Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Richland Nursing & Rehab during CMS and state inspections, most recent first.
Failure to provide ordered PROM for a resident with quadriplegia. A resident with a spinal cord injury, cervical spine fusion, and no cognitive deficits was supposed to receive daily PROM to prevent stiffness and contractures, but the care plan did not include restorative needs and staff were unsure whether the exercises were being done. During observation, a CNA performed PROM but several body parts did not receive the expected 10 repetitions, and the resident stated he was afraid he would develop contractures because staff were not completing ROM effectively.
Catheter care and EBP were not followed for a resident with an indwelling urinary catheter and neurogenic bladder. The resident had inconsistent catheter output documentation, developed a UTI with abnormal UA/culture results, and the family reported a very full drainage bag with urine backing up into the bladder. During observation, a CNA entered without a gown, did not recognize the resident was on EBP, used improper tubing cleansing technique, and handled the drainage system without hand hygiene or sanitizing the spigot.
A resident with severe cognitive impairment received an antipsychotic injection twice within days after the monthly dose was missed and the schedule was changed without documentation, leading to lethargy, tremors, unsteadiness, and an ER visit with poison control contacted; another resident was given evening trazodone and rosuvastatin in the morning after an LPN selected the wrong MAR screen, and the resident was sent to the ER for evaluation.
A facility failed to provide adequate CNA staffing to meet resident needs, and residents reported long waits for call lights and toileting help, especially on night shift. Several residents said call lights were not answered for up to an hour and a half, one resident said she had been left on the toilet for over an hour when only one CNA was working, and a former night-shift LPN told administration that Delta needed another CNA. The DON said the overnight staffing pattern included one CNA for Delta, while the Administrator stated the staffing met requirements.
The facility failed to maintain infection prevention and control practices during resident care and environmental cleaning. A resident who was frequently incontinent had urine spilled in the dining room and hallway, but staff only partially cleaned the area and other staff walked through the urine while moving residents and wheelchairs. During a wound dressing change for a resident with an unhealed heel injury, an ADON handled the dressing with contaminated gloves and did not perform hand hygiene or change gloves appropriately. The facility also lacked records for flushing water lines on a closed unit, despite a Legionella water management policy requiring flushing every 4 days.
Antibiotic Stewardship Monitoring Not Established: The facility failed to establish an antibiotic stewardship program with protocols to ensure appropriate antibiotic use and systems to monitor outcomes. The DON presented an infection control log with monthly antibiotic use summaries, but it did not document resident symptoms, standardized criteria for use, start dates, response to treatment, or lab results. The Regional Nurse stated she only reviewed cultures for patterns, while the DON and Administrator were unsure what had been tracked or monitored.
Infection Preventionist Not On Site: The facility did not have an Infection Preventionist who remained on site. The Regional Nurse stated she was covering the role remotely until the DON completed the course, while the DON had not yet completed it. The Administrator stated the former Infection Preventionist quit without notice and the Regional Nurse was being used for the role even though she was not in the building every day. The facility had 76 residents.
Quarterly MDS assessments were not completed on time for 7 of 7 sampled residents with multiple chronic conditions, including dementia, depression, schizophrenia, seizures, diabetes, COPD, heart failure, and CKD. Staff stated the facility had no MDS nurse, a regional nurse was trying to complete all MDSs, and the administrator said a former employee left without notice and that the facility follows the RAI Manual for MDS timing.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments on time for 4 residents. Each resident had multiple diagnoses, including dementia, diabetes, CKD, anxiety, HTN, and other chronic conditions, and their MDSs were submitted well after the due dates with late-completion warnings. The RN stated there was no MDS nurse and a regional nurse was trying to complete all MDSs; the Administrator stated a former employee quit without notice and the facility had no policy for MDS completion timing, relying on the RAI Manual.
Failure to Offer Activity Packets to Residents Staying in Their Rooms. A resident with chronic respiratory failure, MDD, HF, anxiety, and morbid obesity said she had not received puzzles, coloring items, or reading materials in a long time and wanted them again. Other residents with dementia, COPD, alcohol abuse, CHF, diabetic neuropathy, obesity, GAD, HTN, and urinary retention reported they did not receive daily delights, word searches, puzzles, or reading materials while staying in their rooms. The Activities staff said packets were given in the dining room and to room-bound residents, but some rooms were missed when she got behind; the Administrator stated all residents should receive the packets whether or not they attend activities.
Unsafe environment, incomplete fall investigation, and improper mechanical lift transfer: A resident with dementia and severe cognitive impairment slipped and fell after a powder-like substance was left on the dining room floor. Another resident with dementia and repeated falls slid down in a wheelchair during lunch, but the event was not treated as a fall and no intervention was implemented. A CNA also completed a mechanical lift transfer alone for a resident whose order and care plan required two staff, and a separate resident’s fall investigation was left incomplete.
A facility failed to offer meal alternatives per resident preferences for 4 residents reviewed. Residents with regular diets stated they were not asked what they wanted to eat before meals, were given whatever was served, and in one case coffee was only available during breakfast hours. The Dietary Mgr and Activities staff stated menus and alternates were supposed to be reviewed with residents, and the facility policy required appealing alternate options of similar nutritive value for residents who refused menu items.
Failure to administer ordered pneumococcal vaccines affected 4 residents with chronic conditions including dementia, depression, anxiety, COPD, and heart failure. I-Care and chart review showed missing or incomplete vaccine documentation, and Prevnar 20 doses were found in the med fridge for the residents while an LPN stated the vaccines were being held because consents were not scanned into the chart. The DON stated she had not yet reviewed vaccine status, was unaware the doses were in the fridge, and that staff would not give the vaccines until the consents were scanned.
Incomplete POLST Documentation for a Resident with Advance Directives: The facility failed to complete and sign an IDPH Uniform Practitioner Order for Life Sustaining Treatment (POLST) form for a resident with dementia and other chronic conditions. Staff interviews showed the LPN could not locate the POLST in the EHR, the DON said POLSTs should be in resident documents, and the SSD had a family-signed form but no physician signature. The Administrator stated the SSD was responsible for completing, obtaining physician signature, and uploading the form within 24 hours of admission.
Failure to maintain a clean, homelike environment for two residents. One resident with hemiplegia/hemiparesis and severe cognitive impairment was observed in a wheelchair in disrepair with a bandage on the frame, food debris, hair, dirt, and stained cushion areas; a CNA said night shift staff were supposed to clean wheelchairs but it was not being done. Another resident’s bed frame was visibly soiled with dried food and spills on repeated observation, and the Administrator said the resident often eats and drinks in bed and spills a lot.
Failure to Provide Written Transfer and Bed-Hold Notifications: The facility did not provide written bed-hold or transfer/discharge notices to the resident or representative for three residents sent out for ER/hospital care. One resident with dementia, CKD, and behavioral diagnoses returned from the ER after receiving nighttime meds in the morning instead; another resident with dementia, MDD, anxiety, and hallucinations was sent out after a fall; and a third resident with TIA, schizophrenia, psychosis, COPD, and other diagnoses was sent out after becoming unresponsive and was later admitted with acute encephalopathy and acute hypoxic respiratory failure. The Administrator stated the forms had not been completed.
A resident with Alzheimer’s disease, dementia, CKD stage 4, AFib, systolic HF, and HTN did not have an annual MDS completed and submitted on time. The MDS was due but was completed late, more than 14 days after the ARD. Staff stated the facility had no MDS nurse, a regional nurse was trying to complete the MDSs, and the administrator was unaware a former employee was behind on assessments.
A resident with moderate cognitive deficits and a later-added diagnosis of Schizoaffective Disorder, Depressive Type was not referred for PASARR reevaluation after the new mental health diagnosis appeared in the record. The resident’s prior PASARR screening had found no reasonable basis to suspect MI or DD, and there was no documentation of a new referral despite the updated diagnosis and behavioral health history noted by staff.
Failure to Date and Label Oxygen Equipment: A resident with COPD and two other residents with chronic respiratory conditions had physician orders for weekly oxygen tubing and humidifier bottle changes with dating/labeling, but observations found the tubing and bottles unlabeled or mislabeled. Staff confirmed the equipment should be dated and labeled per the order, yet the required documentation was not present on the oxygen supplies.
The facility failed to prevent multiple episodes of resident‑to‑resident physical abuse involving cognitively impaired residents with serious mental health and dementia diagnoses. In one case, a resident awoke to another resident standing over her in bed with gloved hands pressed over her mouth and nose, an event corroborated by staff interviews and the aggressor’s own statements. In a separate episode, a resident with known aggressive behaviors wheeled into another resident’s room, blocked the resident in a corner, and kicked the resident above the knee before a CNA could intervene. Hours later, the same aggressive resident self‑propelled behind another cognitively impaired resident seated at the nurses’ station and slapped her on the back, an event directly witnessed and reported by a CNA. These incidents occurred despite existing care plans and an abuse prevention policy that defined and prohibited such willful physical abuse.
A resident with dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease had physician orders for daily weights, MD notification for specified weight gains, and PRN bumetanide for weight increases. Weight records showed multiple days where the resident’s weight increased beyond ordered thresholds, but there was no documentation that the MD was notified. An LPN reported administering PRN bumetanide after noting a significant weight gain but did not recall notifying the MD, and the NP who followed the resident stated she was not informed of any weight gains during that period. This occurred despite a facility policy requiring prompt notification of the MD and DON when physician orders are not followed.
A resident with dementia, CKD, localized swelling, and interstitial pulmonary disease had a PRN order for bumetanide 1 mg PO to be given for specified weight gains. Weight records showed multiple days when the resident met the ordered parameters, but the MAR documented the dose as not administered on several of those days, as indicated by initials in parentheses. The Regional Clinical Director confirmed that the medication should have been given on those days according to the order, and the resident’s care plan did not address medication administration despite the PRN diuretic order.
A resident with multiple medical conditions was found unresponsive and did not receive CPR because staff were unaware of the resident's code status, despite documentation indicating full code. The care plan and physician orders lacked code status information, and the POLST form was not completed. Staff failed to follow facility policy requiring CPR initiation in the absence of a documented DNR, resulting in the resident not receiving life-sustaining measures.
A resident with multiple complex medical conditions was admitted without a documented code status or advance directive, and the required POLST form was not completed. Staff interviews revealed confusion about responsibility for advance directive completion, and facility policy requiring timely provision and inquiry about advance directives was not followed.
