Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Galesburg during CMS and state inspections, most recent first.
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
A resident with dementia, legal blindness, hearing loss, hallucinations, and a history of falls was left unsupervised in a lounge area after being placed in a wheelchair for breakfast. Staff reported he frequently tried to stand, was restless, and was unaware of his strength level. He later fell with a turned-over table and sustained traumatic right-hand injuries, including amputation of the right long finger and injury to the right ring finger, with hospital records showing fracture and revision amputation.
Food Storage, Hand Hygiene, and Sanitation Deficiencies: A dietary employee handled raw chicken and spice containers with the same gloves, later used bare hands to grab a bun while assembling a cheeseburger, and multiple refrigerators and storage areas contained improperly dated food items and visible debris. The kitchen ice machine, scoop holder, walk-in cooler, nourishment fridge, and dry storage area all had accumulated dirt, debris, or staining, and the DM reported different departments were responsible for checking some resident food storage areas.
Water Management Program Not Active or Ongoing: The facility failed to maintain an active and ongoing plan to reduce the risk of Legionella and other OPPP. Surveyors observed dead end water lines in the kitchen, a spa tub used for storage, hoppers and shower stalls with no evidence of regular flushing, and multiple fixtures with hot water handles off or stagnant lines. The MD was unsure whether several tubs, showers, and utility room fixtures were used or flushed regularly, and review of the Water Management Program found no risk assessment with a written or visual description of the building water systems.
Dignified Dining Experience Not Maintained During Meal Service: Several residents on the SCU did not receive their dinner trays at the same time as their tablemates, and a second meal cart had to be brought later. One resident with dementia, aphasia, anxiety, and confusion was observed waiting while others ate, two residents with dementia-related conditions received trays only after a delay, another resident became upset and left the room after asking for dinner, and a blind resident had his tray placed on a nightstand before later being assisted with eating. Staff and the DON stated that residents seated together should be served at the same time because it is a dignity concern.
A facility failed to maintain a quiet, homelike nighttime environment when multiple cognitively intact residents reported that 3rd shift staff were loud, slammed doors, talked and laughed at the nurse’s station, and woke them from sleep. Residents with anxiety, insomnia, adjustment disorder, and OSA described repeated overnight disruptions, and Resident Council notes documented ongoing complaints about night shift noise.
Incomplete and inaccurate resident documentation was found for multiple residents involving one-to-one monitoring, wound care, showers, a wander guard, splint use, and a left-hand orthosis. Records contained missing TAR entries, blank shower documentation, and inaccurate charting that did not match staff reports or survey observations. Staff and the DON acknowledged that refusals and monitoring should have been documented, but the chart often showed no entry or conflicting information.
Unsanitary and poorly maintained housekeeping conditions were observed throughout the facility. Surveyors found stored supplies on the floor in central supply, used gloves and razors in a spa room, heavy debris under a shower bed, a nonworking shower call light, soiled over-the-bed tables, trash and dirt in resident rooms, and dried liquid spots in a hallway. Staff interviews confirmed housekeeping shortages, incomplete daily cleaning, and repeated missed room cleanings, and resident council notes documented ongoing complaints about rooms and hall cleaning.
A resident with multiple chronic conditions had no hospice care plan in the medical record even though hospice services were being provided. Another resident with stroke-related weakness, contracture, and toe amputation had orders and a care plan for a prevalon boot and pressure-relief orthotics, but staff observed the resident without the boot in bed and in a Broda chair, and refusals to wear the device were not documented.
A resident with hemiplegia and a left-hand contracture was ordered to wear an air bladder hand orthosis to help manage contracture risk, but staff repeatedly observed the device off and left on a dresser instead of on the resident’s hand. CNAs and nursing staff acknowledged the resident had not been wearing it for weeks, and the record showed missing TAR documentation and little documentation of refusals, despite the DON stating refusals should be documented.
Failure to Implement RD-Recommended Supplements: A resident with a stage 3 sacral pressure ulcer, stroke with left-sided hemiplegia, anxiety, major depression, and chronic pain had repeated RD recommendations for vitamin C and zinc to support wound healing. Although the resident had variable intake and did not always eat facility meals, no physician orders were entered for the supplements, and the RD and DON acknowledged the recommendations were not implemented.
Improper dumpster storage and trash accumulation were observed when the dumpster doors were found pushed open, allowing pests and precipitation to enter. The MD stated staff had difficulty tossing trash bags into the dumpster unless the doors were opened, and excess trash, used gloves, and debris were found around the garbage area.
Failure to Track and Document Flu and Pneumococcal Vaccinations: The facility failed to track and offer influenza and pneumococcal vaccines for 3 of 5 residents reviewed, and there was no documentation of declination for those residents. One resident with multiple chronic conditions was not offered PCV20 or PCV15 after turning 65, another resident’s PCV20 refusal lacked a signed declination, and a third resident’s record showed refusal of flu and pneumococcal immunizations despite a consent for influenza vaccination and no influenza vaccine given.
A resident in an LTC facility, with a history of cerebral infarction and dysphagia, was hospitalized for respiratory distress and unresponsiveness. Despite not being prescribed opioids, the resident tested positive for morphine, suggesting a medication error. The resident's roommate was prescribed morphine, raising concerns about a possible mix-up. The facility's investigation could not confirm how the resident received the opioid, resulting in a deficiency citation.
The facility failed to ensure a dignified environment for residents, with incidents involving staff harassment and inappropriate behavior. A resident felt harassed by a CNA demanding smoking materials, while another incident involved a CNA swearing and slamming a door in front of a cognitively impaired resident. Additional concerns were raised about the rude demeanor of some CNAs, affecting the overall dignity and respect for residents.
A resident with severe cognitive impairment and a history of serious medical conditions was given the wrong medication, leading to a suspected opioid overdose and hospitalization. Despite the incident's severity, the facility did not report it to the State Agency, as the Nursing Home Administrator and DON believed there was no deficient practice to report.
A facility failed to follow physician orders for continuous enteral feeding for a resident, resulting in the feeding being stopped daily against orders. Additionally, the facility did not timely re-weigh the resident after a significant weight change. Another resident experienced a delay in pain assessment and treatment, as staff did not promptly address the resident's complaints of pain. These deficiencies highlight lapses in adhering to professional standards of care.
The facility failed to label and store insulin pens correctly, leading to potential medication efficacy issues. A new nurse was unaware of the labeling policy, and the DON initially miscommunicated the procedure, resulting in insulin pens being improperly managed.
An LPN's lack of specialized dementia care training led to distressing interactions with three residents, resulting in agitation and stress responses. The LPN's unprofessional behavior, including yelling and using profanity, was observed during incidents involving residents with cognitive impairments. The facility's failure to provide comprehensive training contributed to these deficiencies.
The facility failed to meet food safety standards, with improper food storage and labeling observed in various refrigeration units. Cleanliness issues were noted in the kitchen, including debris accumulation and inadequate cleaning of utensils and equipment. The Dietary Manager acknowledged supplier issues and inconsistent staff practices.
