Alden Town Manor Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Cicero, Illinois.
- Location
- 6120 West Ogden, Cicero, Illinois 60804
- CMS Provider Number
- 145736
- Inspections on file
- 43
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Alden Town Manor Rehab & Hcc during CMS and state inspections, most recent first.
The facility failed to maintain essential equipment and to follow its own maintenance request policy, affecting two residents and potentially many others. A resident with intact cognition was observed in a wheelchair with torn, cracked, and loose armrests after having reported the needed repairs to staff, yet the issue was not documented on the maintenance log. Another resident’s room lamp, previously logged as not working, remained nonfunctional when tested by the assistant administrator. The facility had no building manager for several weeks, and the assistant administrator and DON acknowledged that maintenance responsibilities were being covered without proper documentation, as most entries on the maintenance log lacked recorded actions for issues such as a nonworking mechanical lift, malfunctioning call light, bed and wheelchair problems, and other equipment concerns.
A resident with ESRD and dependent on hemodialysis had a physician order to exchange a dialysis catheter due to a broken clamp, but the facility failed to ensure the ordered CVAD replacement occurred. An LPN contacted radiology and faxed requested documents, and radiology reportedly indicated an appointment would be scheduled within a few days, yet no appointment was actually scheduled and no documentation of catheter replacement was found. The DON acknowledged that the catheter was likely never replaced, while the cognitively intact resident reported being told the chest catheter needed changing after two years and confirmed it had not been changed, contrary to facility policies on appointments and CVAD management.
A resident with multiple chronic conditions was readmitted with orders for weekly labs, but due to an error in order entry by an LPN, the labs were not scheduled as recurring. This resulted in missed laboratory draws for two weeks, which was only discovered after the infectious disease clinic contacted the facility. The DON confirmed the original order was missing from the system, and the facility's process for transcribing and tracking lab orders was not followed.
Two residents with significant mobility and medical needs were not provided with appropriate services, equipment, or assistance to maintain or improve their mobility. Despite physician orders and facility policy, staff did not routinely mobilize the residents or provide necessary equipment such as wheelchairs, and therapy evaluations were delayed due to insurance issues. Nursing and therapy staff were aware of the deficiencies, but no restorative programs or therapy services were initiated for one resident, and both residents remained largely bedbound.
A resident experienced a 28% weight loss over seven months due to the facility's failure to identify and evaluate nutritional interventions. Despite the resident's complex medical history and poor appetite, the facility did not adequately monitor or document calorie intake or weight changes. The Weight Committee failed to provide necessary documentation and follow-up, contributing to the oversight in addressing the resident's nutritional needs.
The facility failed to submit accurate and complete Payroll Based Journal (PBJ) data, affecting all 184 residents. The PBJ report for the quarter lacked the required inclusion of the Director of Nursing's (DON) hours, despite the DON being present at least five days a week. An error in the submission of the integrated file for the fourth quarter of 2024 resulted in no data being shown for that period, and the facility's PBJ report did not include the DON's hours as required by CMS policy.
The facility failed to accurately code MDS assessments for residents receiving hospice care and one resident with significant weight loss. Four residents with terminal diagnoses were not correctly documented in the MDS Section J1400, despite having hospice orders and physician certifications. Additionally, a resident with over 10% weight loss in six months was not accurately coded in the MDS Section K0300, highlighting deficiencies in documenting hospice care and nutritional status.
The facility failed to respond promptly to call lights, affecting several residents. One resident reported waiting up to an hour for assistance, while another experienced a four-hour delay in being changed. Staff were noted to turn off call lights without returning, and the Unit Manager was informed but denied prior knowledge of the issue.
Two residents were found to be improperly restrained in a facility that claims to be restraint-free. One resident, with multiple health issues, was observed with a lap belt tied to a wheelchair, which they could not remove unassisted, and lacked a physician's order or proper documentation. Another resident, with chronic conditions, was restricted by side rails and bed bolsters, preventing independent movement, also without proper orders or documentation. The facility's policy on restraints was not followed, leading to this deficiency.
The facility failed to coordinate Level II PASRR assessments for residents with severe mental illness, affecting four out of five reviewed. Residents with diagnoses like major depressive disorder, PTSD, and bipolar disorder did not receive necessary evaluations. Staff showed a lack of clarity in managing PASRR assessments, leading to errors and missing diagnoses on Level I screens.
