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 Nexus At Alton during CMS and state inspections, most recent first.
Failure to obtain physician orders for trach care and suctioning. A resident with a trach was observed self-performing care without hand hygiene, gloves, or cleaning around the stoma, while an ADON present during the procedure did not provide cues or instructions. Another resident was suctioned by an LPN and assisted by an ADON despite no current orders for trach care or suctioning, and a third resident also had no documented orders for trach care or suctioning. The facility policy required a physician order for trach care.
Failure to maintain hand hygiene, glove changes, and Enhanced Barrier Precautions during trach care. An LPN, the ADON, and another LPN were observed providing care to residents with trachs and feeding tubes while repeatedly touching room surfaces, supplies, and equipment with the same gloves, opening sterile items with contaminated hands, and removing gloves without hand hygiene. One resident also performed trach care using a cloth from a dresser drawer, without washing hands or wearing gloves, while the ADON was present and did not provide infection control guidance.
Failure to Treat Residents with Dignity and Respect: Three cognitively intact residents who required assistance with ADLs reported being told to wait for care, being spoken to in a dismissive manner, and being denied timely help with toileting, dressing, and meals. One resident was told she could not eat breakfast because she was late, another said staff made him feel like a bother, and a third remained soiled and uncomfortable while staff said they were busy passing trays. The DON and Medical Director stated residents should be helped right away when requesting assistance and treated with dignity and respect.
Pain medication was not provided timely or consistently for a resident with osteomyelitis and spina bifida who had an order for oxycodone q6h for pain. The resident reported that meds were sometimes late or unavailable, with pain reaching 11/10 and described as horrible and unbearable. The DON acknowledged late and missed administration, and noted agency staff lacked access to the locked pharmacy system, which could delay meds.
A facility failed to ensure a charge nurse was assigned each shift and that enough nursing staff were present to meet resident needs. Staffing sheets showed gaps in nurse coverage, and residents and staff reported periods with no nurse in the building or on the hall, delayed or missed meds, and difficulty reaching management. The DON stated the facility is supposed to run with 4 nurses, but call-offs, no-shows, agency failures, and nurses leaving before relief left only 2 nurses in the building at times.
RN Coverage Not Maintained for Required Hours: The facility failed to ensure an RN was scheduled for at least 8 consecutive hours a day, 7 days a week. Review of staffing schedules showed multiple days without the required RN coverage, and the DON stated the facility had staffing challenges and was actively hiring. The Administrator stated there was no staffing policy and that CMS guidelines were followed. The census documented 82 residents.
Meals were not consistently served hot or on time. Hall trays sat before being delivered, and a resident reported cold food and repeated delays. During a noon meal observation, dietary staff were ready to serve but nursing staff were not present in the dining room, delaying tray service; a test tray from the hall cart was later found lukewarm, with potatoes at 124.5F and chicken at 127.2F. The dietary manager said dietary could not serve without a CNA or nurse present, and the DON acknowledged this had been an ongoing problem with residents complaining of late, cold food.
Failure to maintain clean and good repair environment: Multiple resident rooms had dirty conditions and needed repairs, including dried liquid under a bed, peeling baseboards, an unusable toilet handle, and a shower room door with sharp, peeling wood-like strips. Cognitively intact residents reported rooms were not cleaned regularly and that the shower room was unsafe, while the DON and Administrator acknowledged areas needing repair and that the facility was dirty with strong odors.
The facility failed to administer medications on time and as ordered for multiple residents. MARs showed blank entries and late doses for scheduled meds, including pain medication, antihypertensives, GI meds, insulin, and blood glucose checks. A cognitively intact resident reported that meds were sometimes late or unavailable and that missed pain meds made his pain unbearable; the DON acknowledged late or missed meds and noted agency staff sometimes could not access the locked pharmacy system. Another resident’s medication grievance was confirmed, and staff stated a blank MAR box meant the dose was not given.
A facility failed to ensure working call lights were available and within reach for multiple residents. Residents with documented weakness, ADL dependence, and other medical conditions were observed with missing, disconnected, or nonworking call lights, and some were given bells instead. Residents and staff reported that bells were hard to hear and that call lights were not always answered, while leadership acknowledged ongoing problems with the call light system and rooms without functioning devices.
Delayed Incontinent Care: A cognitively intact resident who was incontinent of bowel and bladder and needed assistance with toileting hygiene and transfers was left soiled after telling a CNA she was wet. The CNA said she had to wait while meal trays were passed, and on another occasion the CNA again said he was busy passing trays and did not help. The DON and Medical Director stated staff should respond to resident requests for assistance right away, and the facility policy required nursing staff to keep residents dry, comfortable, and odor free.
A resident with CKD, CHF, ESRD, DM, and multiple foot wounds did not receive ordered daily wound care, and the TAR and progress notes lacked documentation that the treatments were completed on multiple occasions. The resident was later hospitalized for worsening wound infection, with purulent drainage and concern for osteomyelitis; the wound care provider also reported concerns that ordered dressing changes were not being done and noted worsening skin breakdown to the buttocks.
Failure to complete and document ordered wound care for two residents with significant comorbidities and skin risk factors. One resident with ESRD, CHF, DM, and multiple foot wounds had repeated missing TAR entries and no progress note documentation for ordered dressing changes, and was later hospitalized with worsening wound infection and osteomyelitis after the wound care provider reported concern that the facility was not changing dressings as ordered. A second resident with DM and CKD had ordered sacral and heel wound care, but the record lacked skin assessment details, wound measurements, and descriptions of the wounds.
Failure to Notify Residents Before Room Changes: The facility did not properly notify several residents before room changes. A cognitively intact resident with RA, PTSD, and mobility issues, another cognitively intact resident with DM2, HTN, CKD, and weakness, a cognitively intact resident with PE history and prediabetes, and a moderately cognitively impaired resident with COPD, ESRD, and CHF all stated they were not informed before being moved. Records showed multiple room changes, and one resident’s belongings were moved while he was out of the facility.
Failure to Provide Ordered and Routine Showers: Multiple residents with ADL dependence and bathing assistance needs did not receive showers as documented or requested. One resident with aphasia, hemiplegia, dementia, and total ADL dependence was observed with matted, greasy hair, while other cognitively intact residents reported going weeks without showers, receiving only one shower over an extended stay, or being left unattended and not helped with bathing. Shower logs and grievance records supported the repeated lack of bathing assistance, and the DON stated the shower sheets were the only documentation available.
Failure to Report Injury of Unknown Origin: A resident with aphasia, dementia, hemiplegia, and extensive ADL dependence developed a large area of bruising, swelling, and a blistered injury on the chest, axilla, shoulder, and extremities. Staff noted the injury but did not document or report it immediately, and an RN later stated she saw bruising on the night shift but assumed someone else had reported it. The resident was nonverbal and unable to explain what happened, and hospital and police records described the injuries as unknown in origin.
Failure to Immediately Report Injury of Unknown Origin: A resident with aphasia, dementia, hemiplegia, contractures, and total care needs was found with a large painful area, bruising, swelling, and discoloration to the chest, axilla, arm, and lower extremities. Nursing staff reported seeing bruising earlier but did not notify the DON/Administrator right away, with one RN assuming someone else had already reported it. The Administrator stated she was first notified later, despite facility policy requiring immediate reporting of suspicious bruises or injuries of unknown origin.
Call Light Not Within Reach for Two Residents: A facility failed to ensure a working call system was available in resident rooms and bathing areas. Two cognitively intact residents who needed assistance with ADLs reported they had no call light or bell to summon staff, and observations confirmed no call light or bell was present in their rooms. The facility policy required call lights to be within the resident’s reach at all times.
Surveyors found that the facility did not maintain an adequate supply of towels and washcloths on multiple halls and in linen rooms, with carts often empty or nearly empty and the laundry lacking clean linens ready for use. Staff reported that the facility frequently ran out of towels and washcloths, particularly when only one washer was available, and that they were always short on these items. Cognitively intact residents with complex medical conditions, including CHF, COPD, neuromuscular bladder dysfunction, spinal muscular atrophy, cerebral infarction, DM, HTN, and MDD, reported not receiving regular showers or bed baths and, in one case, having to use a pillowcase to dry off due to the lack of towels. The facility assessment stated that necessary bed and bath linens would be provided for routine care and emergencies, but observations and interviews showed this was not occurring.
Surveyors found that medications scheduled for morning administration were given several hours late and one ordered medication was omitted for three cognitively intact residents with complex medical and psychiatric conditions. An RN, working with fewer nurses than usual, combined morning and later medication passes and appeared flustered while administering multiple cardiac, psychotropic, respiratory, diabetic, and seizure medications well past their scheduled times. Residents reported that medications were sometimes late or missed, and the facility’s own policy required medications to be administered at the proper time and dose, with documentation and provider notification when orders could not be followed.
The facility failed to ensure food was appetizing and maintained at safe, palatable temperatures for two residents, one with dementia and weakness on a regular diet and another with diabetes, prior cerebral infarction, and COPD on a carbohydrate-controlled diet. Both residents, who were cognitively intact and used wheelchairs, complained that the food was terrible and always cold. Meal observation showed chicken at 118°F and broccoli casserole at 114°F, below the facility’s policy requirement to hold food at 135°F or greater. A cook acknowledged food should be around 170°F, the dietary manager attributed low readings to end-of-service timing, and two LPNs reported that nurse aides routinely rewarm residents’ food in the microwave.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternatives provided. Staff and maintenance confirmed the ongoing hot water supply issues, which impacted residents' ability to receive safe and comfortable care.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were either given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternative provided. Staff and maintenance confirmed the hot water shortage and equipment failure, which impacted the facility's ability to meet residents' basic needs.
Failure to obtain ordered meds led to missed doses for two residents. One resident with an AKA, neuropathy, and chronic pain went several days without Lyrica, with MAR entries showing the doses were not given and staff notes stating the med was unavailable or on order; the resident reported severe phantom pain while off the medication. Another cognitively intact resident with DM and multiple chronic conditions did not receive weekly Ozempic as ordered, and the MAR and progress notes documented the injection was not available.
