Aliya Of Highwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Highwood, Illinois.
- Location
- 50 Pleasant Avenue, Highwood, Illinois 60040
- CMS Provider Number
- 145936
- Inspections on file
- 33
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aliya Of Highwood during CMS and state inspections, most recent first.
The facility failed to provide adequate ADL assistance, including incontinence and hygiene care, to multiple dependent residents. One resident with significant physical and cognitive impairments was found lying on a saturated incontinence pad wearing two fully saturated briefs, with a strong urine odor and a reddened, excoriated peri area and buttocks; despite a care plan requiring barrier cream after each incontinent episode, no skin protectant was applied. Another resident, dependent on staff and transferred with a full-body lift, remained in a reclined wheelchair position placing pressure on the coccyx for several hours and was later found in a saturated brief smelling of urine, with a 1-cm open coccygeal area with exposed granulation tissue and no dressing present, despite staff stating the resident was changed every two hours. A third resident with hemiplegia and chronic conditions, who required substantial assistance with personal hygiene, was observed with long fingernails and a large amount of dark debris under the nails, contrary to the facility’s nail care policy and the DON’s expectation that nails be kept clean.
A resident with hemiplegia, muscle weakness, and communication deficits, documented as 73 inches tall, was observed lying in a bed that did not accommodate his height, with bent knees and a foot extending off the wooden footboard. He reported that a longer bed would be more comfortable and demonstrated how his knees were forced upward when his feet were on the bed. The DON stated uncertainty about the availability of a longer bed, and the Administrator reported that staff were unaware of the resident’s desire for a longer bed and could not confirm whether anyone had noticed his feet hanging off the bed, despite a facility policy requiring evaluation and reasonable accommodation of individual needs and preferences.
A resident with left wrist and pelvic fractures returned from an orthopedic follow‑up visit with her cast removed and a wrist brace reportedly provided, but the after‑visit summary only documented an OT referral and did not mention the brace or revised instructions. An RN observed the resident’s swollen wrist without any splint or brace in place, and the ADON was initially unaware that a brace had been issued. No timely nursing documentation of the follow‑up findings or new orthopedic recommendations was entered into the EMR, and updated orders for use of a Velcro wrist brace and related care were not added until two days after the appointment.
Two residents with existing pressure injuries and identified risk did not receive ordered pressure ulcer care and preventive measures. One resident with severe cognitive impairment and multiple heel pressure ulcers was repeatedly observed sitting in a recliner with direct pressure on the coccyx and heels, without heel offloading or a pressure-reducing pad, despite orders and a care plan to offload heels with heel boots or pillows. Another resident with a large stage 3 sacral pressure injury and an unstageable left great toe wound, both with daily treatment orders, was found with no dressings on either wound during care, while heels rested directly on the bed. Staff acknowledged expectations that treatments protect pressure injuries, and facility policy referenced the need for consistent wound monitoring and documentation, but offloading and dressing application were not consistently implemented.
Two residents experienced deficiencies in catheter-related care when staff did not adequately respond to severe new groin pain after a catheter change for a cognitively intact resident with a neurogenic bladder, and did not secure or properly position another resident’s indwelling catheter and drainage bag. In the first case, the resident repeatedly reported intense burning and razor blade-like pain in the groin and scrotum after the catheter change, staff administered tramadol but did not document the pain in the EMR or notify the provider despite facility policies on pain management and change in condition. In the second case, a resident was observed lying on unsecured catheter tubing that was taut from the weight of the drainage system, and a CNA briefly raised the drainage bag above bladder level, allowing urine to flow back toward the catheter, contrary to the facility’s catheter care policy requiring securement with a leg strap or similar device.
