Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nexus At Alton during CMS and state inspections, most recent first.
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.
A resident, who was cognitively intact and had certain medical conditions, experienced verbal abuse from a dietary staff member during breakfast. The staff member used inappropriate language in response to a conversation about the facility's food. The incident was confirmed by another staff member and documented in the facility's report. Despite the facility's policy against abuse, this incident occurred, highlighting a failure to prevent verbal abuse.
A cognitively intact resident reported being inappropriately touched by another resident, but the facility failed to conduct a thorough investigation or report the incident to authorities. Despite the presence of witnesses and available camera footage, the facility did not adhere to its abuse policy, resulting in a deficiency.
The facility failed to follow its Abuse Prevention policy for a resident involved in alleged sexual abuse incidents. Despite being informed of incidents, no investigations were conducted, and they were not reported to an outside agency. The facility's cameras were not reviewed, and the incidents were not reported as required by the facility's policy.
A facility failed to measure, assess, monitor, and treat wounds for a resident with osteomyelitis and diabetes. The resident's left elbow wound was not treated until days after admission, and a right toe wound was not documented or treated promptly. Staff interviews revealed uncertainty in wound assessment procedures, and the facility's policy on wound management was not followed, leading to inadequate documentation and treatment of the resident's wounds.
Two residents in a facility received inadequate care for pressure ulcers due to improper assessment, monitoring, and treatment. One resident had a dressing that was not changed timely, leading to bleeding and drainage, while another received incorrect treatment due to a discrepancy in physician orders. The facility's failure to follow its own wound care policies resulted in these deficiencies.
A facility failed to replace a loose PICC line dressing for a resident with osteomyelitis and diabetes mellitus. An RN observed the loose dressing but did not change it immediately, instead informing the night RN to do so. The facility's policy required dressings to be changed if they were loose, but this was not followed.
A resident's POA repeatedly requested access to medical records without success, despite the facility's policy requiring records to be accessible within 24 hours. The resident, with a complex medical history, had been waiting since early 2024 for the records, with no documentation of the request being fulfilled. Interviews revealed a lack of communication and follow-through by the facility staff.
A resident with multiple medical conditions was discharged from the facility without proper coordination, resulting in a lack of medication provision. The care plan indicated a need for long-term care, but the discharge was not documented or planned accordingly. The family was not informed about the discharge timing, leading to confusion and distress over the lack of medication, which was not documented as sent with the resident.
A resident, who is cognitively intact and frequently incontinent, was not provided with appropriate toileting assistance, compromising his dignity. Despite being independent with toileting before, his care plan did not address his needs, and his wheelchair could not fit through the bathroom door. Staff did not assist him with using a bedside commode, urinal, or bedpan, leading to feelings of helplessness and embarrassment. Facility policies on maintaining dignity and providing adaptive equipment were not followed.
The facility failed to obtain informed consent for psychotropic medications for two cognitively intact residents. One resident received Zoloft without consent, and another was prescribed Trazodone and Duloxetine without being informed or consenting. The facility's policy requires informed consent and documentation, which was not followed.
A resident with a tracheostomy did not receive consistent care as outlined in their care plan, leading to respiratory issues and hospitalization. The resident reported irregular trach care and staff reluctance to perform necessary procedures. Facility documentation and staff interviews confirmed lapses in care, contributing to the resident's health decline.
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.
Verbal Abuse Incident Involving Dietary Staff
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident, identified as R3, who was cognitively intact and had diagnoses of Polyarthritis and Chronic Obstructive Pulmonary Disease. During breakfast in the dining room, a dietary staff member, V3, verbally abused R3 by cursing at him in response to a conversation about the facility's food offerings. This incident was witnessed by another staff member, V4, who confirmed that V3 used inappropriate language towards R3. The incident was documented in the facility's Long Term Care - Serious Injury Incident and Communicable Disease Report, which confirmed the occurrence of verbal abuse. The facility's policy, dated 9/2027, affirms the residents' right to be free from abuse, including verbal abuse, which is defined as the use of disparaging and derogatory language by staff. Despite this policy, the incident occurred, indicating a failure in preventing verbal abuse. The dietary staff member involved admitted to the verbal abuse in a written statement, acknowledging that her actions were wrong. The facility's response to the incident was to immediately suspend and subsequently terminate the employee involved.
Failure to Investigate and Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of sexual abuse involving a resident, identified as R2, who was cognitively intact and had a history of sexual abuse. The incident occurred when R2 reported being inappropriately touched by another resident, R3, while waiting for a smoke break. Despite R2's clear account of the incident and the presence of witnesses, the facility did not conduct a comprehensive investigation or report the incident to the appropriate authorities as required by their abuse policy. R2's care plan indicated a risk for abuse and neglect, and the facility's policy required immediate reporting and a thorough investigation of any allegations of abuse. However, the facility's response was inadequate. The Director of Nursing and the Wound Nurse were informed of the incident, but they did not pursue further investigation or report the incident externally. The facility also failed to review available camera footage that could have provided additional evidence. The facility's Regional Director of Operations acknowledged awareness of the incident but stated that no further investigation was conducted because a staff member did not witness the event. This lack of action and failure to adhere to the facility's abuse policy resulted in a deficiency, as the facility did not ensure the safety and protection of its residents by properly addressing and reporting the allegations of abuse.