A facility failed to follow a physician's orders for a resident with lymphedema by not elevating her legs as recommended. Despite clear instructions in the physician's notes and care plan, staff were unaware of the need for leg elevation, and the task list did not include this requirement. The resident was observed with her legs flat in bed, contrary to the physician's orders.
A facility failed to date oxygen tubing and properly store a nebulizer mask for a resident receiving oxygen therapy and nebulization treatment. The resident's oxygen tubing was undated, and the nebulizer mask was found in an open drawer without a protective bag. Staff acknowledged the need for dating the tubing and proper storage of the mask to prevent contamination, as per facility policies.
The facility failed to report and address allegations of abuse involving three residents. One resident with dementia allegedly inappropriately touched another resident with severe cognitive impairment, but the incident was not reported to IDPH until months later, and no interventions were implemented. Another resident reported being physically restrained by family members, but the incident was not reported to IDPH due to the resident's reluctance to revisit past events. The facility did not adhere to its abuse policy, resulting in a significant deficiency.
The facility failed to thoroughly investigate and report abuse allegations involving three residents. A resident with dementia was reported to have inappropriately touched another resident, but the incident was not promptly reported to IDPH. Another resident reported family abuse, but the facility did not report it to IDPH, citing the resident's wishes. These actions indicate a deficiency in the facility's abuse policy compliance.
A resident with severe dementia, hemiplegia, and impaired mobility did not receive appropriate fall prevention interventions. The care plan included unsuitable measures such as encouraging use of a call light, despite the resident's inability to follow directions. Staff did not consistently provide non-skid footwear or anticipate the resident's needs, and rounding was infrequent. The resident sustained a serious hip fracture after an unwitnessed fall, highlighting the failure to implement effective fall prevention strategies.
The facility failed to manage behaviors for residents with dementia, leading to altercations between residents. One resident, diagnosed with dementia, reacted to another's loud behavior by swatting at her, and previously poured lemonade on a third resident after being provoked. Despite these incidents, the resident's care plan lacked updated interventions to address her behaviors.
A resident with a history of hemiplegia and peripheral vascular disease experienced a significant decline in condition, including increased pain and changes in mobility and skin condition. Despite these changes, the facility staff failed to notify the physician or document the changes, leading to a severe deterioration in the resident's health, resulting in a through-the-knee amputation. The facility did not adhere to its policies on medication refusal and change of condition notification.
A resident with a history of hemiplegia and peripheral vascular disease experienced worsening pain and discoloration in the left leg, which was not adequately assessed by the facility. Despite multiple reports of pain and changes in condition, the facility failed to conduct a thorough assessment, resulting in the resident suffering a displaced fracture, osteomyelitis, and skin necrosis, leading to an amputation. The facility's neglect in addressing the resident's condition highlights a significant oversight in care.
A resident with hemiplegia and peripheral vascular disease suffered an unreported injury of unknown origin, including bruising and a fracture. The facility did not report the incident to the Illinois Department of Public Health as required by their abuse policy. Staff interviews confirmed the lack of reporting, and medical examinations later revealed an acute displaced fracture of the distal tibia.
A resident with multiple health conditions was found with an empty oxygen tank, contrary to physician orders for continuous oxygen at two liters per minute. The facility's policy requires adherence to physician orders and full oxygen tanks, which was not followed in this instance.
Two residents at high risk for falls were inadequately supervised and assisted, resulting in significant injuries. One resident, who was cognitively impaired, fell and sustained a femoral neck fracture after being left unsupervised near the nurses' station. Another resident, dependent on a wheelchair, fell forward and suffered a cervical vertebrae fracture due to lack of clinical staff assistance to maintain a safe sitting position.
A resident with dementia was found with a saturated incontinence brief that had not been changed for several hours. The resident reported not receiving any incontinence care that day, and a CNA confirmed this. The Assistant Administrator stated that residents should be checked and changed every two hours.
A resident with severe cognitive impairment and multiple diagnoses fell from her wheelchair and sustained a contusion to the bridge of her nose after being left unsupervised in the dining room. Despite known fall risks and behaviors, the resident was unattended, leading to the fall and subsequent transfer to a local hospital for evaluation and treatment.
A resident with Dementia and Alzheimer's Disease was physically assaulted by another resident with similar diagnoses. Despite having a care plan to manage aggression, the facility failed to prevent the incident, which was witnessed by the Memory Care Director and confirmed by the involved residents.