Multiple residents experienced physical abuse from peers, including biting, slapping, and hitting, which led to injuries such as bruising and a hip fracture. Staff and LPNs witnessed these altercations, and documentation confirmed that the facility did not prevent these incidents despite having an abuse prevention policy.
A resident with severe cognitive impairment, high fall risk, and dependence for mobility was left standing unassisted in a hallway while a CNA briefly left to retrieve a walker. During this time, the resident fell and sustained a comminuted fracture to the right arm and elbow. Staff interviews and documentation confirmed that the resident required continuous supervision, and the facility's fall management policy was not followed, leading to the incident.
Several residents did not receive timely assistance with ADLs, particularly toileting, and experienced long call light response times. One resident with severe cognitive impairment and incontinence repeatedly requested help for over half an hour without receiving assistance, resulting in an episode of incontinence and visible distress. Other residents reported similar delays, sometimes attempting self-toileting to avoid accidents. Staff cited insufficient CNA coverage and policies that prevented them from interrupting feeding to assist with toileting, despite facility policies requiring prompt response.
The facility did not provide enough nursing staff to meet residents' needs, resulting in delays in toileting assistance, inadequate supervision during meals, and insufficient monitoring of residents with cognitive impairments. Staff and residents reported that care was not delivered in a timely manner, and documentation confirmed low staffing levels across multiple shifts. These deficiencies led to residents being left unattended, soiling themselves, and experiencing falls due to delayed responses.
Surveyors found that the dining room floor remained unclean for two consecutive days, with dried spills, food debris, dirt, and seeds present despite daily housekeeping routines. The administrator agreed the cleanliness did not meet facility standards, and an LPN noted that housekeeping staff were not consistently sweeping and mopping, sometimes requiring nursing staff to clean instead. Facility policy requires daily and as-needed cleaning, but these procedures were not followed, affecting all residents who dined in the area.
Two residents requiring substantial assistance did not receive timely help with ADLs, including toileting and scheduled showers. One resident with severe cognitive impairment and incontinence was left waiting for over 30 minutes for toileting assistance, resulting in incontinence episodes, while another dependent resident missed multiple scheduled showers over two separate six-day periods, with documentation errors and no evidence of alternative hygiene care provided. Staff interviews confirmed delays and inadequate care due to staffing and scheduling issues.
Multiple residents with dementia did not receive timely, person-centered care, including assistance with toileting and supervision during meals, resulting in distress, incontinence, and unsafe behaviors. Staff were unable to meet residents' needs due to inadequate staffing and inconsistent activity programming, and care plans lacked individualized dementia interventions.
A cognitively impaired resident with Alzheimer's and a history of exit-seeking behaviors was able to leave the Dementia Care Unit unsupervised by accessing an unlocked office and exiting through an unsecured window. Staff were unable to redirect the resident despite multiple attempts, and at the time of the incident, were occupied with other residents. The resident was found by police after sustaining injuries from a fall and was treated at the ER. Investigation revealed that required door alarm checks were not performed daily, alarms were malfunctioning, and the environment was not adequately secured, contributing to the resident's elopement.
The facility did not consistently provide enough nursing staff on the Dementia Care Unit, with only one nurse and one or two CNAs often present despite the high care needs of 25 residents, including those requiring total assistance and behavioral supervision. Staff and family members reported difficulties in obtaining timely care and supervision, and assignment records confirmed multiple shifts with insufficient staffing, contrary to the facility's own policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility, was found by police with injuries, and was transported to the ER. The facility did not notify the resident's POA until after the resident returned from the hospital, failing to provide timely and comprehensive information as required by policy.
A facility failed to adhere to transfer protocols, resulting in falls and injuries for three residents. One resident with cognitive deficits fell due to unlocked wheelchair brakes, sustaining a fractured rib and dislocated shoulder. Another resident with cerebral palsy fell when a CNA did not apply necessary interventions, and a third resident with Parkinson's disease fell when a CNA let go of a gait belt. These incidents highlight a lack of adherence to care plans and proper communication among staff.
The facility failed to provide sufficient staff to meet the needs of all 78 residents, particularly in providing care for ADLs and supervision during meals. Residents reported not receiving scheduled showers or bed baths due to staffing shortages, and incidents occurred where a resident took food from others' plates due to inadequate supervision. Staff confirmed the staffing issues, noting that while the facility technically had enough staff according to census, they struggled to meet residents' needs.
The facility failed to maintain dignified dining services and uphold resident rights for four residents with cognitive impairments. A resident repeatedly took food from others' plates during meals, despite requiring supervision. Staff were aware but did not prevent the behavior, and the facility lacked a policy for resident rights, indicating a systemic issue in addressing these deficiencies.
The facility failed to provide adequate assistance with activities of daily living and meals for several residents due to staffing shortages. A resident did not receive regular showers or bed baths, while another was left with an unattended meal for an extended period. Staff confirmed the lack of sufficient personnel to provide necessary care, leading to deficiencies in resident hygiene and nutrition.
A facility failed to identify specific medical conditions necessitating the use of a physical restraint for a resident with dementia and other diagnoses. The resident was observed with a seatbelt restraint in a wheelchair during meals, contrary to the care plan that required the restraint to be removed during such activities. Staff interviews revealed uncertainty about the restraint's use, and the facility did not adhere to its policy on restraint documentation and assessment.
A facility failed to conduct a Level II PASARR evaluation for a resident with mental illness, including visual hallucinations and bipolar disorder. The initial Level I PASARR indicated a need for further evaluation, but it was not completed due to staff assumptions about the resident's other medical conditions. The Social Service Director was unaware of the new bipolar diagnosis, leading to non-compliance with PASARR requirements.
A resident with dementia and dysphagia, requiring a mechanically altered diet, was inadequately supervised during mealtime, leading to multiple instances of the resident taking regular consistency food from other residents' plates. Staff acknowledged the resident's history of such behavior, indicating insufficient supervision and adherence to dietary policies.
The facility failed to provide the correct diet for three residents, including one with dysphagia who received improperly prepared broccoli, another with a low BMI who received unminced vegetables, and a third at risk for impaired nutrition who did not receive finger foods as ordered. The Dietary Manager and Registered Dietician acknowledged issues with menu planning and execution.
The facility failed to follow proper infection control practices, as an LPN did not sanitize hands between administering medications to residents, and staff did not adhere to enhanced barrier precautions for a resident with an open wound and urinary catheter. Despite training, staff were unfamiliar with these precautions, and the DON acknowledged the need for further training.
The facility failed to respond promptly to residents' call lights, affecting the dignity and care of three residents. A resident experienced humiliation and pain from sitting in urine and feces due to delayed assistance. Another resident with moderate cognitive impairment reported waiting over an hour for care, worsening pain from existing wounds. A third resident faced similar delays, exacerbating pain in the coccyx area. Staff shortages were a significant issue, with only two CNAs available for 34 residents, leading to extended wait times.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. A resident reported waiting up to an hour and a half for assistance, leading to pain and incontinence. Another resident with moderate cognitive impairment experienced similar delays, exacerbating his discomfort due to existing wounds. Staff interviews confirmed ongoing staffing challenges, particularly on weekends, with insufficient updates to staffing schedules further complicating the issue.
The facility failed to maintain a clean and pest-free kitchen, affecting all 85 residents. Observations included food particles, debris, and dead bugs, including roaches, throughout the kitchen. The Dietary Manager was unaware of these issues, and the pest control measures were inadequate. The facility's cleaning schedule policy was not properly followed, leading to unsanitary conditions.
The facility failed to maintain an effective pest control program, leading to the presence of roaches and bed bugs. A resident was admitted with bed bugs, and the issue worsened when infested clothes were brought in. The facility did not follow its pest control policy due to a missing document, delaying treatment. In the kitchen, ongoing roach issues were exacerbated by cleanliness problems, hindering pest control efforts. Staff reported sightings of bugs, indicating a failure to adhere to pest control procedures.
A resident with severe cognitive impairment was physically abused by another resident with a known history of aggression. Despite previous interventions, the aggressive resident continued to attack, causing fear and insecurity for the victim. The facility failed to manage the aggressive behavior effectively, leading to a deficiency in providing a safe environment.
Failure to Provide Ordered PROM for Resident With Quadriplegia
Penalty
Summary
The facility failed to implement PROM exercises per COTA recommendations for a resident with quadriplegia, cervical spine fusion, and neuromuscular dysfunction of the bladder. The resident’s MDS documented no cognitive deficits, and the care plan did not include any problem areas related to restorative nursing or therapy services for quadriplegia. The resident stated he was quadriplegic following a spinal cord injury in September 2025, that he hoped to transfer to a facility specializing in spinal cord injury rehabilitation, and that he was afraid he would develop contractures because he did not feel staff were completing his ROM effectively. An OT treatment encounter report documented that the therapist educated staff to perform daily PROM to prevent stiffness and contractures because the resident was unable to move his extremities on his own. The therapist also educated staff on daily bed baths, repositioning every 2 hours, and placed reminders on the resident’s wall for daily baths, repositioning, ROM, and wheelchair use. The COTA later stated she had educated CNA staff that the resident should receive AROM to the head and neck and PROM to the rest of the body at least once daily, but she was not sure whether the CNAs were doing it. She also stated the facility’s two restorative aides had been returned to floor work and would not be replaced. During observation, a CNA was seen performing PROM for the resident, but the movements did not meet the stated minimum of 10 repetitions for multiple body parts. The documented repetitions included right shoulder 2, right fingers and thumb 0, left wrist 8, left thumb and fingers 4, left elbow 6, left shoulder 5, left ankle 7, left knee 5, left hip abduction 0, right hip extension 4, and bilateral toes 0. The CNA stated the resident was to receive PROM once every 12-hour shift. The DON stated CNA staff would be in-serviced on the resident’s restorative needs and that the care plan would be updated.
Catheter Care and EBP Not Followed
Penalty
Summary
The facility failed to provide urinary catheter care according to professional standards of practice for one resident with an indwelling catheter. The resident’s record showed diagnoses including quadriplegia, cervical spine fusion, and neuromuscular dysfunction of the bladder, and the care plan identified the resident as requiring enhanced barrier precautions related to the indwelling catheter and routine assessment of drainage every shift and as needed. The record also showed that catheter output was documented only once daily on some dates in April 2026, with no documentation of urine output on several other dates. The resident’s urinalysis and urine culture showed cloudy urine, abnormal red and white blood cells, many bacteria, and greater than 100,000 gram negative bacilli. A provider note documented that staff reported the resident had increased confusion and that the resident had a UTI, with Keflex started by the primary care physician. The resident and a family member stated the catheter bag had become very full, and the family member reported emptying 2000 cc of urine from the bag after no staff responded to the call light, with an immediate return of 400 cc of residual urine that had been backed up into the bladder. During observation of catheter care, a CNA entered the room without donning PPE, did not wear a gown despite the EBP sign on the door, and stated she did not think the resident was on EBP. The CNA cleansed the catheter tubing by going back and forth with the same washcloth rather than using one motion from proximal to distal, then drained 500 cc of urine while wearing contaminated gloves, did not perform hand hygiene before handling the drainage tube, and re-clamped the tube without sanitizing it. The DON stated catheter bags should be emptied at least every 12-hour shift and no more than 1000 cc should be allowed to collect, and the facility policies required emptying the bag at least every eight hours, documenting output, and using gown and gloves for residents with indwelling devices.