Two residents did not receive their prescribed oxycodone for pain management due to lapses in medication reordering, pharmacy delivery, and prescription renewal. Both residents, who were cognitively intact, experienced missed doses, with one resident missing six doses and reporting significant pain. Staff interviews and documentation confirmed that medication shortages sometimes occurred, particularly during pharmacy changes or when new orders were needed, and that facility policy for handling such situations was not consistently followed.
Five residents with various medical conditions did not receive their physician-ordered health shakes or dietary supplements during meal service. Although the dietary manager prepared the supplements, staff delivering trays failed to check meal tickets and ensure the correct items were provided, leading to the omission of required supplements for residents needing assistance or supervision with eating.
A resident with chronic respiratory failure and tracheostomy status, who relies on staff for daily care, was found with a soiled pillowcase and stained towel that were not changed over multiple days. Facility staff confirmed that dirty linens should be replaced, but the linens remained unchanged during the survey period.
Two residents did not receive complete incontinent care, as staff failed to cleanse all necessary areas and did not use proper technique, such as using new towels for each area and ensuring the skin was dried before applying a new brief. These actions did not follow facility policy for perineal care and hygiene.
A resident with a tracheostomy and chronic respiratory failure was found with soiled trach ties and collar, drainage, and a rash, while performing his own trach care using improper technique. An LPN assisting did not follow sterile procedures or proper hand hygiene, and the DON was unaware the resident was self-performing care without appropriate education or monitoring, contrary to facility policy.
A resident with a tracheostomy and chronic respiratory failure received care from an LPN who did not wear a protective gown, failed to perform hand hygiene when changing gloves, and did not clean multi-use equipment after use. The LPN also touched her hair with gloved hands and did not encourage or assist the resident with hand hygiene, contrary to facility infection control policies.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Three residents did not consistently receive wound treatments as ordered, with multiple days lacking documentation of dressing changes on their TARs. Residents with conditions such as diabetes, obesity, and cellulitis reported missed or inconsistent wound care, and staff confirmed that treatments should be documented immediately after completion according to facility policy.
A resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cataract did not receive a timely ophthalmology appointment despite multiple physician orders and urgent referrals. Staff cited insurance issues and difficulty finding a provider, and documentation showed a lack of consistent follow-up, resulting in the resident's worsening vision and continued impairment.
Several residents with no cognitive deficits reported that staff did not answer call lights in a timely manner, resulting in prolonged waits for assistance, including one instance where a resident remained on a bedpan for an hour and another left unattended in the shower. The ADON stated call lights should be answered within two minutes, in accordance with facility policy.
The facility did not follow its fall prevention policy for three high-risk residents, failing to complete root cause analyses, update care plans, or implement new interventions after each fall. Incident reports were incomplete, and required fall prevention measures were not consistently in place or documented. Staff interviews confirmed that these deficiencies occurred, and activity assessments were not completed as required.
Two residents with a history of incarceration together, both identified as offenders, were involved in repeated incidents where one resident bullied, threatened, and sexually abused another. The victim, who had multiple medical and psychiatric diagnoses, became fearful, isolated, and refused therapy after the abuse. Staff and other residents observed ongoing intimidation, but care plans and facility actions failed to address the bullying or provide adequate protection.
Four residents with severe cognitive and medical conditions did not receive the physician-ordered diets, such as pureed or mechanical soft diets, and instead were served regular meals identical to other residents. Staff were unaware of dietary orders, meal tickets were missing or outdated, and the dietary manager acknowledged the special diet list was not current. Residents and staff confirmed that individualized dietary needs were not met, contrary to facility policy.
Two residents with a history of incarceration together were involved in allegations of sexual assault and ongoing bullying, which were not thoroughly investigated or consistently documented by the facility. Staff and another resident reported knowledge of bullying and threats, but the facility failed to follow its abuse prevention policy, did not report the allegations to the state agency, and conducted an inconsistent investigation, resulting in a deficiency.
A resident with multiple complex medical conditions was admitted with specific hospital discharge medication orders, but these were not transcribed or administered for several days due to failures in the admission process and lack of oversight. The resident did not receive critical medications, resulting in significant adverse effects, including an untreated UTI and hospitalization. Staff interviews confirmed that the required triple check system was not completed and that agency nurses did not ensure timely medication administration.
A resident with multiple chronic conditions was admitted and did not receive several critical medications, including antibiotics, antihypertensives, and diabetes treatments, due to the facility's failure to transcribe hospital discharge orders and obtain medications from the pharmacy. The resident experienced symptoms such as shortness of breath and heart palpitations, and was ultimately hospitalized for untreated infection and other complications. Staff interviews and documentation revealed that the admission process was not completed as required, and established procedures were not followed.
A resident with multiple complex medical conditions did not receive several critical medications after admission due to a failure to timely transcribe hospital discharge orders and complete required medication administration processes. Agency nurses did not complete the transcription or triple check procedures, resulting in missed doses of antibiotics and other essential medications. The resident subsequently experienced shortness of breath, heart palpitations, and an untreated UTI, leading to hospitalization.
A resident with multiple complex medical conditions was admitted and did not receive prescribed medications as ordered by the physician because the admitting nurse failed to transcribe hospital discharge orders to the POS and MAR in a timely manner. The orders were not entered or sent to the pharmacy for several days, and the facility's required triple check system for new admissions was not completed, resulting in a lapse in medication administration.
Multiple incidents occurred in which residents were subjected to physical and sexual abuse by other residents, including inappropriate touching in a dining area, physical altercations involving hitting and object throwing, and insufficient supervision in common areas. Staff and dietary aides often witnessed these events, but were not always able to intervene promptly, and documentation was sometimes incomplete for the residents involved.
A resident with severe cognitive impairment and dependence on dialysis missed multiple dialysis sessions and exhibited a significant change in condition. Facility staff failed to send the resident for evaluation and treatment after repeated refusals, despite policy requiring action after a pattern of treatment refusals. Communication breakdowns among nursing, dialysis staff, and the nephrologist led to a delay in hospital transfer, resulting in the resident's acute deterioration and ICU admission.
A resident with chronic pain and multiple medical conditions did not receive several scheduled doses of prescribed Oxycodone because the medication was out of stock and unavailable in the dispensing machine. Nursing staff confirmed the shortage and the resident reported increased pain and frustration, resulting in him staying in bed and being unable to participate in daily activities.
A resident with chronic pain and multiple medical conditions did not receive several scheduled doses of prescribed Oxycodone because the medication was not available in the facility. The resident experienced significant pain, was unable to participate in daily activities, and expressed frustration. Staff confirmed the medication was out of stock and awaiting pharmacy delivery, and the contingency supply was also depleted.
Several residents with medical needs, including diabetes and renal disease, were not consistently offered nighttime snacks as required. Some reported never receiving snacks at night, while others noted that available snacks were quickly taken by a few individuals, leaving none for the rest. Staff confirmed that snacks were only provided upon request, and meeting minutes reflected ongoing concerns about snack availability after dietary staff hours.
A resident with severe cognitive impairment was prescribed Tramadol for pain and discharged from therapy after repeated refusals, but the Power of Attorney was not notified or asked for consent regarding these significant changes. Staff interviews and record review confirmed the lack of documentation and communication, despite facility policy requiring notification of responsible parties in such situations.
The facility did not provide a final written report of an abuse investigation after an altercation between two residents, despite initial reporting and assessments showing no injuries. The required final report documenting the investigation's results and any corrective actions was not completed or submitted to the Department of Public Health, as mandated by facility policy.
Two residents were involved in an alleged altercation in the dining room, with reports of coffee being thrown and possible physical contact. Although assessments showed no injuries and both residents denied the incident, a dietary staff member reported witnessing physical aggression and intervened. The incident was reported to administration, but there was no evidence that a full investigation was conducted as required by the facility's abuse policy.
Failure to obtain physician orders for tracheostomy care and suctioning
Penalty
Summary
The facility failed to obtain physician orders for tracheostomy care and suctioning for three residents reviewed for tracheostomy care. For one resident with diagnoses including malignant neoplasm of the oropharynx, acute and chronic respiratory failure with hypercapnia, and acquired absence of the larynx, the resident was observed walking in the hall without a trach appliance in place and stated staff did not take care of the tracheostomy and that the resident was responsible for self-care. The resident was visibly drooling and coughing up thin secretions while the tracheostomy was out, and later demonstrated self-care using a torn cloth scrap, soap, a sink, and a pipe cleaner, without hand hygiene, gloves, or cleaning around the stoma. An ADON was present during the self-care demonstration and did not provide cues or instructions, and later confirmed there were no orders for tracheostomy care before the issue was brought to the facility's attention. For another resident with chronic respiratory failure, unspecified dementia, and tracheostomy status, an LPN was preparing to suction the trach but had difficulty connecting the suction equipment. The ADON assisted with the suction setup, left the room without hand hygiene, returned without hand hygiene, and donned gloves to attach the suction tubing. The LPN loosened the trach tie with a gloved hand and then used the same hand to place the suction catheter into the trach cannula while not wearing a gown or mask. The LPN stated the resident was usually suctioned twice daily but did not have specific orders for suctioning or trach care, and the LPN identified a discontinued suction order from an earlier date. A third resident, who had respiratory failure and was severely cognitively impaired, also lacked physician orders for trach care or suctioning. The resident's clinical physician orders did not document any trach care or suctioning orders, although the MDS indicated the resident received tracheostomy care and did not receive suctioning while a resident. The care plan for this resident identified risk for complications related to tracheostomy placement but did not include interventions for actual trach care or suctioning. The facility's tracheostomy care policy stated that residents with tracheostomies should receive routine care to maintain a patent airway and that a physician order is to be obtained for tracheostomy care.