The facility failed to manage pain appropriately for two residents with significant medical conditions and PRN orders for analgesics. One resident with hemiplegia and a reddened perineal area reported back and arm pain and exhibited clear pain behaviors during incontinence care, yet received no PRN acetaminophen that day. Another resident with a pelvic fracture, bladder cancer, urinary drainage bags, and a large sacral wound showed abdominal pain, tensing, moaning, and verbal pain responses during peri-care, wound care, and limb movement, but was not given ordered PRN acetaminophen or hydromorphone on that day. These events occurred despite a facility pain management policy that defines pain as what the resident reports and calls for effective recognition and management of pain.
A deficiency was identified when a physician-ordered OTC medication, dextromethorphan 15 mg for TBI-related mood instability, was not available for a resident and was inaccurately documented on the MAR. An RN could not locate the medication during a morning med pass despite it having been ordered from the pharmacy days earlier. The DON stated that the pharmacy does not supply this OTC drug and that the facility is responsible for providing it, and that the nurse who entered the order should have received and reported a pharmacy message declining delivery. The MAR showed some doses signed as given and others marked as not available, and the facility’s medication ordering policy did not address how to obtain OTC medications.
A resident was observed with lidocaine pain patches left on a bedside table and self-applying them to both knees, while an RN confirmed that staff hand the patches to the resident for self-application. The MAR contained orders for lidocaine 5% patches to be applied to each knee, signed out by nurses as administered, but there was no physician order or interdisciplinary team determination authorizing self-administration of these patches and no corresponding self-administration assessment in the record. This conflicted with facility policies requiring secure medication storage and formal orders and assessments before allowing self-administration.
Two residents did not receive the planned noon meal when staff ran out of turkey casserole due to heaping scoop portions that exceeded the documented 6 oz serving size. The cook and the administrator both plated meals at the steam table, and when the casserole was depleted, the cook substituted hot dogs with carrots for the last two plates instead of the scheduled entrée. One affected resident reported that a higher-level staff member later acknowledged the hot dog was given by accident; the resident stated he would have preferred the regular meal and was not informed of the shortage or offered an alternative choice. The administrator confirmed the resident was not told about the lack of turkey casserole and was not offered an item from the alternative menu, despite the facility’s menu specifying turkey casserole, chopped carrots, and bread pudding for that meal.
A resident did not receive food and supplements consistent with documented dietary preferences and orders. During a mealtime observation, the resident’s tray contained an uneaten turkey casserole, carrots, and a small cup of fluid, but no soup or health shake, despite the dietary sheet specifying a daily health shake, a serving of soup, and no casseroles. The resident reported that the wrong food was sent every day and that requested soup was not provided. An RN confirmed that no health shakes had been sent to the floor after checking multiple dietary carts, and the Dietary Manager acknowledged that soup was not available even though it was listed on the resident’s dietary sheet.
Staff failed to follow the facility’s transmission-based precautions policy for a resident on strict contact isolation for C. diff. A housekeeping staff member cleaned the resident’s room wearing only gloves and no gown, despite a contact isolation sign on the door. At the same time, a CNA assisted the resident and removed dirty laundry in a yellow cinch bag, not an isolation bag, and left the room without wearing any PPE. The ICP later confirmed that gloves and a gown were required upon entry to rooms of residents on contact isolation, and facility records and policy documented that such precautions, including in-room care to prevent cross contamination, were ordered for this resident.
Residents reported ongoing issues with access to properly sized incontinence supplies, often receiving incorrect sizes or insufficient quantities, leading to discomfort and undignified care. Staff confirmed supply restrictions and acknowledged problems with inventory management. Additionally, a resident with behavioral health needs repeatedly directed verbal abuse at others, with staff and other residents witnessing these incidents and facility leadership not consistently intervening. These failures resulted in a lack of dignity and respect for multiple residents.
Staff failed to follow Enhanced Barrier Precautions for two residents with chronic wounds, including not wearing required PPE such as gowns during high-contact care and not posting appropriate EBP signage. Both the DON and Infection Control Nurse confirmed the need for gloves and gowns for residents on EBP, and facility policy requires these precautions for high-risk care activities.