The facility failed to protect the potable water supply from plumbing cross connections, risking contamination. A kitchen mop sink was improperly connected to a chemical system, causing back pressure on the faucet's AVB. In the beauty shop, a dish sprayer replaced the hair washing sink's spray, creating a stop downstream of the AVB. The SCU janitor sink's wasting tee was plugged, preventing pressure relief and causing leakage and corrosion.
Two residents in the facility were found without accessible call lights, hindering their ability to request assistance. One resident's call light was out of reach, while another had no call light due to room setup. Staff were unaware of these issues until identified during observations.
A facility failed to update a resident's DNR order timely, resulting in a discrepancy between the resident's preferences and the Electronic Health Record (EHR). The resident, diagnosed with dementia, was listed as a full code in the EHR despite having a DNR order signed by the guardian. The facility's process of updating code status to full code for residents returning from the hospital and delays in document uploads contributed to the issue. Staff interviews revealed a lack of follow-up and no process to ensure pending forms were completed, leading to the failure to update the resident's code status.
A resident's room in the facility was found to be unsanitary, with a persistent fecal odor, gnats, and unclean conditions despite housekeeping efforts. The issues were linked to the roommate's habits of leaving open snacks and drinks, and the facility's failure to address ongoing housekeeping concerns raised in Resident Council Meetings.
A resident with a history of stroke and mobility issues reported missing clothing and had concerns about laundry services. Despite being cognitively intact, the resident did not receive timely follow-up from the facility after submitting a complaint form. The NHA was unaware of the issue, and no grievance form or investigation was documented. A housekeeper admitted to not completing a grievance form, highlighting a failure in the facility's grievance handling process.
The facility failed to notify the State LTC Ombudsman of transfers and discharges since January 2023. The NHA was unaware of the requirement, and the task was neglected after the responsible nurse manager left the facility.
The facility failed to provide written notification of the bed hold policy to two residents upon their transfer to hospitals. One resident with muscle weakness and another with dementia were transferred without receiving the necessary documentation. The Admissions Staff Member responsible for this task admitted to missing it for one resident and was unaware of the other's transfer.
The facility failed to complete PASARR Level II evaluations for two residents with mental health diagnoses, leading to potential unmet mental health care needs. One resident had significant psychiatric conditions and medications, but their Level II evaluation was delayed due to a submission error. Another resident's need for a Level II evaluation was overlooked by the social worker, despite confirmation from the MDS nurse. The facility did not submit the required documentation for comprehensive screening.
The facility failed to develop and implement person-centered care plans for two residents, one with a psychotic disorder and another with pressure ulcers. The absence of a care plan for antipsychotic and antidepressant use for a resident and the lack of proper positioning and protective measures for another resident with pressure ulcers were observed. Staff interviews confirmed the non-implementation of required interventions, despite existing care plans.
A facility failed to follow physician orders for oxygen administration for a resident, resulting in the oxygen being set at 4 liters per minute instead of the prescribed 2 liters per minute. An LPN confirmed the error and noted a lack of communication from the previous shift about any need for increased oxygen. The LPN also acknowledged that any change in oxygen rate required a physician's order, which was not obtained.
The facility failed to have an RN on duty for 8 consecutive hours on specific dates, leading to potential unmet care needs. Interviews and record reviews showed no RN was scheduled or signed in on those days. The NHA and DON did not assess or document the impact on residents, and although RNs were on call, none were present in the building.
A resident with multiple mental health diagnoses and on psychiatric medications did not receive necessary behavioral health care services. The facility failed to develop a care plan for the resident's conditions and medications, and there were no records of psychiatric service visits or behavioral health referrals. Staff interviews revealed that a required PASARR level 2 screening was not completed, and the resident was not referred to psychiatric services as needed.
A facility failed to discontinue a PRN psychotropic medication after 14 days and did not document a rationale for extending its use for a resident with dementia and severe cognitive impairment. The resident had a physician order for Lorazepam, administered as needed for anxiety, with no stop date. The medication was given 10 times in September, and the PA acknowledged the need for a 14-day stop date for reevaluation.
A facility failed to maintain complete documentation in the treatment administration records for a resident with severe cognitive impairment and multiple wounds. Required dressing changes were not documented on several occasions, indicating potential non-compliance with treatment orders. Interviews with staff confirmed that missing documentation implied the tasks were not completed, highlighting a failure in maintaining accurate medical records.
The facility failed to ensure proper hand hygiene and PPE use during enteral feeding and resident showers, leading to potential infection risks. An LPN did not perform hand hygiene or change gloves while administering feeding to a resident, and staff did not adhere to PPE protocols for residents in enhanced barrier precautions during showers. Additionally, shared equipment was not sanitized between uses.
A facility failed to ensure accurate assessments and documentation for three residents, leading to potential health risks. A resident received an insulin injection without a prescription, resulting in sickness and fear. Another resident, prescribed insulin, had inadequate monitoring and documentation of blood sugar levels. A third resident with skin discoloration experienced delayed assessment and documentation. Staff inconsistencies and lack of proper documentation contributed to the deficiency.
The facility failed to protect a resident from verbal and physical abuse by another resident, resulting in fear, increased agitation, and psychiatric hospitalization. In another incident, the facility failed to protect a resident from physical abuse by another resident, despite being aware of the aggressor's history of aggressive behavior.
The facility failed to initiate appropriate treatment measures for a resident with multiple skin integrity concerns, leading to severe health decline and hospitalization. Despite staff observations of swelling, pain, and functional decline, no treatment orders were obtained, and the resident developed sepsis and an ankle abscess requiring multiple surgeries.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Supervise High-Fall-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with dementia, legal blindness, hearing loss, hallucinations, a history of falls, impaired gait, impaired mobility, and muscle weakness. The resident’s care plan identified him as high risk for fall-related injury and noted that he was unable to ambulate and required maximal assistance, with interventions including wheelchair anti-rollbacks, therapy evaluation, and later a bedside commode for safety. Records also showed use of a self-releasing belt as an enabler device and therapy involvement for wheelchair safety and seating needs. On the day of the incident, staff placed the resident in a lounge area for breakfast and left him unsupervised. Staff interviews described that he frequently attempted to stand, was restless and anxious, and was unaware of his strength level. One staff member reported the resident was toileted before being left in the lounge, while another reported he was being monitored at the nurse’s station area. The resident was later found on the floor beside a turned-over table, lying on his right side, with his wheelchair nearby or rolled away, and he was responsive to verbal stimuli. The fall resulted in traumatic injury to the resident’s right hand, including amputation of the right long finger and injury to the right ring finger, with bruising/redness also noted to the face, shoulders, lower extremities, and right hand. Hospital follow-up documented a comminuted fracture of the distal fourth phalanx and revision amputation with nail bed removal of the right ring finger, along with repair of the damaged right long finger. Subsequent notes also described repeated attempts by the resident to stand from the wheelchair and a later assisted lowering to the floor during toileting, with no immediate intervention put in place to ensure safety after that event.