Failure to Maintain Hand Hygiene, Glove Changes, and Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to prevent potential cross contamination by not using appropriate PPE to maintain Enhanced Barrier Precautions and by not performing appropriate hand hygiene and glove changes during care for three residents with tracheostomies and, for two of the residents, feeding tubes. One resident was observed in the hall without a tracheostomy appliance in place, visibly drooling and coughing up thin secretions. Later, in the resident’s room, the resident demonstrated self tracheostomy care by using a torn cloth scrap from a dresser drawer to wipe the mouth, rinsing the cloth in the sink, and then handling the tracheostomy cannula and supplies without washing hands or wearing gloves. The cannula was placed directly on the bed during care, and the Assistant Director of Nursing was present but did not provide cues, instructions, a barrier, or gloves. There was no sign on the door indicating Enhanced Barrier Precautions should be maintained during trach care. For another resident, an LPN and the ADON entered the room to set up suction and provide oral and tracheostomy care while wearing gloves but repeatedly touched drawers, a wheelchair, a cardboard box of supplies, the bedside table, the feeding pump, and the water bag without changing gloves or performing hand hygiene. The LPN opened sterile packaging with the same gloved hands, handled the suction catheter, removed gloves without hand hygiene, and continued care. The resident coughed up thick secretions, and the LPN wiped the mouth, provided oral care, manipulated the trach opening and catheter, adjusted the feeding pump, and handled the g-tube connection site while using the same gloves. The ADON later returned, donned gloves without hand hygiene, set up the suction machine, removed gloves, and left without hand hygiene. A sign on this resident’s doorframe documented Enhanced Barrier Precautions with guidelines for PPE use. For a third resident, an LPN entered to perform trach care and donned a gown, mask, and gloves without first performing hand hygiene. The LPN removed gloves and performed hand hygiene at the sink, then continued care while touching the bed crank, pillows, trach supplies, and a biohazard bag with gloved hands. The LPN opened a sterile trach kit, removed gloves without hand hygiene, donned sterile gloves, and handled gauze and saline with dirty gloved hands. The LPN removed and replaced trach ties, adjusted the resident’s hair and gown, opened another sterile kit, and performed suctioning after removing gloves and donning new sterile gloves without hand hygiene. The LPN also opened the drawer with the back of a gloved hand, suctioned the trach, removed gloves again without hand hygiene, placed a trach oxygen mask, gathered trash, and left the room without hand hygiene before later washing hands at the nurse’s station.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect for 3 of 4 residents reviewed for Resident Rights. R6 was cognitively intact and required substantial to maximal assistance with toileting hygiene and partial to moderate assistance with transfers; her care plan documented that she required assistance with daily care needs. On 6/16/26, a CNA told R6 she should not be getting changed every day at shift change and said, "you can't be doing this all the time, this is ridiculous," then went with her into her room. On 6/17/26, R6 was crying in the dining room after stating she had been told she was late and could not have breakfast; she later stated staff had been late getting her dressed and up for breakfast, and that a kitchen staff member told her she could not eat because she was late. R6 stated she felt she was not getting the care she needed, felt unworthy of care and shamed, and said the interactions made her feel worse about herself. R7 was cognitively intact and required partial to moderate assistance with toileting hygiene and transfers. On 6/17/26, R7 stated that when he asks staff for help, they tell him to wait because they are too busy and will help him later. He stated the way staff treat him makes him feel worse about himself and like he is a bother to them. R8 was cognitively intact and required partial to moderate assistance with toileting hygiene and transfers. On 6/17/26, she stated she was still waiting to be cleaned up after telling a CNA she was wet around 1:00 PM, and that the CNA told her she had to wait until he was done passing meal trays. She stated she was still sitting soaked and uncomfortable, and that when she tells staff they are being too rough during care, they act like she is being a baby and tell her, "Oh, you're fine." On 6/18/26, R8 again asked for assistance and a CNA said he was busy passing trays and did not provide help. R8 stated these interactions made her feel insignificant. The facility's Resident Rights policy stated that accommodating resident needs and preferences is intended to create an individualized, homelike environment to maintain dignity and well-being.
Pain Medication Not Provided Timely or Consistently
Penalty
Summary
Safe, appropriate pain management was not provided for R5, a cognitively intact resident with osteomyelitis and spina bifida who experienced pain almost daily. R5’s care plan identified pain as a concern related to those diagnoses, and the physician ordered Oxycodone HCl 10 mg by mouth every 6 hours for pain. Medication monitoring records showed gaps and delays in administration, including documentation that the last dose was given on 5/1/2026 at 11 AM, the first dose on 5/2/2026 at 6 AM, no dose administered on 5/18/2026 at 12 AM, the last dose on 6/6/2026 at 12 PM, and the first dose on 6/7/2026 at 12 AM. During interview, R5 stated that the facility was sometimes late with pain medication and sometimes it was not available at all. R5 reported pain as high as 11 on a 1-10 scale and described it as horrible and unbearable, affecting day-to-day life. The DON stated that if a resident did not receive pain medication timely or at all, pain would increase, and acknowledged problems with nursing staff administering medication late and sometimes not at all. The DON also stated that agency staff were not given a code for the locked pharmacy system, which could delay medication administration and contribute to missed medication. The Medical Director stated that if pain medication was not available and a resident was in severe pain of 7 or higher, it would be reasonable to expect the pain would increase.
Insufficient Nursing Staff and No Charge Nurse on Shift
Penalty
Summary
The facility failed to ensure that a nurse was appointed as charge nurse on each shift and that sufficient nursing staff were available to provide nursing and related services to meet residents’ needs safely. The daily staffing sheets showed that on June 13, 2026, the facility had 77 residents and scheduled V15, V8, V22, and V9 for the day shift, with V8 also listed for the night shift; on June 14, 2026, the staffing sheet documented only V8 scheduled for the day shift and no other nurses listed for that shift. The daily census provided on June 15, 2026, documented 82 residents in the facility. During interviews, residents and staff described periods when no nurse was present in the building or on the hall, including reports that medication was delayed or not given on time because a nurse was not available. R5 stated that there was no nurse last weekend and that medication was sometimes hours late. R11 stated there was no nurse for the hall that weekend. R3 stated that nurses do not show up, others leave, and medication is not given on time or at all; R3’s MDS documented that R3 was cognitively intact. V18, a CNA, stated that there were no nurses in the facility, residents were asking for medication, attempts to contact management were unsuccessful, and a nurse did not arrive until around midnight. V2, the DON, stated the facility is supposed to run with 4 nurses, but due to call-offs, no-shows, agency not showing up, and nurses leaving before relief, there were only 2 nurses in the building that weekend and medication administration was delayed. V1, the Administrator, stated the facility does not have a staffing policy and follows CMS guidelines.
RN Coverage Not Maintained for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. On 6/16/2026, staffing schedules for May and June 2026 were reviewed and showed that the facility did not have at least 8 consecutive hours of RN coverage on multiple dates, including 5/1 through 5/6, 5/11, 5/13 through 5/24, 5/26, 5/29 through 5/31, and 6/1 through 6/4, 6/6, 6/8 through 6/11, and 6/14 through 6/17. On 6/18/2026, the DON stated the facility had challenges with nurses, used a scheduling program, and was actively hiring. The Administrator stated the facility did not have a staffing policy and followed CMS guidelines. The daily census dated 6/14/2026 documented 82 residents in the facility.
Meals Served Late and at Improper Temperature
Penalty
Summary
Food and drink were not consistently provided at a palatable, attractive, and safe appetizing temperature. On 6/16/2026, hall trays were observed sitting at the top of the hall at 1:05 PM and were not delivered to the 300 hall until 1:15 PM. At that time, a resident stated her food was cold and said this happens all the time, explaining that the cart sometimes sits in the dining room because no one comes to get it. Another resident stated her food is rarely hot and is always late, and staff noted that meals sometimes do not get served until 1:30 PM. During the noon meal observation on 6/17/2026, dietary staff were ready to serve at 12:00 PM, but nursing staff were not available in the dining room until 12:14 PM, delaying the first tray until 12:15 PM. The dining room was completed at 12:44 PM, the 100/200 hall cart was prepared at 12:45 PM, and the 300/400 hall cart was not served until 1:15 PM. A test tray from the 300/400 cart was checked at 1:29 PM and the potatoes were 124.5F and the chicken was 127.2F, with the food described as lukewarm to touch. The dietary manager stated dietary prepares the meals but nursing delivers them, and that dietary is not allowed to serve unless a CNA or nurse is in the dining room, which causes delays. The DON stated this had been an ongoing problem and residents were complaining of food being late and cold.
Failure to Maintain Clean and Good Repair Environment
Penalty
Summary
The facility failed to maintain the environment in clean and good repair for 8 of 15 residents whose rooms were reviewed. A cognitively intact resident stated that his room was dirty, housekeeping did not clean it regularly, stains had been on the floor for days, and the shower room was unsafe because the drain and door were broken. Another cognitively intact resident stated that the room was sometimes cleaned and sometimes not, and directed surveyors to look under the bed where she said the area was never cleaned. Surveyors observed dried liquid under one resident’s bed and on the floor between two residents’ areas, and the toilet handle was flipped backwards and unusable. Baseboards were observed coming away from the wall in multiple resident rooms, and dried liquid remained on the baseboard on a later observation. The 300-hall shower room door had multiple strips of wood-like particles peeling away and hanging off the door with sharp edges. Staff and leadership acknowledged that rooms and the shower room required repairs, that the facility was working to get the building clean, and that the facility was dirty with strong odors.