Medication administration errors involving antipsychotic and evening medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for 2 of 13 residents reviewed for medication errors. One resident with diagnoses including schizoaffective disorder, bipolar type, hypertension, diabetes, and severe cognitive impairment was ordered Invega Sustenna 234 mg IM monthly on the 8th of each month. The January MAR documented that the injection was not given on the scheduled date, with a notation that the date was changed, but there was no documentation that the order had been changed. Nursing notes later documented that the injection was given on 1/31/26 and then again on 2/5/26, only days apart, after staff determined the medication had not been received in January. After the second injection, staff observed increased lethargy, hand tremors, unsteadiness, nausea, back pain, and increased need for assistance with transfers. The resident was sent to the ER, where the chart documented the resident had received Invega injections on 1/31/26 and again on 2/5/26. The hospital record listed the clinical impression as medication overdose, accidental or unintentional, and poison control was contacted. The resident’s record also documented that the resident was severely cognitively impaired and was being monitored for adverse drug reactions related to antipsychotic use. A second resident with diagnoses including metabolic encephalopathy, acute kidney failure, unspecified dementia with behavioral disturbance, diabetes, anxiety, depression, and mood disorder had orders for trazodone 50 mg and rosuvastatin 20 mg to be given in the evening between 4:00 PM and 6:00 PM. An LPN reported that she selected the wrong screen during morning medication administration and gave the resident evening medications in the morning. The DON was notified, the physician was contacted, and the resident was sent to the ER for further evaluation. The MAR showed the trazodone and rosuvastatin were marked with the nurse’s initials under the evening time slot, indicating they were not given at the ordered time.
Inadequate CNA Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate CNA staffing to meet resident needs on all shifts, with multiple residents and staff reporting prolonged waits for call lights and toileting assistance. Facility grievance and concern documents stated that call lights were not answered for hours, including one report that no one answered a call light from 2 a.m. or 3 a.m. until 6 a.m., another that call lights were not being answered timely, and another that a resident waited 45 minutes to be placed on the toilet and then 45 minutes to get off the toilet. During interviews, a resident stated that when only one CNA was working, she had been left on the toilet for over an hour, and another resident stated he had waited over an hour for his call light on the Delta Unit night shift. At the Resident Council Meeting, residents stated that call lights on night shift could take up to an hour and a half to be answered, and another resident stated her call light could take up to 45 minutes. One resident reported that night shift CNAs would turn off the call light, say they had too much paperwork to catch up on, and leave until morning shift arrived. A former night-shift LPN stated she had told administration that Delta needed another CNA on night shift. The DON stated the staffing pattern included one CNA for Delta on 6 p.m. to 6 a.m. shifts, and the Administrator stated this met staffing requirements. Daily assignment sheets for several dates documented one CNA and one licensed nurse for East/Center, one nurse for Delta and Gardens, two CNAs for Gardens, and one CNA for Delta on the overnight shift, while the facility census was 76 residents total across the units.
Infection Control Failures During Urine Cleanup, Dressing Change, and Water Management
Penalty
Summary
The facility failed to establish and maintain infection prevention and control practices during care and environmental cleaning. R35, whose diagnoses included spinal stenosis, type 2 diabetes mellitus, bipolar disorder, seizures, chronic diastolic heart failure, acute kidney failure, COPD, and GERD, was documented as frequently incontinent of bowel and bladder. On 04/14/2026, R35 was observed sitting in the dining room with a puddle of liquid under his wheelchair, and he rolled himself through the center hall to his room. A CNA was observed cleaning only part of the wet area in the dining room and stopping after cleaning about two feet outside the dining room, while wet spots were then observed the entire length of the hallway. Staff were observed walking through the wet spots and pushing wheelchairs through the urine on the floor. A CNA stated the puddle was urine from R35 being incontinent and that she cleaned it with bleach wipes, while an LPN stated she was unaware of the wet spots and would have housekeeping clean it up. The DON later stated the urine should have been cleaned up immediately and no one should have walked through it, and the Administrator stated staff should have cleaned the entire hallway. The facility also failed to follow standard infection control practices during a wound dressing change for R5. R5’s record documented diagnoses including sepsis, altered mental status, coronary artery disease, atrial fibrillation, and type 2 diabetes mellitus, and the MDS showed a BIMS score of 15 with intact cognition. R5 had an unhealed pressure ulcer/injury area and was ordered to have the left heel cleansed and covered with calcium alginate with silver and a dry dressing. During the dressing change, the ADON and CNA donned gowns and gloves, but the ADON handled the dressing materials and the resident’s heel, removed and replaced a glove without hand hygiene, and then adjusted the calcium alginate with both hands and reapplied the dressing without doffing gloves, hand hygiene, or new gloves. The ADON later stated she should have completed hand hygiene and donned new gloves before adjusting the dressing, and the Administrator stated staff were expected to follow standard infection control practices during dressing changes. The facility also did not maintain its Legionella water management practices for a closed unit. The Maintenance Director stated the old dementia unit with rooms 168 through 192 had been shut down for a long period of time and that he flushed the water lines on the closed unit every couple of weeks without keeping a record. He stated he did not know how long the area had been vacant and believed the water on the closed unit did not travel to other parts of the building. The Administrator stated she was not sure how long the area had been shut down, was not sure what the policy required for flushing frequency, and expected a log to be kept. The facility policy titled Legionella Water Management Program stated chlorine and pH were monitored at least every 4 days and areas with potential for bacterial growth were flushed every 4 days for 15 seconds at each point of stagnation. The facility application documented 76 residents living in the facility.
Antibiotic Stewardship Monitoring Not Established
Penalty
Summary
The facility failed to establish an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use and systems to monitor antibiotic outcomes. On 04/16/2026, the Director of Nursing presented an infection control log that included a floor plan for January 2026 through April 2026 and a monthly summary of antibiotics used during those months. The log was printed on 04/16/2026 at 12:48 P.M., but it did not document resident symptoms, whether any standardized criteria were used to justify and guide antibiotic use, when antibiotics were first initiated, whether response to treatment was monitored, or any laboratory results when available to guide appropriate antibiotic use. On 04/17/2026, the Regional Nurse stated she had been monitoring infections in the facility since January 2026 and said she did not have any tracking, but instead logged into the computer and looked at cultures to see if there was a pattern. The DON stated she started at the facility on 03/09/2026 and was not sure what the previous DON was tracking or how infections were being tracked; she also stated she was not sure there was any tracking being completed on antibiotics or what organisms were being monitored. The Administrator stated she was not sure what the previous DON was tracking and understood that the Regional Nurse, who is certified as an Infection Preventionist, was doing monitoring. The facility policy titled Antibiotic Stewardship - Review of Antibiotic Use and Outcomes, dated October 2017, stated antibiotic usage and outcome data would be collected and documented using a facility-approved antibiotic surveillance tracking form to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.
Infection Preventionist Not On Site
Penalty
Summary
The facility failed to employ an Infection Preventionist who remains on site for the infection prevention and control program. On 04/17/2026, the Regional Nurse stated she was responsible for the infection preventionist role until the Director of Nursing completed the course, and she was not sure how often she was actually at the facility because she logged in remotely and reviewed infections from off site. The DON stated she had not completed the course but would be taking it to become the infection preventionist. The Administrator stated the former employee who had been the infection preventionist quit without notice, and that the Regional Nurse was currently being used for the role even though she was not in the building every day and reviewed facility data remotely. The facility application dated 4/15/26 documented 76 residents living at the facility.
Late Quarterly MDS Assessments
Penalty
Summary
Quarterly MDS assessments were not completed within required time frames for 7 of 7 residents reviewed for quarterly MDS assessments in a sample of 51. The residents identified were R2, R20, R48, R57, R68, R72, and R81. Each resident had an ARD in March 2026, but on 04/15/2026 the regional nurse stated that each of these quarterly MDS assessments had not yet been completed. The residents had multiple diagnoses, including dementia, depression, schizophrenia, intellectual disabilities, seizures, diabetes, COPD, heart failure, chronic kidney disease, and other chronic conditions. The regional nurse stated the facility does not have an MDS nurse and that a regional nurse was trying to complete all of the MDSs, with corporate working on the overdue quarterly MDSs. The administrator stated a former employee quit without notice on 03/24/2026 and that she was not aware the former employee was behind on completing MDS assessments. The administrator also stated the company does not have a policy on when MDSs are to be completed and follows the RAI Manual, and that it was her expectation for MDSs to be completed on time.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete and transmit quarterly MDS assessments within the required timeframe for 4 residents in the sample. R8, admitted with diagnoses including metabolic encephalopathy, acute kidney failure, dementia, type 2 diabetes mellitus, anxiety disorder, essential hypertension, hyperlipidemia, GERD, and mood disorder, had a quarterly MDS submitted on 04/14/2026 with a target/due date of 03/03/2026 and a warning that the assessment was completed late by more than 14 days after the assessment reference date. R13, admitted with unspecified dementia, type 2 diabetes mellitus, Alzheimer's disease, chronic kidney disease, essential hypertension, hypothyroidism, delusional disorder, and B12 deficiency anemia, also had a quarterly MDS submitted on 04/14/2026 with a target/due date of 03/05/2026 and the same late-completion warning. R51, admitted with spinal stenosis, low back pain, polyosteoarthritis, cardiomegaly, generalized anxiety disorder, and essential hypertension, had a quarterly MDS submitted on 04/14/2026 with a target/due date of 03/03/2026 and a warning that it was completed late by more than 14 days after the assessment reference date. R56, admitted with unspecified dementia, generalized anxiety disorder, hypothyroidism, depression, and urinary tract infection, had a quarterly MDS submitted on 04/14/2026 with a target/due date of 03/06/2026 and the same late-completion warning. The Regional Nurse stated the facility did not have an MDS nurse and that a regional nurse was trying to complete all MDSs. The Administrator stated a former employee quit without notice on 03/24/2026, she was not aware the employee was behind on MDS assessments, the company did not have a policy on when MDSs are to be completed, and they follow the RAI Manual.