Failure to Maintain and Document Repairs of Essential Resident Equipment
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential equipment in safe working order, to follow its own maintenance request policy, and to ensure that maintenance concerns were documented and addressed. The facility census was 187 residents. One resident with intact cognition (BIMS score 15) was observed in a wheelchair with both vinyl armrests visibly damaged and cracked, with the left armrest torn and the cushion exposed; both armrests were loose when shaken. This resident reported that the wheelchair needed tightening and that staff had been informed of the needed repairs. Despite this, the wheelchair issues were not documented on the maintenance and housekeeping request log. Another resident’s room lamp, which had been logged as not working, remained nonfunctional when tested by the assistant administrator in the resident’s presence. The facility lacked an employed building manager, who per policy was responsible for maintenance, and had been without one for about three weeks. The DON stated that the assistant administrator was currently responsible for maintenance repairs, and the administrator stated that an outside management service assisted with maintenance as needed. The assistant administrator reported that maintenance requests were to be documented in binders on each floor and reviewed by the building manager or assistant administrator. However, review of the second-floor maintenance and housekeeping request log from mid-February to late March showed that most entries lacked documentation of actions taken, including multiple issues with essential equipment such as a missing wheel on a linen cart, a nonworking mechanical lift, a TV that had fallen off the wall, a call light not working, bed rails needed, a wheelchair lock not working, and beds not functioning properly. The assistant administrator stated that these items had been fixed but not documented, and direct observation of the unresolved lamp issue contradicted this assertion.
Failure to Follow Physician Order and Schedule CVAD Replacement for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and internal policies regarding the management and replacement of a central venous access device (CVAD) for a resident receiving hemodialysis. The resident, who has end stage renal disease and is dependent on renal dialysis, had a physician order dated 2/24/26 for an exchange of the dialysis catheter due to a broken clamp. Progress notes show that on 2/24/26 an LPN called radiology to schedule the catheter change and was told radiology would call back, and on 2/25/26 the LPN called again, received no answer, and left a voicemail. The facility’s appointments policy states that physician orders are received for appointments and that assistance will be given to residents in arranging and scheduling appointments. The emergency care for dialysis residents policy notes that there is always a potential for infection with CVADs. Despite these orders and policies, there is no documentation that the dialysis catheter was ever replaced as ordered. When interviewed, the DON stated that radiology likely never replaced the resident’s subclavian catheter and that staff had attempted to make the appointment and left a message but did not know what happened after that. The LPN reported that radiology requested a face sheet and a doctor’s order to change the port, which the LPN stated were faxed, and that radiology indicated it would take 2–3 days to schedule the appointment; however, the appointment was never scheduled. The resident, who had an intact cognition score of 15 on a BIMS assessment, reported being told by hospital staff that the chest catheter needed to be changed after two years and confirmed that it had not been recently changed. The surveyor requested additional documentation to verify that the catheter had been changed around the time of the order, but no such documentation was provided.
Failure to Complete Weekly Laboratory Services as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were completed as ordered and in a timely manner for one resident following her readmission from the hospital. The resident, an elderly female with multiple diagnoses including chronic heart failure, COPD, diabetes, and a history of falls, was readmitted with discharge orders specifying weekly laboratory tests (CBC with differential, BUN, creatinine, and LFTs) to be faxed to her infectious disease physician. However, after her readmission, the standing order for weekly labs was incorrectly entered as two one-time orders rather than a recurring weekly order. As a result, laboratory tests were only performed on two consecutive weeks and then not again until the infectious disease clinic contacted the facility regarding missing results. Interviews with nursing staff and record review revealed that the error occurred during the transcription of hospital discharge orders into the facility's electronic medical record system. The LPN responsible for the readmission could not recall if new lab orders were received or properly entered, and the DON confirmed that the original standing order was missing from the system. The facility missed scheduled weekly labs for two weeks, and the issue was only identified after an external clinic inquired about the missing results. The facility's job description for nursing staff includes the responsibility to arrange for diagnostic and therapeutic services as ordered by the physician, which was not fulfilled in this instance.