Food Storage, Hand Hygiene, and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food service safety practices in the kitchen and in resident and activity area refrigerators and storage spaces. During observation of the two-door cooler, a tub of nourishment shakes and snacks used for tray line was found dated for a week at a time, and half a dozen Magic Cups were stored inside the tub even though the manufacturer’s directions stated they must be consumed within five days under refrigeration. In the activity rooms pantry refrigerator and resident refrigerator, multiple items were found past or lacking proper date marking, including unopened yogurts, an unopened chicken bowl, vanilla pudding, a container of chili with no name and date, milk cartons with best-by dates, and Ready Whip containers with use-by dates from July 17, 2025. The Dietary Manager stated that the activities department takes care of the resident refrigerator and kitchen staff stock and check the pantry refrigerator. The report also documented unsafe food handling by a dietary employee while preparing raw chicken for lunch. The employee used the same gloves that had handled raw chicken to add spices from original containers, with the gloves visibly wet and greasy, and then stopped, discarded the gloves, and washed hands when questioned. Later, on the serving line, the employee used bare hands to grab a hamburger bun to assemble a cheeseburger and then put gloves on to add cheese. The report further identified sanitation concerns in multiple food service areas. The walk-in cooler had debris on wire slats and dirt and debris on the floor juncture, corners, and rack legs. The kitchen ice machine had black debris on the inside plastic lip, and debris and items including plastic lids, plastic bags, and a nutritional cup were found underneath and behind it. The ice room scoop holder had heavy black spotted debris, the activity fridge freezer and nourishment fridge had yellow debris, staining, dust, and black spotted debris, and the dry storage room had debris along the back floor and wall with plastic spoons and a nutritional cup present.
Water Management Program Not Active or Ongoing
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation, multiple water fixtures and plumbing components were found in conditions suggesting they were not being routinely used or flushed, including three dead end water lines at the kitchen hand sink on the cook line, the three compartment sink, and the single compartment preparation sink. The hot water handle was not on the kitchen faucet, which did not allow for use or easy flushing of the water line. Additional observations found a spa tub in the central bath surrounded by resident equipment and used for storage, with the Maintenance Director unsure whether it was used or flushed regularly. In the skilled hall soiled utility room, the hopper had no running water from the spray or the hot side of the overhead faucet, and the Maintenance Director was unsure if it was flushed. In the [NAME] Hall shower room, two of three shower stalls had items stored in them and appeared not to be regularly used, and the Maintenance Director was unsure whether they were used or flushed. In the [NAME] Hall soiled utility room, the hot water on the overhead faucet was not turned on, indicating a stagnant line. In the Birch Hall weight room, a shower stall was present in the back left corner, and the Maintenance Director was unsure if the shower spray was flushed regularly. In the Birch Hall soiled utility room, brown and discolored water came from the hot water fixture of the hopper faucet, and the spray to the hopper was not turned on, indicating a stagnant line. Review of the facility's Water Management Plan and related meeting minutes found only the previous Maintenance staff present and no risk assessment with a written or visual display describing the building water systems.
Dignified Dining Experience Not Maintained During Meal Service
Penalty
Summary
The facility failed to provide a dignified dining environment for five residents on the Specialty Care Unit when dinner trays were not delivered to all residents seated at the same time. During observation, the meal cart on the SCU had no other meals on it and staff reported that more meals still needed to be brought by dietary staff. At that time, Residents #35, #39, #42, #57, and #7 either had not received meal trays or were waiting for staff assistance with their meals. A second cart was later brought to the unit, and the remaining residents received their meals after a delay. Resident #35, a female with dementia, aphasia, anxiety, and confusion, was observed looking around the dining room while her table mate was nearly finished eating and later eating dessert before she received her tray. Resident #39, a male with anemia, dementia, PTSD, vitamin D deficiency, and mixed irritable bowel syndrome, and Resident #42, a male with traumatic brain injury, dementia, mild intellectual disabilities, seizures, and signs and symptoms concerning food and fluid intake, were seated together with another resident who already had a tray, and they did not receive theirs until the second cart arrived. Resident #57, a male with diabetes, dementia, kidney disease, GERD, edema, stroke, and anxiety, asked for his dinner after seeing others receive theirs and later left the room upset after stating he did not like what was served. Resident #7, a male with dementia, legal blindness, and hearing loss, had his tray delivered to his room and placed on his nightstand while he remained lying with his head in the opposite direction; he was later assisted with eating after telling staff he was hungry. Staff and the DON stated that residents seated at the same table should receive their meals together because it was a dignity concern when one resident was eating while another had not yet received a meal.
Night Shift Noise Disrupted Resident Sleep
Penalty
Summary
The facility failed to maintain a quiet, homelike environment in resident areas at night. Multiple cognitively intact residents reported that third shift staff were loud, talked and laughed at the nurse’s station, slammed doors, and hollered in the hallways during overnight hours. Residents stated that the noise woke them up, disrupted their sleep, and caused frustration and dissatisfaction with the nighttime environment. Resident #15, who had a diagnosis of anxiety and a BIMS score of 15/15, stated that third shift staff were loud and did not care if they woke residents. Resident #54, who had insomnia and a BIMS score of 15/15, reported that staff slammed doors and hollered all night long. Resident #33, who had anxiety and insomnia and a BIMS score of 15/15, stated that third shift CNAs talked loudly in the hall and disrupted sleep. Resident Council meeting notes also documented repeated complaints about night shift slamming doors across multiple meetings. Resident #79, who had adjustment disorder, a history of falling, and a BIMS score of 15/15, reported that staff gathered outside her door, talked and laughed while she was trying to sleep, and that she was tired from being kept awake. Her care plan included interventions to create a quiet environment for altered sleep patterns. Resident #20, who had obstructive sleep apnea and a BIMS score of 15/15, reported that staff were laughing and carrying on loudly at about 5 AM and woke her up. A guest assistance form documented the same complaint, and staff interviews confirmed that noise complaints had been raised about third shift activity.