Failure to Offer Activity Packets to Residents Staying in Their Rooms
Penalty
Summary
The facility failed to ensure that residents who chose to stay in their rooms were offered activities for 4 of 4 residents reviewed for activities. R64, admitted 1/11/24 with diagnoses including chronic respiratory failure, major depressive disorder, heart failure, anxiety, and morbid obesity, stated that she had not received any activities she could remember and that she preferred to remain in her room rather than be transferred to a chair for dining room activities and meals. She reported that she used to receive puzzles, coloring items, and reading materials, but could not remember the last time they were provided, and said she would like to receive them again. R66, admitted 2/6/19 with unspecified dementia, COPD, and alcohol abuse, stated that he did not get daily delights or puzzles passed out to him and said he would like to receive word searches and puzzles to work on in his room or in the hall. R22, admitted 6/16/25 with anxiety, CHF, diabetic neuropathy, obesity, and anxiety disorder, stated that he did not get any daily handouts with activities and wanted to see what they were. R80, admitted 12/21/23 with generalized anxiety disorder, chronic respiratory failure, hypertension, morbid obesity, and urinary retention, stated that he did not recall ever receiving daily handouts with reading materials and puzzles and would like to see them and possibly work on some puzzles. The Activities staff member stated that daily delights, puzzles, and coloring pages were passed out in the dining room and also to residents who stayed in their rooms, but that there were days she did not make it to all rooms because she got behind. The Administrator stated that all residents should be receiving the activity packets whether they attended planned activities or not.
Unsafe Environment, Incomplete Fall Investigation, and Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide an environment free of hazards, implement appropriate interventions for falls, and provide safe transfers with a mechanical lift for four residents reviewed for accidents. The report describes multiple events involving residents with cognitive impairment and fall risk, including a resident with dementia and severe cognitive impairment who slipped and fell in the dining room after a powder-like substance was present on the floor. The resident’s care plan included interventions related to visual and cognitive impairment and keeping the floor free of glare, liquids, and foreign objects, but staff observed and later described the slippery substance in the dining room at the time of the fall. The facility also failed to follow its own fall-related process after a resident slid down in a wheelchair during lunch. The resident had dementia, agitation, diabetes with circulatory complications, bradycardia, and repeated falls, and the care plan required staff re-education on proper use of fall prevention devices. During the meal, the resident’s seat belt had been undone, the resident slid down until sitting on the wheelchair leg rest, and one CNA used her leg to hold the resident in place while another CNA assisted in moving the resident back into the chair. The LPN was notified, but stated that because the resident did not reach the floor, the occurrence was not reported to the DON and no intervention was implemented. The facility policy defined a fall to include an episode where a resident lost balance and would have fallen without staff intervention. The facility further failed to ensure that a resident ordered to be transferred with a mechanical lift was transferred with two staff members present. The resident had dementia, depression, anxiety, hallucinations, and an order for mechanical lift transfers, with the care plan also stating mechanical lift use with two assist. A CNA was observed completing the transfer alone, and later stated she knew two people were required but proceeded without getting another staff member. The DON and Administrator both stated that two staff members should always be present for mechanical lift transfers, and the facility policy stated that two staff members are required. In addition, for another resident who fell and was sent to the ER with severe hip pain, the event report investigation was left incomplete, including sections for fall history, date of fall, recent change of condition, and environmental issues, and the Administrator confirmed that the root-cause investigation was not completed.
Failure to Offer Meal Alternatives and Resident Food Choices
Penalty
Summary
The facility failed to offer food alternatives per resident preferences for 4 of 4 residents reviewed for meal alternatives in a sample of 51. R80, R64, R66, and R22 each had regular diets ordered, but during interviews they stated they were not given choices before meals and generally received whatever was served. R80 said he would not eat the carrots because they were served too often, ate the baked pasta, and discarded hard garlic bread; he also stated he never gets to make food choices before meals. R64 stated she was never asked what she wanted to eat before meals and wanted to know what other choices were available. She also stated she could only get coffee during breakfast hours and was told it was only available then. R66 stated he just ate what he got because he did not know there were other options to choose from, and R22 stated he did not get choices on meal options and only received what was served. The Dietary Manager stated that activities staff were supposed to meet with residents daily to review the menu and complete the menu for the following day, including planned alternatives, and on Fridays they filled it out for the weekend through Monday breakfast. Activities staff stated she filled out menus with residents during the day while doing activities. The facility meal substitutions policy dated 12/2016 states that appealing alternate options of similar nutritive value shall be available for all meals for residents who choose not to eat the food initially served or who request a different meal choice, and that alternates shall be offered to residents who refuse menu items.
Failure to Administer Ordered Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal immunizations for 4 of 9 residents reviewed for immunizations in a sample of 51. R18, R47, R62, and R64 were all over the age threshold referenced in the report and had diagnoses including dementia, depression, anxiety, hypertension, COPD, heart failure, and other chronic conditions. I-Care records showed no pneumococcal vaccines for R18, R62, and R64, while R47 had prior pneumococcal polysaccharide and Prevnar 13 vaccinations documented. Each of these residents had vaccine consent forms dated only by year 2026 and progress notes stating consent was obtained and orders were entered for Prevnar 20, but the vaccines were not administered at the time of the survey review. On observation of the medication room, surveyors found Prevnar 20 vaccines stored in the medication refrigerator for all four residents. The order dates on the vaccines were in March 2026, yet the vaccines remained in the refrigerator and had not been given. An LPN stated the vaccines had not been administered because the consents were not scanned into the chart. Another staff member stated she believed the residents now had consents. The DON stated that when the medical records employee quit, there was a pile of papers that needed to be scanned into the chart and that this had not been done. The DON further stated that nurses would not give Prevnar 20 until the consents were scanned into the chart. She also stated she had recently started at the facility, had just gained access to I-Care, had not yet reviewed who was up to date or needed vaccines, and was not aware that vaccines were in the medication refrigerator awaiting administration. The Administrator stated it was her expectation that vaccines be given when ordered and that staff follow the vaccination policy, but she was not aware the consents had been obtained but not scanned. The facility policy stated residents should be protected from incident of pneumonia by obtaining pneumococcal vaccines per CDC guidelines.
Incomplete POLST Documentation for Resident with Advance Directive
Penalty
Summary
The facility failed to sign and complete an IDPH Uniform Practitioner Order for Life Sustaining Treatment (POLST) form for one resident, R87, who was reviewed for advance directives. R87’s admission record documented an admission date of 4/05/2026 and diagnoses including unspecified dementia with anxiety, other chronic pain, cognitive communication deficit, pain, edema, and insomnia. The MDS also documented the admission date of 4/5/2026. During interviews on 4/15/2026, an LPN stated advance directives are located on the residents’ medication administration sheet in the EHR and that R87 did not have a POLST form in the EHR. The DON stated she does not handle POLST documentation but that it should be in the EHR under resident documents. The SSD stated she completes the POLST form upon admission, sends it to the physician, and scans it into the EHR; she had R87’s POLST form dated by family on 3/26/2026, but it had no physician signature. The Administrator stated the SSD should complete the POLST form, send it to the physician for signature, and upload it into the EHR, and that this should be completed within 24 hours of admission. The facility’s Advance Directive Policy stated advance directives will be respected in accordance with state law and facility policy, and that upon admission the resident will be provided written information concerning the right to refuse or accept treatment and to formulate an advance directive.
Failure to Maintain Clean Resident Equipment and Bed Area
Penalty
Summary
The facility failed to provide a clean, homelike environment for 2 of 2 residents reviewed for cleanliness. One resident with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and with severe cognitive impairment documented on the MDS, was observed self-propelling in a wheelchair that was in disrepair. The wheelchair had a bandage wrapped around both sides of the frame near the seat, and the frame was observed with red sauce, old cheerios, hair, and dirt. The resident’s non-slip grip under the cushion also had food stains on the outside of the cushion. The resident’s care plan noted unclear speech and difficulty finding words, with interventions to observe closely and anticipate needs as needed. A second resident’s bed frame was observed to be visibly soiled with dried food and spills, and the same condition was still present on a later observation. The Administrator stated that the resident likes to eat and drink in bed and spills a lot of food and is a messy eater, and said someone would be brought in to clean the bed frame. A CNA stated that night shift nursing staff are supposed to clean wheelchairs but that it was not being done, and also stated there was no documentation for the wheelchair being cleaned and did not know why there was a bandage on it.
Failure to Provide Written Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written transfer/discharge or bed-hold notification to the resident or the resident’s representative for 3 of 3 residents reviewed for discharge notification/bed hold. For R6, the record showed an admission date of 10/01/2025 and diagnoses including metabolic encephalopathy, acute kidney failure, unspecified dementia with behavioral disturbance, type 2 diabetes mellitus, anxiety disorder, depression, and mood disorder due to a known physiological condition. R6 was sent to the local emergency room by ambulance on 4/1/2026 and returned to the facility the same day, but the facility could not produce evidence that a bed-hold notice was provided to the resident or representative for that emergency room visit. For R2, the record documented an admission date of 11/22/2023 and diagnoses including unspecified dementia, major depressive disorder, anxiety, and visual hallucinations. R2 was sent to the emergency room after a fall with pain noted to the joint area on 12/5/25, and the facility could not produce evidence that a bed-hold notice was provided to the resident or representative. For R7, the record documented diagnoses including transient cerebral ischemic attack, paranoid schizophrenia, unspecified psychosis, type 2 diabetes mellitus, COPD, anxiety disorder, essential hypertension, and GERD. R7 was sent to the hospital on 04/13/2026 after being unresponsive to verbal stimuli and was later documented as admitted with acute encephalopathy and acute hypoxic respiratory failure, but the facility could not produce evidence of a bed-hold notice. The Administrator stated that social services used to do bed-hold and transfer documents, and that no one had been doing the forms; she also stated R7 was never given one.