Medication Administration Not Timely or Consistently Documented
Penalty
Summary
The facility failed to ensure medications were administered timely and as ordered for 4 of 4 residents reviewed for medication administration. The report documents multiple instances of blank MAR entries and late administration for scheduled medications, including carvedilol, amlodipine, aspirin, apixaban, gabapentin, polyethylene glycol, Protonix, sevelamer, acetaminophen, nystatin, and bisacodyl for one resident with diagnoses including essential hypertension, dissection of the ascending aorta, gout, syncope and collapse, and bilateral below-knee amputations. The resident’s MARs showed several scheduled doses left blank across April, May, and June, and the medication administration audit report documented that scheduled medications were administered late on 6/7/26 and 6/18/26. A second resident, who was cognitively intact and experienced pain almost daily, had an order for oxycodone 10 mg every 6 hours for pain. The medication monitoring control record showed gaps and delays in administration, including periods where doses were not given as scheduled and the record reflected late or inconsistent administration across April, May, and June. The resident stated that the facility was sometimes late with medication and sometimes it was not available at all, and that when pain medication was not received his pain became unbearable. The DON stated that the resident was alert and oriented, that late or missed pain medication would increase pain, and that agency staff were sometimes unable to access the locked pharmacy system, which could delay or contribute to missed medication. Two additional cognitively intact residents also had missed medication administration documented on their MARs. One resident stated that she felt she was not getting the care she needed and reported missed medication administration on multiple days, mostly on day shift, including a weekend occurrence she remembered from about three weeks earlier; her May MAR showed a blank box for all 9:00 AM medications on 5/16/26. Another resident’s May MAR showed that she did not receive any of her 9:00 AM medications on 5/16/26, and she also did not receive sliding scale insulin lispro or blood glucose checks before meals that day. A grievance form documented that the medication administration issue for that resident was confirmed, and a nurse was counseled. Staff stated that a blank MAR box meant the medication was not administered, and the facility policy required medications to be given at the proper time and, if not present, pharmacy should be contacted to obtain them.
Nonfunctioning and Missing Resident Call Lights
Penalty
Summary
The facility failed to ensure that a working call light system was available in resident bathrooms and bathing areas and, in multiple resident rooms, failed to provide a functioning call light within reach. During observation, interview, and record review, call lights were found missing, disconnected, or not working for 5 of 15 residents reviewed: R2, R3, R4, R6, and R10. The facility’s own policy required that the call light be within the resident’s reach at all times and within easy reach when the resident was in bed or confined to bed or chair. R3’s records showed multiple sclerosis, COPD, asthma, OSA, epilepsy, SOB, type 2 diabetes, heart failure, and muscle weakness, and documented that she could use a call light and needed assistance with daily care needs. However, observations on 6/15 and 6/16 found no call light in her room, with a bell placed on the overbed table near her roommate’s bed instead. R3 stated she did not have a call light, that staff had given her a bell, and that no one responded when she used it; her roommate also stated that R3 did not have a call light and that staff sometimes did not respond when the bell was rung. Staff confirmed that R3 did not have a call light and that some residents had bells that were difficult to hear. R2’s records documented weakness, hepatic encephalopathy, high fall risk, and that he could use a call light. His grievance stated the call light was not working and not lighting up outside the room. On observation, there was no call light in place, only a metal plate and button, and pressing it did not activate the light outside the room. R2 stated he had no way to call for help and that the string attached to the device kept coming apart. R6 and R10 were also observed with call lights that did not work when pressed, and R6 stated she was scared of being in bed without a working call light because she could not get up and sometimes CNAs were nowhere to be found. Staff and leadership acknowledged that some rooms had broken or missing call lights, that some residents were given bells instead, and that the system had ongoing problems.
Delayed Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for one resident who was cognitively intact and required partial to moderate assistance with toileting hygiene and transfers. The resident’s care plan documented that she was incontinent of bowel and bladder and required staff assistance with daily needs and activities of daily living. During interview, the resident stated she was waiting to be cleaned up because she was soiled, and reported that she had told a CNA she was wet around 1:00 PM but was told she had to wait until the CNA finished passing meal trays. She stated she was still sitting soaked and that it was very uncomfortable and made her feel insignificant. The resident pressed her call light at 1:57 PM, a staff member responded at 2:01 PM and said she would clean her up, and incontinent care was provided at 2:04 PM. On another occasion, the resident asked for assistance and the CNA stated he was busy passing trays and did not provide assistance. The DON stated that if a resident is in need of assistance or requests help, staff should help right away and not tell the resident to wait, especially if not helping another resident at the time. The Medical Director stated that when a resident requests or needs assistance, staff are expected to respond and triage appropriately. The facility’s incontinence care policy stated nursing staff are responsible for keeping residents as dry, comfortable, and odor free as possible and helping prevent skin breakdown.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care services as ordered by the physician for one resident with multiple chronic conditions, including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and diabetes-related foot wounds. The resident’s records showed a BIMS score of 15, indicating cognitive intactness, and documented multiple wounds, including ulcers on both feet, a diabetic foot ulcer, and a wound infection. Physician orders required daily wound care to the left calcaneus, right calcaneus, right plantar foot, right medial foot, and daily povidone-iodine application to the right foot, but the TAR did not document completion of these treatments on multiple dates in May 2026, and the progress notes also lacked documentation that the treatments were completed. The resident was hospitalized on 5/26/26 with worsening wound infection. The hospital history and physical documented ESRD on daily dialysis, CHF, COPD, DM, depression, HTN, prior MI with stenting, oxygen use, chronic wound status, and ulcers of both feet with necrosis of muscle. The hospital record stated the resident reported the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated the right foot wound had purulent drainage, she was concerned about osteomyelitis, and she sent the resident to the emergency room. She also stated she had concerns that the facility was not completing the ordered dressing changes and that the resident had worsening buttocks skin breakdown, while the DON stated treatments should be completed as ordered and documented on the TAR or in progress notes.
Failure to Document and Complete Ordered Wound Care
Penalty
Summary
The facility failed to complete ordered pressure ulcer and wound care for two residents who were at risk for skin breakdown. One resident had multiple diagnoses including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and was cognitively intact with a BIMS score of 15. That resident required substantial to maximal assistance with toileting, was incontinent of urine and bowel, had two foot ulcers, a diabetic foot ulcer, and a wound infection, and was assessed as at risk for pressure ulcer development. For that resident, physician orders included daily wound care to the left calcaneus, right calcaneus, right plantar foot, and right medial foot, along with topical povidone-iodine to the right foot. The TAR for 5/2026 did not document completion of the ordered wound care on multiple dates, and the progress notes also lacked documentation that the treatments were completed on those dates. The resident’s hospital history and physical documented worsening wound infection, multiple wounds in both feet with significant purulent drainage and necrosis, and the resident reported that the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated she was concerned the facility was not completing the dressing changes as ordered and sent the resident to the emergency room, where the resident was admitted with osteomyelitis of the right foot. The second resident had diagnoses including type 2 DM, stage 4 CKD, anemia, and HTN, and had a BIMS score of 15. The resident’s care plan identified risk for skin complications, and physician orders included daily wound care to the sacrum and right heel using wound cleanser, Medi honey, and bordered gauze. However, the nursing admission observation had no documentation that the skin was assessed, the nursing admission assessment documented skin conditions requiring monitoring/treatment without measurements, locations, or descriptions, and the skin assessment documented no new findings without documenting the current areas. There was no documentation of wound measurements or descriptions from 1/15/26 through the resident’s discharge to the hospital on 2/25/26.
Failure to Notify Residents Before Room Changes
Penalty
Summary
The facility failed to properly notify 4 of 6 residents reviewed for room change notification before moving them to different rooms. R5, who was cognitively intact and had diagnoses including rheumatoid arthritis of the left hip, PTSD, unsteadiness on feet, and need for assistance with personal care, stated she was not informed of her room change before being moved and that her family was not notified. The census record showed she was moved from one room to another on 1/15/26. R7, also cognitively intact and diagnosed with type 2 diabetes mellitus, hypertension, chronic kidney disease, and muscle weakness, stated she was not notified before room changes. Her census record showed multiple room changes, including changes on 2/1/26, 3/9/26, and 4/1/26. R12, who was cognitively intact and had diagnoses including pulmonary embolism without acute cor pulmonale, prediabetes, and a personal history of venous thrombosis and embolism, stated he was not notified prior to his room move. His census record showed multiple room changes between 2/1/26 and 5/17/26. R14, who was moderately cognitively impaired and had diagnoses including COPD, gait and mobility abnormalities, muscle weakness, hypertension, ESRD, and chronic diastolic CHF, stated he was not informed his room would be changing and found his belongings gone when he returned. His grievance stated he was not notified about moving to a different room and was not present during the moving of his personal items. The administrator stated the facility was not doing room move notifications properly and that R14 had been moved while out of the facility without notification.