Failure to Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to initiate its Abuse Prevention policy for a resident involved in an alleged sexual abuse incident. On 10/31/2024, the Regional Director of Operations, V9, stated that they were informed of an incident that occurred on 10/22/2024. Despite being notified, no further investigation was conducted, and the incident was not reported to an outside agency because the Staffing Coordinator, V6, did not witness anything. Additionally, V9 mentioned that they were later informed of another incident that occurred on 10/13/2024, which was also not reported or investigated. The facility has cameras, but the footage was not reviewed. The facility's Administrator, V2, confirmed that the incidents from 10/13 and 10/22 were not reported to an outside agency. According to the facility's Abuse Policy, any incident or allegation involving abuse should result in an investigation, and the Department of Public Health's regional office should be notified immediately. A complete written report of the investigation's conclusion should be sent within five working days. The facility's failure to follow these procedures resulted in a deficiency in handling the alleged abuse incidents.
Failure to Properly Assess and Treat Wounds
Penalty
Summary
The facility failed to properly measure, assess, monitor, and treat wounds for a resident identified as R4, who was admitted with osteomyelitis and diabetes mellitus. Upon admission, R4 had a left elbow infection and was on intravenous antibiotics. However, there was a lack of timely documentation and treatment for the wounds. The Treatment Administration Record showed no treatment for the left elbow wound before October 17, 2024, and no treatment for the right second toe wound before October 23, 2024. Additionally, the Skin and Wound Note from October 11, 2024, incorrectly documented that R4 had no open wounds, despite the presence of a left elbow wound noted upon admission. Interviews with facility staff revealed gaps in the wound assessment process. The Licensed Practical Nurse (LPN) responsible for wound care admitted uncertainty about whether wounds were measured upon admission or readmission. The Director of Nurses stated that wounds should be measured and described when found, with weekly follow-ups or if the condition worsens. The facility's policy on Skin and Wound Management Guidelines was not followed, as it required comprehensive nursing assessments, including skin integrity documentation and obtaining treatment orders for wounds present on admission. The policy also lacked documentation for ongoing wound or pressure ulcer assessment.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers, provide physician-prescribed treatment, and maintain clean dressings for two residents. One resident, who was at risk for developing pressure ulcers due to conditions such as Type 2 Diabetes Mellitus and End Stage Renal Disease, was found with a dressing that had not been changed in a timely manner, leading to bleeding and drainage. The resident's right heel dressing was improperly positioned, and the left heel had no dressing at all. The facility's records showed inconsistent documentation and assessment of the resident's pressure ulcers, with significant gaps in the medical record. Another resident, who had a Stage 4 pressure ulcer on the sacrum, received incorrect treatment due to a discrepancy between the physician's orders and the treatment administered by the staff. The staff member responsible for the treatment admitted to entering the wrong order into the system, which could have led to the resident receiving the wrong treatment if another nurse had performed the dressing change. The facility's policy on skin and wound management was not followed, as there was a lack of comprehensive assessment and documentation of the resident's wounds upon admission and readmission. The facility's failure to adhere to its own policies and procedures for wound care management resulted in inadequate care for residents with pressure ulcers. The lack of consistent assessment, documentation, and adherence to physician orders contributed to the deficiencies observed by the surveyors. The facility's staff, including the Director of Nurses and the Wound Nurse Practitioner, acknowledged the shortcomings in the wound care process, but the report does not mention any corrective actions taken to address these issues.
Failure to Secure PICC Line Dressing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident with a Peripherally Inserted Central Catheter (PICC) line. During an observation, the Assistant Director of Nurses, a Registered Nurse (RN), was seen disconnecting an IV antibiotic from a resident's PICC line and flushing it with normal saline. However, the PICC line dressing was noted to be loose at the bottom, and the RN did not replace it at that time. Instead, she informed the night RN to change it later. The resident, who was admitted with osteomyelitis and diabetes mellitus, had physician orders to change the PICC line dressing weekly and as needed using sterile technique. The facility's policy required dressings to be changed every seven days or more frequently if they were soiled, damp, or loose. The Director of Nurses later stated that RNs should change a PICC line dressing immediately if it is not secure.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to uphold a resident's right to access their medical records, as evidenced by the case of a resident whose Power of Attorney (POA) repeatedly requested access to the resident's medical records without success. The resident, who has a complex medical history including sepsis, transient cerebral ischemic attack, type 2 diabetes, and Alzheimer's disease, was admitted to the facility and later transported to the emergency room. Despite the POA's multiple attempts to obtain the records since February 2024, including filling out necessary forms and meeting with facility staff, the records were not provided, and no documentation of the request was found in the resident's progress notes. Interviews with facility staff revealed a lack of communication and follow-through regarding the request for records. The Medical Records staff member, who had been in the position for only three months, indicated that requests go through a legal process and require a fee, but there was no evidence that the records were sent or that the family was informed of any fees. The facility's policy states that records should be accessible within 24 hours of a request, yet the family had been waiting for months without resolution. The facility ultimately provided the records, but there was no documentation showing that the request had been fulfilled or communicated to the family.