A facility failed to double lock controlled substances in a medication cart, leaving them unsecured during medication administration. An LPN left the cart unattended and out of sight while administering medications to residents, with the lockbox containing controlled substances unlocked. The DON confirmed the importance of double locking to prevent theft, as outlined in the facility's policy.
A facility failed to refer a resident with bipolar disorder for a Level II PASARR screening, despite a reasonable suspicion of mental illness. The resident, admitted in 2019, was on antipsychotic and antidepressant medications. The Social Services Director could not find documentation of the required screening or referral, and the facility's policy for completing PASARR screenings prior to admission was not followed.
A facility failed to assess and document treatment orders for a new wound on a resident with a history of venous stasis wounds and lymphedema. Despite the resident's report of a new sore, the nursing staff did not document the wound or obtain treatment orders promptly. The wound care nurse was unaware of the blister until it was brought to her attention, and the wound doctor was notified two days later. The facility's Skin Management policy was not followed, leading to a deficiency in care.
A resident with severe cognitive impairment and high fall risk was transported in a wheelchair without foot pedals by the Social Service Director, leading to a deficiency in safety measures. The resident's toes repeatedly hit the ground during transport, despite staff awareness of the need for foot pedals to prevent injury. A policy for safe wheelchair transport was requested but not provided.
A resident with severe cognitive impairment and multiple medical conditions received a water flush through a G-tube without prior verification of tube placement by a nurse. The facility's policy did not explicitly state the procedure for checking tube placement, contributing to the deficiency.
A facility failed to follow manufacturer instructions for an insulin pen, impacting a resident with type II diabetes. A nurse prepared the pen without attaching the needle during priming, contrary to guidelines, potentially affecting the insulin dose administered. The DON confirmed the correct procedure involves attaching the needle before priming to ensure accurate dosing.
A resident was repeatedly found without access to water, displaying signs of dehydration such as dry lips and mouth. Despite no fluid restrictions or swallowing issues, the facility staff failed to ensure water was within reach, contrary to the care plan and hydration policy.
A facility failed to provide wound treatment as ordered for a resident with a stage 4 pressure ulcer. The Wound Care Nurse/ADON found that the resident's dressing was not changed as scheduled, with the last change occurring four days prior, despite orders for every other day treatment. An LPN confirmed that wound care should follow the doctor's orders.
A facility failed to investigate an abuse allegation when a resident reported that his roommate used a racial slur against him. The incident was reported to a registered nurse and the police, and the accused resident was moved to a different room. However, the facility administrator did not conduct an investigation, contrary to the facility's abuse policy, which mandates prompt investigation of all abuse allegations.
A resident with multiple diagnoses refused medication administration, leading to a failure in protocol when the nurse left the medication at the bedside. Despite the resident's refusal, the Medication Administration Record was inaccurately signed as if the medication was given. The ADON acknowledged the error, noting that the facility's policy requires staff to ensure medication is taken, which was not adhered to in this instance.
The facility failed to provide necessary wound care for two residents with nonpressure wounds. One resident with necrotizing fasciitis had undressed wounds despite daily care orders, while another with Hidradenitis Suppurativa missed multiple wound care treatments. The facility lacked a policy for nonpressure wound care.