Failure to Provide Mobility Services and Equipment for Two Residents
Penalty
Summary
The facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility for two residents with significant medical needs. One resident, who had diagnoses including cerebral vascular accident with left hemiparesis and dysphagia, was cognitively impaired and required assistance with activities of daily living and mobility. Despite having physician orders allowing the resident to be up as tolerated, staff only assisted the resident out of bed for doctor's appointments, and the resident did not have a wheelchair provided by the facility. A family friend reported having to bring a wheelchair from outside, and staff confirmed that the resident was not routinely mobilized. Another resident, with multiple complex diagnoses such as tracheostomy, chronic kidney disease, and chronic respiratory failure, also had physician orders to be up as tolerated and to receive physical and occupational therapy evaluation and treatment. However, this resident had not been evaluated by therapy, had not received a wheelchair, and had not been mobilized since admission. Staff interviews revealed that the lack of insurance information delayed therapy evaluation and equipment provision, and there was no restorative program in place for this resident. Nursing and therapy staff were aware of the orders but did not initiate services or equipment pending insurance verification. Facility policies required assessment for restorative nursing programs and therapy services upon admission and as needed, but these were not consistently implemented. The Director of Nursing and Administrator acknowledged that residents should be evaluated and provided with necessary equipment and services regardless of insurance status, but there was no policy for equipment ordering for new admissions. The failure to follow physician orders and facility policy resulted in residents not receiving appropriate interventions to maintain or improve their mobility.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately identify and evaluate nutritional interventions for a resident, resulting in a significant unplanned weight loss of 28% over seven months. The resident, who has a complex medical history including conditions such as hypertension, dysphagia, and rheumatoid arthritis, was observed to have poor appetite and inconsistent eating habits. Despite being able to participate in feeding with assistance, the resident often did not consume meals provided, as noted by both the CNA and RN. The facility's Registered Dietician confirmed the significant weight loss and noted that the resident's weight had decreased from 146 pounds in July 2024 to 111 pounds by March 2025. The facility's staff, including the MDS Nurse and Nurse Practitioner, were aware of the resident's weight loss and poor nutritional intake. However, there was a lack of documented evaluation of calorie counts and insufficient follow-up on the resident's nutritional status. The Nurse Practitioner mentioned attempts to encourage eating, provide supplements, and use appetite stimulants, but these interventions were not effectively monitored or documented. The resident's care plan included meal monitoring and recording, but there was no evidence of comprehensive calorie or protein intake analysis. The facility's Weight Committee, which is responsible for discussing residents with significant weight changes and developing care plans, failed to provide documentation of their procedures and interventions for the resident. Despite policies requiring weekly weight monitoring and documentation of nutritional status, the facility did not consistently record or evaluate the resident's weight changes. The lack of adherence to these policies contributed to the oversight in addressing the resident's nutritional needs and significant weight loss.
Failure to Submit Accurate PBJ Data
Penalty
Summary
The facility failed to submit accurate and complete data on the Payroll Based Journal (PBJ), which has the potential to affect all 184 residents. During the survey, the Administrator acknowledged that there were no staffing waivers and confirmed that the PBJ data is submitted quarterly without including the resident census. The Nurse Consultant mentioned that the Interim Director of Nursing (DON) is present at least five days a week for at least eight hours, but the PBJ report for the quarter did not include the DON's hours. The Administrator admitted that there was an error in the submission of the integrated file for the fourth quarter of 2024, resulting in no data being shown for that period. Despite notifying CMS and IDPH of the submission error, the facility's PBJ report still lacked the required inclusion of the Director of Nursing's hours, as mandated by the CMS Electronic Staffing Data Submission Payroll Based Journal Long Term Care Facility Policy Manual.
Inaccurate MDS Coding for Hospice and Weight Loss
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of hospice care and weight loss. Specifically, four residents receiving hospice care were not correctly coded in the MDS Section J1400, which should indicate a prognosis of a life expectancy of six months or less. Despite having hospice admission orders and physician certifications confirming their terminal status, the MDS for these residents inaccurately documented that they did not have a life expectancy of less than six months. For instance, one resident with a diagnosis of cerebrovascular accident was admitted to hospice with a terminal diagnosis of senile degeneration of the brain, yet their MDS incorrectly indicated no terminal condition. Similarly, another resident with Alzheimer's disease had hospice orders and a physician certification stating a prognosis of six months or less, but their MDS was not updated to reflect this. Two other residents with terminal diagnoses of Parkinson's disease and congestive heart failure also had incorrect MDS coding, despite being certified for hospice care. Additionally, the facility failed to accurately code the weight assessment for a resident who experienced significant weight loss. The resident had a documented weight loss of over 10% in six months, which was not reflected in the MDS Section K0300. The registered dietician confirmed the weight loss, and the MDS nurse acknowledged the oversight but did not initially update the MDS to reflect the significant weight change. This discrepancy highlights a failure in accurately documenting the resident's nutritional status, which is critical for their care plan.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to meet the needs of residents when they utilized call lights for assistance, affecting five residents out of a sample of 54. During a Resident Council interview, several residents reported significant delays in response times to call lights, with one resident stating they waited up to an hour for assistance. Another resident mentioned that their request for food was delayed by several hours, and they could hear staff talking and laughing in the hallway instead of attending to their needs. Additionally, two residents reported that staff would turn off the call light, promise to return shortly, but then fail to come back, leaving them waiting for extended periods. One resident reported that they pressed the call light during the night shift due to vomiting and coughing, but no staff responded throughout the night. Another resident stated that they waited four hours to be changed after requesting assistance during the night shift. The Unit Manager was informed of these concerns but denied having been previously approached by the resident about the issue. The facility's call light policy was not dated, and there were previous complaints documented in the Resident Council Minutes about call light response times.
