and that he had been crying all morning due to this restriction. Further interviews revealed that the wound nurse instructed staff not to assist the resident out of bed until the physician arrived, and that the resident refused wound care because he wanted to get up. The resident reported that he was not opposed to wound care but objected to being made to stay in bed for extended periods. The DON acknowledged that requiring the resident to remain in bed for hours was a violation of his rights, stating that a short wait would be acceptable but not a prolonged one. The facility's policy affirms residents' rights to a dignified existence and to be treated with respect, which was not upheld in this instance.
Inaccurate Completion of Resident Assessment
Penalty
Summary
A comprehensive assessment for one resident was inaccurately completed when the medication section indicated the resident was taking an antibiotic during the assessment period. However, a review of the resident's February 2025 Order Summary Report and Electronic Medical Record showed no documentation of any antibiotic orders or administration during that time. The MDS Coordinator, who completed the assessment, confirmed that the resident was not prescribed or given any antibiotics during the look-back period. The facility's policy requires all individuals completing any portion of the MDS assessment to attest to the accuracy of the information provided.
Failure to Update Wound Care Orders and Follow Sterile Technique
Penalty
Summary
A deficiency occurred when staff failed to enter new wound dressing change orders and did not provide wound care in accordance with professional standards for a resident diagnosed with Idiopathic Aseptic Necrosis of both feet and Peripheral Vascular Disease. The wound nurse performed a dressing change on the resident's right foot, cleansing the wound with Betadine and then, without changing gloves, applied a new clean dressing. The nurse later confirmed that she should have removed her dirty gloves before handling the clean dressing, as per the facility's wound care policy, which requires the use of sterile technique and glove changes to prevent contamination. Additionally, the wound nurse did not update the resident's wound care orders in the computer system after the wound doctor changed the treatment plan. As a result, wound care continued to be provided and documented under the previous orders, which differed from the new physician's instructions. The nurse acknowledged that the new orders should have been entered into the system on the same day they were received, but this was not done, leading to a failure to provide care according to the most current physician orders.
Failure to Prevent Cross Contamination During Catheter Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during catheter care for a resident with multiple complex medical conditions, including hereditary spastic paraplegia, morbid obesity, neuromuscular dysfunction of the bladder, and a suprapubic catheter. The LPN removed a contaminated split gauze from the resident’s suprapubic catheter insertion site, which had yellow/pink drainage, and cleansed the area by wiping the gauze back and forth multiple times over the same area. Without changing gloves or performing hand hygiene, the LPN then placed a new split gauze over the insertion site using the same contaminated gloves. The resident’s medical records indicated a physician’s order for twice-daily cleansing of the suprapubic catheter site, but the resident reported that staff never clean the site daily, only during monthly catheter changes. The LPN acknowledged contaminating the site by not changing gloves between cleaning and dressing application. The Director of Nursing confirmed that contaminating an open wound could lead to infection. Facility policy required staff to discard gloves and perform hand hygiene after cleansing around the catheter site, which was not followed in this instance.
Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to offer, administer, or obtain consent or declination for Influenza and Pneumococcal vaccinations for two residents out of five reviewed for immunizations. Both residents had been admitted to the facility and were documented as severely cognitively impaired according to their Minimum Data Set (MDS) assessments. Review of their electronic medical records revealed no documentation of consent, administration, or refusal of the required vaccinations since their admission. During an interview, the facility's Registered Nurse/Infection Preventionist confirmed that there was no documentation available to show that the two residents had been offered or had received the Influenza or Pneumococcal vaccines, nor was there evidence of refusal. Facility policy requires that Influenza vaccines be offered to all residents between October 1 and March 31, and that Pneumococcal vaccination status be assessed within five working days of admission, with all actions documented in the resident's medical record. These procedures were not followed for the two residents in question.