Incomplete and Inaccurate Resident Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, with missing or inaccurate documentation related to one-to-one monitoring, wound treatments, showers, a wander guard, splint use, and a left-hand orthosis. The report identified deficiencies for 7 of 18 residents reviewed, including residents with dementia, cognitive impairment, pressure ulcers, paralysis, contractures, and elopement risk. Surveyors reviewed records, observed residents, and interviewed staff and residents to verify that documentation was absent or did not match what was observed or reported. For one resident with Alzheimer’s disease, dementia, hallucinations, and anxiety, the record showed multiple instances of missing one-to-one monitoring documentation, including two full days with no entries. Staff stated that one-to-one monitoring required documentation every 15 minutes and that the nurse was responsible for ensuring the checklist was completed and reviewed. The DON stated missing entries meant the facility could not ensure the resident’s safety because it was not known whether the resident was monitored, eloped, or fell. For another resident with a stroke, hemiplegia, depression, chronic pain, and a stage 3 sacral pressure ulcer, the TAR contained multiple missed entries for ordered wound treatments in both August and September. The resident stated wound treatments were supposed to be changed twice daily but were not always completed as ordered. Staff reported the resident often refused wound care and that refusals should have been documented in the treatment record, but the record contained numerous blank entries instead. Additional record failures were identified for residents receiving showers, a wander guard, splints, and a hand orthosis. One resident with moderate cognitive impairment had multiple days with no documentation showing whether showers were given or refused, and another cognitively intact resident had two days with no shower documentation and reported staff did not return later if he was unavailable. A resident at risk for elopement had a wander guard in use without a current physician order in the chart, and staff acknowledged the order had been missed after a hospital return. Another resident with quadriplegia and contractures had inconsistent splint documentation, including blank entries and a charted indication that the splint was worn when staff later stated it had not been. A resident with hemiplegia and a left-hand contracture had a left-hand orthosis frequently not in place, with blank TAR entries and no additional documentation of refusals, while staff and the DON acknowledged the resident often did not wear it.
Unsanitary and Poorly Maintained Housekeeping Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment. On 9/8/25, surveyors observed numerous items stored on the floor and underneath storage racks in the central supply room, including personal hygiene products and resident care items such as gauze and oxygen supplies. In the [NAME] Hall spa room, used gloves, a used razor, and used plastic razor guards were found spread on the floor, and the underside of the shower bed had an excess accumulation of what appeared to be skin flakes, hair, bowel movement, and dirt debris. In the Birch Hall spa room, washcloths were laid out next to the sink, the shower call light cord was brown and black with visible accumulation, and the call light did not activate an audible response in the hall when tested. Surveyors also observed unsanitary conditions in resident rooms and hallways. An over-the-bed table in room [ROOM NUMBER] on the west hall was soiled with a dry, sticky spilled substance, and the floor had dirt, crumbs, brown spillage, and visible trash under and around the bed. Another room on the west hall had a floor soiled with dirt, debris, and visible trash. On the next day, the same room conditions were again observed, including the soiled over-the-bed table and floor with dirt, crumbs, brown spillage, and trash. Light brown dried liquid spots were also observed on the floor beginning near the nurse's station and continuing three-quarters of the way down the skilled hallway. Interviews and record review showed housekeeping staffing and cleaning issues. A housekeeping aide reported the facility was short a housekeeper, that there was no one cleaning on the west hall, and that when short staffed the rooms only received the "highlights" of cleaning, meaning tables and trash unless there was a visible soiled spot. The housekeeping director reported every room should be cleaned daily, including sweeping and mopping floors, sanitizing high-touch surfaces, removing trash, and cleaning bathrooms, but confirmed there was no housekeeper on the west hall the prior day and most rooms did not get cleaned as scheduled. The nursing home administrator reported there had been a problem with housekeeping and the facility had been without a director since March 2025. Resident council meeting notes from April through August 2025 documented repeated complaints that rooms and west hall areas were not being cleaned regularly and that housekeeping was not mopping or changing trash every time.
Failure to Develop Hospice Care Plan and Implement Ordered Pressure-Relief Device
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with kidney disease, dementia, high blood pressure, prostate cancer, blocked and narrowed carotid artery, legal blindness, and hearing loss. During observation, the resident was seated in a reclined Geri-chair across from the nurse’s station, and a hospice CNA reported she came to the facility a couple times a week to see him. Review of the medical record showed there was no care plan for hospice services in place, and the MDS Coordinator stated that when an MDS was completed for hospice it would generate the hospice care plan, but this had not yet been done. The facility also failed to implement person-centered care plan interventions for a resident with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, left hand contracture, and acquired absence of right toes. The resident had orders to wear a prevalon boot to the left foot to offload pressure while in bed and to wear left pressure relief ankle foot orthotics with AM care and off with PM care as tolerated. Although the care plan identified the resident as at risk for impaired skin integrity and included a left prevalon boot as tolerated, staff observed the resident in bed and in a Broda wheelchair without the boot in place, with bare feet/legs resting directly on the mattress or wheelchair. Staff reported the boot had been missing, that the resident refused to wear it most of the time, and that refusals were not being documented in the medical record.
Failure to Apply and Document Ordered Hand Orthosis
Penalty
Summary
The facility failed to ensure an orthosis device ordered to help manage a resident’s left-hand contracture was used as directed. Resident #63 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, left-hand contracture, and acquired absence of right toes. Her care plan identified her as at risk for contracture development and directed staff to apply the left-hand air bladder orthosis as tolerated. The order summary directed that the left-hand orthosis be donned with AM care and doffed with PM care, with skin monitoring before and after application. During observations, Resident #63 was repeatedly found without the orthosis in place, including while sitting in her wheelchair and later while in bed. The device, described by staff as a “carrot,” was observed sitting on top of the dresser in her room rather than on her hand. Staff interviews confirmed that the orthosis had not been applied for weeks, that nursing staff were responsible for applying and documenting it, and that the resident refused to wear it. A CNA stated there was no way to document refusals, while an RN later documented a refusal only after being asked during the survey. Review of the TAR showed blank or missing documentation on some dates, while other dates were charted as if the orthosis had been in place each day. The DON reviewed the record and confirmed the missing documentation and that the resident was not wearing the orthosis when observed. The facility policy stated that refusals must be documented in the resident’s medical record, and the DON reported that refusals should be circled back to and documented, but the record contained no additional refusal documentation beyond the one note entered during the survey.
Failure to Implement Dietitian-Recommended Nutritional Supplements
Penalty
Summary
The facility failed to address and implement dietitian recommendations for nutritional supplements for a resident with a stage 3 sacral pressure ulcer. The resident had diagnoses including stroke with left-sided hemiplegia, anxiety, major depression, chronic pain, and a stage 3 sacral pressure ulcer. The care plan identified the resident as at risk for altered nutrition and fluid status related to the pressure area, depression, and anxiety, and included interventions to request vitamin C and zinc to promote healing. Multiple nutritional assessments documented that the resident’s intake varied between 50% and 100% at meals, that he did not always eat meals served, and that he had his own frozen, prepackaged meals and snacks. The dietitian repeatedly recommended vitamin C 500 mg daily and zinc sulfate 220 mg for 10 days to support wound healing, and later noted that no order was in place and requested the supplements again. Review of the order summary showed no physician orders for vitamin C or zinc between February 2025 and September 2025. The RD and DON both acknowledged that the supplements recommended for wound healing were not implemented.
Improper Dumpster Storage and Trash Accumulation
Penalty
Summary
The facility failed to store trash and refuse containers covered and in a manner that maintains the area to prevent the harborage or feeding of pests. During observation of the outside dumpsters with the Maintenance Director, the dumpster doors were found pushed open, allowing pests and precipitation to enter. The Maintenance Director stated that staff have a hard time tossing bags of trash into the dumpster unless the doors are opened. Further observation of the dumpster area found excess trash, used gloves, and debris on the inside perimeter of the garbage area.