Inappropriate Use of Restraints on Residents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, as evidenced by the cases of two residents, R2 and R10. R2, who has cerebrovascular disease, neuromuscular dysfunction of the bladder, and an acquired absence of bilateral legs above the knee, was observed with a lap belt tied to the wheelchair, which R2 could not remove unassisted. Despite the facility's policy of being restraint-free, the lap belt was used without a physician's order or proper documentation, and R2's care plan did not include the use of a lap belt. The facility staff acknowledged that the lap belt was considered a restraint since R2 could not remove it independently. R10, diagnosed with chronic kidney disease, bipolar disorder, schizoaffective disorder, and chronic obstructive pulmonary disease, was found with side rails and bed bolsters in place, which restricted R10's ability to move or get out of bed unassisted. The facility staff confirmed that these devices were considered restraints as they restricted R10's movement, and there was no physician order or documented consent for their use. The care plan for R10 did not reflect the current use of these restraints, and the facility's policy on restraints was not followed. The facility's policy states that it supports a restraint-free environment and that any use of restraints must be ordered by a physician and documented through the care planning process. However, in both cases, the necessary documentation, physician orders, and consents were missing, leading to the inappropriate use of restraints on residents R2 and R10. This failure to adhere to policy and regulatory requirements resulted in the deficiency noted by the surveyors.
Failure to Coordinate Level II PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to coordinate Level II PASRR assessments for residents with severe mental illness diagnoses, affecting four out of five residents reviewed for PASRR screening. The residents involved included individuals with diagnoses such as major depressive disorder, PTSD, bipolar disorder, dementia, schizoaffective disorder, and anxiety. Interviews and record reviews revealed that the facility did not ensure that Level II assessments were conducted for these residents, despite their mental health conditions warranting such evaluations. For instance, one resident with PTSD and depression was not aware if a Level II screen was completed, and another resident with bipolar disorder had not received the necessary assessment. The facility's staff, including the Admissions Director and Social Services, demonstrated a lack of clarity and coordination in managing PASRR assessments. The Admissions Director admitted to relying on hospitals for PASRRs and was unsure of the diagnoses requiring Level II screens. Social Services acknowledged the importance of Level II assessments for providing appropriate interventions but admitted to errors in completing Level I assessments and failing to identify residents needing Level II evaluations. The facility's documentation showed discrepancies, such as missing diagnoses on Level I screens and incorrect determinations that no Level II was required, leading to a failure in addressing the mental health needs of the residents.
Failure to Follow Physician's Orders for Leg Elevation
Penalty
Summary
The facility failed to adhere to a physician's orders for a resident diagnosed with lymphedema, dementia, pulmonary hypertension, and atherosclerotic heart disease. The physician had recommended that the resident's legs be elevated at all times to aid circulation and prevent fluid pooling. However, during the survey conducted from March 18 to March 21, 2025, the resident was observed with her legs flat in bed, and no additional pillows were available to elevate her legs as per the physician's instructions. Interviews with the restorative nurse, memory care director, and nurse practitioner revealed a lack of awareness regarding the physician's recommendations for leg elevation. The physician's progress notes from March 7 and March 14, 2025, clearly documented the need for leg elevation, yet the resident's progress notes did not indicate any refusal of this intervention. Additionally, the resident's care plan included interventions to encourage and assist with leg elevation, but the point of care task list did not reflect this requirement, leading to the deficiency in care.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not dating the oxygen tubing and improperly storing the nebulizer mask. The resident had a physician's order for oxygen therapy via nasal cannula and albuterol sulfate nebulization for respiratory symptoms. During an observation, the resident was found with undated oxygen tubing and a nebulizer mask stored in an open nightstand drawer without a protective bag. A nurse confirmed that the resident was readmitted the previous night and acknowledged that the oxygen tubing should be dated and the nebulizer mask should be stored in a plastic bag to prevent contamination. The regional nurse consultant also stated that the oxygen tubing should be dated for timely changes and the nebulizer mask should be stored in a plastic bag for infection control. Facility policies require monthly changes of nasal cannulas and proper storage of equipment to prevent cross-contamination.