Failure to Provide Ordered and Routine Showers
Penalty
Summary
The facility failed to provide showers to 4 of 6 residents reviewed for ADL care. R2 had diagnoses including aphasia, hemiplegia, weakness, abnormal posture, contractures of both knees and ankles, and dementia; the MDS documented that R2 was rarely or never understood, had memory problems, used a wheelchair, and was dependent on staff for showering/bathing and multiple other ADLs. R2 was observed in bed wearing a hospital gown with hair that appeared matted, greasy, and unkept, and the shower sheets showed the last shower had been given weeks earlier. R5, R7, and R15 also had care plans and MDS assessments showing they required assistance with bathing and other ADLs. R5 stated she had not been offered or received a shower for about two weeks, despite a physician order requesting morning showers with assistance; the shower sheets showed an earlier last shower date. R7 stated she had been in the facility since January and had only received one shower, and that she was not offered a shower or bed bath weekly. R15 stated she very seldom received a shower, was unsure when she last had one, and had filed a grievance because staff reportedly left her unattended in the shower room and did not help her wash properly; grievance records documented repeated complaints about not getting showers or receiving them only rarely. The DON stated the shower sheets provided were the only documentation showing showers were given, and the Administrator stated showers were to be given at least weekly, often twice weekly depending on resident preference.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not reporting an injury of unknown origin for one resident who was reviewed for abuse, neglect, and injuries of unknown origin. The resident had multiple significant medical conditions, including aphasia, hemiplegia, weakness, abnormal posture, contractures of both knees and ankles, and dementia. The care plan documented that the resident was nonverbal, unable to communicate effectively, and considered at risk for abuse or neglect due to mood, cognition, weakness, and behavioral/physical deficits. The MDS also documented that the resident was rarely or never understood, had memory problems, was dependent for many activities of daily living, and was always incontinent of bowel and bladder. Nursing documentation showed that a nurse was called to the resident’s room after staff noticed an area on the resident’s chest. The nurse found a large raised, firm, warm, dried popped blistered area extending from the right armpit to the right upper chest and shoulder, with severe pain. The nurse also noted bruising and swelling on the chest, bruising on the right side, scattered bruises, scabs, discoloration on both lower extremities, and a very swollen and painful right elbow. The nurse documented that there had been no prior progress note or risk management documentation and notified administration. The administrator was told that a CNA said a night nurse had noticed the areas on Sunday night, and the administrator later informed the nurse that a police officer would come to the facility. Hospital records and police documentation described bruising and unknown injuries with no documented explanation. The hospital noted significant bruising and swelling of the right chest wall, right axilla, and right upper arm, with an associated scrape in the axilla, and staff reported the bruising had been noted on Sunday and Monday without documentation of any injuries. The police report stated the resident had a large amount of bruising and unknown injuries, and the responding nurse reported that a night nurse on Sunday had verbally stated she noticed bruising. Interviews later showed one RN stated she saw bruising on the night of 5/10/26 but did not report it to administration because she assumed someone else had already done so, while a CNA stated the RN showed pictures of the bruises and did not report them that night. The administrator stated she was first notified on 5/13/26 and expected staff to report any allegation of abuse, neglect, or injury of unknown origin immediately.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin immediately to Administration for one resident. The resident had a history of aphasia, hemiplegia, weakness, abnormal posture, contractures of both knees and ankles, dementia, and was documented as nonverbal, rarely/never understood, and dependent on staff for most care. The care plan identified the resident as at risk for abuse or neglect due to mood, cognition, weakness, and behavioral/physical deficits. Nursing documentation stated that a nurse was called to the resident’s room and found a large, raised, firm, warm, severely painful area extending from the right armpit to the right upper chest and shoulder, along with bruising, swelling, scattered bruises, scabs, discoloration to both lower extremities, and a very swollen, painful right elbow. The note stated there was no prior documentation and no risk management report completed. The nurse then called Administration and was told a police officer would come to the facility. Hospital records described significant bruising and swelling of the right chest wall, right axilla, and right upper arm, with a scrape in the axilla, and noted staff reported the bruising had been seen on Sunday and Monday with no documentation of any injuries. Interviews showed conflicting and delayed reporting. One RN stated she noticed bruising on the night of 5/10/26 but did not report it to Administration because she assumed another staff member already had. A CNA stated the RN showed pictures of the bruises and asked if anyone knew about them, but no staff were aware and the RN did not report the bruises that night. The Administrator stated she was first notified on 5/13/26 and that allegations of abuse, neglect, or injuries of unknown origin are to be reported to her immediately. The facility policy required staff to report suspicious bruises or other abnormalities of unknown origin as soon as discovered and to notify the administrator immediately.
Call Light Not Available Within Residents’ Reach
Penalty
Summary
The facility failed to provide a working call system in resident bathrooms and bathing areas, and failed to ensure call lights or another mechanism to alert staff were within residents’ reach in their rooms for 2 of 6 residents reviewed. R7’s records showed diagnoses including Type 2 DM, HTN, CKD, and muscle weakness. R7 was cognitively intact, needed partial/moderate assistance with toileting hygiene and showering/bathing, supervision or touching assistance with chair/bed transfers, and was occasionally incontinent of bladder. R7 stated she did not have a call light, bell, or other device to get staff’s attention and said she would yell for staff if she needed help. No call light or bell was observed in R7’s room during two separate observations. R12’s records showed diagnoses including pulmonary embolism without acute cor pulmonale, prediabetes, and personal history of venous thrombosis and embolism. R12 was cognitively intact, used a wheelchair, needed partial/moderate assistance with toileting hygiene, showering/bathing, sitting to standing, and chair/bed to chair transfers, and was always continent of bowel and bladder. R12 stated he did not have access to his call light or a bell and did not know what to do if he needed help. The Administrator stated a third call light had been ordered for rooms with three residents and that bells had been purchased for residents to use while waiting for the call lights to arrive. The facility’s policy stated to ensure the call light is within the resident’s reach at all times.
Failure to Maintain Adequate Supply of Towels and Washcloths for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of towels and washcloths, resulting in residents not receiving safe, clean, and comfortable care and bathing. Surveyors repeatedly observed linen carts and clean linen rooms on multiple halls with few or no towels and washcloths over two consecutive days. On one day, three of four hall linen carts had no towels or washcloths and the fourth had only one towel; the clean linen room for two halls contained only three towels and eight washcloths. The following day, several carts and linen rooms still had minimal or no towels and washcloths, and the laundry room had no clean towels or washcloths ready for distribution, with the laundry aide folding only a few items. A CNA reported that the facility runs out of towels and washcloths, especially when only one washer is available, and the laundry aide stated they are always short on these items and was unsure if linens had been ordered recently. Cognitively intact residents reported that the lack of linens directly affected their bathing and hygiene. One resident with encephalopathy, a right below-knee amputation, chronic systolic CHF, and HTN stated the facility ran out of towels and washcloths and she had to use a pillowcase to dry off after bathing. Another resident with COPD, abnormal posture, depression, neuromuscular bladder dysfunction, and weakness stated she had not received a shower since the previous week because staff told her there were no towels or washcloths. A third resident with neuromuscular bladder dysfunction, Arnold Chiari syndrome, spinal muscular atrophy, and congenital spinal cord malformations stated showers were offered only "once in a blue moon" and that the facility never had towels and washcloths for showers or bed baths. A fourth resident with cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis stated there were never enough towels and washcloths. The administrator acknowledged awareness of linen supply issues and referenced prior lapses in ordering under previous administration, while the facility assessment documented that the facility would provide necessary bed and bath linens for day-to-day operations and emergencies.
Late and Omitted Medication Administration Due to Inadequate Nurse Staffing
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the specified time frames and as ordered for three residents during a medication pass. On 2/19/26, an RN was observed administering multiple morning medications scheduled for 9:00 AM to three residents between 11:36 AM and 12:04 PM. For one resident, loratadine, nicotine patch, metformin, atorvastatin, buspirone, famotidine, hydrochlorothiazide, lisinopril, Seroquel, and a mometasone furoate inhaler, all ordered for 9:00 AM, were not administered until 11:36 AM. This resident had diagnoses including paranoid schizophrenia, hyperlipidemia, hallucinations, mild intellectual disabilities, depression, shortness of breath, and weakness, and the care plan included interventions to administer statin, psychotropic, and respiratory medications as ordered. A second resident’s medications, including Anora Ellipta inhaler, atorvastatin, cetirizine, cholecalciferol, lisinopril, a multivitamin with minerals, levetiracetam, and metformin, all ordered for 9:00 AM, were not administered until 11:44 AM. This resident, who was cognitively intact, reported that nurses were sometimes late with medications. The resident’s diagnoses included cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis, and the care plan documented risks related to diabetes, hypertension, statin use, psychotropic use, COPD, and seizure activity, with interventions to administer medications as ordered. For a third resident, iron sulfate, divalproex, duloxetine, cyanocobalamin, metoprolol, Abilify, furosemide, potassium chloride, Entresto, and hydroxyzine, ordered for 9:00 AM (with Entresto ordered at 7:00 AM and 7:00 PM), were not administered until 12:04 PM, and dapagliflozin ordered for 9:00 AM was not available and therefore not given. This resident had multiple diagnoses including multiple sclerosis, pulmonary nodule, polyosteoarthritis, anemia, thyrotoxicosis, muscle spasm, hyperlipidemia, PTSD, congestive heart failure, low back pain, hypokalemia, vitamin deficiency, anxiety disorder, and bipolar disorder, with a care plan calling for administration of statin and psychotropic medications as ordered. The RN administering medications appeared flustered and stated that only three nurses were working instead of the usual four, causing her to run behind and combine morning and 11:00 AM medications, and stated that having only three nurses was affecting the quality of care. The facility’s medication administration policy required medications to be given at the proper time and dose, with documentation and provider notification if medications were not given as ordered or not present.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide appetizing food at palatable and safe temperatures for residents receiving food and nutrition services. One resident with dementia and weakness, who was cognitively intact, used a wheelchair, and was on a regular therapeutic diet, reported that the food was horrible and always cold. Another cognitively intact resident with diabetes mellitus, cerebral infarction, and COPD, who also used a wheelchair and was on a carbohydrate-controlled diet, stated that some of the food was terrible and that they would not even give that food to a dog. During observation of a meal service, food temperatures were taken with a calibrated metal thermometer after the last resident tray was served. The chicken measured 118°F and the broccoli casserole measured 114°F, while the cook stated the temperature should be around 170°F. The dietary manager later stated that the temperatures may have been lower because they were taken at the end of service. Two LPNs reported that the food is always cold and that nurse aides always have to rewarm residents’ food in the microwave. The administrator stated she expects dietary staff to follow the facility’s undated Food Temperatures Policy, which requires food to be held at 135°F or greater throughout the service process.
Failure to Provide Consistent Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide consistent access to hot water for bathing for four cognitively intact residents, each with significant medical conditions such as fractures, diabetes, cerebral infarction, multiple sclerosis, and malnutrition. Over a period earlier in the month, these residents experienced a lack of hot water for several days, with some reporting up to two weeks without hot water. During this time, residents were either given cold showers, wet wipe baths, or had to refuse bathing altogether, with no alternative options consistently offered. Staff interviews and documentation confirmed that the facility experienced ongoing issues with its hot water supply due to malfunctioning water heaters, which were unable to meet the demand. Maintenance staff and administration acknowledged the problem, noting that one of the two hot water tanks was out of order and that the facility had a history of running out of hot water under normal conditions. The lack of hot water affected both the men's shower room and general bathing routines, resulting in residents not receiving safe and comfortable bathing as required by resident rights policies.