Failure to Track and Document Flu and Pneumococcal Vaccination Offers and Refusals
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after interview and record review showed the facility failed to track and offer influenza and pneumococcal vaccines for 3 of 5 residents reviewed for immunizations. The record review also showed there was no documentation of declination for these residents, and they were not given the opportunity to receive or decline the influenza and/or pneumococcal vaccination. Resident #9 was a male with diagnoses including right-sided paralysis, stroke, seizures, asthma, and heart failure. Review of his medical record showed he was not offered PCV20 or PCV15 in 2024 after turning 65, and there was no signed consent or declination in the record. Resident #7 was a male with diagnoses including kidney disease, dementia, high blood pressure, prostate cancer, and carotid artery disease; his record showed he refused PCV20, but no signed declination could be found. Resident #2 was a male with diagnoses including heart failure, kidney disease, respiratory failure with hypoxia, COPD, oxygen dependence, diabetes, and stroke; his record documented refusal of influenza and pneumococcal immunizations, but a consent dated 3/29/24 for influenza vaccination was located and he had not been immunized with the influenza vaccine per the medical record.
Resident Suffers Opioid Overdose Due to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who was transferred to an acute care hospital emergency room for treatment and admission to a medical intensive care unit. The resident, who had a history of cerebral infarction, dysphagia, and acute respiratory failure, was found to have a positive urine drug screen for opioids, despite not being prescribed any opioid medications. The resident's condition deteriorated, leading to respiratory distress and unresponsiveness, which prompted the administration of Narcan, resulting in a full recovery. The investigation revealed that the resident received all nutrition, hydration, and medications through a G-tube and was dependent on staff for all care. The resident's medication administration record indicated scheduled enteral feedings, and there was no record of opioid prescriptions. Interviews with staff members, including LPNs and the DON, confirmed that the resident did not receive any narcotic medications during the shift, and there were no discrepancies in the narcotic count. However, the resident's urine drug screen was positive for morphine, raising concerns about a possible medication error. Further investigation highlighted that the resident's roommate was prescribed morphine sulfate, and there was a possibility of medication mix-up due to the similarity in appearance between liquid Tylenol and morphine sulfate. Despite the facility's efforts to identify the source of the opioid exposure, the investigation was unable to confirm how the resident received the opioid, leading to the deficiency citation for failing to ensure residents were free from significant medication errors.
Deficiency in Resident Dignity and Respect
Penalty
Summary
The facility failed to provide a dignified environment and ensure that staff treated residents with dignity and respect, as evidenced by multiple incidents involving staff interactions with residents. One incident involved a resident who felt harassed by a CNA who persistently demanded her smoking materials, leading to a verbal altercation. The resident, who was moderately cognitively impaired, expressed feeling targeted and upset by the CNA's behavior, which was corroborated by other staff members who witnessed the incident. Another incident involved a CNA who was observed swearing and slamming a door in the presence of a severely cognitively impaired resident. Although the resident's ability to comprehend the situation was limited, the behavior was deemed inappropriate and unprofessional. Staff members reported feeling unsafe and concerned about the CNA's unpredictable behavior, which had been an ongoing issue. Additional concerns were raised by residents and staff about the general demeanor and attitude of some CNAs, who were described as rude and unapproachable. Residents reported feeling like an inconvenience when asking for assistance, and staff noted that some CNAs did not provide adequate care, particularly to residents who were unable to voice their concerns. These issues contributed to an environment that did not respect or enhance the dignity of the residents.
Failure to Report Medication Error and Resulting Hospitalization
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who received the wrong medication, leading to a serious medical emergency. The resident, who had a history of cerebral infarction, dysphagia, acute respiratory failure with hypoxia, and pneumonitis, was found to be severely cognitively impaired. On the evening of the incident, the resident was observed to be very drowsy with increased secretions, and vital signs indicated respiratory distress. The resident was transferred to an acute care hospital emergency room, where they were treated with Narcan for a suspected opioid overdose, despite not being prescribed any opioid or narcotic medication. Subsequent drug tests confirmed the presence of morphine in the resident's system. Despite the severity of the incident, the facility did not report the event to the State Agency. The Nursing Home Administrator and Director of Nursing both concluded that there was no deficient practice to report, as they determined that narcotics were not missing and believed the hospital would notify the state. This lack of reporting was a failure to comply with the requirement to report suspected abuse, neglect, or theft, and the results of the investigation to the proper authorities, as the resident's hospitalization and positive drug screen were not communicated to the state agency.
Failure to Follow Physician Orders and Address Pain Timely
Penalty
Summary
The facility failed to ensure that Resident #101 received enteral feeding in accordance with physician orders. Resident #101 was admitted with a diagnosis of dementia and required continuous enteral feeding through a G-tube due to dysphagia. However, the nursing staff, including LPN L and RN G, were not aware of the updated continuous feeding order following the resident's hospital readmission. As a result, the tube feeding was stopped daily between 10:00 AM and 2:00 PM, contrary to the physician's orders. This oversight was confirmed by multiple staff members, including the Unit Manager and the Physician Assistant, who expected the continuous feeding order to be followed. Additionally, the facility did not timely re-weigh Resident #101 after a significant weight change was noted. The resident's weight increased by 13 pounds within 22 days, which constituted an 8.64% change. Despite this significant change, the facility's dietician and interdisciplinary team failed to identify and report the weight change, and no re-weight was conducted to confirm the accuracy of the initial measurement. The facility's policy required re-weights for significant changes, but this was not adhered to, as confirmed by the Director of Nursing and the Registered Dietician. Resident #103 experienced a delay in pain assessment and treatment. Despite showing signs of pain and indicating discomfort by pointing to his ribs, the resident was not assessed or provided pain medication in a timely manner. LPN L was informed of the resident's pain at 11:40 AM but did not assess or administer pain relief until after 1:15 PM. The Nursing Home Administrator acknowledged that the delay in addressing the resident's pain was not in line with the facility's expectations for prioritizing and managing residents' pain complaints.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
The facility failed to properly label, date, and store medications, specifically insulin pens, in one of the two medication carts reviewed. During an interview, a Registered Nurse (RN) expressed concerns about the lack of labeling on insulin pens when opened, which was not addressed adequately by the Director of Nursing (DON). The DON had instructed nurses to contact the pharmacy to determine the delivery date of the insulin pens, which was not an accurate method to ascertain when the pens were opened. This led to confusion and inefficiency in determining the usability of the insulin pens. Observations revealed that insulin pens in the medication cart were either not labeled with the date they were opened or were stored improperly. A new nurse was unaware of the facility's policy on labeling insulin, indicating a lack of proper training or communication. Further interviews confirmed that the insulin pens without labels were unsafe for use and should be discarded. The Unit Manager confirmed that the facility expected nurses to label and date insulin pens upon opening and to keep them refrigerated until needed. The DON later acknowledged the expectation for nurses to date the pens when opened, highlighting a miscommunication in the facility's procedures.