Failure to Report and Address Allegations of Abuse
Penalty
Summary
The facility failed to implement its policy for reporting allegations of abuse, neglect, or theft, affecting three residents. The first incident involved a resident with dementia and cognitive deficits, who allegedly inappropriately touched another resident with severe cognitive impairment and multiple physical disabilities. The incident was reported by housekeeping staff to a registered nurse, who then informed the Director of Nursing and the Administrator. However, the Social Services Director was not informed, and the incident was not reported to the Illinois Department of Public Health (IDPH) until over two months later. Additionally, no interventions were implemented in the care plans of the involved residents following the incident. The second incident involved a resident who reported being physically restrained by family members. The Social Services Director was informed of the allegation but did not gather further details. The Administrator spoke with the resident, who expressed a desire not to revisit past events, leading to the decision not to report the incident to IDPH. Despite this, the resident's care plan indicated a risk for abuse, and Adult Protective Services were contacted. The facility's abuse policy requires immediate reporting of allegations and prompt investigation, with a final report completed within five working days. However, the facility failed to adhere to these procedures, as evidenced by the delayed reporting to IDPH and lack of timely interventions in the residents' care plans. The facility's inaction in these cases highlights a significant deficiency in following established protocols for handling allegations of abuse and ensuring resident safety.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to provide evidence that all alleged abuse violations were thoroughly investigated, affecting three residents. Resident 1, diagnosed with dementia and other conditions, was reported by a registered nurse (V9) to have inappropriately touched Resident 2, who has severe cognitive impairment and is dependent on staff for care. The incident was initially reported to the Director of Nursing and Administrator, but the Social Services Director (V3) was not informed. The Administrator (V5) was unaware of the incident until informed by V3, and a report to the Illinois Department of Public Health (IDPH) was delayed until 3/11/25, despite the incident being documented in progress notes on 1/5/25. Resident 3, with a history of abuse allegations, reported to V3 that her family had tied her up at home. V3 informed the Administrator, who did not report the incident to IDPH, as Resident 3 expressed a desire not to revisit past issues. However, progress notes indicated that Adult Protective Services were contacted, and the resident's care plan identified her as at risk for abuse. The facility's failure to promptly and thoroughly investigate these allegations and report them to the appropriate authorities constitutes a deficiency in their abuse policy and procedure compliance.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate fall prevention interventions for a resident with a significant history of falls and multiple risk factors. The resident, an elderly female with diagnoses including severe dementia, hemiplegia, muscle weakness, and difficulty walking, was assessed as having severely impaired cognition and was unable to follow directions or use a call light. Despite these limitations, the care plan included interventions such as encouraging the resident to call for help and promoting the placement of the call light within reach, which were not suitable for her cognitive status. Observations revealed that the resident was not consistently provided with proper non-skid footwear, as required by her care plan. Staff interviews indicated that the resident was impulsive, attempted to get up unassisted, and was unable to follow simple instructions. Certified Nurse Assistants reported that they were not specifically instructed to anticipate the resident's needs, and rounding occurred only about three times per shift. The Director of Nursing acknowledged that frequent rounding and appropriate footwear were necessary interventions, but these were not reliably implemented. The resident sustained a significant injury, a displaced right intertrochanteric femur fracture, after an unwitnessed fall that occurred while she was away from the facility with family. Upon return, the resident did not immediately report pain, and her injury was not identified until days later. The facility's fall management policy emphasizes proactive identification and intervention for residents at risk for falls, but in this case, the interventions were not tailored to the resident's cognitive and physical limitations, contributing to the deficiency.