Late Annual MDS Assessment
Penalty
Summary
The facility failed to complete R73’s comprehensive annual assessment and submit it on time. R73 was admitted on 03/03/2025 and had diagnoses including Alzheimer’s disease, unspecified dementia, chronic kidney disease stage 4, paroxysmal atrial fibrillation, unspecified systolic heart failure, and essential hypertension. A final validation report dated 04/14/2026 showed that the annual MDS had a target/due date of 03/04/2026 but was not completed until 04/14/2026, with a warning that the assessment was completed late, more than 14 days after the assessment reference date. The regional nurse stated the facility did not have an MDS nurse and that a regional nurse was trying to complete all of the MDSs. The administrator stated a former employee quit without notice on 03/24/2026 and that she was not aware the employee was behind on completing MDS assessments.
Failure to Refer Resident for PASARR Reevaluation After New Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident for PASARR reevaluation after a diagnosis of Schizoaffective Disorder, Depressive Type was added to the resident’s record. R28’s face sheet showed an admission date of 10/31/17 and listed Schizoaffective Disorder, Depressive Type with an effective date of 9/7/24. The resident’s MDS documented moderate cognitive deficits, and the care plan identified antidepressant medication for appetite and Schizoaffective Disorder, Depressive Type. However, the Illinois Department of Healthcare and Family Services Interagency Certification of Screening Results dated 10/31/17 indicated that nursing facility services were appropriate and that there was no reasonable basis for suspecting MI or DD, and there was no documentation that the resident was referred for reevaluation after the new diagnosis was added. During interview, the Behavioral Health Case Manager stated the resident had a long history of mental illness from prior community mental health services and had initially been admitted for skilled nursing care before later moving to the behavioral health unit. The Administrator stated there may be other residents in the facility who need to be rescreened for PASARR and said she would audit and have those residents rescreened. The facility policy stated that any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual authority for a level 2 resident review.
Failure to Date and Label Oxygen Tubing and Humidifier Bottles
Penalty
Summary
The facility failed to follow physician orders for dating and labeling oxygen tubing and humidifier bottles for three residents who were receiving oxygen therapy. R66 had diagnoses including COPD and centrilobular emphysema, and the physician ordered weekly changes of oxygen tubing and humidifier bottle with initials and date once a day on Saturday. Although the MAR documented weekly changes, the tubing observed on 4/15/26 had a label with a date of 3/14 and no time, and the humidifier bottle was not labeled with a date or time. The regional nurse confirmed the tubing date was 3/14 and that the tubing and bottle should be changed weekly and labeled as ordered. An LPN stated nursing was supposed to date and label the oxygen tubing when changed, and the regional clinical staff stated the equipment company services or switches out equipment as needed, but the tubing and bottle still should be dated and labeled when changed. R64, who had diagnoses including acute and chronic respiratory failure with hypoxia, secondary pulmonary arterial hypertension, and COPD, also had an order to change oxygen tubing and humidifier bottle weekly and initial and date once a day on Saturday. The MAR documented Saturday changes, but on multiple observations the tubing and humidifier bottle had no date or time showing when they were last changed. R64 stated the tubing was not getting changed as regularly as it used to and that one nurse would do it if working, otherwise it never got changed. R80, who had chronic respiratory failure and anxiety, had the same weekly oxygen tubing and humidifier bottle order with Saturday changes documented on the MAR, but the tubing and humidifier bottle were not labeled with the date and time of the last change when observed. The administrator stated the oxygen tubing should be labeled with the date and time of exchange as the order states.
Failure to Prevent Multiple Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse on the behavioral unit and other units, resulting in multiple altercations. One incident involved a resident with schizoaffective disorder and moderate cognitive impairment who was asleep in bed when she awoke to another resident, also diagnosed with schizoaffective disorder and anxiety disorder, standing over her with gloved hands placed over her mouth and nose and pushing down. The sleeping resident reported that the other resident was trying to kill her and yelled for her to get out of the room. Staff, including an LPN and a CNA at the nurses’ station, heard the yelling, observed the alleged aggressor coming up the hallway wearing medical gloves, and were informed by the victim that the aggressor had tried to cut off her breathing. Multiple staff interviews documented that the alleged aggressor did not deny placing her hands over the other resident’s mouth and nose and, in some accounts, demonstrated how she did it and stated she had planned it because she believed the other resident had taken fentanyl patches. A second incident involved a resident with severe dementia, expressive aphasia, and a history of cerebral infarction, who had care plan interventions for communication deficits and pain assessment. Another resident with dementia, cognitive communication deficit, and a care plan identifying wandering, verbal aggression, physical aggression, and resisting care was observed entering the first resident’s room. A CNA reported seeing the aggressive resident block the other resident in the room with her wheelchair in a corner and, before she could intervene, saw the aggressive resident kick the other resident above the knee. Nursing documentation confirmed that the resident was kicked by another resident, with no injury or complaints of pain noted at that time. A third incident occurred a few hours later and involved the same aggressive resident and another resident with unspecified dementia with behavioral disturbance, Alzheimer’s disease, seizures, generalized anxiety disorder, major depressive disorder, atrial fibrillation, delusional disorder, and chronic heart failure, who was severely cognitively impaired and care planned as at risk of abuse/neglect related to dementia. A CNA sitting at the nurses’ station witnessed the aggressive resident self‑propel her wheelchair behind this resident, who was seated in a wheelchair, and slap her on the back. The CNA separated the residents and notified nursing and administration. Progress notes and the facility’s incident reports documented that the aggressive resident had hit another resident in the back and that these were resident‑to‑resident altercations. Across these events, the facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and required steps to prevent further potential abuse while investigations were in progress, but the incidents demonstrate that residents were not kept free from physical abuse by other residents.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of significant weight changes for a resident as required by physician orders and the care plan. The resident was admitted with diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a moderate cognitive deficit per the MDS. The care plan identified a problem of risk for impaired nutrition and hydration, with an intervention to monitor weight and notify the provider of significant weight changes. Physician orders directed staff to obtain daily weights before breakfast and to notify the physician for weight gain greater than 3 pounds in 1 day or 5 pounds in 1 week, and also included an order for PRN bumetanide to be given for specified weight gains. The resident’s January weight records showed multiple instances where the notification parameters were met: a 3‑pound gain in one day on three separate dates and a 5‑pound gain in one week on another date. An LPN stated she noted a 3‑pound weight gain on one of those days and administered the PRN bumetanide but did not remember notifying the physician. The Regional Clinical Director reviewed the resident’s weights and progress notes and was unable to find documentation that the physician had been notified of the weight changes as ordered. The Nurse Practitioner who routinely followed the resident stated she had not been notified of any weight gains during that month and indicated that, if notified, she would have directed staff to administer the PRN bumetanide as ordered. The facility’s policy on obtaining and following physician orders states that if orders are not followed for any reason, the physician and DON will be promptly notified, which did not occur in this case.
Failure to Administer PRN Bumetanide per Physician Order Based on Weight Gain
Penalty
Summary
Surveyors identified a deficiency related to failure to ensure a resident was free from significant medication errors when PRN bumetanide was not administered as ordered. The resident had diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a Brief Interview for Mental Status score indicating moderate cognitive deficit. The physician’s order, effective since 12/08/2025, directed administration of bumetanide 1 mg by mouth daily as needed for weight gain of more than two pounds in one day or more than three pounds in five days. The resident’s care plan did not include a problem area related to medication administration. Weight records for the month showed multiple instances of weight gain that met the parameters for bumetanide administration. The vitals/weight report documented specific daily weights demonstrating that the resident met the criteria for bumetanide on several days. Based on these weights, the medication should have been administered on multiple dates, including 1/3, 1/6, 1/7, 1/9, 1/11, 1/16, and 1/22. However, review of the Medication Administration Record showed that on many days the medication entry was marked with initials in parentheses, which the Regional Clinical Director confirmed indicated the medication was not given. The Regional Clinical Director also confirmed that the medication should have been administered whenever the resident had the specified weight gain and that this did not occur on at least 1/6, 1/7, and 1/16, contrary to the physician’s order and the facility’s policy requiring physician orders to be followed or the physician and DON to be notified if not followed.
Failure to Initiate CPR Due to Lack of Code Status Documentation
Penalty
Summary
Facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive, despite the resident being a full code. The resident was discovered without a pulse or respirations by two CNAs, who then notified a Registered Nurse (RN). The RN did not know the resident's code status and did not initiate CPR, assuming the resident was a Do Not Resuscitate (DNR) because there was no documentation in the electronic medical record. However, the resident's progress notes and hospital discharge summary indicated that the resident was a full code. The care plan and physician order summary did not document the code status, and the POLST form was not completed during the resident's 12-day stay at the facility. Multiple staff members, including CNAs and nurses, were unaware of the resident's code status at the time of the incident. The CNAs relied on the RN for direction, and the RN failed to check or confirm the code status before pronouncing the resident deceased. The facility had a system in place to indicate code status with colored stars outside resident rooms and in the electronic medical record banner, but this information was either missing or not utilized. Staff interviews revealed confusion and lack of familiarity with the resident and the facility's protocol for determining and documenting code status. The failure to initiate CPR was contrary to facility policy, which states that in the absence of a documented code status, staff should treat the resident as a full code and begin CPR. The lack of documentation, incomplete admission paperwork, and failure to verify code status led to the resident not receiving life-sustaining measures when found unresponsive. The resident was pronounced dead at the facility without any attempt at resuscitation, and the incident was identified as Immediate Jeopardy due to the failure to provide basic life support as required.
Removal Plan
- V2 (Director of Nursing), V14 (LPN / MDS) and V20 (LPN) were educated by V10 (Regional Clinical Director) on code status policy, death of a resident and change of condition policy, and the CPR policy.
- V4 (Registered Nurse) was educated by V2 on Code status policy, death of a resident, change in condition policy, notifications, and CPR policy.
- V9 (Social Services Director) and V14 completed an audit of all residents to ensure an order for a code status was in place, POLST form was in place and care plan indicates the order appropriately.
- V3 completed an audit of all staff who are CPR certified and schedule a class for the staff who are not.
- V3 reviewed the facility policy on CPR.
- V2 initiated and completed the following in-servicing with all nursing staff on CPR initiation policy including immediate initiation of CPR for all full code residents when unresponsive, documentation of a death, code status when to initiate CPR and change in condition policy.
- V9 (Social Service Director) will be doing ongoing monthly audit to ensure all code status orders remain accurate and current.
- V2 (Director of Nursing) will monitor. Random audits of 3 resident records per week for accuracy of code status and 2 staff interviews to verify knowledge of protocol. Results will be reviewed by V1 (Administrator) and the Quality Assurance Committee monthly.