Inadequate Dementia Care Training Leads to Resident Distress
Penalty
Summary
The facility failed to ensure that three residents with dementia were treated in a manner that supported their psychosocial wellness, leading to avoidable stress responses. Resident #101, who was cognitively impaired with a BIMS score of 7/15, experienced agitation after an LPN entered her room and spoke to her in an emotionally charged tone. The LPN's lack of specialized dementia care training contributed to the resident's negative response, as she became agitated and unsafe after the interaction. Resident #102, also cognitively impaired with a BIMS score of 6/15, was subjected to aggressive behavior from the same LPN. The LPN, appearing stressed, yelled at the resident after being physically contacted by her. This interaction led to the resident becoming agitated and pulling a fire alarm. The LPN admitted to being overwhelmed and acknowledged her unprofessional behavior, which was exacerbated by insufficient dementia care training. Resident #103, with a BIMS score of 10/15, was involved in an incident where the LPN, frustrated by the resident's bowel incontinence, used profanity while providing care. This behavior left the resident quiet and withdrawn. The LPN admitted to ranting about the situation, indicating a lack of appropriate response to the resident's needs. The facility's failure to provide comprehensive dementia care training contributed to these incidents, as the LPN was not adequately prepared to handle the residents' behaviors effectively.
Deficiencies in Food Safety and Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food storage and labeling. During a kitchen tour, surveyors found a container of sliced turkey, an open gallon of milk, and a container of hot dogs in the reach-in cooler without proper discard dates. Additionally, thawed Mighty Shakes and Magic Cups were found without discard dates, despite their packaging indicating specific time frames for consumption. Similar issues were observed in the Activity refrigeration units and the SCU dining room, where items like thickened lemon water and med pass 2.0 were not properly dated, and chocolate milk was stored past its best-by date. Interviews with the Dietary Manager revealed that there were issues with supplier deliveries and that staff were responsible for dating items, but this was not consistently done. The facility also exhibited significant cleanliness and maintenance issues in the kitchen and surrounding areas. Observations included an accumulation of crumbs, dirt, and various debris around the ice machine, juice machine, and cooler areas. The walls near the juice machine were stained with orange splash and debris due to a leak. Further inspections revealed dirt and grime around the dish machine line, cook line corner, and hand sink, with some areas having loose or missing vinyl coving, which compromised the ability to maintain cleanliness. Dusty debris was also found on lights over the preparation and cook line area, and a ceiling vent and tower fan were covered in dust and debris. Additional deficiencies were noted in the handling and storage of kitchen utensils and equipment. Clean utensils were stored in colander pans that contained crumbs and plastic debris, and the frequency of cleaning these pans was uncertain. The inside of the microwave had dried debris accumulation, and the juice dispenser spout was not adequately cleaned. Sheet pans on the drying rack were greasy and had carbon accumulation, and the ice scoop holder in the ice room contained slimy debris. These observations indicate a failure to maintain equipment and food-contact surfaces in a clean and sanitary condition, as required by the FDA Food Code.
Failure to Protect Potable Water Supply
Penalty
Summary
The facility failed to properly protect the potable water supply from plumbing cross connections, which could potentially lead to increased illness and contamination of the domestic water. During a tour of the kitchen, it was observed that the mop sink in the janitors' closet was left on and connected to a pre-dispense chemical system. This setup placed undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which is not approved for constant back pressure. In the beauty shop, the hair washing sink's spray was replaced with a kitchen dish sprayer that controls pressure with a thumb valve, creating a stop downstream of the faucet's AVB. The sprayer was found lying in the bottom of the sink near the drain. Additionally, the SCU janitor sink's wasting tee was plugged, preventing the device from relieving undue back pressure on the faucet's internal AVB, which was also observed to be leaking with visible heavy corrosion.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were available and within reach for two residents, resulting in their inability to call for staff assistance. Resident #84, who was admitted with diagnoses including difficulty in walking, muscle weakness, and dementia, was found to have a call light that was either on the ground or out of reach on two separate occasions. Despite being encouraged to use the call light for assistance, Resident #84 was unable to do so due to its inaccessibility. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the call light was out of reach. Similarly, Resident #75, who was admitted with dementia, did not have a call light in his room at all. During observations, it was noted that the room setup only allowed for one call light, which was being used by the roommate. Staff, including a CNA, LPN, and a Physician Assistant, were unaware of the absence of a call light for Resident #75, despite his need for assistance due to anxiety and frequent visits to the nurse's station. The Nursing Home Administrator confirmed the deficiency and indicated that maintenance would be contacted to address the issue.
Failure to Update DNR Order Timely
Penalty
Summary
The facility failed to ensure an accurate do not resuscitate (DNR) order was updated timely for a resident, resulting in the potential for the resident's preferences for medical care to not be followed. The resident, who was originally admitted with a diagnosis of dementia, was noted as a full code in the Electronic Health Record (EHR), despite having a DNR order signed by the guardian. The discrepancy arose because the facility updated the code status to full code for residents returning from the hospital until their re-admission paperwork was signed and scanned into the EHR. The resident returned from the hospital, and the facility was behind on uploading documents, leading to the outdated code status in the EHR. Interviews with facility staff revealed that the social worker was responsible for verifying the accuracy of resident code status at care conferences, but the resident's code status was not updated after a care conference that discussed the resident's desire to be noted as DNR. The medical records staff had requested the updated DNR form from the resident's guardian but had not received it back and did not follow up. There was no process in place to ensure pending forms were completed and received back, which contributed to the failure to update the resident's code status in a timely manner.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, resulting in potential dissatisfaction with living conditions. The resident, who was cognitively intact and had diagnoses of anxiety, depression, and paranoid schizophrenia, was found in a room that smelled like feces, with a dried-up red spill on the floor and a dusty hairbrush under the bed. Despite housekeeping efforts, the room continued to smell, and gnats were observed flying around the resident's bedside table, bed, and curtain divider. The presence of gnats was attributed to open snacks and drinks left by the resident's roommate. The Resident Council Meeting Minutes from previous months indicated ongoing concerns about housekeeping, specifically regarding items left under beds and inadequate cleaning. Interviews with the Nursing Home Administrator and a Licensed Practical Nurse confirmed awareness of the issues, including the persistent odor and presence of gnats. The administrator acknowledged the challenges posed by the roommate's habits, such as refusing to be changed and keeping unfinished drinks, which contributed to the unsanitary conditions in the room.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, resulting in feelings of frustration and anger for the resident. The resident, who had a history of cerebral infarction and difficulty walking, reported missing clothing items and had concerns about his clothes returning from the laundry. Despite being cognitively intact, as indicated by a BIMS score of 14/15, the resident had not received any follow-up from the management team regarding his missing clothing, even after completing a complaint form over a week prior. The Nursing Home Administrator (NHA) was unaware of the resident's concerns and could not provide any documentation of a grievance form or investigation into the missing clothing. A housekeeper acknowledged being informed by the resident about the missing items but did not complete a grievance form. The NHA stated that staff members are expected to complete a concern form or provide one to the resident when a concern is raised. However, no grievance forms were found for the resident, indicating a failure in the facility's grievance handling process.