Failure to Implement Behavioral Interventions for Dementia Residents
Penalty
Summary
The facility failed to implement interventions to manage behaviors for residents diagnosed with dementia, affecting three residents. One resident, R1, exhibited loud behavior in the dining room, repeatedly calling out for food, which led to a confrontation with another resident, R2. R2, who has a diagnosis of unspecified dementia, reacted to R1's loudness by swatting at her, although no contact was made due to the quick intervention of a CNA. This incident was not isolated, as R2 had previously been involved in another altercation with a third resident, R3, where R2 poured lemonade on R3 after being provoked by name-calling. Despite these incidents, R2's care plan did not include any new interventions to address her behaviors. Staff interviews revealed that R2 often refuses care and can be redirected most of the time, but her behaviors have led to her being sent to the hospital's psychiatric unit on two occasions. R2's psychiatric progress notes indicate she is alert, calm, and cooperative but suffers from memory impairment and progressive cognitive decline. Despite these observations, the facility did not update R2's care plan with interventions following the incidents, highlighting a deficiency in managing dementia-related behaviors effectively.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition, which included new onset of pain, changes in mobility, skin changes to the lower left extremities, and refusal of a doppler study for over six days. This oversight affected a resident who had a history of hemiplegia, hemiparesis, peripheral vascular disease, and a history of falls. The resident was cognitively intact and required substantial assistance for mobility. Despite the resident's complaints of increased pain and changes in her condition, the facility staff did not notify the physician or document these changes in the medical record. The resident began complaining of pain in her left contracted leg at the end of August, which worsened after a self-reported fall. The resident's condition deteriorated, with her leg showing signs of redness, swelling, and eventually turning dark purple. Despite these changes, the facility staff, including CNAs and nurses, failed to notify the physician or take appropriate action. The resident's refusal of a doppler study was also not communicated to the physician, which could have prompted further investigation or treatment. The lack of communication and documentation led to the resident being found with an acute displaced fracture of the distal tibia, osteomyelitis, and skin necrosis, ultimately resulting in a through-the-knee amputation of the left lower extremity. The facility's policies on medication and treatment refusal, as well as change of condition, were not followed, contributing to the severity of the resident's condition and the subsequent amputation.
Failure to Assess Resident's Condition Leads to Severe Injury
Penalty
Summary
The facility failed to adequately assess and respond to a resident's change in condition, resulting in severe consequences. The resident, who had a history of hemiplegia, hemiparesis, peripheral vascular disease, and previous fractures, was observed with worsening pain, redness, swelling, and dark purple bruising on the left lower extremity for over four weeks. Despite these symptoms, the facility did not conduct a timely and thorough assessment, leading to the resident being found with an acute displaced fracture of the distal tibia, osteomyelitis, and skin necrosis, ultimately requiring a left through-the-knee amputation. Interviews and records revealed that the resident, who was cognitively intact, reported being dropped by staff during a transfer, which was denied by the facility. The resident experienced significant pain for three weeks and requested to go to the hospital, but this request was denied. Staff members, including CNAs and nurses, noted the resident's complaints of pain and changes in the condition of the leg, such as discoloration and swelling, but failed to perform a comprehensive body assessment or take appropriate action. The facility's lack of response to the resident's worsening condition and pain complaints was a significant oversight. The facility's failure to act on the resident's condition was compounded by communication breakdowns among staff. Despite multiple reports of the resident's pain and changes in condition during stand-up meetings, no decisive action was taken to address the issue. The facility's policy on neglect, which emphasizes the importance of providing necessary goods and services to avoid physical harm and pain, was not adhered to, resulting in the resident's severe injury and subsequent amputation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin, specifically bruising and an acute displaced fracture of the distal tibia, to the State regulatory agency as required by their abuse policy. This deficiency affected a resident diagnosed with hemiplegia, hemiparesis, and peripheral vascular disease. The incident was not reported to the Illinois Department of Public Health, as confirmed by the regional office staff and the regional consultant, who could not find any record of the report being sent. Interviews with facility staff, including the assistant director of nursing and the administrator, confirmed that injuries of unknown origin should be reported to the state agency. The incident involved a resident who was observed by a CNA to have a dark discoloration on the ankle, which was initially thought to be gangrene. The CNA reported this to the unit manager, and the treatment nurse was informed of a bruise on the resident's lower leg. Despite the resident's history of peripheral vascular disease, a full body assessment was not conducted by the nurse, and the incident was not reported within the required two-hour timeframe. Subsequent medical examinations revealed a possible fracture, and an X-ray confirmed an acute displaced fracture of the distal tibia. The facility's abuse policy mandates immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician's orders for a resident's oxygen therapy. Resident R4, who was admitted with diagnoses including nephrotic syndrome, hypertensive heart disease with heart failure, and kidney disease, was observed with a nasal cannula attached to an empty oxygen tank. The physician's order specified that R4 should receive oxygen at two liters per minute continuously, but the nurse confirmed that the oxygen was set to one liter and the tank was empty. The facility's oxygen care plan and policy require that oxygen be administered per physician orders and that tanks should not be empty. The Assistant Director of Nursing acknowledged that oxygen should be applied according to physician orders and tanks should always be full.