Failure to Formulate or Offer Advance Directive Upon Admission
Penalty
Summary
The facility failed to formulate or offer to formulate an advance directive for one resident upon admission, despite the resident having multiple significant medical diagnoses, including cerebral infarction due to embolism, acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, type 2 diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, and unspecified intellectual disabilities. The resident's face sheet and physician order summary did not include a code status or advance directive, and the care plan lacked a focused area addressing the resident's choices regarding advance directives. The POLST (Physician Order for Life-Sustaining Treatment) form was not completed at the time of admission, and there was confusion among staff regarding who was responsible for ensuring its completion. Interviews with facility staff revealed a lack of clarity and communication about the process for obtaining and documenting code status and advance directives. The administrator was unaware of the facility's policy on when POLST forms should be completed, and the social services director indicated a preference for residents to arrive with a completed POLST from the hospital. The social services director also noted that the resident was difficult to assess due to behaviors and a low BIMS score, and had not reviewed all hospital paperwork or ensured the POLST was completed. The nurse practitioner confirmed that no discussion had occurred with the resident's family regarding code status, and that in the absence of a POLST, the resident was automatically considered a full code. Facility policy required that written information about advance directives be provided to residents prior to or upon admission, and that staff inquire about the existence of any written advance directives. However, these procedures were not followed for this resident, resulting in a lack of documented code status or advance directive for 12 days after admission. Multiple staff members expressed uncertainty about their roles and responsibilities in this process, contributing to the deficiency.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three out of six residents reviewed for abuse. In one incident, a resident with unspecified dementia and anxiety was bitten on the wrist by another resident with severe dementia, behavioral disturbances, and other neurological and psychiatric diagnoses. The biting incident resulted in a bruise, and in response, the first resident grabbed the other by the shirt and slapped them on the face. Staff witnessed the altercation, and documentation confirmed the physical interactions and resulting injuries. Another incident involved a resident with dementia and behavioral disturbances who was struck on the shoulder by a recently admitted resident with severe cognitive impairment and a history of traumatic brain injury, bipolar disorder, and major depressive disorder. The striking occurred as the first resident was walking by the second resident's room, leading to a loss of balance and a fall that resulted in a right hip fracture. Witnesses, including CNAs and a wound care nurse, confirmed the sequence of events and the resulting injury. The resident who initiated the physical contact stated they were trying to prevent the other from entering their room. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm or mental anguish. Despite this policy, the incidents described demonstrate that the facility did not effectively prevent resident-to-resident abuse, as evidenced by physical altercations resulting in injuries such as bruising and a hip fracture. The report includes direct observations and statements from staff and residents involved in the incidents.
Failure to Provide Adequate Supervision During Ambulation Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to provide proper supervision during ambulation for a resident with severe cognitive impairment and a high risk for falls. The resident had multiple diagnoses, including unsteadiness on feet, dementia, and a history of fractures. The care plan and assessments indicated that the resident was dependent for mobility, required maximum assistance from two staff members, and was not safe to ambulate or stand unassisted. Despite these documented needs, the resident was left standing in the hallway while a CNA briefly left to retrieve a walker, during which time the resident fell and sustained a comminuted fracture to the right arm and elbow. Interviews with staff confirmed that the resident was unsteady, impulsive, and should not have been left alone while standing or walking. The CNA involved stated that he attempted to get the resident to sit back in the wheelchair and then moved a few feet away to get the walker, at which point the resident stumbled and fell into the handrail. Other staff, including LPNs, the DON, and the facility administrator, all acknowledged that the resident required continuous supervision and should not have been left unassisted during ambulation or while standing. The facility's fall management policy required individualized interventions and supervision for residents at high risk for falls, including the use of assistive devices and staff assistance as necessary. The failure to follow these protocols and provide adequate supervision directly resulted in the resident's fall and subsequent injury. Documentation and staff interviews consistently indicated that the resident's needs for supervision were well known but not adhered to at the time of the incident.
Failure to Provide Timely ADL Assistance and Call Light Response, Compromising Resident Dignity
Penalty
Summary
The facility failed to ensure timely assistance with activities of daily living (ADLs), specifically toileting, and did not respond promptly to call lights, compromising the dignity of several residents. One resident with severe cognitive impairment and frequent incontinence was observed repeatedly requesting help to use the bathroom over a 35-minute period, both verbally and by seeking out staff, but did not receive assistance. During this time, staff members, including CNAs and a patient aid, informed the resident that they could not help due to being occupied with feeding other residents, and the resident ultimately experienced an episode of incontinence in a public area, becoming visibly upset and distressed. Other residents also reported excessive wait times for call lights to be answered, with some stating they had to attempt self-toileting to avoid accidents, despite requiring assistance. Multiple residents described call light response times as too long, sometimes up to an hour, particularly during meal times or when staffing was reduced. Staff interviews confirmed that there were not enough CNAs on duty to meet residents' needs in a timely manner, and that they were instructed not to interrupt feeding to provide toileting assistance. Facility policies reviewed by the surveyor required prompt response to residents' requests for toileting assistance and call lights, and prohibited practices that compromise resident dignity. Despite these policies, staff actions and statements indicated that care was delayed due to staffing shortages and prioritization of other tasks, resulting in residents' needs not being met in a manner that promotes dignity and respect.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to monitor and deliver timely care to residents, as evidenced by multiple direct observations, interviews, and record reviews. During a lunch period on the Alzheimer's unit, a resident with severe cognitive impairment and incontinence repeatedly requested assistance to use the bathroom but was told by staff that they could not help her immediately due to being occupied with feeding other residents. The resident became visibly upset, cried out for help, and ultimately soiled herself after waiting for an extended period without assistance. Other residents were observed wandering unsupervised, attempting to exit the facility, and eating food from other residents' plates, indicating a lack of adequate supervision and timely care. Staff interviews confirmed that the unit was short-staffed due to a CNA leaving early, leaving only two CNAs and a patient aid (PA) present. Staff consistently reported that this level of staffing was insufficient to meet residents' needs in a timely manner, especially during busy periods such as mealtimes. Staff also described being unable to stop feeding residents to provide other necessary care, and noted that administrative and nursing staff were not available to assist during these times. The PA stated she was not permitted to provide direct care, further limiting the available support. The nurse manager and DON acknowledged the chaotic environment and agreed that more staff would be beneficial, particularly during meals and evenings. Additional documentation and interviews revealed similar staffing concerns on other units and shifts, including night shifts where a nurse was shared between two units and only two CNAs were present. Staff described delays in responding to alarms, providing incontinence care, and assisting residents with activities of daily living. One resident experienced a fall when staff were occupied elsewhere and alarms were not heard in time. Multiple staff members and residents reported that care was not provided in a timely manner due to inadequate staffing, and assignment sheets confirmed the low staffing levels. The facility's own policy stated that adequate staffing would be maintained to meet residents' needs, but this was not observed in practice.
Failure to Maintain Clean and Sanitary Dining Room Environment
Penalty
Summary
The facility failed to maintain the dining room floor in a clean and sanitary condition for all residents who dined in the Center and East Halls Dining Room. Over the course of two consecutive days, surveyors observed multiple dried liquid spots, including what appeared to be dried milk and other clear or semi-clear substances, as well as debris such as food particles, dirt, and maple tree seeds scattered throughout the dining room floor. These observations were made despite the presence of housekeeping staff, and the same spills and debris remained unaddressed from one day to the next. The administrator acknowledged that the cleanliness observed did not meet the facility's standards. Interviews with staff revealed concerns about the adequacy and consistency of cleaning practices. A housekeeper described the daily cleaning routine, which included cleaning tables, sweeping, mopping, and taking out trash, and stated that the current staffing level was sufficient. However, an LPN reported that housekeepers were not routinely sweeping and mopping as expected, leading nursing staff to sometimes clean areas themselves. Facility policy requires daily cleaning and immediate attention to spills or soiling, but these procedures were not followed, resulting in a failure to provide a clean, safe, and homelike environment for residents.
Failure to Provide Timely ADL Assistance and Scheduled Showers
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who required substantial help, resulting in unmet care needs. One resident with severe cognitive impairment, frequent incontinence, and a care plan requiring substantial assistance with toileting repeatedly requested help to use the bathroom over a 33-minute period. Despite her visible distress and repeated verbal requests to multiple staff members, she was not assisted in a timely manner. Staff were observed prioritizing feeding other residents and charting over responding to her toileting needs, and the resident ultimately urinated on herself while waiting for assistance. Interviews with staff confirmed that staffing shortages and task prioritization contributed to the delay, and documentation indicated that the resident was found with soiled clothing and incontinence products after the incident. Another resident, who was dependent on staff for bathing and required two-person assistance with transfers, did not receive scheduled showers for two separate six-day periods. The resident reported not having received a shower in two to three weeks, despite a physician's order for twice-weekly showers. Documentation errors were identified, with a CNA admitting to mistakenly recording showers that did not occur. There was also no documentation to support claims that the resident received bed baths during the missed shower periods. Staff interviews revealed that showers were often scheduled late at night, which may have contributed to missed care, but the resident denied refusing showers. The facility's own bathing policy requires regular and as-needed bathing assistance, but this was not followed for the residents in question. Staff and management acknowledged that the expected frequency of showers was not met and that residents should have been offered alternative hygiene care when showers were missed. The deficiencies were substantiated through direct observation, resident and staff interviews, and review of care plans and documentation.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide necessary person-centered care and services to residents with dementia, as evidenced by multiple direct observations and staff interviews. During a continuous observation of the Alzheimer's unit dining area, a resident with severe cognitive impairment repeatedly requested assistance to use the bathroom but was not promptly assisted by staff, resulting in visible distress and incontinence. Staff were observed prioritizing other tasks, such as feeding residents and documenting, and stated they were not allowed to interrupt these duties to assist with toileting. The resident's care plan did not include progressive, person-centered interventions specific to her dementia diagnosis. Another resident with moderate dementia and behavioral disturbances was observed wandering the hallways and eating food from other residents' plates, despite being on a mechanical soft diet. Staff redirected her only after she had already consumed food from multiple plates. The care plan for this resident also lacked individualized, progressive interventions tailored to her dementia-related needs. Staff interviews confirmed that residents frequently wander into other rooms and that there are insufficient activities and supervision to engage and monitor them effectively. A third resident with severe cognitive impairment was observed handling dirty dishes and smearing food on her hands without appropriate staff intervention until after the fact. Staff interviews and record reviews revealed that staffing levels were inadequate to meet residents' needs in a timely manner, and that activity programming was inconsistent and often disrupted. The care plans for all three residents reviewed did not reflect person-centered, progressive interventions for dementia care, and the facility's own dementia protocol was not followed as required.