Failure to Provide Adequate ADL, Incontinence, and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including incontinence and hygiene care, to residents who were dependent on staff. One resident with hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, and abnormal posture required substantial/maximal assistance with personal hygiene and was dependent on staff for toileting hygiene. This resident was found lying in bed on an incontinence pad with a large yellow wet area and a darker yellow ring, wearing two incontinence briefs that were completely saturated with urine and emitting a strong urine odor. When the CNA removed the briefs and provided incontinence care, the resident’s peri area and buttocks were reddened and excoriated, and the resident moaned and said “ouch” multiple times during cleansing. Despite a care plan directing staff to apply barrier cream after each incontinent episode for moisture-associated skin damage, no skin protectant was applied before a new brief was placed. Another resident, who was dependent on staff and used a reclining wheelchair and full-body mechanical lift, was observed sitting for hours in a reclined position that placed pressure directly on the coccyx, without engaging activity. When CNAs later transferred this resident to bed, the incontinent brief showed dark blue wetness indicator lines and was saturated with dark yellow urine, and the resident smelled of urine. Examination of the coccyx revealed a 1-centimeter open area with exposed granulation tissue, surrounding pallor, and mottled redness, with no dressing found in the bed or brief. A CNA stated that this resident is changed every two hours and is laid down after lunch, but also reported that the last incontinence change had occurred when the resident was gotten up at breakfast, indicating a gap of several hours without incontinence care. A third resident with hemiplegia, repeated falls, aphasia, and chronic kidney disease required substantial/maximal assistance with personal hygiene. This resident was observed with a splint on the left hand and long fingernails on the right hand, with a large amount of dark substance under the fingernails. When asked, the resident agreed to have the nails cleaned and cut. The care plan indicated the resident required assistance with daily care needs related to hemiplegia, and the facility’s nail care policy required removal of dirt from under fingernails and performance of nail care on shower days and as needed. The DON stated that residents’ hands should be washed before meals and that he would expect residents’ nails to be clean, but the resident’s observed nail condition showed that this assistance with hygiene had not been provided as required.
Failure to Provide Bed Accommodating Resident’s Height
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate an individual resident’s need for a bed suited to his height. The resident was admitted with diagnoses including hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia, and his record showed a height of 73 inches. During observation, he was seen lying in bed with the head of the bed slightly elevated, his knees bent, and his left foot extending off the wooden foot end of the bed. When asked about his comfort, he reported that he was 6 feet 2 inches tall and that a longer bed would be more comfortable. He demonstrated that when he placed his feet on the bed, his knees were forced upward, and there was only a small amount of mattress above his head. In interviews, the DON stated he was not sure if a longer bed was available for this resident. The Administrator later reported that staff did not know the resident wanted a longer bed and could not say whether any staff had noticed that his feet were hanging off the foot of the bed. These findings occurred despite the facility’s Accommodation of Needs policy, which states the facility will evaluate and make reasonable accommodations for each individual’s needs and preferences, except when health and safety would be at risk.
Failure to Timely Clarify and Implement Orthopedic Brace and Wrist Care Orders
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred when the facility did not obtain or clarify new orthopedic recommendations following a resident’s follow‑up appointment and did not timely update the medical record. The resident had a history of fractures of the left hand, distal radius and ulna of the left wrist, and superior and inferior pubic ramus fractures of the left pelvis, with prior instructions to use a left wrist splint and a platform walker to avoid weight bearing through the left wrist. During a morning medication pass, an RN observed that the resident’s left arm cast had been removed after an orthopedic follow‑up visit and noted that the left wrist remained slightly swollen. The resident and her husband reported that a brace had been provided and that they were told it could be worn whenever the resident wanted, but at that time the resident was not wearing the brace and there was no documentation in the electronic medical record regarding new orthopedic instructions or the brace. The after‑visit summary for the follow‑up appointment documented only an occupational therapy referral and did not mention a brace or revised instructions for wrist support or weight bearing. The ADON initially stated he was unaware of any brace sent with the resident after the appointment, and by the end of that day there were still no nursing notes in the EMR describing the orthopedic follow‑up findings or any new recommendations. A late entry progress note later documented that the splint had been removed and an OT referral given, but the original lack of timely documentation and clarification meant that the resident’s care orders, including use of a Velcro wrist brace and clarification of weight‑bearing status, were not updated in the EMR until two days after the follow‑up visit.