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to provide written notification to the State Long-Term Care Ombudsman regarding facility-initiated transfers and discharges since January 2023. This deficiency was identified through an email from the Ombudsman, which indicated that the required notices had not been received. During an interview, the Nursing Home Administrator (NHA) admitted to being unaware of the regulation requiring such notifications and was uncertain about the facility's process for notifying the Ombudsman. It was revealed that a nurse manager, who was previously responsible for sending these notices, had left the facility, and the task was not reassigned, resulting in the oversight.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon discharge to an acute care hospital. This deficiency was identified for two residents who were transferred to hospitals for emergency care. Resident #8, who had a diagnosis of muscle weakness, requested to be sent to the hospital, and the transfer was facilitated by a physician assistant and emergency medical services. However, a review of Resident #8's electronic health record did not reveal any documentation of a bed hold policy being provided upon discharge. Similarly, Resident #17, who had a diagnosis of dementia, was transferred to a psychiatric hospital, but there was no documentation of a bed hold policy being provided. During interviews, the Admissions Staff Member responsible for ensuring the distribution of bed hold policies admitted to missing the task for Resident #17 and was unaware of Resident #8's transfer. The Nursing Home Administrator confirmed that the Admissions Staff Member was responsible for this task, which had not been completed.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASARR) Level II evaluations for two residents, resulting in potential unmet mental health care needs. Resident #77, who was admitted with diagnoses including schizophrenia, unspecified psychosis, major depressive disorder, generalized anxiety disorder, and insomnia, was receiving significant psychiatric medications. Despite having a Level I PASARR screening indicating mental illness, there was no Level II screening in the resident's record. Interviews revealed that the PASARR Level II was stuck in a queue and had not been submitted to OBRA as required. The medical records staff only notified the provider about the need for a Level II evaluation after the survey inquiry. Similarly, Resident #27 was admitted with diagnoses of depression, mild cognitive impairment, adjustment disorder with mixed anxiety and depression, and psychotic disorder with delusions. The resident's PASARR Level I screening indicated the need for a Level II evaluation due to mental illness, but it was not completed. The social worker incorrectly stated that the resident did not meet the criteria for a Level II evaluation, while the MDS nurse confirmed the need for it. The facility's failure to submit the necessary documentation to the local Community Mental Health Service Program for a comprehensive Level II screening contributed to the deficiency.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, leading to potential unmet care needs. Resident #44, who was admitted with diagnoses of depression, anxiety, mild cognitive impairment, and a psychotic disorder, did not have a care plan addressing their psychotic disorder or antidepressant use. The social worker responsible for completing these care plans confirmed the absence of such plans in the resident's chart. Resident #36, diagnosed with dementia and pressure ulcers on the sacrum and both heels, was observed multiple times without proper positioning or protective measures in place. Despite having a care plan that included interventions like repositioning every two hours and using prevalon boots to protect the heels, these measures were not implemented. Observations showed the resident's heels and sacrum were in direct contact with the mattress, and the protective boots were not being used as required. Interviews with facility staff, including a CNA, LPN, DON, and RN, revealed that the expected care plan interventions for Resident #36 were not being followed. Staff acknowledged the resident's dependency on them for repositioning and the necessity of using heel protectors, yet these interventions were not consistently applied. The facility's care planning policy emphasizes the development and implementation of person-centered care plans based on comprehensive assessments, which was not adhered to in these cases.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of oxygen to a resident, leading to incorrect oxygen settings. Resident #81, who was admitted with a diagnosis of adult failure to thrive, had an order for oxygen to be administered at 2 liters per minute via nasal cannula as needed for shortness of breath. However, during observations on two consecutive days, the resident's oxygen was found to be running at 4 liters per minute, which was not in accordance with the physician's order. An LPN confirmed the discrepancy and admitted to not being aware of the incorrect oxygen rate, as she had not checked on the resident that day. Furthermore, the LPN reported that there was no communication from the evening nurse regarding any changes in the resident's condition that would necessitate an increase in oxygen. The LPN also confirmed that any change in the oxygen rate required a new order from the physician, which had not been obtained.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours on specific dates, namely 4/13/2024, 4/27/2024, 5/25/2024, and 5/26/2024. This deficiency was identified through interviews and record reviews, which revealed that no RN was scheduled or signed in on these dates. The PBJ Report indicated staffing concerns, highlighting the absence of RN coverage for 8 consecutive hours during the third quarter of 2024. General and Administration (GA) GG admitted to not scheduling an RN on the mentioned dates, citing a shortage of RNs at the time. Although the facility has since increased its RN staff, there was no RN coverage on those specific days. Interviews with the Nursing Home Administrator (NHA) A and the Director of Nursing (DON) B revealed a lack of assessment and documentation regarding the impact of the RN coverage deficiency on residents. NHA A acknowledged the issue but was unable to provide evidence of discussions or evaluations related to the deficiency during Quality Assurance Performance Improvement (QAPI) meetings. Additionally, DON B confirmed that no assessments were conducted to determine if residents were affected by the lack of RN coverage. Despite having RNs on call, there were no RNs physically present in the building on the specified dates.
Failure to Provide Behavioral Health Care Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident with multiple mental health diagnoses, including schizophrenia, unspecified psychosis, major depressive disorder, generalized anxiety disorder, and insomnia. Despite being prescribed several psychiatric medications such as Aripiprazole, Trazodone, Venlafaxine, Zyprexa, and Clonazepam, the resident did not have a care plan developed for these conditions or medications. Additionally, there were no records of psychiatric service visits, social service notes, or behavioral health referrals in the resident's health records. Interviews with facility staff revealed that the resident had a Preadmission Screening and Resident Review (PASARR) level 1 indicating mental illness, but a level 2 screening was not completed. The MDS Nurse acknowledged that the PASARR level 2 was pending submission since May 2024. The Social Worker confirmed that the resident should have been seen by psychiatric services monthly and should have had a care plan in place, but these actions were not taken. The Director of Nursing agreed that the resident required a care plan and behavioral health services, but these were not implemented upon admission.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to discontinue the use of psychotropic medications prescribed as needed (PRN) after 14 days and did not document a rationale for extending the PRN use for a resident reviewed for unnecessary medications. This deficiency involved a resident who was admitted with a diagnosis of dementia and had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 6/15. The resident had a physician order for Lorazepam, a psychotropic medication used as a sedative, to be administered every four hours as needed for anxiety, with no specified stop date. The medication was administered 10 times in September, and the order was written by a Physician Assistant (PA). During an interview, the PA acknowledged that the order should have included a 14-day stop date to ensure reevaluation of the resident's condition.