Failure to Maintain Functional Bathroom Ventilation Fan
Penalty
Summary
The facility failed to maintain a functional bathroom ventilation fan for one resident. On two separate occasions, it was observed that the bathroom ventilation fan in the resident's room was inoperable, with the fan blades not moving when the switch was turned on. The resident reported that the fan had not worked since admission in June 2024 and expressed a desire for it to be operational. The resident also stated that multiple requests had been made to various staff members over time to repair the fan, but no action had been taken to address the issue.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident by not implementing resident-centered fall interventions and not thoroughly investigating a fall incident. The resident, who had a history of falls and was assessed as a fall risk, experienced a fall resulting in a forehead laceration that required emergency room treatment and sutures. The resident's care plan included interventions such as wearing non-skid socks and ensuring the bed was in a low position, but these were not adequately implemented or monitored. Observations revealed that the resident's bed was positioned against a wall with multiple pillows, which crowded the resident and forced her to sleep close to the edge, increasing the risk of falling. The resident's call light was not within reach, and staff were not aware of the resident's fall risk status or specific care plan interventions. Interviews with staff indicated a lack of awareness and understanding of the resident's care plan and fall interventions, with some staff relying on visual cues like floor mats to identify fall risks rather than documented care plans. The interdisciplinary team reviewed the fall incident but failed to address the root cause effectively. The resident's sleeping patterns and the inappropriate use of pillows were not included in the care plan, leading to confusion among agency staff. The facility's policy on falls required continuous evaluation and identification of fall causes, but this was not adequately followed, resulting in the resident's preventable fall and injury.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident, who was known to exit seek and had a history of elopement. This resident, who was at high risk of falls and was receiving anticoagulation therapy, managed to exit the facility through a deactivated alarmed exit door without staff knowledge or supervision. The resident walked approximately 0.4 miles in extreme cold weather, down a busy street, before being found by a passerby who alerted the facility. Staff were unaware of the resident's absence for approximately one-half to one hour. The resident's medical history included severe dementia with mood disturbance, delirium, restlessness, agitation, hypertension, paroxysmal atrial fibrillation, muscle weakness, and gait abnormalities. Despite these conditions and a documented history of falls, the facility did not update the resident's care plan to address elopement risks in a timely manner. The resident had been observed wandering and exit-seeking prior to the incident, yet no effective interventions were implemented to prevent the elopement. Additionally, after the resident was returned to the facility, staff failed to conduct a full body assessment to check for injuries or hypothermia. The facility also did not ensure that exit door alarms were functional, contributing to the resident's ability to leave the premises unnoticed. These failures highlight significant lapses in supervision and safety measures, which placed the resident at risk of serious harm.
Removal Plan
- Confirmed the facility identified residents affected or likely to be affected by completing resident elopement assessments and reassessments and updating care plans.
- Confirmed elopement binder was updated and at the nurses' stations, and the reception desk.
- Confirmed Accidents and Incidents- Investigating and Reporting Policies including documentation of the condition of the affected person, including vital signs was revised and updated.
- Staff training was initiated and is ongoing. In-service training on elopement protocol and retention quiz were not provided prior to start of shift for several staff.
- Confirmed V1, V2 and V28 Assistant Director of Nurses initiated education relating to immediate head to toe assessments following unusual occurrences.
- Confirmed V12, Maintenance Director assessed all doors, exit alarms, and the departure alert system to ensure proper working order and observed during survey. Ad-Hoc QAPI meeting was completed discussing event and evaluating the current elopement program including conducting daily assessments of exits, and routinely scheduled elopement drills to be ongoing. One mock drill was completed during survey.
- Confirmed V1, provided training to the IDT regarding development of care plans to address residents who are newly identified with exit-seeking /wandering behaviors and elopement risk.
- Confirmed Ad-Hoc QAPI meeting, including the Medical Director by phone, to discuss the incident and the corrective actions to prevent similar events.
- Confirmed in interviews, Daily IDT meetings were conducted to discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring appropriate clinical interventions are implemented to prevent an incident of elopement.