Failure to Provide Consistent Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide consistent access to hot water for bathing for four cognitively intact residents, each with significant medical conditions such as fractures, diabetes, cerebral infarction, multiple sclerosis, and malnutrition. Over a period earlier in the month, these residents reported having no hot water for several days, with some stating the issue lasted up to two weeks. During this time, residents were either forced to take cold showers, refuse showers, or were only offered wet wipe baths as an alternative. Documentation and interviews confirm that staff were aware of the lack of hot water, and that the issue affected both the men's shower room and the general hot water supply after a water tank failure. Staff interviews and facility records indicate that the hot water shortage was due to malfunctioning water heaters, with one tank completely out of order and the facility unable to meet hot water demand under normal conditions. The maintenance director and regional maintenance director confirmed the problem, noting that the facility ran out of hot water after a few showers and that professional services were required to replace the faulty equipment. During the outage, there was no consistent alternative provided to residents for bathing, and the facility's own policy requires a safe, comfortable, and homelike environment, which includes access to hot water.
Failure to Obtain Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that prescribed medications were obtained and administered as ordered for two residents. One resident had diagnoses including right above-knee amputation, peripheral vascular disease, diabetes, COPD, neuropathy, heart failure, hypertension, anxiety, and depression, and was cognitively intact. That resident’s Lyrica 75 mg order for nerve pain was not available for multiple scheduled doses, and the MAR documented repeated #9 entries for doses that were not given. Nursing notes repeatedly documented that the medication was not available, reordered, or on order, and staff statements showed confusion about why the prescription had not been renewed or obtained in time. The resident reported being without Lyrica for 5 days and stated the medication manages phantom pain from the amputation. The resident said the phantom pain had been between 7 and 10 out of 10 while without the medication, compared with about 3 out of 10 when receiving it as ordered. Staff interviews showed the RN, DON, ADON, and APRN were aware the medication was unavailable, but the process to timely obtain it was not initiated effectively. An incident report later stated the medication was to be placed on hold until it became available, but the resident’s progress notes did not document the incident, and the APRN stated there was no documentation that the resident’s clinician had been notified or that an order to hold the medication had been implemented. A second resident, who had diagnoses including cerebral infarction, diabetes, COPD, anemia, hypothyroidism, hyperlipidemia, anxiety, obstructive sleep apnea, hypertension, osteoarthritis, and depression, was cognitively intact and dependent on staff and a mechanical lift for transfers. That resident stated she had not been receiving her weekly Ozempic injection as ordered and that nurses told her they could not find it. The MAR documented Ozempic as not administered and marked with #9, and the progress note stated the medication was not in. The administrator stated residents were expected to receive medications as ordered, but the record showed the medication was not provided as prescribed.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to two residents, resulting in missed doses and unmanaged pain. One resident, who was cognitively intact and suffered from phantom limb pain and a wound infection, missed six doses of oxycodone over a three-day period. The resident reported significant pain during this time, stating that the medication had run out and expressing uncertainty about whether the issue was due to a failure to reorder or a delay in pharmacy delivery. Documentation confirmed the missed doses, and staff interviews indicated that the prescription had expired and there was a possible change in providers. Another cognitively intact resident also missed three doses of prescribed oxycodone. Nursing notes revealed that the pharmacy had only partially filled the order, and a new prescription from the physician was required. Staff interviews acknowledged that running out of pain medication sometimes occurred, especially during pharmacy transitions or when new prescriptions were needed. The facility's policy required staff to check for misplaced medications, contact the pharmacy, use contingency supplies if available, and notify the physician if orders could not be followed, but these steps were not effectively implemented, resulting in the residents not receiving their prescribed pain management.
Failure to Provide Physician-Ordered Dietary Supplements During Meal Service
Penalty
Summary
The facility failed to provide physician-prescribed health shakes to five residents during meal service. On observation, none of the five residents received their ordered dietary supplements with their meals, despite having physician orders specifying the need for health shakes or supplements such as diabetic shakes or Med Pass 2.0. Interviews revealed that the dietary manager had prepared the shakes and placed them on the cart, but the aides delivering the trays did not check the meal tickets to ensure the correct supplements were provided. One resident reported that the shakes are often forgotten. The affected residents had various diagnoses, including aphasia, cerebrovascular disease, diabetes, dementia, schizoaffective disorder, hemiplegia, and alcohol-induced disorder. Their cognitive and physical abilities ranged from severely impaired to cognitively intact, with most requiring some level of assistance or supervision with eating. Facility policy required staff to verify that the correct tray and diet matched the resident's needs at delivery, but this procedure was not followed, resulting in the omission of prescribed dietary supplements.
Failure to Provide Clean Linens for a Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic respiratory failure, hypoxia, and tracheostomy status, was observed to have soiled linens that were not changed over multiple days. The resident, who is cognitively intact and dependent on staff for activities of daily living and mobility, was found lying in bed with a pillowcase that had a large brown stain on two consecutive days. Additionally, a white towel with dried green and brown stains was observed on the resident's bed rail. Interviews with facility staff, including the DON and Administrator, confirmed that linens should be changed when dirty, but the soiled linens remained in place during the observations.
Incomplete Incontinent Care and Perineal Hygiene
Penalty
Summary
Staff failed to provide complete incontinent care for two residents who were always incontinent of bowel and bladder. For one resident with severe cognitive impairment and total dependence on staff for toileting, a CNA missed cleansing the left buttock during perineal care after removing a soiled brief containing urine and feces. The CNA acknowledged missing this area due to nervousness. For another resident, who was cognitively intact but required supervision and assistance with toileting, a CNA used the same portion of a washcloth to cleanse multiple areas, did not cleanse the right buttock, and did not dry the resident before applying a new brief after removing a urine-soiled brief. The facility's policy requires complete cleansing of the perineal area with appropriate cleansers, use of multiple towels for cleaning, rinsing, and drying, and cleansing from front to back. The Director of Nurses confirmed that staff should be performing complete incontinent care, including using new towels for each area and ensuring residents are dried before a new brief is applied. These requirements were not followed during the observed care for both residents.
Failure to Provide Complete and Sterile Tracheostomy Care
Penalty
Summary
The facility failed to provide complete and appropriate tracheostomy care for a resident with chronic respiratory failure and a tracheostomy. The resident was observed with wet, soiled tracheostomy ties and collar, yellow, green, and brown drainage, and a foul odor, as well as a red spotted rash on the neck and upper chest. There was no drainage sponge under the tracheostomy, and the resident was seen cleaning the area himself using the same gauze pad multiple times, without being offered hand hygiene. The LPN assisting the resident did not consistently perform hand hygiene between glove changes, touched her hair with gloved hands, and did not follow sterile technique as outlined in the facility's tracheostomy care policy. The resident, who is cognitively intact but dependent on staff for activities of daily living, reported that he has been caring for his tracheostomy for several years and prefers to do it himself, although staff will assist if asked. The DON was unaware that the resident was performing his own tracheostomy care and acknowledged that the resident should have been educated and monitored to ensure proper technique. The facility's policy requires daily cleaning of the inner cannula, changing of tracheostomy ties and collar when soiled, and strict adherence to sterile procedures, which were not followed in this instance.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection prevention and control protocols while providing tracheostomy care to a resident with chronic respiratory failure, hypoxia, and a tracheostomy. The LPN did not wear a personal protective gown as required for Enhanced Barrier Precautions, did not consistently perform hand hygiene when changing gloves, and failed to provide a sterile field for supplies. During the care, the LPN touched her hair with gloved hands, reused gloves without hand hygiene, and did not encourage or assist the resident with hand hygiene before, during, or after the procedure. Additionally, the LPN did not clean multi-use equipment, such as a pulse oximeter, after use on the resident. The resident, who was colonized for wounds, had visible drainage on the tracheostomy collar and neck. The LPN and the resident both handled supplies and performed parts of the care without appropriate infection control measures, including the reuse of gauze pads and lack of hand hygiene. Facility policies required the use of gowns and gloves for high-contact care, hand hygiene before and after resident contact, and cleaning of equipment between residents, but these protocols were not followed during the observed care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Perform and Document Wound Treatments as Ordered
Penalty
Summary
The facility failed to perform wound treatments as ordered for three residents, as evidenced by interviews and record reviews. One resident reported not always receiving dressing changes to his left knee as prescribed, with treatment administration records (TARs) showing multiple days in May and June without documentation of the required wound care. This resident had a history of left knee pain, morbid obesity, and a left artificial knee joint, and was assessed as cognitively intact but requiring assistance with mobility and hygiene. Another resident stated that dressing changes to his left middle finger were not performed daily as ordered, with TARs indicating several days in June and July without documentation of the treatment. This resident had diagnoses of type 2 diabetes and hypertension and was at risk for skin complications due to a cerebrovascular accident and malnutrition. A third resident reported that staff did not change the dressing on his left lower leg daily, sometimes going multiple days without a change. Review of TARs for this resident, who had cellulitis and congestive heart failure, showed several days in June and July without documentation of the required dressing changes. Facility staff, including the DON and wound nurse, confirmed that dressing changes are to be documented on the TAR as soon as they are completed, and that lack of documentation would indicate the treatment was not performed. The facility's policy requires consistent implementation of wound monitoring and documentation protocols.
Failure to Arrange Ophthalmology Appointment for Resident with Severe Vision Impairment
Penalty
Summary
The facility failed to arrange a specialty physician appointment for a resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cortical age-related cataract in the right eye. Despite multiple physician orders and care plan interventions indicating the need for ophthalmology evaluation and treatment for cataracts and worsening vision, the resident did not receive an appointment with an eye doctor for an extended period. Documentation showed repeated referrals and urgent requests for ophthalmology consultation, but the resident reported never having seen an eye doctor since admission. Staff interviews confirmed the resident's ongoing vision impairment and the lack of successful appointment scheduling due to insurance issues and difficulty finding a provider who accepted the resident's insurance and treated cataracts. Observations revealed the resident ambulating with a slow gait, using hands to navigate due to severely impaired vision. The resident expressed that his vision had worsened during his stay and described pain in his right eye. The facility's transportation staff kept only handwritten notes to track appointment attempts, and there was no documented evidence of consistent follow-up or outreach to ophthalmologists. The facility's policy required physician orders to be followed as written, but there was no proof that the necessary steps were taken to ensure the resident received timely ophthalmology care.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for six residents who were reviewed for call light response. Multiple residents, all documented as having no cognitive deficits per their Minimum Data Set (MDS), reported that staff did not respond promptly to their call lights. One resident stated they had to wait on a bedpan for an hour due to unanswered call lights, while another reported being left unattended in the shower. Additional residents confirmed during a resident council meeting that staff routinely ignored call lights, with one resident noting that they had to call out for their roommate because staff did not respond. The Assistant Director of Nursing stated that the expectation is for call lights to be answered within two minutes. The facility's call light policy, revised in September 2022, provides guidance for staff on responding to residents' requests and needs.
