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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Bella Of Morrison during CMS and state inspections, most recent first.
Therapeutic Leave Approved Without Practitioner Order: A resident went out on community pass and stayed overnight at a girlfriend's home after signing himself out. Staff said the resident was allowed to leave based on cognition, but an LPN stated a doctor should normally be called for an order and an RN agreed. The resident's chart had no therapeutic leave order, although the social service assessment noted he was alert, oriented, and able to navigate safely, and the facility policy required a practitioner order for therapeutic leave.
Failure to Maintain Resident Dignity: A former agency CNA entered resident rooms after being DNR'd, asked residents if they wanted to go to the bar and get drunk, and tried to get them to say bad things about the facility. An LPN found him in one resident's room laying on her while she was screaming and upset, and residents reported being bothered and shocked by his behavior.
Failure to Protect Resident from Physical Abuse: A cognitively impaired resident who wandered into other residents’ rooms entered another resident’s room, struggled over a box of Kleenex, and then punched the resident in the arm. The injured resident, who was cognitively intact and bedbound, reported the wandering resident frequently took belongings and had said, “I will show you,” before striking her. An LPN stated the incident was reported to the administrator, who said resident-to-resident hitting is physical abuse, but she was unaware of the event until the interview.
Failure to report resident-on-resident physical abuse. A resident entered another resident’s room, tried to take property, and then punched the other resident in the arm after a verbal exchange. The LPN said she reported the altercation to the Administrator, but the Administrator stated she was unaware of the incident and did not report or investigate it. The facility policy defined hitting and punching as physical abuse and required immediate reporting to the Administrator and state agency.
Failure to investigate alleged physical abuse between two residents. A resident entered another resident’s room, tried to take property, and then hit/punched the other resident in the arm. The injured resident described the incident as a punch, and an LPN stated she immediately reported the altercation to the Administrator, who was the abuse coordinator. The Administrator stated she was unaware of the incident and did not investigate it, despite the facility policy requiring immediate investigation of suspected abuse.
Incorrect and Late Wound Treatment Orders for a Surgical Stump Wound: A resident with a surgical dehiscence to the stump after a BKA had wound care orders that changed between collagen and xeroform, but the TAR showed late order entry and missed treatment changes. During observation, an RN attempted to apply xeroform even though the resident stated the current wound care was collagen, and the chart still reflected the wrong order at that time.
Failure to Follow Ordered Wound Treatment for Pressure Injury: A resident with DM2, CKD, PVD, CAD, AFib, HF, and a stage 3 pressure ulcer had an open wound on the right buttock, but staff found a collagen piece and dressing in place that did not match the documented treatment. The TAR listed a left buttock hydrocolloid dressing order, while the wound note identified the right buttock and recommended hydrocolloid and leave open to air; the ADON later confirmed the wound was on the right buttock and the order had been clarified.
Staff Provided THC Vape Pen to Resident: A laundry/housekeeping employee reported seeing a former agency CNA give a resident a THC vape pen while residents were outside smoking, and said the resident used it. An RN and an LPN also said they had heard staff were giving residents THC pens. The resident, who was cognitively intact, denied receiving a THC pen and said he had only been given a nicotine vape pen. The CNA denied the allegation, and the Administrator stated she was not aware of the THC pen incident.
A resident with rheumatoid arthritis, fibromyalgia, and ongoing foot/heel pain did not receive prescribed Norco for several days after the last dose was given. The resident reported severe pain and said she usually takes 2 Norco tablets daily, while the MAR showed no doses administered for multiple days. An RN stated the medication had not been delivered from the pharmacy, and the ADON said the facility had a Pyxis system that could have been used to obtain doses.
Failure to monitor a resident with dementia who wandered into other residents’ rooms and became physically aggressive. The resident’s care plan noted severe cognitive impairment, wandering, and a history of aggression, with directions for close monitoring and diversion. Records and resident interviews showed the resident repeatedly entered rooms, took belongings, argued with residents, and on one occasion struck another resident before staff intervened.
A resident room shared by two residents had a nonworking HVAC unit. One resident reported no AC or heat for two weeks, and surveyor observation confirmed the wall unit would not turn on. The maintenance director stated the fuse was blown and the unit was going bad, while the administrator said the issue had been reported earlier but remained unresolved when checked.
Failure to provide timely incontinence care and scheduled showers for a dependent resident. A resident with COPD, lymphedema, DM2, PVD, CKD, MDD, morbid obesity, and anxiety was found soaked with urine, with staff confirming she had not been changed since the prior night. She also reported missing showers for an extended period, and records showed missed weekly bathing with no nursing documentation of shower refusals.
The facility failed to maintain a functional call system for three residents on one hallway, resulting in non‑working call lights in bedrooms and bathrooms and, in one case, the complete absence of a call light. One resident, care planned to use a call light, instead received a drum she could not effectively use, requiring her to yell or wait for staff checks. Another resident with a traumatic brain injury and convulsions reported having no call light or alternative device and having to walk to the nurses’ station for help. A third resident with diabetes and anxiety also reported a non‑functioning call light and no alternative call system, stating he had to search for staff. The Administrator and a CNA confirmed the south hallway call lights had been inoperative for an extended period, and the acting Maintenance Director acknowledged awareness of the problem and the importance of a working call system.
The facility failed to complete and document required initial and weekly wound assessments for two residents with significant lower extremity wounds and amputations. One resident on hospice with bilateral frostbite-related foot wounds did not have a complete wound assessment on admission, and no weekly assessments were documented for several weeks. Another resident with bilateral lower extremity surgical amputation sites had a care plan requiring weekly wound measurements and detailed documentation, but assessments were missed on multiple consecutive weeks without any record of refusal. These practices did not follow the facility’s wound management and documentation policies, which require admission and weekly assessments with specific wound measurements and characteristics.
A cognitively intact resident who was independent in self-care and mobility received an involuntary discharge notice for non-payment, while the ombudsman was actively assisting with an appeal and hearing. The resident chose to leave and was discharged home before the planned discharge date, but the facility did not notify the ombudsman of this discharge. The ombudsman learned of the discharge from an APS worker and confirmed that no discharge notice had been received, and the administrator acknowledged that required notification to the ombudsman, as outlined in facility policy, had not been provided.
Two residents were not safely transferred according to their assessed needs and facility policy, resulting in injuries requiring emergent hospital evaluation. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance was transferred by a single CNA unfamiliar with her status, leading to a leg laceration when her leg likely caught on the wheelchair during a hurried transfer. Another resident with cognitive impairment, right-sided paralysis, and a fall history, who required a gait belt and one-person assist, was stood from the toilet without a gait belt and left unsupported when the CNA turned away, causing a fall with head impact and leg pain.
A resident was admitted from a hospital with discharge orders and a POLST indicating DNR status, and a POA document identified a healthcare representative. Despite this, a physician order listed the resident as Full Code, and the admission care plan omitted any reference to advance directives. The POA reported being told that the facility could not honor the POLST until the medical director signed it, even though the DON later confirmed that a physician-signed POLST should be honored without additional signatures. The facility’s policy requiring advance directives to be copied, charted, and communicated on admission was not followed, resulting in the resident’s DNR wishes not being implemented.
Two residents who were cognitively impaired and dependent on staff for toileting and incontinence care were not provided timely incontinence care consistent with their assessments, care plans, and facility policy. One resident’s brief was last changed early in the morning and was not changed again for over five hours while the resident remained in common areas and then in her room, after which she was found incontinent of urine with reddened buttocks. Another resident, care planned for q2h checks and assistance, was observed with a stool odor in the room and was found to have a brief unchanged since the night shift, containing a large amount of liquid stool and with bright pink buttocks. The DON stated residents needing assistance are to receive toileting and incontinence care every two hours and as needed.