Failure to Offload Heels and Maintain Ordered Dressings for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer care and preventive measures for two residents with existing pressure injuries and identified risk. For one resident with severe cognitive impairment and dependence for all footwear tasks, surveyors observed on multiple occasions that the resident was seated in a reclining chair with direct pressure on the coccyx and both heels resting on the leg rest, without heel offloading or a pressure-reducing pad in the chair. The wound nurse confirmed the resident had a Stage 4 pressure ulcer and an unstageable pressure ulcer on the left heel and two unstageable pressure ulcers on the right heel, and stated the resident should wear pressure-reducing heel boots in bed and in the chair. The LPN reported the pressure reduction boots were in the closet, and the physician’s orders and care plan both directed that the heels be offloaded with heel boot protectors or pillows. The facility’s skin management policy did not include guidance for offloading pressure ulcers. For a second resident admitted with multiple diagnoses and assessed as at risk for pressure injuries, orders were in place for daily wound treatments to a sacral wound and a left great toe wound. During incontinence care, surveyors observed a large sacral wound with a dark central area and red surrounding tissue, with no dressing in place; the CNA stated she did not know when the dressing came off. Later, the wound nurse assessed the resident, who exhibited pain responses during sacral wound care, and confirmed an unstageable wound on the left great toe, also without a dressing in place, while the resident’s heels were directly on the bed. Wound documentation showed a Stage 3 sacral pressure injury measuring 10 cm by 10 cm and an unstageable pressure injury on the left big toe. The DON stated that treatments to pressure injuries are intended to add protection and that he expects treatments to be in place, and the facility’s skin management policy emphasized the need for a system to assure consistent implementation of monitoring and documentation protocols.
Failure to Address Catheter-Related Pain and Maintain Proper Catheter Positioning
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess and respond to a resident’s significant increase in groin pain following a urinary catheter change, and failure to maintain proper positioning and securement of another resident’s indwelling urinary catheter and drainage bag. One resident, cognitively intact and with a history of neurogenic bladder requiring an indwelling catheter, reported severe burning and razor blade-like pain in the groin and scrotal area beginning after a catheter change. Over several days, the resident repeatedly stated that the pain was intense, interfered with eating, and that he felt no one was paying attention to it, although he acknowledged receiving pain medication that only partially helped. Nursing staff, including an RN, were aware of the resident’s ongoing groin pain and were administering tramadol, and the DON and ADON knew he was in pain and had an upcoming urology appointment. However, they were unsure whether the physician had been notified, and it was later confirmed that no one had contacted the physician about the new or increased pain following the catheter change. The resident’s EMR contained no documentation of his pain complaints despite staff awareness and administration of pain medication. The resident’s care plan for indwelling catheter use included monitoring for signs and symptoms of UTI and notifying the MD of abnormal findings, and the facility’s pain management policy defined pain as what the resident says it is and allowed for notifying the health care provider of new or changed pain, but these provisions were not followed in relation to his reported catheter-associated pain. A second resident with an indwelling urinary catheter was observed lying on their side with the catheter exiting through the back of an incontinent brief, unsecured, and with the drainage tubing suspended off the bed so that the weight of the tubing held the catheter taut. When staff repositioned the resident up in bed, the catheter stretched, and the tubing remained under the resident’s leg. A CNA then lifted the urinary collection bag above the level of the bladder, causing urine in the collection tubing to flow back toward the catheter. The CNA acknowledged the resident should not be lying on the catheter tubing and that the securing device had come loose, noting that the securing device is applied by a nurse. The facility’s indwelling catheter care policy required securing and anchoring the catheter with a leg strap or other device, which was not done in this instance.