Failure to Follow Fall Prevention Policy and Update Care Plans After Falls
Penalty
Summary
The facility failed to follow its Fall Prevention and Management policy for three residents identified as high risk for falls. For one resident with severe cognitive impairment and multiple comorbidities, the care plan was not updated after a fall, and no new interventions were documented to reduce future fall risk. The fall was not recorded in the electronic medical record, and there was no documentation of post-fall monitoring or follow-up, despite the resident being sent to the emergency department for evaluation. The Director of Nursing confirmed that required documentation and monitoring were not completed as per facility policy. Another resident with moderate cognitive impairment and a history of repeated falls experienced multiple falls, but incident reports lacked root cause analyses and did not document new interventions to prevent further incidents. Required sections of the incident reports, such as environmental and physiological factors, were left blank. Observations revealed that prescribed fall prevention interventions, such as side rails and floor mats, were not in place at the time of surveyor inspection, and the care plan was not updated after each fall as required. A third resident, also severely cognitively impaired and dependent for all activities of daily living, experienced several falls. Incident reports for these events did not include root cause analyses or documentation of new interventions. The care plan was not updated following these incidents, and the activity director was unaware of the resident's fall interventions and had not completed an activity assessment since admission. The facility's policy requires a root cause analysis and care plan update with new interventions after each fall, but these steps were not followed for the residents reviewed.
Failure to Prevent Resident-on-Resident Abuse and Bullying
Penalty
Summary
The facility failed to protect two residents from abuse and the assertion of dominance by another resident, despite both individuals being identified offenders with a known history of prior incarceration together. One resident, who had diagnoses including cerebral infarction, cerebral palsy, epilepsy, schizophrenia, and major depressive disorder, reported being sexually assaulted in his room by another resident. The victim described being physically overpowered and sexually abused, recognizing the perpetrator by voice and sight. Multiple interviews with the victim, other residents, and staff confirmed ongoing bullying, threats, and physical intimidation by the alleged perpetrator, both in the facility and previously in prison. The care plans for the victim documented risks for abuse and prior allegations of sexual assault, but did not address the ongoing bullying or dominance by the other resident. There was no evidence of behavior tracking for the victim, and the care plan lacked interventions specific to the bullying and dominance issues. Staff and other residents reported witnessing the perpetrator's aggressive and intimidating behavior, including physical threats and harassment during smoke breaks and in common areas. Staff also reported that previous concerns about the perpetrator's behavior had been dismissed by prior administration. The facility's policies required the identification and care planning for residents at risk of abuse, as well as the incorporation of security measures for identified offenders. However, the care plans and progress notes for the perpetrator did not document the abuse allegations or the need for enhanced supervision. The facility failed to implement adequate measures to prevent further abuse, intimidation, and psychological harm, resulting in the victim becoming fearful, socially withdrawn, and refusing therapy and medical evaluation due to fear and embarrassment.
Failure to Provide Physician-Ordered Diets to Residents
Penalty
Summary
The facility failed to provide physician-ordered diets to four residents with significant medical conditions, including severe cognitive impairment, diabetes, stroke, and swallowing difficulties. Despite clear care plans and physician orders specifying specialized diets such as pureed, mechanical soft, and carbohydrate-controlled diets, these residents consistently received regular meals identical to those served to other residents. Observations revealed that meal tickets indicating dietary requirements were missing or not updated, and staff were unaware of the specific dietary needs of the residents. For example, one resident with a pureed diet order due to high aspiration risk was observed receiving and struggling to eat regular food items like toast and cereal. Staff, including CNAs and the DON, were unaware of the resident's dietary restrictions, and the dietary manager admitted the resident was not listed on the special diet roster. Other residents with orders for mechanical soft diets also received regular meals, such as noodles and beef, which were not appropriately modified according to their dietary needs. The dietary manager and cook acknowledged that the food provided did not meet the required texture modifications and that the list of residents on special diets was outdated. Interviews with residents confirmed that they routinely received the same food as everyone else, regardless of their prescribed diets. Staff interviews further revealed a lack of communication and understanding regarding residents' dietary orders. The facility's own policy required individualized diet modifications based on physician and speech-language pathologist recommendations, but these procedures were not followed, resulting in the failure to provide appropriate diets as ordered.
Failure to Thoroughly Investigate and Document Alleged Abuse and Bullying
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of abuse for two residents, both of whom were identified as offenders and had a history of incarceration together. One resident, who was cognitively intact and had multiple diagnoses including schizophrenia and cerebral palsy, reported being sexually assaulted and bullied by another resident. The care plans for both residents did not address the ongoing bullying or dominance behaviors, and there was no behavior tracking provided for the resident who reported the abuse. Multiple staff and another resident observed or were aware of the bullying and dominance behaviors, but these concerns were not consistently documented or investigated. Interviews with staff and residents revealed that the alleged perpetrator had a history of threatening and intimidating both residents and staff, including a nurse practitioner who reported being threatened. Despite these reports, the facility did not have documentation of any abuse investigations related to the bullying or the alleged sexual assault prior to the current administrator's tenure. The administrator and DON were both new to their positions and were unaware of previous allegations or investigations. The facility's abuse prevention policy required that all incidents and allegations be investigated and documented, but this was not followed in these cases. When the sexual assault allegation was finally investigated, the process was inconsistent, with residents being asked different questions and key witnesses not being asked about what they had observed. The investigation relied heavily on video surveillance, which did not substantiate the allegation, and the final report concluded the abuse was unsubstantiated. However, the lack of consistent and thorough investigation, as well as the failure to report the allegation to the state agency as required, constituted a deficiency in the facility's response to alleged violations.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that medications for a newly admitted resident were transcribed to the Physician Order Sheet (POS) and Medication Administration Record (MAR), obtained from the pharmacy, and administered as ordered by the physician. The resident, who had multiple complex diagnoses including chronic kidney disease, heart conditions, diabetes, and a recent urinary tract infection, was admitted with specific hospital discharge medication orders. However, these orders were not transcribed or acted upon for several days following admission. Record reviews and staff interviews revealed that the admission process was not completed in a timely manner. The admitting nurse, who was from an agency, did not transcribe the medication orders upon admission as required. The facility's triple check system, designed to ensure accurate and complete admissions, was not performed. As a result, the resident did not receive critical medications, including antibiotics, cardiac medications, and diabetes medications, for several days. Staff interviews confirmed that the medications were not available or administered, and that the issue was only discovered days later when a nurse attempted to give the resident his medications and found none available. The failure to transcribe and administer the prescribed medications led to the resident experiencing significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection. The resident reported feeling as though he was going to die. Both the facility's pharmacist and medical director confirmed that the missed medications constituted significant medication errors, with the lack of antibiotic administration resulting in hospitalization for a urinary tract infection.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
The facility failed to complete the admission process and transcribe physician-ordered medications to the Physician Order Sheet and Medication Administration Record for a newly admitted resident. As a result, the resident did not receive multiple critical medications, including antibiotics for a urinary tract infection, antihypertensives, diabetes medications, and other essential treatments for several days following admission. Documentation shows that the hospital discharge orders were not transcribed until several days after admission, and medications were not obtained from the pharmacy or administered as ordered. The resident, who had a complex medical history including chronic kidney disease, diabetes, heart disease, and a recent fracture, repeatedly reported not receiving medications and experienced symptoms such as shortness of breath, heart palpitations, and elevated blood glucose levels. Progress notes and interviews confirm that staff, including agency nurses, were aware that medications were missing and not available, and that attempts to contact the pharmacy were made but not successful in a timely manner. The facility's own policies required prompt assessment and medication reconciliation upon admission, but these steps were not completed as required. Ultimately, the resident's condition deteriorated, leading to hospitalization where it was confirmed that he had not received his prescribed medications for several days, resulting in untreated infection and other complications. Interviews with staff and review of records indicate that the failure to transcribe orders, obtain medications, and administer them as ordered was due to lapses in the admission process, lack of oversight, and failure to follow established procedures for new admissions.