Inadequate Supervision and Assistance for High Fall Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision for a high fall risk resident, R1, who was restless and attempting to ambulate unassisted. R1, who was cognitively impaired and had a history of falls, was left unsupervised near the nurses' station. Despite being placed there for monitoring, no staff was assigned to watch over him continuously. R1 attempted to stand from a sitting position and fell, resulting in an acute nondisplaced right femoral neck fracture. Interviews with staff revealed that R1 was awake and walking around the halls during the night, but no interventions such as offering snacks or assisting with bathroom needs were provided. Another resident, R2, who was also a high fall risk due to severe cognitive impairment and dependency on a wheelchair, was not provided with the necessary clinical staff assistance to maintain a safe sitting position. R2 was seen leaning forward in her wheelchair and eventually fell, sustaining a closed nondisplaced fracture of the fourth cervical vertebrae. The activity aide present in the room was not authorized to reposition residents and did not seek assistance from clinical staff to adjust R2's position in the reclining wheelchair. The facility's failure to implement appropriate fall prevention measures and ensure adequate supervision and assistance for these high-risk residents resulted in significant injuries. The facility's policy on falls, which requires the development and implementation of a care plan to address hazards and risks, was not effectively followed, leading to these incidents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident diagnosed with dementia. The resident's Minimum Data Set (MDS) indicated that she was always incontinent, and her care plan required assistance with toileting needs. On the day of the observation, the resident was found sitting on the side of her bed with a saturated incontinence brief marked with the time 6:20 AM, indicating it had not been changed for several hours. The resident was alert and oriented, and she reported not receiving any incontinence care that day. A Certified Nursing Assistant (CNA) confirmed that she had not provided care to the resident, who was her last assigned resident. The Assistant Administrator stated that residents should not remain in the same incontinence brief for over two hours and should be checked and changed throughout the day.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to supervise a resident (R4) who was at risk for falls, resulting in the resident falling from her wheelchair and sustaining a contusion to the bridge of her nose. R4, who has severe cognitive impairment and multiple diagnoses including end-stage renal disease, type II diabetes, major depression, Alzheimer's disease, anxiety disorder, dementia, and hypertension, was found on the floor in the dining room. The incident occurred after R4 was left unsupervised, despite her known fall risk and behaviors such as yelling for help and threatening to throw herself on the floor. A housekeeping staff member (V22) witnessed R4 yelling for help but did not stay with her, and R4 subsequently fell when V22 turned her back for a brief moment. The fall was unwitnessed by any direct care staff, and R4 was later transferred to a local hospital for evaluation and treatment of her injuries. The incident report and interviews with staff revealed that there were no other staff present in the dining room at the time of the fall, and the resident was left unattended despite her known risk factors. The restorative nurse (V7) confirmed that staff should be present in common areas when residents are there, especially for those with a high risk of falls. The hospital records documented the resident's injuries and noted that the nursing home staff mentioned the resident's tendency to throw herself on the floor. The facility's failure to provide adequate supervision and monitor the resident in the dining room directly led to the fall and subsequent injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse by another resident. Resident 2 (R2), who has diagnoses including Dementia and Alzheimer's Disease, was physically assaulted by Resident 3 (R3), who also has Dementia, Encephalopathy, and Alzheimer's Disease. R3's care plan, initiated on 12/29/23, indicated that he exhibits aggression towards staff and peers, with interventions to calmly and firmly redirect him. However, on 2/21/24, R3 became physically aggressive and hit R2 on the head with an open hand. This incident was witnessed by the Memory Care Director (V8), who was sitting at the nurse's station and heard the two residents shouting before seeing R3 hit R2. R2 confirmed the incident in her witness statement, stating that she did nothing to provoke R3, who came over yelling and hit her. The facility's abuse policy, dated 9/20, states that residents have the right to be free from abuse, including physical abuse such as hitting and slapping. Interviews with staff further corroborated the incident. The Administrator (V1) confirmed the physical altercation and stated that an investigation substantiated the physical aggression. A Certified Nursing Assistant (V17) mentioned that R3 has episodes of agitation that staff usually manage by redirecting him with activities or snacks. Despite these interventions, the facility failed to prevent the physical abuse of R2 by R3, as evidenced by the incident report and witness statements. The facility's final State Survey Agency incident report completed by V1 also documented the physical aggression, confirming that R3 hit R2 on the head, which was witnessed by V8.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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