A resident sustained a sutured left lower leg laceration and was discharged with orders for daily wound cleansing and specific dressings each day shift. Review of the TAR and interviews showed that daily wound treatments and dressing changes were not provided on multiple days, and the resident’s private caregiver reported that dressings were not changed on at least two of those days and that she frequently had to request dressing changes. On observation, the leg dressing was undated, appeared dirty, and had yellow drainage, and there was no documentation of wound care for the prior day. The DON later added initials to previously blank TAR entries for two dates, then admitted she had not performed the wound care and had documented after the fact because she had been told not to leave charting blank, contrary to the facility’s wound treatment policy and documentation expectations.
A resident with diabetes had physician orders for blood glucose checks before meals and at bedtime, scheduled insulin doses with meals, and Reglan to be given before meals. On an observed morning, the resident had already eaten part of breakfast and stated he was done when an LPN checked the blood glucose after the meal, then administered Humulin R and Reglan more than two hours past the ordered times and after the meal, instead of before as ordered. The DON stated that medications are considered late if given more than one hour after the scheduled time and that blood sugars should be checked prior to eating, and facility policies required adherence to physician orders and correct timing for blood glucose monitoring, insulin, and medication administration.
A resident with pneumonia, Alzheimer’s disease, anxiety, and heart failure missed multiple ordered meds, including antibiotic eye ointment, Cefdinir, diuretics, buspirone, and alprazolam, because the medications were not yet delivered to the facility. Staff described the resident as anxious, combative, mostly nonverbal, and requiring 1:1 supervision. The resident later had coughing and low O2 saturation and was sent to the hospital, where he was admitted for pneumonia.
Staff could not reliably contact the Medical Director or confirm physician coverage for residents when he was on vacation. An LPN reported long-standing difficulty reaching the physician, the DON and Administrator were unsure who was covering, and a posted notice directed staff to send issues to the ED and stated no scripts would be available. Interviews and the facility policy showed the Medical Director was expected to oversee resident care when attending physicians were not available.
The facility failed to ensure access to convenience medications and timely pharmacy delivery for two residents. One resident with severe cognitive impairment and multiple diagnoses did not receive most ordered medications for the first 48 hours after admission, while staff reported the electronic convenience medication cart was not accessible and agency nurses were told they could not use it. Another resident reported that medications, including a laxative, were sometimes unavailable, and the eMAR documented lactulose, potassium chloride, and nortriptyline as unavailable. Staff and the pharmacist described repeated delays after the pharmacy change and the DON/administrator acknowledged the access issues.
The facility did not develop or document discharge plans in the care plans or electronic medical records for two residents with complex medical needs. Both residents were unaware of their discharge plans, and staff confirmed that required discharge planning was missing, despite facility policy mandating comprehensive, person-centered discharge documentation.
Two residents in the facility suffered from inadequate pressure ulcer care due to failures in implementing necessary interventions and treatments. One resident was found on a deflated air mattress without heel protection, leading to a stage 3 pressure injury. Another resident's stage 2 pressure wound worsened to stage 3 without documented treatment. The facility did not follow its policy for assessing and treating skin alterations, resulting in inadequate care.
The facility failed to ensure a safe, clean, and comfortable environment, with deficiencies in the resident shower room and lack of hot water in bathrooms. The shower room had an uncovered drain, missing tiles, and exposed wood, while residents reported consistently cold water in their bathrooms. Staff acknowledged these issues, which were confirmed by temperature measurements and resident feedback.
The facility failed to maintain safe water temperatures and ensure call light accessibility. Hot water in resident areas exceeded the policy limit, and a resident at high fall risk had an unreachable call light. The Maintenance Director did not conduct additional checks or contact another plumber after identifying the issue. Staff confirmed call lights should be within reach, highlighting a lack of supervision and safety measures.
The facility failed to assess and authorize two residents to self-administer medications. One resident was found with lidocaine patches and an inhaler without proper orders, while another resident used an inhaler for shortness of breath without authorization. The facility's policy requires an assessment, physician's order, and care plan for self-administration, which were not completed for these residents.
A cognitively impaired female resident with autistic disorder and Down syndrome was observed wearing a restraint vest without a physician's order or a completed restraint assessment since admission. Staff provided conflicting accounts of the resident's ability to remove the harness, and the Director of Nursing confirmed the lack of assessment. The facility did not provide a restraint policy during the survey.
A facility failed to include necessary interventions for a chest harness restraint in a resident's care plan. The resident was observed using the harness multiple times, but no assessment had been completed since admission. The DON acknowledged the need for a restraint in the care plan, yet it was missing.
A facility failed to trim the nails of a resident with a hand contracture, resulting in indentations in the resident's palm. Despite the resident not refusing hygiene assistance, the nails remained untrimmed over consecutive days. Staff acknowledged the need for nail trimming, which is usually done during showers, but the facility's policy on grooming was not followed.
A resident with a history of lower extremity edema and congestive heart failure did not have elastic bandages applied as required by physician orders and care plan. Observations showed the resident without the bandages on multiple occasions, and staff interviews revealed a lack of awareness and adherence to the care plan. The resident's condition necessitates the use of these bandages to manage edema and circulation.
A facility failed to include a stop date in a psychotropic medication order for a resident with generalized anxiety disorder. The order for Lorazepam Oral Concentrate did not specify a duration, contrary to the facility's policy requiring PRN orders to be limited to 14 days. This was confirmed by the administrator.
The facility failed to assess and offer pneumococcal immunizations to two residents upon admission. The Director of Nursing acknowledged that the admitting nurse is responsible for screening and administering vaccines, but this process was not followed. The facility's policy requires assessment and offering of the vaccine upon admission, which was not adhered to.
The facility did not post daily staffing information for 35 residents as required. Staffing details were kept in a binder at the nurse's station, but not displayed near the front door for visitors. The CNA Supervisor was unaware of the requirement to visibly post staffing information.
The facility failed to test its water system for Legionella and did not prevent water from becoming sedentary in an unoccupied area. Maintenance staff were unsure if a water system assessment had been conducted, and there was no evidence of Legionella testing. Observations revealed a therapeutic bathtub with a continual slow drip and a long brown stain, and the facility's policies and procedures for Legionella management were not followed.
The facility failed to have a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The DON, who was identified as the IP, did not have the required certification. The Administrator acknowledged the requirement and mentioned that the DON was in the process of obtaining certification but was not currently certified. The facility's job description for the IP role specified that the individual must have completed specialty training in infection prevention and control through accredited continuing education such as the CDC or APIC.
The facility failed to update a resident's advanced directives as requested. Despite the resident opting to become a DNAR and signing the POLST form, the form lacked necessary signatures and was not processed correctly, leaving the resident still considered a full code.
The facility failed to ensure a resident received necessary post-amputation care, including follow-up with her surgeon, obtaining a properly fitted shrinker, and assisting in the process to obtain a prosthetic leg. The resident reported significant delays and improper fittings, and staff were unaware of the specific orders for her care.
The facility failed to implement pressure ulcer interventions and identify pressure injuries before they progressed to stage 2 for two residents. One resident's stage 2 pressure wound was not identified until it had been present for more than four days, and another resident was observed without a pressure-relieving device despite having a stage 2 pressure wound and orders for a pressure relief cushion.
The facility failed to ensure proper catheter care for a resident, leading to deficiencies such as improper cleaning techniques and incorrect placement of the catheter drainage bag. The CNAs involved were unaware of the correct procedures, and the resident's care plan lacked specific interventions to prevent these issues.