Unsupervised Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Environmental Security
Penalty
Summary
A cognitively impaired, ambulatory resident with a diagnosis of Alzheimer's disease and a history of exit-seeking behaviors was able to leave the facility's Dementia Care Unit unsupervised and unwitnessed. The resident exited the building, walked approximately one block away, fell in the street, sustained a skin tear over the left temporal region and abrasions on both hands, wrists, and elbows, and then entered an unlocked private vehicle. The resident was found by an off-duty police officer, who noted confusion and inability to provide his address or explain his whereabouts. The resident was subsequently transported to the emergency room for evaluation and treatment of his injuries. The resident's care plan and elopement evaluation had previously identified him as being at risk for elopement, with interventions such as redirection, notification of staff, diversional activities, and 30-minute checks. Despite these interventions, staff were unable to effectively supervise the resident on the day of the incident. Staff interviews and documentation revealed that the resident had been displaying increased exit-seeking and challenging behaviors throughout the day, including attempts to open doors, requests for keys, and verbal aggression. Staff attempted various redirection techniques, but these were unsuccessful. At the time of the elopement, staff were occupied with other residents, and the resident was able to access an unlocked office, open a window, and push out the screen to exit the building without triggering door alarms. Further investigation found that the facility had several environmental and procedural lapses that contributed to the incident. The office door providing access to the window was left unlocked, and the window was unsecured. Additionally, the north exit door's alarm system was not functioning properly, allowing doors to be opened without alerting staff. Maintenance logs showed that door alarms were not being checked daily as required by facility policy, and staff were unaware of this requirement. Staffing levels were also cited as a concern, with staff reporting that increased supervision was not possible due to the number of residents and the level of care required on the unit.
Removal Plan
- R1 was placed on 30-minute checks.
- R1's Care Plan was updated to reflect elopement interventions.
- V9 ensured the office door from which R1 was believed to have accessed a window to elope was locked.
- V5 installed a self-locking doorknob, replaced the window screen and secured the window.
- All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Elopement Binder by V9.
- V5 installed a self-locking doorknob on the north hall shower room, and secured the window so as not to allow opening.
- V5 and V13, Corporate Regional Director, confirmed the north exit door did not automatically open with 15 seconds of pressure.
- V9 completed Elopement Assessments on all residents of the Dementia Care Unit.
- V14, Minimum Data Set Coordinator, completed a Care Plan audit on all residents of the Dementia Care Unit to ensure Care Plans addressed elopement risk.
- V13 reviewed the Resident Supervision Policy with no changes made.
- V2 and V15, LPN/Assistant DON, completed staff education on resident supervision with all staff.
- V13 completed education for V5 regarding window and door security.
- V5 will complete window and door audits daily for one week, twice weekly for two weeks.
- V2 will complete a Facility Activity Audit to identify exit seeking behavior of residents daily for one week, twice weekly for two weeks, and weekly for 4 weeks.
- V9 will complete an audit of the Elopement Binder to ensure it is up to date according to Elopement Assessments daily for one week, twice weekly for two weeks, and weekly for four weeks.
Inadequate Staffing on Dementia Care Unit
Penalty
Summary
The facility failed to provide adequate nursing staff on the Dementia Care Unit, which affected all 25 residents living on that unit. The Director of Nursing (DON) confirmed that the standard staffing pattern was one nurse and two CNAs per shift, but acknowledged that this was not always achieved due to CNA call-ins. Staff interviews revealed that the unit was often staffed with only one nurse and one or two CNAs, which was insufficient given the residents' high level of care needs, including incontinence, mechanical lift transfers, total feeding assistance, and behavioral supervision. Staff also reported that requests for increased staffing were denied by corporate administration. Family and staff interviews further documented the impact of inadequate staffing, including difficulty finding staff to assist with resident care and supervision, and instances where family members were called to help manage resident behaviors. Assignment sheets confirmed that on multiple occasions, only one CNA and a shared nurse were present on the Dementia Unit during overnight shifts. The facility's own staffing policy required adequate staffing to meet resident needs and regulatory requirements, but documented staffing levels did not consistently meet these standards.
Failure to Timely Notify POA After Resident Elopement and Injury
Penalty
Summary
The facility failed to promptly notify a resident's Power of Attorney (POA) and provide a comprehensive report following an elopement incident. The resident involved had diagnoses including Alzheimer's Disease and Hypertensive Heart Disease with Heart Failure, was severely cognitively impaired, and had a documented history of wandering and exit-seeking behaviors. The care plan included interventions such as redirecting the resident, notifying staff of exit-seeking tendencies, providing diversional activities, and conducting 30-minute checks. On the date of the incident, the resident was found by an off-duty police officer approximately 0.2 miles from the facility, sitting in a vehicle with visible injuries including a laceration on the left eyebrow and abrasions on the hands, wrists, and elbows. The resident was disoriented, unable to state his address, and was subsequently transported to the emergency department for evaluation. Medical records confirmed the injuries and noted that the resident had escaped from the memory care unit, tripped, and fallen on the street before being returned to the facility. The facility did not notify the resident's POA until after the resident had returned from the emergency department, several hours after the elopement and subsequent injuries occurred. The POA reported being upset about not being informed when the facility first became aware of the elopement and not receiving full details of the event. Facility policy required prompt assessment and notification of a resident's designated medical contact in the event of a change in condition, which was not followed in this case.
Failure to Follow Transfer Protocols Leads to Resident Falls
Penalty
Summary
The facility failed to safely transfer residents according to their Transfer Assessments and Care Plans, resulting in falls and injuries. One resident, who had severe cognitive deficits and required substantial assistance for transfers, fell during a transfer from the toilet to a wheelchair. The resident's wheelchair brakes were not properly locked, leading to a fall that resulted in a fractured rib and dislocated shoulder. The resident had a history of impulsive behavior and agitation, which contributed to the incident. Another resident, diagnosed with cerebral palsy and requiring maximal assistance for transfers, fell when a CNA attempted to transfer her without applying necessary interventions such as shoes, socks, and a leg brace. The resident's legs gave out during the transfer, and she was lowered to the floor by the CNA. The resident was not injured, but the failure to follow the care plan and use appropriate equipment was evident. A third resident, with moderate cognitive deficits and Parkinson's disease, fell during a transfer to a bedside commode. The CNA assisting the resident let go of the gait belt to adjust the resident's oxygen tubing, resulting in the resident losing balance and falling. The resident sustained minor injuries, including skin tears. The CNA was unaware that the resident required assistance from two staff members for transfers, highlighting a lack of adherence to the care plan and proper communication among staff.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of all 78 residents, particularly in providing care for Activities of Daily Living (ADL) and supervision during meals. This deficiency was observed through multiple instances where residents did not receive scheduled showers or bed baths due to staffing shortages. For example, one resident, who is dependent on two-person assistance for transfers, reported not receiving a shower for over a month and only occasionally receiving bed baths. Another resident, also requiring substantial assistance, similarly reported not receiving regular showers or bed baths, with staff confirming that showers were missed due to insufficient staffing. Additionally, the facility failed to provide adequate supervision during meal times, leading to incidents where a resident with cognitive impairments took food from other residents' plates. This lack of supervision resulted in residents not receiving their dietary requirements, as seen when one resident's meal was taken by another, and the replacement meal did not meet the original dietary specifications. Staff acknowledged the issue, noting that additional help would be beneficial to ensure residents receive proper assistance during meals. The facility's Director of Nursing and several Certified Nurse Assistants confirmed the staffing issues, noting that the facility technically had enough staff according to census but still struggled to meet residents' needs. The documentation discrepancies, such as incorrect charting of shower tasks, further highlighted the staffing inadequacies. The facility's policy mandates regular showers and adequate staffing to meet residents' needs, yet these were not consistently met, as evidenced by the observations and interviews conducted during the survey.
Failure to Maintain Dignified Dining Services and Resident Rights
Penalty
Summary
The facility failed to provide dignified dining services and maintain resident rights for four residents with cognitive impairments, including dementia and communication deficits. One resident, who was unable to complete a mental status interview, repeatedly took food from other residents' plates during meal times. This resident, who required supervision or assistance with eating, was observed taking ham from the plates of three other residents, all of whom also had cognitive impairments and required dietary accommodations. The incidents occurred despite the presence of staff, who were aware of the resident's behavior but did not prevent it. The facility lacked a policy for resident rights, and staff were observed attempting to address the situation only after the food was taken. In one instance, a Certified Nurse Aide offered a replacement meal to a resident whose food was taken, but the replacement did not match the original dietary order. The facility's staffing policy indicated that adequate staffing should be maintained to meet residents' needs, yet the repeated incidents suggest a failure to adequately supervise and protect residents during meals. The facility administrator confirmed the absence of a policy for resident rights, highlighting a systemic issue in addressing and preventing such deficiencies.
Inadequate Assistance with ADLs and Meals Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically eating and bathing, for several residents. Resident R55, who is cognitively intact but dependent on assistance for bathing, reported not receiving a shower for over a month due to staffing shortages. Despite being scheduled for showers twice a week, documentation showed multiple instances where the activity did not occur, and staff confirmed the lack of sufficient personnel to provide the necessary care. R55 expressed a willingness to receive bed baths but noted that these were also infrequent. Resident R63, with severely impaired cognition, also did not receive regular showers or bed baths as required. The care plan indicated a need for substantial assistance, yet documentation and staff interviews revealed that showers were often missed due to inadequate staffing. R63 reported not remembering the last time he received proper bathing care, and observations noted poor hygiene, including oily hair and body odor. Staff acknowledged the challenges in providing care due to the limited number of CNAs available during night shifts. Residents R71 and R52 experienced issues with meal assistance. R71, who requires supervision and assistance with eating, was left with her meal covered and unattended for an extended period, resulting in her not eating until a new tray was provided. Similarly, R52, who is dependent on assistance for eating, waited over an hour before receiving help with his meal. The facility's policy on maintaining adequate staffing was not adhered to, leading to these deficiencies in resident care.