- Confirmed QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for several residents, as observed during a survey. On multiple occasions, a resident was seen sitting at a dining room table covered with napkins, tissues, condiments, and personal items, including mucous-filled tissues. This behavior was noted to be disruptive and unpleasant for other residents, leading to complaints. One resident expressed discomfort and a loss of appetite due to another resident's habit of hacking and spitting up mucous, which was also thrown onto the floor. This resident reported having complained to the staff about the issue, but no action was taken to address the behavior. The administrative assistant acknowledged awareness of the disruptive behavior, which continued to occur daily. The care plan for the resident exhibiting the behavior documented the need for supervision and reminders to refrain from such actions during meal times. Despite this, the behavior persisted, affecting the dining experience and comfort of other residents. The facility's inaction in managing the situation and ensuring a clean and comfortable environment for all residents led to the deficiency noted in the report.
Failure to Address Resident Grievances Regarding Disruptive Behavior
Penalty
Summary
The facility failed to honor the residents' right to voice grievances without discrimination or reprisal, as evidenced by the lack of a filed grievance for a known complaint. Two residents expressed dissatisfaction with another resident's behavior, which involved hacking, spitting up mucous, and discarding tissues on the floor in the dining room. These actions were reported to staff, including the Assistant Administrator, but no grievance was filed, and the issue remained unaddressed. The facility's grievance policy, dated April 2017, mandates that grievances be investigated and resolved promptly, with a written response provided within five working days. Despite this policy, the Assistant Administrator acknowledged awareness of the disruptive behavior but did not file a grievance, mistakenly attributing the issue to the resident's behavior rather than recognizing it as a grievance-worthy complaint. This oversight resulted in the residents' complaints not being documented or addressed according to the facility's established procedures.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, resulting in multiple missed doses for three residents. One resident, who was cognitively intact, reported that the facility had run out of their medications, including Duloxetine and Lorazepam, on several occasions. The Medication Administration Records (MARs) and nursing notes documented that these medications were unavailable on specific dates, and there was no evidence that the resident's physician was notified of the missed doses. Another resident, also cognitively intact, stated that their bone medication was unavailable for several weeks. The MARs indicated that Alendronate-Cholecalciferol was not administered as scheduled due to a billing issue and lack of prior authorization. Despite multiple attempts to resolve the issue, the medication remained unavailable, and there was no documentation that the physician was informed of the missed doses until a later date. A third resident did not receive their prescribed Aripiprazole because the medication was not found in the facility's backup supply. The LPN responsible for administering the medication confirmed its unavailability and reordered it from the pharmacy. However, there was no documentation of follow-up with the pharmacy or physician regarding the medication's unavailability. The facility's policies outlined procedures for handling unavailable medications, but these were not followed, contributing to the deficiency.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer insulin timely, resulting in significant medication errors for one resident. The resident, who is cognitively intact, reported not receiving medications on time, including insulin, which led to fluctuations in blood sugar levels. The resident's Medication Administration Record (MAR) indicated that Lispro insulin was scheduled to be administered three times daily at specific times. However, the Medication Administration Audit Report showed multiple instances where the insulin was administered hours later than scheduled. The Director of Nursing confirmed that medication administration times should be documented accurately and that medications should be given within an hour of the scheduled time unless specified otherwise. The facility's policy on administering medications, dated April 2019, also states that medications should be administered according to physician's orders and within one hour of the prescribed time. Despite these guidelines, the facility repeatedly failed to administer insulin within the required timeframe, leading to significant medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered for three residents, resulting in a 12% medication error rate. For one resident, the Licensed Practical Nurse (LPN) did not administer Ferrous Sulfate 325 mg as scheduled during the morning medication pass, despite confirming that the medication administration was complete. The facility's medication pass times indicated that the medication should have been administered between 6:00 AM and 11:00 AM. Another resident received an incorrect dosage of Breo Ellipta inhaler, which was intended for a different resident, and was not instructed to rinse their mouth after administration as required. The inhalers were stored incorrectly, leading to the administration error. Additionally, a third resident did not receive their prescribed Aripiprazole due to the medication being unavailable in the facility, and there was no documentation of the physician being notified of the missed dose. The facility's policy requires medications to be administered according to physician orders, ensuring the right resident, medication, dosage, time, and method.