Failure to Provide PRN Pain Management During Care and Wound Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate pain management for residents who required such services, specifically affecting two residents reviewed for pain management. One resident was admitted with hemiplegia, hemiparesis, muscle weakness, abnormal gait, cognitive communication deficit, dysphagia, and abnormal posture. His care plan, initiated in December and updated in January, included participation in a personal pain management program, education on pain management including non-pharmacological approaches, and pain management as needed. An order was in place for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain. On one observed day, this resident reported back pain and an inability to move his right arm while lying in bed. Shortly afterward, a CNA provided incontinence care and lifted the resident’s right arm to change his shirt, during which the resident hollered, moaned, and stated that his right arm hurt. The CNA apologized and continued care, removing the resident’s soiled incontinence brief. The resident’s perineal area was noted to be very reddened, and when the CNA wiped the area with a towel, the resident moaned, moved side to side, and complained that his perineal area hurt. The Medication Administration Record for that day shows the resident did not receive any pain medication, although he did receive pain medication the following day for pain rated 7 out of 10. The second resident involved was admitted with diagnoses including a right pubis fracture, malignant neoplasm of the bladder, major depressive disorder, right hip pain, anxiety disorder, and osteoarthritis. Orders were in place for acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain, and hydromorphone 0.5 ml by mouth every eight hours as needed for pain. During an observed peri-care episode, CNAs removed the resident’s incontinence brief and noted a moderate amount of blood, believed to be from the rectum. When asked about pain, the resident patted her abdomen. The resident had two urinary drainage bags from the back area and a large, uncovered sacral wound. During wound care by an LPN/Wound Care Nurse, the resident tensed and moaned, and when asked afterward if the sacral area hurt, she nodded yes. When her right lower extremity was lifted, she said “Ow.” The Medication Administration Record for the month shows she had received acetaminophen and hydromorphone on earlier dates for high pain scores but did not receive any pain medication on the day of the observed pain behaviors, despite the facility’s pain management policy emphasizing recognition, management, and monitoring of residents’ pain.
Failure to Provide and Accurately Document Ordered OTC Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered medication was available and accurately documented as administered for a resident. During a morning medication pass, an RN was unable to locate the ordered dextromethorphan tablets, which had been ordered from the pharmacy several days earlier. The DON later explained that dextromethorphan is an OTC medication that the facility, not the pharmacy, is responsible for providing, and that the floor nurse who entered the order should have received and reported a pharmacy message indicating the medication would not be delivered. The resident’s January MAR showed an order for dextromethorphan 15 mg at bedtime for 3 days for TBI-related mood instability, with doses signed out as given, and a second order for dextromethorphan 15 mg twice daily for the same indication, with only the first dose signed out as given and subsequent doses marked as not available. The facility’s medication ordering policy did not address procedures for obtaining OTC medications, and no additional pharmacy policies were provided.
Improper Storage and Unauthorized Self-Administration of Pain Patches
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling of medication storage and administration for one resident using lidocaine 5% pain patches. During observation, the resident was found lying in bed with medication patches on her bedside table, which she stated were for knee pain and that she would apply when ready. During the same interaction, she placed both patches below each knee herself and reported that she always applies and removes them on her own. A subsequent interview with an RN confirmed that nurses give the patches to the resident and that the resident applies them herself. Record review showed active MAR orders for lidocaine 5% external patches to be applied topically to the left and right knees for pain management, with nurses signing these medications as given. However, there was no physician order authorizing self-administration of the lidocaine patches and no corresponding self-administration assessment for these patches in the electronic medical record. The only self-administration assessment on file, dated several months earlier, pertained to a different medication. This practice conflicted with the facility’s own policies, which require medications to be stored securely and accessible only to authorized staff, and which state that self-administration must be determined by the interdisciplinary team and supported by a specific order after assessing the resident’s ability to self-administer.