Failure to Transcribe and Administer Medications Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident was admitted with multiple complex diagnoses, including chronic kidney disease, heart failure, diabetes, and a recent urinary tract infection. Upon admission, the resident's hospital discharge orders, which included several critical medications such as antibiotics, antihypertensives, anticoagulants, and diabetes medications, were not transcribed to the Physician Order Sheet (POS) or Medication Administration Record (MAR) in a timely manner. The orders were not entered until several days after admission, resulting in the resident not receiving prescribed medications for multiple days. The facility's process required the admitting nurse to transcribe orders into the electronic health record system and send them to the pharmacy, with a triple check system in place to ensure accuracy. However, the admitting nurse was from an agency, and subsequent care was also provided by agency nurses. The facility's Assistant Director of Nursing (ADON) and other staff confirmed that the transcription and triple check processes were not completed as required. The delay in transcription and medication procurement led to the resident missing essential doses of medications, including antibiotics for a urinary tract infection and medications for chronic conditions. As a result of these failures, the resident experienced significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection, which ultimately led to hospitalization. Interviews with facility staff and the medical director confirmed that the lack of timely medication administration constituted a significant medication error with serious consequences for the resident.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility and the admitting nurse failed to transcribe the hospital discharge medication orders to the Physician Order Sheet (POS) and Medication Administration Record (MAR) in a timely manner. The resident, who had multiple complex diagnoses including acute kidney injury, chronic kidney disease, hypertension, diabetes, and a history of cardiac issues, was admitted with specific medication orders from the hospital. These orders were not entered into the facility's records or sent to the pharmacy upon admission, resulting in the resident not receiving prescribed medications for several days. Record review showed that the hospital discharge orders, dated 4/2, were not transcribed to the POS and MAR until 4/5. The MAR for April documented no medication orders for the resident on 4/2, 4/3, and 4/4, and the orders only appeared on 4/5 and later dates. Interviews with facility staff, including the previous DON, interim DON, and LPNs, revealed that the admission process was handled by agency nurses, and the required triple check system for new admissions was not completed. The interim DON confirmed that medications should have been transcribed within the first few hours of admission, but this did not occur. The facility's policy requires that medication orders be documented and transcribed promptly upon admission, with orders entered into the electronic system and transmitted to the pharmacy. In this case, the process was not followed, and the resident did not receive their prescribed medications as ordered by the physician during the initial days of their stay. Staff interviews indicated a lack of clarity and follow-through in the admission process, particularly with agency nurses responsible for the resident's care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent multiple instances of physical and sexual abuse among residents, as evidenced by several documented incidents involving both cognitively impaired and intact individuals. In one case, a severely cognitively impaired resident was inappropriately touched by another resident in the dining room, with the incident being witnessed by dietary staff. The involved residents were separated, and the event was reported to authorities, but the medical record for the alleged perpetrator did not contain any documentation related to the incident. Staff interviews confirmed that there was no staff present in the dining room at the time of the incident, and dietary staff, who are not permitted to physically intervene, were the first to respond. Additional incidents included a cognitively impaired resident striking another resident with a phone, resulting in a visible red mark, and altercations between residents involving physical aggression such as hitting and throwing objects. In one instance, a resident with dementia wandered into another resident's room and was punched in the chest. In another, two residents engaged in a physical altercation in the dining room, with one throwing coffee and the other retaliating with a punch. Documentation and staff interviews indicate that these altercations were often witnessed by non-nursing staff or occurred in areas with insufficient supervision. The records show that the residents involved had varying degrees of cognitive impairment and behavioral issues, including dementia, schizophrenia, and mood disorders. The facility's documentation and staff statements reveal that supervision was lacking at critical times, and that staff were not always able to intervene promptly to prevent or stop abusive interactions. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the events described demonstrate failures in monitoring and protecting residents from physical and sexual abuse by others.
Failure to Send Resident for Evaluation After Multiple Missed Dialysis Treatments
Penalty
Summary
A resident with severe cognitive impairment and multiple complex diagnoses, including end-stage renal disease requiring dialysis five times per week, experienced a significant change in condition after repeatedly refusing dialysis treatments. Documentation shows that the resident last received dialysis on 3/11/25 and subsequently refused all care for approximately eight days. During this period, staff noted the resident's increasing lethargy and unresponsiveness, culminating in a medical emergency that required transfer to the emergency room, where the resident was admitted to the ICU and required central venous access and vasopressor support. Interviews and record reviews revealed that the facility failed to send the resident for evaluation and treatment after multiple missed dialysis sessions. The dialysis nurse reported informing the nephrologist about the refusals and was advised to do what she could, but also stated that after three missed treatments, the standard practice was to send the resident to the hospital. The nephrologist confirmed that the resident should have been sent to the hospital after the third missed treatment, as further dialysis would not be safe without updated lab work. However, there was a breakdown in communication between the dialysis nurse, nursing staff, and facility leadership, resulting in the resident not being sent out in a timely manner. Facility policy required nursing staff to notify the physician and responsible party in the event of a significant change in condition or a pattern of refusing treatments. Despite this, the necessary notifications and actions were not consistently carried out, as some staff were unaware of the need to send the resident to the hospital after missed treatments. This lapse in following policy and communication protocols directly contributed to the resident's acute deterioration and subsequent hospitalization.
Failure to Provide Prescribed Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to a resident with diagnoses including Spina Bifida, Anxiety, and Bipolar Disorder, who was cognitively intact and had a documented order for Oxycodone 10 mg every four hours for osteomyelitis of the lumbar vertebra. According to the Medication Administration Record, the resident did not receive multiple scheduled doses of Oxycodone over a two-day period. Nursing staff confirmed that the medication was unavailable due to running out of stock and awaiting pharmacy delivery, and it was not accessible from the automatic medication dispensing machine. As a result of not receiving the prescribed pain medication, the resident reported significant pain, with a pain level reaching 7 out of 10, and stated he had to remain in bed all day due to abdominal pain from multiple hernias. The resident expressed frustration at not receiving his medication, which impacted his ability to participate in normal daily activities. The facility's pain management policy emphasizes the importance of providing necessary comfort and promoting resident independence and dignity, which was not achieved in this instance.
Failure to Provide Prescribed Pain Medication Due to Unavailable Supply
Penalty
Summary
The facility failed to provide a physician-prescribed pain medication, Oxycodone 10 mg, to a resident with diagnoses including Spina Bifida, Anxiety, and Bipolar Disorder. The resident, who was cognitively intact, had an active order for Oxycodone to be administered every four hours for osteomyelitis of the lumbar vertebra. According to the Medication Administration Record, the resident did not receive multiple scheduled doses of Oxycodone over a two-day period because the medication was not available in the facility. The resident reported not receiving his morning dose due to the medication running out, and staff confirmed that the pharmacy delivery was pending and the medication was not available in the automatic dispensing machine or contingency supply. As a result of not receiving the prescribed pain medication, the resident experienced significant pain, reporting a pain level of 7 out of 10, and was required to stay in bed all day, leading to frustration and inability to participate in normal daily activities. The facility's policy required staff to check for misplaced medications and contact the pharmacy or use contingency supplies if a medication was not present, but these steps did not result in the resident receiving his scheduled doses.
Failure to Consistently Offer Nighttime Snacks to Residents
Penalty
Summary
The facility failed to consistently offer nighttime snacks to four out of six residents reviewed for snack provision. Interviews and record reviews revealed that residents with significant medical conditions, such as end stage renal disease, dependence on renal dialysis, diabetes mellitus, and bipolar disorder, were not routinely offered snacks at bedtime. One resident with diabetes reported that snacks were not available, and when their blood sugar was low, staff had to purchase snacks from a vending machine using their own money. Another resident stated that snacks were sometimes available but not every night, while others reported never being offered snacks at night. The Director of Nurses stated that snacks are kept at the nurse's station and are available upon request, but this practice did not ensure that all residents were offered snacks as required. Resident Council Meeting minutes also documented concerns about the lack of snacks after dietary staff leave. The facility's own policy indicated that nursing services are responsible for delivering individual snacks to identified residents and for offering evening snacks to all other residents, which was not consistently followed.
Failure to Notify Power of Attorney of Narcotic Use and Therapy Refusal
Penalty
Summary
The facility failed to notify the legal guardian (Power of Attorney) of a resident with severe cognitive impairment regarding the initiation of a narcotic pain medication (Tramadol) and the resident's refusal and subsequent termination of therapy. The resident, who has diagnoses including Schizophrenia, Dementia, Alzheimer's Disease, and End Stage Renal Disease, was prescribed Tramadol for pain management after staff reported ongoing pain issues. Documentation shows that the resident received multiple doses of Tramadol, but there is no evidence in the medical record that the Power of Attorney was informed or gave consent for this medication, despite the resident's cognitive status and the guardian's stated concerns about the use of pain medications. Additionally, the resident began and was later discharged from both speech and physical therapy, with records indicating frequent refusals of therapy. However, there is no documentation that the Power of Attorney was notified of these refusals or the termination of therapy. Interviews with staff confirmed that notification was not documented, and attempts to contact the Power of Attorney were either not completed or not properly documented. The facility's policy requires notification of the responsible party in cases of significant changes, including new medication orders and patterns of treatment refusal, but this was not followed in this instance.
Failure to Complete and Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to provide a final abuse investigation report for two residents involved in a reported altercation. According to incident and nursing notes, an altercation occurred between two male residents in the dining room, during which coffee was thrown and there were allegations of physical contact. Both residents denied the altercation, but an eyewitness from the dietary department reported seeing one resident hit the other and intervened to separate them. Assessments were completed for both residents, with no injuries or pain reported, and both residents were monitored following the incident. The initial report of the incident was made, and the administrator was notified at the time. Despite the initial reporting and assessments, the facility did not complete or provide a final written report of the results of the abuse investigation as required by their policy. The current administrator was unable to locate a file on the incident, and only the initial report was found in an email from the DON. The facility's policy requires that a final written report, including the results of the investigation and any corrective actions, be forwarded to the Department of Public Health within five working days, but this was not done for the incident in question.
Failure to Investigate Alleged Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged altercation between two male residents, both of whom were their own responsible parties. According to incident reports and nurses' notes, a possible altercation occurred in the dining room, during which coffee was thrown and there were allegations of physical contact. Assessments were completed for both residents, and no injuries were noted. Both residents denied the altercation, but an eyewitness from the dietary department reported seeing one resident hitting the other and physically intervened to separate them. The incident was reported to the administrator, and statements were obtained from both residents, who continued to deny any physical altercation. Despite the facility's abuse policy requiring a full investigation—including interviews with all involved parties and review of relevant documentation—there was no evidence that a comprehensive investigation was conducted for this incident. The Director of Nursing stated that the initial report was made, but the current administrator could not locate a file or documentation of an investigation beyond the initial report. The only available documentation was an email from the Director of Nursing confirming the initial report, with no further evidence of follow-up or a completed investigation as required by facility policy.
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Illustrative
What surveyors actually found near you
We read the 703 citations issued within 25 miles in the last 12 months — including the 22 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alton Memorial Rehab & Therapy | 1.9 mi | ★★★★★ | 9 | 0 |
| Bria Of Woodriver | 2.5 mi | ★★★★★ | 22 | 7 |
| La Bella Of Alton | 2.8 mi | ★★★★★ | 3 | 0 |
| Bria Of Godfrey | 7 mi | ★★★★★ | 4 | 0 |
| Stonebridge Florissant | 7.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.