Therapeutic Leave Approved Without Practitioner Order
Penalty
Summary
The facility failed to follow its policy for a safe community pass for one resident. On 5/27/26, the resident was observed sitting outside in a wheelchair and stated he had recently gone out on pass with his girlfriend to her house, fell asleep watching a movie, stayed overnight, and returned to the facility the next morning. He also stated that he signed himself out of the facility. Staff interviews showed the LPN who worked that day asked the Administrator if the resident was allowed to go out on pass, and was told he could go because he had a high enough cognition score, although the LPN stated that normally a doctor should be called for an order. An RN stated, "Oh yeah, you are supposed to call the doctor!" The Administrator stated she was not aware of needing a doctor's order and would need to look at the policy. Record review showed the resident's May 2026 physician orders did not include an order for therapeutic leave. The resident's sign out/in record showed he signed out on 5/17/26 at 6:30 PM. The social service quarterly assessment documented that the resident was sufficiently alert, oriented, coherent, and knowledgeable to be considered for independent outside pass privileges and that he could move and navigate safely on community streets and, if in a wheelchair, propel safely and carefully. The care plan listed diagnoses of chronic congestive heart failure, anemia, cardiac pacemaker, acquired absence of both feet, and acquired absence of the right leg below the knee, and noted he could transfer independently, but it did not address his community pass ability. The facility's therapeutic leave policy stated that the nurse will obtain an order from the practitioner specifying approval of a therapeutic leave.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner for 3 of 13 residents reviewed for dignity, including R4, R6, and R12. On 5/4/26, R6 stated that V10, a former agency CNA, came into rooms asking residents if they wanted to go to the bar and get drunk, which R6 declined. R12 stated that V10 came into his room asking if he wanted to go to the bar with him, and R12 told him to get out of the room. R4 stated that V10, who had previously provided her care, later returned after being terminated and came into her room trying to hug her, while an LPN was in the hallway telling him he should not be there and to leave. On 5/5/26, the LPN stated she found V10 in R4's room laying on her, and R4 was screaming and very upset. The LPN stayed to console R4, who was upset and scared because of what V10 had been saying to her about being terminated and because she thought she was going to get blamed for it or involved in it. On 5/6/26, the Administrator stated V10 had been DNR'd for creating a non-homelike environment, but he returned two more times after being DNR'd, causing a scene and bothering residents by asking them to go to the bar and trying to get them to say bad things about the facility. The facility's resident rights policy stated residents have the right to a dignified existence, self-determination, communication, and a safe, clean, comfortable, and homelike environment.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when one resident entered another resident’s room, attempted to take a box of Kleenex, and the two residents tugged back and forth over the item before the first resident hit the other resident. The resident who was hit was cognitively intact and stated that the other resident frequently entered rooms, took belongings, and had punched her in the right arm after saying, “I will show you.” The resident who struck the other resident was severely cognitively impaired due to dementia, was ambulatory, wandered throughout the facility, and had a care plan noting wandering into and rearranging other residents’ rooms, liking to touch, hug, or kiss others, and having a history of physical aggression. A licensed practical nurse stated that the resident had wandered into the other resident’s room on one prior occasion without physical contact and then returned again when the hitting occurred. The nurse stated she immediately reported the physical altercation to the administrator, who was the facility’s abuse coordinator. The administrator stated that resident-to-resident hitting is physical abuse and is investigated as abuse, but also stated she did not report or investigate the incident because she was not aware of it until the day of the interview.
Failure to Report Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving one resident and another resident to the administrator and other required officials, including the State IDPH. A health status note dated 2/26/26 documented that one resident wandered into another resident’s room, tried to take a box of Kleenex, and the two residents tugged back and forth over the box before the first resident hit the other resident. On 5/4/26, the resident who was hit stated the other resident entered rooms, took things, yelled at staff for help, and then punched the resident in the right arm after saying, “I will show you.” The resident described the act as a punch, not a slap, and stated the resident was mad. On 5/4/26, the LPN stated she immediately reported the physical altercation to the Administrator, who was also the facility’s abuse coordinator. The Administrator stated that a resident hitting another resident is physical abuse and that staff are to report abuse allegations immediately, but she did not report or investigate the incident because she said she knew nothing about it until that day. She further stated the LPN never reported the incident to her. The facility’s Abuse, Neglect, and Exploitation policy stated physical abuse includes hitting and punching and requires reporting alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to investigate an allegation of physical abuse involving one resident and another resident. A health status note documented that one resident wandered into another resident’s room, tried to take a box of Kleenex, and the two residents tugged back and forth over the box before the first resident hit the other resident. During interview, the resident who was struck stated the other resident entered rooms, took things, yelled, and then punched the resident in the right arm, describing the act as a punch rather than a slap. The LPN stated she immediately reported the physical altercation to the Administrator, who was the facility’s abuse coordinator. However, the Administrator stated she did not report or investigate the incident because she was not aware of it and said the LPN never reported it to her. The facility’s Abuse, Neglect, and Exploitation policy required immediate investigation of suspected abuse and included interviewing involved persons and documenting the investigation completely and thoroughly.
Incorrect and Late Wound Treatment Orders for a Surgical Stump Wound
Penalty
Summary
The facility failed to ensure prescribed wound treatments were provided according to orders for a resident with a surgical wound to the right stump after a below-the-knee amputation. The resident’s diagnoses included absence of the left foot, absence of the right leg below the knee, severe protein-calorie malnutrition, and chronic systolic congestive heart failure. During observation, the RN was preparing to apply xeroform and a dressing to the stump wound, but the resident stated that the dressing order had been changed to collagen with a dressing and that xeroform was keeping the wound wet. The RN checked the computer order, which still showed xeroform and a dressing, while the resident stated that was incorrect and that the wound care doctor did not want that dressing. Record review showed the wound treatment orders changed multiple times, with collagen ordered at one point and xeroform ordered at another, but the TAR reflected late entry of orders and missed treatment changes. The collagen order was entered 5 days late, one dressing change was missed with the new treatment orders, and when collagen was discontinued, no treatment change was documented that day. The xeroform order was also entered late, and the resident received xeroform on a day when the record showed collagen should have been used. The resident was cognitively intact, and the care plan directed staff to provide treatment as ordered and to follow current orders in the chart/eTAR.
Failure to Follow Ordered Wound Treatment for Pressure Injury
Penalty
Summary
The facility failed to ensure a resident with a pressure injury received the prescribed treatment. The resident had multiple diagnoses including diabetes mellitus type 2, heart failure, chronic kidney disease, a stage 3 pressure ulcer of the right buttock, major depressive disorder, peripheral vascular disease, atrial fibrillation, coronary artery disease, and hypertension. During observation, the resident had an open pressure ulcer about the size of a dime on the right buttock, and the RN removed a dressing that contained a white piece of collagen and a dressing over it, stating that it was not the resident’s dressing and she was unsure why it had been applied. The resident’s treatment record for May listed a left buttock wound order for cleansing and hydrocolloid dressing every 3 days and as needed, with a start date of 4/29/26, but there were no orders for the right buttock. The skin and wound note documented a pressure ulcer to the right buttock with treatment recommendations for hydrocolloid and leave open to air. The ADON later stated she clarified the order and it was for a hydrocolloid dressing, and confirmed the wound was on the right buttock, not the left. The care plan identified a documented pressure ulcer and included wound care per treatment order, and also listed the right buttock stage 3 pressure ulcer among areas of skin impairment. The facility’s wound treatment management policy stated wound treatments are to be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.