Failure to Follow Planned Menu and Portion Sizes Resulting in Substitute Entrées Without Resident Choice
Penalty
Summary
The deficiency involves the facility’s failure to follow the planned noon meal menu and portion sizes, resulting in two residents not receiving the scheduled turkey casserole meal. During observation of the noon meal service, the cook used a white 6 oz scoop to plate turkey casserole and chopped carrots while staff verbally requested meal textures. The administrator went behind the steam table and also began plating, using heaping scoop portions that created a mound over the flat of the scoop. As the last room cart was being plated, the cook scraped the metal tray to fill the scoop and ran out of turkey casserole, despite believing the correct serving ladle was used. Staff informed the cook that two more plates were needed, and the cook plated hot dogs with carrots for those two meals instead of the planned entrée. The dietary manager later confirmed that the facility ran out of turkey casserole and that two residents did not receive the regular meal, stating that the scoop sizes had been too large and should have been flat. One of the affected residents reported receiving a tray with a hot dog, believing it was the normal meal being served, and stated that a female staff member with long black hair, described as someone higher up, later told him they had accidentally given him the hot dog. The resident said he would have preferred the regular meal and felt he should have been given a choice of an alternative and informed that the facility had run out of the planned meal. The administrator confirmed that this resident was not informed of the shortage of turkey casserole and was not offered a choice from the alternative menu. The facility’s diet spreadsheet menu documented the turkey casserole portion size as 6 oz, with 4 oz soft chopped carrots and bread pudding as part of the planned meal.
Failure to Honor Resident Dietary Preferences and Ordered Supplements
Penalty
Summary
The facility failed to provide a resident with food that accommodated documented preferences and ordered supplements. On 01/12/2026 at 1:02 PM, the resident was observed lying in bed with the head of the bed at a 20-degree angle and an over-bed table holding an uneaten turkey casserole, uneaten carrots, and one 120 milliliter cup of fluid, with no health shake and no soup present. At that time, the resident reported that every day the facility sent the wrong food, that the facility never served the food on the menu, that soup had been requested but not provided, and that the resident could not eat the food that was sent. At 1:10 PM, an RN stated that dietary usually sent health shakes on the cart with the milk and, after checking four dietary carts on different hallways, reported that the kitchen had not sent any health shakes to the floor. At 1:20 PM, the Dietary Manager reviewed the resident’s dietary sheet and stated that the facility did not have soup and that health shakes were on the carts with the milk. The resident’s dietary sheet dated 01/12/2026 documented ordered supplements and preferences including “HEALTH SHAKE – 1 each,” “SOUP – 1 serving,” and “NO CASSEROLES,” which did not match the meal and items actually provided to the resident at the time of observation. These observations, interviews, and record review show that the resident did not receive the ordered health shake and soup and was instead served a casserole contrary to the documented preference of no casseroles, demonstrating a failure to accommodate the resident’s food and drink preferences as specified in the dietary sheet.
Failure to Ensure Required PPE Use for Resident on Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of personal protective equipment (PPE) for a resident on contact isolation. On 1/12/26 at 12:51 PM, a housekeeping staff member (V17) was observed cleaning the room of resident R91, whose door displayed a sign indicating "Contact isolation." During this activity, V17 was only wearing gloves and was not wearing a gown as required by the facility’s transmission-based precautions policy for contact isolation. At the same time, a CNA (V19) was in the same room assisting R91 and removing the resident’s dirty laundry, which was placed in a yellow cinch bag rather than an isolation bag. The CNA carried the laundry from the resident’s room to the soiled utility room without wearing any PPE, including gloves or a gown. On 1/13/26 at 1:05 PM, the facility’s infection control preventionist nurse (V18) stated that staff should wear gloves and a gown upon entering the room of a resident on contact isolation. Facility records showed that R91 was on strict contact isolation precautions due to C. diff, with orders indicating that all needs were to be rendered in the room to prevent cross contamination. An isolation list provided by the facility documented that R91 was on contact isolation for C. diff with a start date of 1/10/26 and a potential stop date of 1/20/26. The facility’s transmission-based precautions policy dated 1/1/25 specified that for contact precautions, hand hygiene and gloves upon entry to the room were required, and a gown was required.