Failure to Perform Wound Care Leads to Maggot Infestation
Penalty
Summary
The facility failed to complete wound dressing changes as ordered by the wound care physician for a resident, resulting in the resident's wounds becoming infested with maggots. The resident, who was admitted with multiple diagnoses including wounds and dementia, had specific wound care orders that were not followed. The wound care physician had prescribed the application of Triamcinolone cream and compression wraps twice a week, but these were not consistently documented or performed. On one occasion, a nurse admitted to not performing a dressing change due to being busy, despite having charted it as completed. The resident experienced significant pain and deterioration of the wounds, which were found to be infested with maggots on two separate occasions. The room was noted to have a strong smell of urine and fly strips with flies, indicating poor sanitation. The Director of Nursing acknowledged the unacceptable care, and the wound physician expressed concerns about infection due to the maggot infestation. The resident's condition worsened, with new wounds developing and existing wounds declining in size and condition.
Fly Infestation Due to Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest management program, resulting in a significant fly infestation affecting all 141 residents. The facility's pest control policy, dated March 2024, assigns the Environmental Services Director the responsibility for coordinating pest control, which should be conducted regularly and as needed. However, pest control service reports from April to August 2024 did not document flies as an area of concern. Observations on August 19 and 20, 2024, revealed numerous fly strips with flies attached in several resident rooms, including one room with over 50 flies on a strip. A resident reported having to use fly strips for the past 2-3 months due to the fly problem, and an LPN confirmed that many residents were using fly strips to keep flies away. The Maintenance Director acknowledged the presence of fly traps and a fly light at the courtyard door but dismissed flies as pests. The contracted pest control representative was not informed of the fly issue until the survey and identified entry points for flies through air conditioning units and standing water outside the building as breeding sites. The representative recommended fly lights and noted that the fly strips in use were not provided by their company, indicating a lack of communication and coordination in addressing the pest issue. Additionally, the Director of Nursing confirmed that a resident had maggots found in wounds on two occasions in the past week, further highlighting the severity of the infestation.
Failure to Provide Prescribed Diabetic Diets
Penalty
Summary
The facility failed to provide a diet as ordered for five residents with diabetes, resulting in a deficiency. The facility's Physician Order Policy requires that after an order is received and confirmed, it should be completed as directed by the prescriber. However, the facility provided only one meal option for all residents, regardless of their dietary needs. Specifically, residents with orders for a low concentrated sweets diet were not given meals that adhered to these dietary restrictions. Instead, they were served the same meals as other residents, which included items not suitable for a diabetic diet, such as ravioli and sauce for lunch, and a breakfast of biscuit, sausage gravy, and a banana. The deficiency was confirmed through observations and interviews with facility staff. The Dietary Assistant Manager and the Director of Nursing both acknowledged that there were no different menus or portion sizes for diabetic residents. The Registered Dietician was unaware that the staff were not serving a low concentrated sweets diet to diabetic residents, which could lead to health issues such as elevated blood sugar levels, weight gain, and poor circulation and wound healing. The failure to provide the prescribed diet as ordered for diabetic residents was a significant oversight in the facility's dietary management.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident (R1) struck another resident (R2) in the face. This incident occurred after R1 became aggressive upon returning to the facility. Multiple staff members, including CNAs and an LPN, witnessed the altercation and reported that R1 was yelling profanities and making racial remarks towards the staff. The police were called to manage the situation, and R2 was moved to a different room for safety. R2 experienced discomfort and swelling on the left side of the face near the eye as a result of the altercation. The facility's investigation revealed that R1 had borrowed money from R2 and failed to repay it, leading to the confrontation. R2 expressed fear of R1 following the incident and was relieved to be moved to a different room. The facility's Abuse Prevention and Reporting Policy, dated October 2022, explicitly prohibits abuse, neglect, and mistreatment of residents, yet this policy was not effectively enforced in this case, resulting in a failure to protect R2 from physical harm.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Danville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorne Inn Of Danville | 1.8 mi | ★★★★★ | 0 | 0 |
| Accolade Healthcare Danville | 2.4 mi | ★★★★★ | 8 | 0 |
| Goldwater Care Danville | 3.3 mi | ★★★★★ | 4 | 0 |
| Waters Of Covington, The | 12.1 mi | ★★★★★ | 27 | 2 |
| Williamsport Nursing And Rehabilitation | 18.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.