Staff Provided THC Vape Pen to Resident
Penalty
Summary
The facility failed to ensure staff did not provide a THC vape pen to a resident for use. During observation and interviews, a laundry/housekeeping employee stated he saw a former agency CNA outside with residents while they were smoking and saw the CNA give a THC vape pen to a resident, who took the pen and used it. The employee said he recognized it as a THC vape pen because of its style and that it looked different from nicotine vape pens. He also stated other staff told him the CNA had done this before, but he did not report the information to the Administrator. Additional staff interviews supported the allegation. An RN stated she had heard staff were giving THC pens to residents and that the laundry/housekeeping employee told her he saw the CNA give the THC pen to the resident on the patio. An LPN also stated she was aware staff were giving residents THC pens and reported hearing that the CNA gave his THC pen to the resident outside. The resident was cognitively intact per the MDS and denied that the CNA gave him a THC pen, stating the CNA had only given him a nicotine vape pen. The former agency CNA denied giving any THC pens to residents and said he smoked marijuana at home but not at work. The Administrator stated the CNA had already been DNR'd for sleeping while working and for letting residents smoke outside of scheduled smoke time, and she was not aware he was giving THC pens to the resident.
Pain medication not administered as prescribed
Penalty
Summary
The facility failed to manage a resident’s pain by not administering prescribed analgesic medication for one of three residents reviewed for pain management. The resident had a physician order for Hydrocodone-Acetaminophen (Norco) 5/325 mg, 1 tablet every 6 hours as needed for pain, and a provider note documented continued complaints of right foot/heel pain while awaiting insurance approval for a CT scan. The resident reported a history of rheumatoid arthritis and fibromyalgia and stated she usually took 2 Norco tablets a day for pain. On observation, the resident stated she had not received any Norco since the prior Thursday and rated her pain as 9/10. The April and May MARs showed the last Norco dose was given on 4/30/26, with no doses administered from 5/1/26 through 5/4/26. The RN stated the resident was out of Norco and that the medication had been ordered but not delivered from the pharmacy yet, and the RN gave Flexeril instead, acknowledging it was not the same as Norco. The ADON stated staff are to reorder medications when a resident has seven doses left, the pharmacy delivers daily, staff should notify leadership if medications run out, and the facility had a Pyxis system that could have been used to obtain Norco doses.
Failure to Monitor Wandering Resident with Dementia
Penalty
Summary
The facility failed to monitor and prevent a resident with a diagnosis of dementia from wandering into other residents’ rooms and interacting aggressively with them. The resident’s care plan identified severe cognitive impairment, ambulation, wandering throughout the facility, rearranging another resident’s room, touching, hugging, or kissing others, and a history of physical aggression. The plan directed staff to closely monitor and intervene as needed to prevent the resident from entering other residents’ rooms by offering structured activities and pleasant diversions. Record review showed the resident was found in another resident’s room on multiple occasions attempting to take belongings, and verbal arguments occurred when the other resident objected. On one occasion, the resident attempted to hit the other resident but staff intervened in time; on another occasion, the resident hit the other resident before staff intervened. Interviews with other residents described the resident entering rooms frequently, taking items, and coming close to residents without personal space. Staff interviews confirmed the resident’s wandering behavior and that staff tried to keep the resident busy and watch her, while the social services staff stated the resident’s known behavior required monitoring and intervention when she attempted to enter other residents’ rooms.
Nonworking HVAC Unit in Resident Room
Penalty
Summary
The facility failed to maintain a working heating/air conditioning unit in a resident room shared by two residents. During observation and interview, one resident stated she had no air conditioning or heat in the room for the prior two weeks and said the unit did not work. Surveyor observation confirmed the wall unit was plugged in but would not turn on when the power button was pressed. The resident had two fans on an overbed table pointed at her bed, and the outside temperature had been in the low to mid 80s on several prior days. The maintenance director from a sister facility was unable to turn the unit on and stated the fuse was blown and there was no click when he pushed the buttons on the electrical cord plug. He said the unit was going bad, the compressor was getting too hot and blowing the circuit breaker, and that he would replace the unit. The administrator stated the residents had reported the AC was not working at the end of the prior week and said the former maintenance worker had told her it was fixed, but it remained nonfunctional when checked.
Failure to Provide Timely Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to ensure a dependent resident received incontinence care and showers. The resident had diagnoses including COPD, lymphedema, type 2 diabetes, peripheral vascular disease, chronic kidney disease, major depressive disorder, morbid obesity, and generalized anxiety. On 5/1/26, surveyors observed two CNAs providing incontinence care while a strong smell of urine was coming from the resident’s room. The resident stated she was soaked with urine and said the last time she had been changed was at 10:30 PM the night before. She also stated she had been awake since 5:00 AM and was not changed until the time of the observation, and that she preferred to be changed in the early morning rather than being left wet while sleeping. The resident stated her shower days were Wednesday and Saturday, but she did not receive a shower for 10 days in April and said showers were missed when agency staff were working. A CNA confirmed the resident was dependent on staff for incontinence care and said she was soaked that morning and should have been changed earlier. The administrator stated there had been concern about the resident not getting showers and confirmed she did not receive a weekly shower; the administrator also stated that on 4/18/26 an agency aide did not give the resident a shower. Review of the care plan showed the resident was dependent on staff for showers and incontinence care, requested incontinence checks every two hours during the day, and wanted her last nighttime check between 11:00 PM and 12:00 AM and her next check between 4:00 AM and 5:00 AM. Shower reports from 4/15/26 through 4/25/26 showed she did not receive her weekly shower, and the shower report for 4/18/26 documented that she refused the shower, while nursing notes for April 2026 contained no documentation of shower refusals.
Failure to Maintain Functional Call System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system in resident rooms, bathrooms, and bathing areas for three residents on the south hallway. One resident’s admission record showed she was elderly and care planned to have her call light within reach and to be encouraged to use it for assistance. On observation, her bed and bathroom call lights were not working, and she confirmed this, stating staff had given her a drum to signal for help. She reported she was unable to use the drum effectively, and when she attempted to use it, no audible sound could be heard at her door. She stated that when she needed help, she had to yell or wait for staff to check on her. Her daughter‑in‑law confirmed that the resident was not physically capable of making a loud sound with the drum and that the call light system had not worked since admission. A second resident, with diagnoses including traumatic brain injury and convulsions, was observed in bed with no call light present in the room and a non‑functioning call light in the bathroom. This resident stated she did not have a call light and had to walk to the nurses’ desk to find staff when she needed help, and that no alternative call system such as a noise maker had been provided. A third resident, diagnosed with diabetes and anxiety, reported his call light was not working and that staff had not provided an alternative call system; he stated he had to look for staff when he needed assistance, and no noise maker was observed in his room. The Administrator stated the call light system on the south hallway had not been working for about two weeks. A CNA reported that call lights on the south hallway were not working and that the facility had provided drums as noise makers, while the acting Maintenance Director stated he became aware of the call light system problem the previous week and acknowledged the importance of a working call system so residents can contact staff.