Inadequate Discharge Planning and Medication Provision
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a safe and orderly discharge for a resident diagnosed with multiple medical conditions, including cerebral infarction, type 2 diabetes, and epilepsy. The resident, who required a wheelchair and had an impairment in the lower extremity, was discharged without proper coordination and communication. The care plan indicated a desire for long-term care, but the discharge was not documented or planned accordingly. The resident's family was not informed about the discharge timing, leading to confusion and a lack of medication provision at the time of discharge. The resident's family reported that they did not receive any medication or prescriptions upon discharge, which was confirmed by the facility's progress notes that lacked documentation of medication being sent with the resident. The facility's discharge policy requires that discharge instructions and medication lists be reviewed and signed by the resident or representative, but this process was not followed. The family expressed distress over the situation, highlighting the facility's neglect in ensuring the resident had necessary medications post-discharge.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance to a resident, R3, which compromised his dignity and self-determination. R3, who is cognitively intact and frequently incontinent, was not assisted with toileting despite being independent with toileting prior to his transfer to the facility. His care plan did not address his toileting needs, and his wheelchair could not fit through the bathroom door. The staff did not assist him with using a bedside commode, urinal, or bedpan, and instead, he was given an adult brief and told to use it. This lack of assistance led to R3 feeling helpless, ashamed, and embarrassed as he had to lay in his own body fluids. Interviews with R3 and his sister, who is his power of attorney, revealed that R3 was dissatisfied with the care he received, as he was not provided with the necessary support to use the toilet. R3 expressed that he felt demeaned and disgusted with himself due to the situation. Staff members, including CNAs, confirmed that R3 was not taken to the bathroom and that the full body mechanical lift used for his transfers could not fit in the bathroom. The facility's policies on resident rights and activities of daily living emphasize the importance of maintaining residents' dignity and providing necessary adaptive equipment, but these were not implemented in R3's case.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for two residents, R3 and R4, who were cognitively intact and part of a sample of eight residents reviewed. R3's care plan indicated the use of Zoloft for managing depression, and the medication was administered from August 31, 2024, to September 13, 2024, without documented consent. R3 stated that he was not informed about the medication or its risks and benefits, and he did not provide verbal or written consent. The Director of Nursing, V2, provided a blank consent form and claimed that consents were in the electronic health record, but upon review, it was found that multiple residents lacked consent documentation. Similarly, R4's care plan did not address psychotropic medication use, and the resident was prescribed Trazodone and Duloxetine for major depressive disorder without documented consent. R4, who was new to the facility, stated that he did not take antidepressants or antipsychotic medications and had not given consent for such medications. R4 mentioned that he was not informed about the new medications or their potential adverse reactions, assuming his hospital medications followed him to the facility. The facility's psychotropic medication program requires informed consent and documentation of the indication for medication use, which was not adhered to in these cases.
Inadequate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident, identified as R3, who was at risk for complications related to tracheostomy placement. R3's care plan required regular assessment for signs of infection and tracheostomy care, including changing the trach collar twice weekly and cleansing the trach every shift using sterile technique. However, documentation revealed that trach care was not consistently performed, with several instances where the procedure was not completed as ordered. This lack of care led to R3 experiencing shortness of breath and low oxygen saturation levels, necessitating increased oxygen support and medical intervention. R3, who was cognitively intact, reported that trach care was not provided regularly, leading to concerns about his health and safety. He expressed fear that the staff were not adequately trained or willing to perform the necessary care, resulting in his trach remaining capped when it should have been placed on a mask at night. R3 also reported experiencing drainage with an odor from his trach site, which was not addressed promptly by the facility staff. Interviews with facility staff, including LPNs, revealed inconsistencies in the provision of trach care. One LPN stated that she performed trach care when on duty, while another admitted to not performing the care, leaving R3 to manage it himself. The facility's equipment change schedule outlined specific procedures for trach care, which were not followed, contributing to R3's deteriorating condition and eventual transfer to a local hospital for further evaluation and treatment.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 656 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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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 | ★★★★★ | 21 | 7 |
| La Bella Of Alton | 2.8 mi | ★★★★★ | 3 | 0 |
| Bria Of Godfrey | 7 mi | ★★★★★ | 5 | 0 |
| Stonebridge Florissant | 7.6 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.