Failure to Properly Assess and Document Restraint Use
Penalty
Summary
The facility failed to properly identify specific medical conditions or symptoms that necessitated the use of a physical restraint for a resident, referred to as R71, who was part of a sample of 50 residents. R71, who has diagnoses including dementia, type 2 diabetes mellitus, and anxiety disorder, was observed with a seatbelt restraint while in a wheelchair. The Minimum Data Set (MDS) for R71 indicated that restraints and alarms were not used, yet the care plan documented the use of a seatbelt due to cognitive decline and safety risks. The care plan also specified that the restraint should be removed during activities of daily living, dining, and leisure activities, but observations showed that the seatbelt was not undone during meals, and R71 did not attempt to remove it herself. Observations over several days revealed that R71's seatbelt remained fastened during meal times, and she did not make any movements towards her food or the seatbelt. Interviews with staff, including a Certified Nurse Aide and the Administrator, indicated uncertainty about when the seatbelt should be undone and whether R71 could remove it on command. The facility's policy on restraint use emphasized the need for ongoing documentation and assessment, including recording the duration of restraint use and attempts to reduce its use. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and assessment for R71's restraint use.
Failure to Conduct Level II PASARR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a mental illness diagnosis was referred to the appropriate state-designated authority for a Level II PASARR evaluation. The resident, identified as R48, was admitted with diagnoses of visual hallucinations and bipolar disorder. The initial Level I PASARR form indicated a need for a Level II evaluation due to the mental health conditions. However, the Level II evaluation was not conducted because the facility staff believed the diagnoses were related to other medical conditions such as Parkinson's disease and Lewy body disease. The Social Service Director (SSD) was unaware of the new bipolar disorder diagnosis and did not initiate a new Level I screen or the necessary Level II evaluation. The facility's policy requires coordination with the PASARR program to ensure appropriate placement of residents with serious mental disorders. Despite this policy, the staff did not notify the SSD of the new bipolar diagnosis, leading to a failure in conducting the required Level II PASARR evaluation. This oversight resulted in non-compliance with the PASARR requirements for residents with mental health conditions, as the resident did not receive the necessary evaluation to determine the need for specialized services.
Inadequate Supervision During Mealtime for Resident with Special Dietary Needs
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R28, during mealtime, which led to multiple incidents of the resident taking food from other residents' plates. R28, who has diagnoses including dementia, anxiety disorder, and dysphagia oropharyngeal phase, requires a mechanically altered diet and supervision or assistance with eating. Despite these needs, R28 was observed on several occasions taking regular consistency food, specifically ham, from other residents' plates and consuming it, which is not suitable for her dietary requirements. These incidents occurred over a period of time during a single mealtime, indicating a lack of adequate supervision. Staff members, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), acknowledged that R28 has a history of taking food from other residents and requires constant redirection. The facility's policy on consistency modified diets emphasizes the need for individualized diets based on residents' chewing and swallowing abilities, which was not adhered to in R28's case. Additionally, the facility's staffing policy states that adequate staffing should be maintained to meet residents' needs, which was evidently not sufficient in this instance, as R28 was able to repeatedly access inappropriate food items without proper intervention.
Failure to Adhere to Dietary Orders for Residents
Penalty
Summary
The facility failed to provide the diet as ordered for three residents, leading to deficiencies in meeting their nutritional needs. Resident 28, who has dementia and dysphagia, was observed receiving broccoli pieces that were not mechanically soft as per her dietary order. This inconsistency in food preparation could potentially impact her ability to safely consume her meals. Resident 71, who has dementia and a BMI less than 20, also received broccoli pieces that were not minced as required for her mechanical soft diet. The Dietary Manager acknowledged that the spreadsheet used for meal preparation did not differentiate between regular and mechanical soft diets, leading to the oversight. This failure to adhere to dietary orders could affect the resident's nutritional intake and overall health. Resident 66, who is at risk for impaired nutrition and hydration, did not receive finger foods as ordered. Instead, she was served mashed potatoes and gravy, which are not suitable as finger foods. The Dietary Manager admitted that the facility lacked a finger food menu, and the Registered Dietician was unaware of this issue. This lack of appropriate menu planning and execution could hinder the resident's ability to maintain adequate nutrition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during resident care, as observed in the actions of a Licensed Practical Nurse (LPN) and other staff members. The LPN did not wash or sanitize her hands between administering medications to multiple residents, even after handling used medication and water cups by their rims. This lapse in hand hygiene was acknowledged by the LPN, who admitted to being nervous and unaware of her failure to sanitize. The Director of Nursing confirmed that hand sanitization between residents is a standard practice expected of the nursing staff. Additionally, the facility did not implement enhanced barrier precautions for a resident with an open wound and an indwelling urinary catheter, despite signage indicating the need for such precautions. Both a Wound Care Nurse and a Certified Nursing Assistant performed care without donning protective gowns, contrary to the facility's policy. Although both staff members had received training on enhanced barrier precautions, they were unable to explain the principles or demonstrate proper adherence. The Director of Nursing acknowledged the need for further training on infection control procedures and enhanced barrier precautions.
Delayed Response to Call Lights Affects Resident Dignity and Care
Penalty
Summary
The facility failed to respond to residents' requests for assistance in a timely manner, impacting the dignity and quality of life for three residents. Resident R3, who is cognitively intact and requires a mechanical lift for transfers, experienced significant delays in receiving assistance, leading to discomfort and humiliation from sitting in urine and feces. R3 reported waiting up to four hours for assistance on weekends, causing pain in the coccyx area and anxiety about when help would arrive. Resident R6, with moderate cognitive impairment and requiring substantial assistance for transfers, also experienced delays in care. R6 reported waiting over an hour for call lights to be answered, which exacerbated pain due to existing wounds and the inability to reposition independently. R6 emphasized the need for more staff, particularly on weekends, to address these delays. Resident R7, who is cognitively intact and at risk for pressure ulcers, faced similar issues with delayed responses to call lights. R7 reported waiting up to an hour for assistance, which worsened pain in the coccyx area. Staff shortages were noted as a significant issue, with only two CNAs available to care for 34 residents on certain days, leading to extended wait times for residents needing assistance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by multiple instances of delayed response to call lights and inadequate care. Resident R3, who is cognitively intact and requires assistance with transfers, reported waiting up to an hour and a half for assistance, leading to pain and incontinence. On one occasion, R3's call light was observed to be unanswered for nearly an hour, and R3 expressed that the lack of staff was a consistent issue, particularly on weekends. Resident R6, who has moderate cognitive impairment and requires substantial assistance, also reported waiting over an hour for care, which exacerbated his discomfort due to existing wounds. Similarly, Resident R7, who is at risk for pressure ulcers, stated that the facility's staffing issues resulted in long waits for care, including the application of necessary creams to manage his condition. These delays in care were attributed to insufficient staffing, particularly on weekends, as noted by both residents and staff members. The facility's staffing records and interviews with staff members, including the Director of Nursing and Certified Nursing Assistants, confirmed the ongoing staffing challenges. The facility's policy requires adequate staffing to meet residents' needs, but the actual staffing levels often fell short, with call-ins and unfilled positions exacerbating the issue. The facility's failure to update staffing schedules accurately further complicated the situation, leading to inadequate care and unmet resident needs.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean, sanitary, and pest-free condition, which has the potential to affect all 85 residents. During a kitchen tour, several issues were observed, including the absence of paper towels at the handwashing sink, jelly packets, and cereal pieces on the storeroom floor, and food particles, dust, dirt, and debris scattered throughout the kitchen. Dead bugs, including roaches, were found on a paper bait trap and behind the oven. Additionally, bones were found on the floor under a metal table, and a towel under a leaking sink was brown and speckled. The Dietary Manager, V5, stated that the morning and evening staff are responsible for cleaning the kitchen, but was unaware of the bugs, debris, and bones on the floor. The facility's pest control measures were inadequate, as V1, the Temporary Administrator, acknowledged the presence of roaches in the kitchen and stated that the pest control company had been spraying routinely. However, the Pest Control Employee, V17, noted that cleanliness was an issue and that bugs would not be attracted to bait with food particles present. The facility's cleaning schedule policy, dated February 2012, requires a comprehensive cleaning schedule to be posted and monitored, but V5 admitted to discarding the old schedule after creating a new one. Despite the expectation for the kitchen to be cleaned continuously, the facility failed to adhere to its cleaning and sanitation policies, resulting in unsanitary conditions.
Pest Control Deficiency Due to Ineffective Program and Cleanliness Issues
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and bed bugs, which could potentially affect all 85 residents. The issue began when a resident was admitted with bed bugs, and the problem was exacerbated when the resident's family brought in clothes infested with bed bugs. Despite initial attempts to isolate the issue by moving the resident's roommate and conducting tape tests, the facility did not follow its policy due to the inability to locate it on the server. The pest control company was eventually called to treat the affected rooms, but the treatment was delayed. In the kitchen, the facility had ongoing issues with roaches, as evidenced by food debris and dead bugs found on the floor and behind equipment. The pest control company had been conducting routine treatments, but the problem persisted due to cleanliness issues. The pest control employee noted that the presence of food particles hindered the effectiveness of the bait traps. Despite assurances from the pest control company that a new treatment plan would resolve the issue, the facility continued to struggle with maintaining a clean environment, which contributed to the pest problem. Interviews with staff revealed that the facility had a history of pest issues, with staff reporting sightings of bugs in the kitchen and dish room. The facility's pest control policy required routine inspections and monitoring, but the lack of cleanliness and delayed response to pest sightings indicated a failure to adhere to these procedures. The facility's inability to promptly address the pest issues and maintain a clean environment led to the deficiency noted in the report.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse of a resident by another resident with a known history of aggression. Resident 1, who has severe cognitive impairment, was physically abused by Resident 2, who also has severe cognitive impairment and a history of aggressive behavior. Resident 2, who was admitted with diagnoses including Moderate Dementia with Agitation and Intermittent Explosive Disorder, exhibited aggressive behavior towards Resident 1 on multiple occasions. These incidents included slapping, choking, and hitting Resident 1, which were witnessed by staff and reported by Resident 1's family. Despite previous interventions, Resident 2 continued to exhibit aggressive behavior towards Resident 1, leading to two documented incidents of physical abuse. The facility's records and staff interviews confirmed that Resident 2 had physically attacked Resident 1 on at least two occasions, causing fear and insecurity for Resident 1. The facility's failure to effectively manage Resident 2's aggressive behavior and protect Resident 1 from abuse constitutes a deficiency in providing a safe environment for its residents.
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Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Olney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Helia Healthcare Of Olney | 0.7 mi | ★★★★★ | 21 | 0 |
| The Haven Of Bridgeport | 17.1 mi | ★★★★★ | 6 | 0 |
| Helia Healthcare Of Newton | 17.9 mi | ★★★★★ | 1 | 0 |
| The Haven Of Ridgeview | 20 mi | ★★★★★ | 3 | 0 |
| Axiom Gardens Of Flora | 22.2 mi | ★★★★★ | 19 | 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 October 2026) and official state health department websites.