Failure to Complete Initial and Weekly Wound Assessments per Facility Policy
Penalty
Summary
The facility failed to complete required initial and weekly wound assessments for residents with significant lower extremity wounds, contrary to its own wound management and documentation policies. One resident was admitted with multiple serious diagnoses including COPD, severe calorie malnutrition, gangrene, chronic respiratory failure, and was on hospice services with moderate cognitive impairment and extensive care needs. A skin check completed on the admission date documented only a right heel issue without measurements and did not include the left foot wound. The next available wound assessment, dated nearly a month later, documented large eschar-covered wounds on both feet attributed to frostbite, with measurements and a palliative care plan, but there were no wound assessments documented upon admission for the bilateral lower extremity wounds and no weekly assessments for several consecutive weeks following admission. Another resident, admitted with chronic CHF, severe protein-calorie malnutrition, multiple lower extremity amputations, and a cardiac pacemaker, had a care plan requiring weekly wound treatment documentation for bilateral lower extremity surgical sites, including detailed measurements and wound characteristics. The record showed weekly wound assessments were completed on one date in late February and then not again until late March, with no weekly assessments documented on four intervening weeks for the right and left stump wounds. The resident’s medical record contained no evidence of refusal of wound assessments, and the resident reported that a wound doctor and another individual came to measure the wounds only occasionally. The facility’s written policies required wound assessments on admission, weekly, and as needed with specific elements such as wound type, location, measurements, tissue type, peri-wound condition, drainage, odor, and pain, which were not consistently documented for these residents.
Failure to Notify Ombudsman of Resident Discharge After Involuntary Discharge Notice
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the ombudsman of a resident’s discharge following an involuntary discharge notice for non-payment. The resident was admitted on an unspecified date and was documented as cognitively intact on a 3/3/26 assessment, with independence in self-care (with supervision) and mobility. On 2/13/26, the Administrator issued the resident an involuntary discharge notice due to non-payment, with a planned discharge date of 3/16/26. The ombudsman reported that she was actively working with the resident on the involuntary discharge case, including filing an appeal and arranging a hearing, and had obtained representation for the resident and notified the facility of these actions. Despite the pending appeal and scheduled hearing, the resident discharged to home on 3/11/26, which the Administrator stated was the resident’s choice. The ombudsman stated that she learned of the discharge from an APS care worker’s message and that, as of 3/19/26, the facility had not sent any discharge notification to her office. The Administrator acknowledged that either she or social services should have notified the ombudsman of the resident’s discharge and confirmed, after reviewing email communications, that no such notification had been sent. This failure occurred despite the facility’s transfer and discharge policy dated 10/13/25, which requires that notice of transfer or discharge, including any updated information, be provided to the resident, the resident’s representative if appropriate, and the ombudsman as soon as practicable, and that the facility maintain evidence that the notice was sent to the ombudsman.
Failure to Safely Transfer Residents and Use Required Gait Belts
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer residents in accordance with assessed needs and established procedures, resulting in resident injuries. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance for transfers and standing was transferred by a single CNA who was unfamiliar with the resident’s transfer status. During a wheelchair-to-bed transfer, the CNA attempted to stand the resident, who became frantic and panicked. The CNA, feeling anxious, hurried to complete the transfer instead of stopping to seek additional help or allowing the resident time to calm down. The resident’s leg likely became caught on the wheelchair leg during this process, causing a large skin laceration that required emergent hospital evaluation and repair with nine sutures. Another resident with impaired cognition, right-sided paralysis from a prior stroke, nonverbal status, and a history of falls had a care plan requiring use of a gait belt and one-person assistance for transfers, standing, and ambulation. While assisting this resident from the toilet, a CNA did not use a gait belt as required. After helping the resident to stand, the CNA turned away to remove gloves and wash hands, leaving the resident unsupported. During this time, the resident fell and struck her head on the sink, later complaining of right leg pain and requiring emergent hospital evaluation. The facility’s policy required the use of gait belts for residents who could not independently ambulate or transfer, and restorative staff confirmed that a gait belt was to be used for this resident.
Failure to Honor Resident’s Documented DNR Status
Penalty
Summary
The deficiency involves the facility’s failure to honor and implement a resident’s documented DNR (do not resuscitate) status as indicated on a valid POLST (Physician Orders for Life-Sustaining Treatment) form. The resident was admitted from a hospital with discharge orders clearly indicating DNR status, and a POLST form dated later in the month also documented the resident as DNR. The resident’s healthcare POA was identified in a POA document, and the POA stated that the facility had a signed POLST form but reported being told by facility staff that they could not honor it until the facility’s medical director signed off on the DNR. Despite these existing documents, a physician order entered shortly after admission listed the resident as Full Code. The admission care plan documented that the resident was cognitively impaired but did not include any information related to advance directives. The facility’s DON confirmed that if a resident has a POLST form signed by a physician, the facility is supposed to honor it and that the medical director’s additional signature is not required for validity. Upon reviewing the POLST, hospital discharge orders, and current admission orders, the DON acknowledged not knowing why the resident was listed as Full Code and stated the resident should be DNR. The facility’s own policy on Residents’ Rights Regarding Treatment and Advance Directives states that upon admission, existing advance directives are to be copied, placed in the chart, documented in the medical record, and communicated to staff, but this was not carried out for this resident’s DNR status.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting assistance to residents who were cognitively impaired and dependent on staff for these activities of daily living. One resident’s assessment showed cognitive impairment and dependence on staff for toileting and incontinence care. A private caregiver reported that staff did not toilet or change this resident’s brief unless prompted and that the resident would sit in the same brief for hours. On the survey day, the resident’s brief was last changed around 7:00 AM before being dressed and taken to breakfast. The resident remained in common areas and then in her room for several hours, during which time the private caregiver stated no staff offered toileting or incontinence care. When the resident was finally transferred to bed at 12:37 PM, staff confirmed the brief had not been changed since 7:00 AM, the resident was incontinent of urine, and her buttocks were red. Another resident’s assessment showed severe cognitive impairment, dependence on staff for toileting and incontinence care, and incontinence of stool and urine. The resident’s care plan directed staff to check the resident every two hours and assist with toileting as needed. On the survey day, the resident was observed seated in a wheelchair with an odor of stool in the room. A CNA stated the resident’s brief had last been changed by night staff sometime before 5:00 AM and that the resident was already up and dressed at the start of the CNA’s shift. When CNAs transferred the resident to bed and removed the brief, the resident was found incontinent of a large amount of liquid stool, and the buttocks appeared bright pink. The DON later stated that residents requiring assistance with toileting and/or incontinence care are to receive such care every two hours and as needed, and the facility’s incontinence policy indicated that all incontinent residents will receive appropriate treatment and services based on their comprehensive assessment.
Failure to Provide and Accurately Document Daily Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide daily wound treatments and dressing changes as ordered for a resident who sustained a left lower leg laceration requiring nine sutures after being injured during a transfer by facility staff. Hospital discharge instructions and a physician order dated 2/7/26 directed staff to cleanse the wound on the left lower extremity with wound cleanser and cover it with xeroform, maxorb, an abdominal pad, and kerlix dressing every day shift. Review of the February 2026 Treatment Administration Record (TAR) showed no documentation that wound treatments or dressing changes were provided on 2/11/26 or 2/12/26. The resident’s private caregiver reported that on those two days the dressing was not changed at all and stated that she had to ask staff every day to change the dressing. On subsequent observation, the resident was seen with a gauze dressing on the left lower leg that had no date and later appeared dirty with a moderate amount of yellow drainage, with the caregiver stating that no dressing change had been done the previous day. Review of the TAR on 2/24/26 showed no wound treatment or dressing change documented for 2/23/26. New entries had been added to the TAR indicating that the DON had provided wound care on 2/11/26 and 2/12/26, but in interview the DON admitted she had not performed the wound care on those dates and had entered her initials the previous night because she was told by corporate to never leave charting blank. The facility’s Wound Treatment Management policy required that wound treatments be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.