Incomplete Documentation in Treatment Administration Records
Penalty
Summary
The facility failed to ensure complete documentation in the treatment administration records (TAR) for a resident with severe cognitive impairment and multiple wounds, including pressure ulcers on the sacrum and both heels. The resident's treatment orders required specific wound care procedures to be documented in the TAR, but several instances of missing documentation were identified. For example, there was no documentation for certain dates in July, August, and September, indicating that the required dressing changes may not have been completed as ordered. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and an RN, confirmed that if the TAR was left blank, it indicated that the task was not completed. The DON and RN both stated that their expectation was for the TAR to be completed when dressing changes were performed, and if not signed, it implied the treatment did not occur. This lack of documentation suggests a failure in maintaining accurate medical records in accordance with professional standards, potentially impacting the resident's care.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during the administration of enteral feeding for a resident with severe cognitive impairment and multiple gastrointestinal conditions. An LPN was observed preparing medications and a bolus feeding for the resident without performing hand hygiene or applying PPE before entering the resident's room. The LPN used the same gloves throughout the procedure, including when adjusting the resident's bed, obtaining tap water, and administering medications and feeding through the resident's PEG tube. The LPN also used an ink pen from her pocket to puncture the formula bottle, further compromising infection control protocols. Additionally, the facility did not ensure the proper use of PPE by staff for residents in enhanced barrier precautions during showers. A CNA was observed transporting a resident to the shower room without wearing any PPE, despite signage indicating the need for enhanced barrier precautions. Interviews with staff revealed a lack of adherence to PPE protocols during resident showers, with some staff unaware of the requirements or failing to reapply PPE when necessary. The absence of PPE storage in the shower rooms contributed to this deficiency. The facility also failed to sanitize resident-shared equipment between uses, as observed when a mechanical lift was not cleaned after being used for a resident in enhanced barrier precautions. The DON provided education to a CNA about the need for PPE but did not sanitize the equipment before leaving it in the hallway. Interviews with staff, including the DON and the Infection Preventionist, highlighted an education gap regarding enhanced barrier precautions and the expectation that shared equipment should be sanitized after each use.
Failure to Ensure Accurate Assessment and Documentation
Penalty
Summary
The facility failed to ensure a complete and accurate assessment for three residents, leading to potential health risks. Resident #101, who was cognitively intact, reported receiving an insulin injection from RN F despite not having a prescription for insulin. The resident experienced sickness after the injection and expressed feelings of anger and fear. The facility's records showed no physician order for insulin for Resident #101, and the nurse involved denied administering the injection. The investigation revealed inconsistencies in the documentation and monitoring of the resident's condition following the alleged medication error. Resident #110, who shared a room with Resident #101, was prescribed insulin for diabetes management. The facility's records indicated that both residents had their blood sugars checked, but there was a lack of documentation regarding the monitoring and assessment of their conditions after the incident. The Director of Nursing (DON) and other staff members acknowledged the absence of proper documentation and monitoring, which should have included skin assessments and blood sugar monitoring for three days. Resident #100, who had multiple diagnoses including Alzheimer's disease and was a hospice patient, was found to have skin discoloration under her breast. The incident was reported by a CNA, but there was a delay in proper assessment and documentation by the nursing staff. Interviews with staff revealed that the discoloration was noticed by several aides, but the information was not promptly communicated to management or documented in the resident's records. The facility's failure to document and investigate the skin discoloration in a timely manner contributed to the deficiency.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident #100 from verbal and physical abuse by another resident, Resident #102. Resident #100, who was severely cognitively impaired and had diagnoses including anxiety disorder and major depressive disorder, was found injured on the bathroom floor after being pushed by Resident #102. Multiple staff members, including CNAs and LPNs, reported witnessing Resident #102 verbally abusing and threatening Resident #100 on several occasions prior to the incident. Despite these reports, no action was taken to separate the residents or address the ongoing conflict, resulting in Resident #100 experiencing fear, increased agitation, and requiring inpatient psychiatric hospitalization. In another incident, the facility failed to protect Resident #102 from physical abuse by Resident #101. Resident #102, who was also severely cognitively impaired, was punched in the face by Resident #101 outside the activity room. Staff members reported that Resident #101 had a history of becoming verbally and physically aggressive, especially in crowded areas. Despite this known behavior, Resident #101 was not adequately monitored or separated from other residents, leading to the physical altercation with Resident #102. Both incidents highlight the facility's failure to take appropriate measures to prevent resident-to-resident abuse, despite being aware of the ongoing conflicts and aggressive behaviors. The lack of timely intervention and appropriate room assignments contributed to the physical and emotional harm experienced by the residents involved.
Failure to Initiate Appropriate Treatment Measures
Penalty
Summary
The facility failed to initiate appropriate treatment measures for Resident #100, who was admitted with multiple skin integrity concerns, including a skin tear on his right lower leg. Despite the facility's policy requiring notification of the resident's practitioner for any change in status, no treatment orders were obtained for Resident #100's skin tears from 2/8/24 to 2/21/24. Licensed Practical Nurse (LPN) J reported that the absence of a Unit Manager led to a lapse in obtaining necessary treatment orders, and although she wrapped the wound in gauze, it did not stay in place. Other staff members, including LPN Q and LPN V, confirmed that it was the nurse's responsibility to notify the provider for treatment orders, but this was not done for Resident #100's skin tears. Resident #100's condition deteriorated significantly upon his return to the facility. Competency Evaluated Nursing Assistants (CENAs) P, D, and R observed that Resident #100's right lower leg was swollen, painful, and that his functional abilities had declined. Despite these observations and reports of increased pain, no appropriate medical intervention was initiated. The Wound Care Physician (MD) T and Nurse Practitioner (NP) S were not alerted to the resident's condition, and no orders for wound care were documented until 2/22/24. By this time, Resident #100's condition had worsened, leading to a large draining wound on his ankle. On 2/13/24, LPN K noticed the severity of Resident #100's condition and reached out to the provider, resulting in an ultrasound order to rule out a deep vein thrombosis. However, the ultrasound was not completed before Resident #100 was transferred to the hospital on 2/14/24. At the hospital, Resident #100 was diagnosed with sepsis, an ankle abscess, and other serious conditions, requiring multiple surgical interventions. The facility's failure to follow its own policies and obtain timely treatment orders directly contributed to the resident's severe health decline and subsequent hospitalization.
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Illustrative
What surveyors actually found near you
We read the 299 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Galesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa At Borgess Place | 5.8 mi | ★★★★★ | 45 | 0 |
| Harold And Grace Upjohn Community Care Center | 7.5 mi | ★★★★★ | 7 | 0 |
| Evergreen Manor Senior Care Center | 8.6 mi | ★★★★★ | 19 | 0 |
| Plainwell Pines Nursing And Rehabilitation Communi | 9.7 mi | ★★★★★ | 12 | 1 |
| Medilodge Of Portage | 10.4 mi | ★★★★★ | 4 | 0 |
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