Failure to Administer Insulin, Reglan, and Blood Glucose Monitoring at Ordered Times
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of pharmaceutical services related to medication and blood glucose administration for one resident with diabetes mellitus. The resident’s admission record documented a diagnosis of diabetes and physician orders for blood glucose (Accu-check) monitoring before meals and at bedtime, specifically at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. The resident also had orders for Humulin R insulin, 3 units SQ with meals at 7:30 AM, 12:00 PM, and 5:30 PM, and Reglan 10 mg to be given before meals at 6:30 AM, 11:30 AM, and 4:30 PM. The resident’s POA reported that staff were not checking the resident’s blood glucose levels as ordered and were administering medications late. On the morning observed, the resident was seated in the dining room with breakfast and had already consumed approximately 25% of the meal and stated to staff that he was done eating. At 8:33 AM, an LPN checked the resident’s blood glucose after he had eaten, obtaining a reading of 256, and then administered 3 units of Humulin R at 8:39 AM, more than two hours after the ordered 7:30 AM administration time. At 8:56 AM, the LPN administered 10 mg of Reglan, also more than two hours late and after the resident had eaten, contrary to the order for administration before meals. The DON confirmed that medications are to be given at the scheduled time per physician order, that medication is considered late if given more than one hour past the scheduled time, and that blood sugars are to be checked prior to eating. Facility policies on blood glucose monitoring, timely administration of insulin, and medication administration all required adherence to physician orders and correct timing, which was not followed in this case.
Significant Medication Errors With Missed Ordered Medications
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors. The resident was admitted with diagnoses including pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of the prostate, Alzheimer's disease, and heart failure. The facility assessment showed severe cognitive impairment and dependence on staff for all cares. The care plan identified the resident as having an eye infection, bacterial pneumonia, diuretic therapy needs, and use of antianxiety medications, with orders to administer medications as prescribed. The October 2025 eMAR showed missed doses of multiple ordered medications. The resident missed doses of Neomycin-Polymyxin-Dexamethasone ophthalmic ointment on 10/16/25 through 10/20/25, Cefdinir on 10/16/25 through 10/19/25, furosemide and spironolactone on 10/16/25 and 10/17/25, buspirone on 10/16/25 through 10/18/25, and alprazolam on 10/16/25 through 10/19/25. The facility pharmacist stated the first medication delivery to the facility occurred on 10/19/25 at 3:45 AM, with buspirone, doxycycline, and furosemide delivered then, Cefdinir and alprazolam delivered on 10/20/25 at 2:43 AM, and the antibiotic eye ointment delivered on 10/21/25 at 3:21 AM. Staff described the resident as very anxious, combative, difficult to communicate with, and requiring 1:1 supervision due to agitation, anxiety, combativeness, and fall risk. One nurse stated the resident was in a really bad state of being and was mostly nonverbal, while another said once alprazolam and buspirone were onboard, it helped and that the facility was contacting the pharmacy constantly because those medications were needed. The resident was later noted coughing, with oxygen saturation of 88% on room air, and the wife/POA requested emergency evaluation; the resident was then sent to the hospital and was admitted for pneumonia.
Physician Coverage Not Available for Resident Care
Penalty
Summary
The facility failed to ensure a physician was overseeing the care of all residents when the Medical Director was unavailable and staff could not reliably contact a covering provider. A resident roster dated 11/22/25 showed 36 residents in the facility. On 11/22/25, surveyors observed a posted notice at the nursing station stating the Medical Director was on vacation from 11/20/25 to 12/1/25 and directing staff not to call or text him, but instead to call the office number. A handwritten note on the posting stated that no one answered at that number or its extensions, there was no option to leave a message except with billing, and that the Administrator and DON were aware and unsure of the situation. The note also instructed staff to send issues to the ED and stated there would not be any scripts available. Interviews confirmed staff did not have effective access to a physician. An LPN said it had been an impossibility for a very long time to contact the physician and that there was no one covering that she knew of, adding that if she needed a physician she did not know what she could do. The Administrator said she did not know if the Medical Director was the physician for all residents or whether anyone was covering while he was on vacation. The Medical Director’s nursing home coordinator later said he was still taking call and that if staff could not reach him, the Administrator could contact her and she could reach him, but also stated the posted note was incorrect and should have indicated an NP would cover during the day. Other nurses reported they could not get ahold of the Medical Director or leave messages, and the facility policy stated the Medical Director was to be available to oversee the medical care of all residents when other attending physicians were not available.
Medication Access and Pharmacy Delays
Penalty
Summary
The facility failed to ensure nurses had access to convenience medications and failed to ensure medications were available from the pharmacy for 2 of 3 residents reviewed for pharmacy services. One resident was admitted with diagnoses including pneumonia due to gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of the prostate, Alzheimer’s disease, and heart failure, and was assessed as having severe cognitive impairment and being dependent on staff for all cares. His October physician orders included buspirone, alprazolam, cefdinir, donepezil, doxycycline, furosemide, memantine, spironolactone, and tamsulosin, but his eMAR showed that for the first 48 hours after admission the only medication administered was melatonin. Staff interviews described repeated delays in obtaining medications after the pharmacy change on October 1. An LPN stated the electronic convenience medication cart had Wi-Fi problems, disconnected frequently, and had not been functioning or accessible. Another LPN said agency nurses were told they did not have access to the cart, and an RN reported that at least one resident each time she worked did not have medications available. The facility pharmacist stated the first delivery of the resident’s medications did not occur until several days after admission, with some ordered medications delivered even later. The administrator acknowledged delays with the new pharmacy and stated agency nurses should have access to the convenience medications. A second resident, who had diagnoses including dementia without behavioral disturbance, schizophrenia, anxiety disorder, major depressive disorder, hypothyroidism, slow transit constipation, insomnia, and chronic kidney disease, reported that medications were sometimes unavailable and that her laxative was the most recent medication she had trouble obtaining. Her November eMAR showed lactulose was not available on one date and potassium chloride and nortriptyline were unavailable on another date. The facility’s policy required medication carts to be stocked, a supply of commonly used medications to be maintained, and immediate action when medications were unavailable, including notifying the physician and obtaining alternative orders, but the record and interviews showed repeated medication unavailability and access problems.
Failure to Document and Implement Discharge Planning in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a discharge planning process and include this process in the electronic medical record and comprehensive care plan for two of three residents reviewed for discharge planning. One resident expressed uncertainty about his discharge date and reported not being informed about his discharge plans, aside from being told he would be discharged. Staff interviews revealed that discharge planning was not documented in the electronic medical record or care plan, and communication about discharges was primarily through dashboard alerts. The care plan for this resident did not include any discharge planning, and there were no physician orders for discharge at the time of review. The facility's policy requires that the comprehensive, person-centered care plan contain the resident's goals for admission and desired outcomes aligned with discharge, with supporting documentation of the resident's intent to leave and documented discussions, which was not present in this case. Another resident also did not have a discharge plan documented in her care plan, despite her goal to return to the community being noted in the Minimum Data Set. She was unaware of her discharge plan and only knew she would be receiving cancer treatment. The care plan lacked any information related to discharge, and staff confirmed that a discharge plan should have been in place. Both residents had complex medical histories, including chronic conditions and recent treatments, but the required discharge planning and documentation were not completed as per facility policy.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement necessary interventions and treatments for pressure injuries for two residents, leading to a deficiency in care. Resident R33 was found with a deflated air mattress and without heel protection boots, which are essential for pressure relief. The air mattress was turned off, and the heel boots were not in use, contrary to the care plan. The Director of Nursing (V2) was unaware of the pressure injury until it was reported on 2/27/25, although it was initially noted on 2/17/25. The wound physician (V6) confirmed the injury as a stage 3 pressure injury, indicating it had been present for more than three days without appropriate treatment or pressure-relieving interventions. Resident R21 also experienced a lapse in care, as her stage 2 pressure wound progressed to a stage 3 wound without documented treatment. The Treatment Administration Record for January 2025 did not show any scheduled treatment for her pressure ulcer, and there were no orders for wound treatment from 1/23/25 to 2/5/25. The Director of Nursing (V2) acknowledged the oversight, noting that treatment orders were not entered into the system until the day after the wound physician's rounds. The facility's failure to adhere to its Assessment of Skin Alteration Policy, which mandates assessment and treatment of skin alterations as ordered by a physician, contributed to the worsening of pressure injuries for both residents. The lack of timely intervention and communication among staff members resulted in inadequate care and management of the residents' pressure injuries.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of the resident shower room and the lack of hot water in resident bathrooms. Observations revealed that the shower room had an uncovered drain, missing tiles, exposed wood framing, and tiles held in place with duct tape. A Certified Nursing Assistant reported that a wheelchair wheel got stuck in the drain, and a resident who had been at the facility for nine years expressed ongoing dissatisfaction with the shower room's condition. The facility's administrator acknowledged awareness of the issues, and the Resident Council Minutes from June 2024 indicated that updates to the shower room were needed. Additionally, the facility failed to provide hot water in resident bathrooms, with temperatures recorded significantly below acceptable levels. Residents reported that the water never got warm, even after running for extended periods. A staff member indicated that the north wing had issues with hot water, possibly due to a lack of a return circuit. Temperature measurements taken during the investigation confirmed that the hot water in several residents' bathrooms was consistently below 61 degrees Fahrenheit, failing to meet the residents' rights to a safe and comfortable environment.
Deficiencies in Water Temperature Monitoring and Call Light Accessibility
Penalty
Summary
The facility failed to ensure that water temperatures in resident care areas were monitored and maintained within safe limits, as well as failed to ensure a resident's call light was within reach. Observations revealed that the hot water temperature in a shared resident bathroom was measured at 121.5 degrees Fahrenheit, exceeding the facility's policy limit of 110 degrees Fahrenheit. The Maintenance Director, V9, acknowledged the high temperatures and stated that the hot water heater was turned down to 125 degrees Fahrenheit a week prior, but no further action was taken to address the issue. Despite identifying the problem, V9 did not conduct additional water temperature checks beyond the regular Friday rounds, nor did he contact another plumber after the initial one was unavailable. Additionally, a resident identified as R4, who was at high risk for falls due to dementia and required assistance with personal care, was found with her call light coiled and out of reach on the floor. This was contrary to the facility's Call Light Policy, which mandates that call lights be within reach and secured as needed. The Director of Nursing and a Certified Nursing Assistant confirmed that call lights should be accessible to residents. These deficiencies indicate a lack of adequate supervision and environmental safety measures to prevent accidents and ensure resident safety.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess, care plan, and obtain physician orders for two residents to self-administer medications. Resident 27, who is [AGE] years old, was found with a box of lidocaine patches and an inhaler in her bedside stand, which she used for pain and respiratory issues, respectively. Despite having an order for the lidocaine patch, there was no order for her to self-administer any medications. The Director of Nursing confirmed that no residents had orders or assessments to self-administer medications, and the facility could not provide a medication self-administration assessment for Resident 27. Similarly, Resident 22, a [AGE] year old cognitively intact resident with chronic obstructive pulmonary disease and congestive heart failure, was observed with an inhaler on her bedside table, which she used as needed for shortness of breath. Her physician order sheet included an order for an Albuterol Sulfate inhaler but did not authorize self-administration. The facility's policy requires an assessment, physician's order, and care plan for residents to self-administer medications, none of which were completed for Resident 22.
Failure to Assess Resident for Restraint Use
Penalty
Summary
The facility failed to ensure a resident was properly assessed for the use of a physical restraint. A cognitively impaired female resident with diagnoses of autistic disorder and Down syndrome was observed wearing a restraint vest while seated in a wheelchair near the nurse's station. The vest was secured with straps and clips, but there was no physician order for its use, nor was there a restraint assessment completed since the resident's admission. Staff members provided conflicting accounts of the resident's ability to remove the harness independently, with one CNA stating the resident could move the top straps over her head, while another CNA indicated that staff were responsible for undoing the harness. The Director of Nursing confirmed that no restraint assessment had been conducted since the resident's admission. The facility did not provide a restraint policy during the survey.
Failure to Include Restraint in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for a resident included necessary interventions for a chest harness restraint. This deficiency was identified during a survey where the resident was observed wearing a restraint harness while in her wheelchair on multiple occasions. Despite the use of the harness, the resident's medical record showed no assessment had been completed since her admission. Additionally, the Director of Nursing acknowledged that a restraint should be included in a resident's care plan, yet the current care plan for the resident lacked any focus area or interventions related to the restraint.
Failure to Trim Nails for Resident with Hand Contracture
Penalty
Summary
The facility failed to ensure proper grooming for a resident with a hand contracture, leading to a deficiency in providing activities of daily living (ADL) assistance. The resident, a male with a history of stroke affecting his left side, was observed with fingernails approximately 1/4 inch long, causing indentations in his palm due to the contracture. Despite the resident not refusing hygiene assistance, his nails remained untrimmed over consecutive days. A Certified Nursing Assistant and a Certified Nursing Supervisor both acknowledged the need for nail trimming, which is typically performed during a resident's shower. The resident's care plan indicated a need for ADL assistance, but the facility's policy on providing resident care, including grooming, was not adequately followed.
Failure to Apply Elastic Bandages for Resident with Edema
Penalty
Summary
The facility failed to ensure that elastic bandages, known as tubi grips, were applied to a resident with a history of lower extremity edema. This deficiency was observed in one of the twelve residents reviewed for quality of care. On multiple occasions, the resident was seen in the activity room without the required elastic wraps on her legs, despite having physician orders to wear them daily from her toes to her knees. The resident's care plan also specified the need for these bandages to manage her condition, which includes congestive heart failure and a history of cellulitis. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. A CNA assigned to the resident admitted to not applying the elastic bandages, stating she was unaware of the requirement. A Licensed Practical Nurse confirmed that the resident was supposed to wear the bandages to aid circulation and prevent edema. The Director of Nursing acknowledged the resident's history of edema and cellulitis, emphasizing the importance of the bandages in managing her condition, especially since the resident prefers to remain active and upright.
Failure to Include Duration in Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included a duration for one of the six residents reviewed for psychotropic medications. Specifically, a resident with a diagnosis of generalized anxiety disorder had a physician's order for Lorazepam Oral Concentrate 2 MG/ML to be administered 0.25 ml by mouth every 2 hours as needed for anxiety. This order, dated 1/13/25, did not include a stop date or duration, which is a requirement according to the facility's policy. The policy, dated 3/2025, mandates that PRN orders for psychotropic medications, excluding antipsychotics, should be limited to no more than 14 days. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that all psychotropic as-needed medications should have a stop date.
Failure to Assess and Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that residents were assessed and offered pneumococcal immunizations upon admission, as evidenced by the cases of two residents. Resident 15's admission record indicated no historical or current record of having had or being offered a pneumococcal immunization. Similarly, Resident 21's records showed no evidence of being assessed or offered the vaccine. The Director of Nursing/Infection Prevention Nurse acknowledged that the admitting nurse is responsible for screening residents for vaccination status and administering vaccines, but noted that the previous Director of Nursing failed to ensure this process was followed. The facility's policy, reviewed in January 2025, mandates that each resident be assessed for pneumococcal immunization upon admission and offered the vaccine, which was not adhered to in these cases.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing information for all 35 residents reviewed for staffing. During the survey conducted from March 3 to March 5, 2025, it was observed that there were no staffing postings near the front door on the entry table or bulletin boards. The facility's Long Term Care Facility Application for Medicare and Medicaid indicated a resident census of 35. On March 5, 2025, at 1:25 PM, the Certified Nursing Assistant (CNA) Supervisor stated that staffing information was kept in a binder at the nurse's station, which included monthly and daily schedules for nursing and CNA staff. The CNA Supervisor admitted that staffing was not posted near the front door for visitors to see and was unaware that it needed to be visibly posted.
Failure to Test Water System for Legionella and Prevent Water Stagnation
Penalty
Summary
The facility failed to ensure its water system was tested for Legionella and did not prevent water from becoming sedentary in an unoccupied area. The maintenance staff admitted to flushing toilets and running water weekly but was unsure if a water system assessment had been conducted to identify potential problem areas conducive to waterborne pathogen growth. There was no evidence of Legionella testing being done, and the Business Office Manager confirmed that the city only tested for chlorine and fluoride, not Legionella. Additionally, there were no logs to show any flushing or water temperature checks were done on the south hall, which had been unoccupied since 2018-2019. Observations revealed a large therapeutic bathtub with a lift system in a common bathroom near the north nurse's station, which had a continual slow dripping of water and a long brown stained area. Staff were observed toileting residents in the room, and the door was wide open when not in use. The south end of the facility, which was unoccupied, also had a large therapeutic soaking tub that was inoperable. Despite this, the maintenance staff confirmed that water did come from the faucet when turned on. The facility's Legionella Environmental Assessment Form and Management Procedure showed no evidence of maintenance, disinfecting, or monitoring of the tubs. The facility's policies and procedures for Legionella management were not followed. The Legionella Environmental Assessment Form completed by a Corporate Administrator inaccurately marked the presence of hot tubs, whirlpool, or hydrotherapy spas as not applicable. The facility's Legionella Management Procedure required staff to be informed of good practices and for approved contractors to undertake surveys and risk assessments, but there was no evidence of such actions being taken. The Illinois Compiled Statutes require facilities to develop a policy for testing water supply for Legionella bacteria, including a risk assessment, water management program, and documentation of results and corrective actions, none of which were evident in the facility's practices.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to have a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Director of Nursing (DON), who has been at the facility since January 29, 2024, was identified as the IP but did not have the required certification. The facility's application for Medicare and Medicaid indicated there were 28 residents. The Administrator acknowledged the requirement for a certified IP and mentioned that the DON was in the process of obtaining certification but was not currently certified. The facility's job description for the IP role specified that the individual must have completed specialty training in infection prevention and control through accredited continuing education such as the CDC or APIC. The facility's QAPI team roster also identified the DON as the IP.
Failure to Update Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure a resident's advanced directives were updated as requested. Resident R18, who was admitted to the facility on an unspecified date, had a Practitioner Order for Life-Sustaining Treatment (POLST) form dated 12/16/21 indicating he opted to be a full code. However, a new undated POLST form on the front of R18's chart showed he opted to become a Do Not Attempt Resuscitation (DNAR). This new form was signed by R18 but lacked a witness signature and the required signature by a healthcare practitioner. Despite R18 being cognitively intact and having expressed his wishes, the form was not properly processed, leaving him still considered a full code according to the April 2024 Physician Order Sheet (POS). The facility's policy requires that no order for DNAR be effective until the POLST form is signed by both the resident and the physician, which was not adhered to in this case. Interviews with staff revealed that the form had not been sent to the physician for signature, as confirmed by the Registered Nurse (RN) and the Director of Nursing (DON). The DON stated that the procedure on admission involves having residents fill out and sign the POLST form, which should then be sent out for the physician's signature. The failure to follow this procedure resulted in the resident's advanced directives not being updated as requested, thereby not honoring the resident's right to refuse treatment as per his wishes.
Failure to Provide Necessary Post-Amputation Care
Penalty
Summary
The facility failed to ensure a resident received necessary treatment and services for her amputated leg, including following up with her surgeon, obtaining a sleeve for her stump, and assisting in the process to prepare and obtain a prosthetic leg. The resident, who had been at the facility for 9 months following a house fire that resulted in numerous injuries including a left above-the-knee amputation, reported that it took 4.5 months to get a shrinker, which was too large and not measured properly. The resident also stated that she never followed up with the surgeon after being transferred to the facility, and the facility did not arrange for the necessary follow-up appointments or fittings for a prosthetic leg as indicated in her hospital discharge documents and physician orders. The Director of Nursing (DON) and Social Services staff were unaware of the orders for the resident's follow-up care and the need for a properly fitted shrinker. The facility's records did not show any follow-up appointments with the surgeon or any fitting of a sleeve for the resident's stump. The DON and Social Services staff acknowledged the importance of having the correct measurements for the shrinker to reduce swelling and prepare for a prosthetic leg but admitted to not being aware of the specific orders or the resident's needs. The facility also lacked a policy for quality of care, post-surgical care, or current standards of practice related to the care of a resident after an amputation, which contributed to the oversight in the resident's care.
Failure to Implement Pressure Ulcer Interventions and Identify Pressure Injuries
Penalty
Summary
The facility failed to ensure pressure injury interventions were in place as ordered and did not identify a pressure injury before it progressed to a stage 2 pressure injury for two residents. One resident, admitted to the facility and documented as being at risk for pressure injuries, had a stage 2 pressure wound to the sacrum that was not identified until it had been present for more than four days. The resident's treatment record did not show any skin checks ordered or completed, and the care plan required weekly skin checks, which were not documented. The RN and DON confirmed that the pressure injury should have been identified earlier and documented in the nursing progress notes. Another resident was observed in a wheelchair without a pressure-relieving device, despite having a stage 2 pressure wound and orders for a pressure relief cushion. The resident's care plan did not include interventions for offloading and repositioning, which were necessary to prevent the wound from worsening. The DON confirmed that the resident should have had a pressure relief cushion to relieve pressure and prevent the wound from getting worse. The facility's policy required additional interventions to be established and noted on the care plan when a pressure ulcer is identified, which was not done in this case.
Deficient Catheter Care Practices
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to several deficiencies. The resident was observed with a catheter drainage bag attached to the lower bed frame and without a secure device for the catheter tubing. During catheter care, a CNA used a wet washcloth to clean the resident's groin and vaginal area, then wiped down the catheter tubing without changing the washcloth, which is against proper infection control practices. Additionally, the catheter drainage bag was placed on the resident's bed during repositioning, which is not allowed for infection control reasons. The CNAs involved were unaware of these requirements. The Director of Nursing confirmed that the catheter drainage bag should not be on the bed and that the washcloth should be folded differently or changed before cleaning the catheter tubing. The resident had a history of multiple medical conditions, including neurogenic bladder and a wound infection requiring antibiotics. The care plan indicated catheter care every shift and weekly changes, but did not include specific interventions to prevent the observed deficiencies. The facility's catheter care policy did not specify the need to use a clean washcloth or turn an existing one before cleaning the tubing, and the catheter insertion policy required securing the catheter to the thigh, which was not done in this case.
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 77 citations issued within 25 miles in the last 12 months — including the 1 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 Morrison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resthave Home-whiteside County | 0.7 mi | ★★★★★ | 8 | 0 |
| Allure Of Prophetstown | 9.3 mi | ★★★★★ | 16 | 0 |
| Winning Wheels | 9.9 mi | ★★★★★ | 6 | 0 |
| Allure Of Sterling | 12.9 mi | ★★★★★ | 16 | 1 |
| Eagle Point Nursing And Rehabilitation | 13 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for La Bella Of Morrison.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.