Failure to Ensure Resident Dignity and Adequate Incontinence Supply
Penalty
Summary
The facility failed to ensure residents' dignity and rights by not providing incontinence supplies in the correct sizes and quantities, as well as by not preventing undignified interactions between residents. Multiple residents without cognitive impairment reported ongoing issues with access to appropriately sized incontinence briefs and pull-ups, with some residents forced to use incorrect sizes or go without supplies for extended periods. Staff interviews confirmed that supply distribution was restricted, with diapers stored in locked areas and limited quantities provided per shift, leading to shortages. The central supply and administrative staff acknowledged ongoing problems with supply management, including attempts to control inventory due to concerns about hoarding, but residents continued to report unmet needs. Additionally, the facility failed to prevent or address undignified verbal interactions among residents. Several residents and staff described incidents where one resident, with a history of mental illness and behavioral symptoms, verbally harassed and insulted other residents, including making derogatory comments about their weight and threatening statements. These behaviors were witnessed by other residents and staff, and in some cases, were not reported to or addressed by facility leadership. The affected residents generally reported feeling safe, but the incidents were recurrent and known to staff. The facility's policies regarding resident rights and dignity were requested but not provided during the survey. The combination of inadequate supply management for incontinence products and insufficient intervention in resident-to-resident verbal abuse resulted in a failure to uphold residents' rights to dignity, self-determination, and respectful treatment.
Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Chronic Wounds
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for two residents with chronic wounds. In one instance, a CNA provided morning care to a resident on EBP, including changing an incontinent brief, transferring the resident, and changing bed linens, while only wearing gloves and not a gown as required. The CNA acknowledged awareness of the EBP protocol and the need to wear both gown and gloves to prevent cross-contamination. The resident's care plan documented the need for EBP due to infection prevention standards. In another case, a resident with a surgical wound requiring daily dressing changes and recent antibiotic treatment did not have the required EBP signage or orange dot indicator outside the room. The DON confirmed the resident was on EBP and that the sign may have been removed during a room change or cleaning. Both the DON and Infection Control Nurse stated that staff should wear gloves and gowns when providing care to residents on EBP, and facility policy specifies the use of gown and gloves for high-contact care activities for residents at high risk of MDRO transmission.
Failure to Double Lock Controlled Substances in Medication Cart
Penalty
Summary
The facility failed to ensure that controlled substances were double locked in a medication cart, as required by regulations. During an observation of medication administration, it was noted that the staff member, identified as V5, did not lock the medication cart when entering residents' rooms to administer medications. This occurred on multiple occasions, specifically when V5 was administering medications to residents R16, R56, and R17. During these times, the medication cart was left unattended and out of V5's line of sight, with the controlled substance lockbox within the cart being unlocked and accessible without a key. The facility's Director of Nursing, identified as V2, acknowledged that the medications in the controlled substances box are prone to abuse and theft, emphasizing the importance of double locking these medications. The facility's Medication Administration policy, dated January 2023, explicitly states that the medication cart should never be left open and unattended. Despite this policy, the controlled substances for residents, including narcotic pain medications and anti-anxiety medications, were not secured as required, posing a risk of theft or misuse.
Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a resident with a reasonable suspicion of mental illness was referred for a Level II PASARR screening. The resident, who had been diagnosed with bipolar disorder and had a history of suicidal ideations, was admitted to the facility in 2019. Despite the initial screening indicating a reasonable suspicion of mental illness, the facility did not complete the necessary referral for a Level II PASARR screening. The resident's care plan included antipsychotic and antidepressant medications, and he exhibited mood problems related to his bipolar disorder. Interviews with facility staff revealed that the Social Services Director, who was not in her current role at the time of the resident's admission, was unable to find documentation of the Level II PASARR screening or any referral made to the appropriate agency. The facility's policy required the completion of Level I and II screenings prior to admission, but the documentation was missing. The Director of Nursing confirmed that she was not involved in the PASARR screenings, indicating a lack of clarity in the roles and responsibilities for ensuring compliance with PASARR requirements.
Failure to Assess and Document New Wound
Penalty
Summary
The facility failed to assess and document treatment orders for a new wound on a resident with a history of venous stasis wounds and lymphedema. The resident, who has moderate cognitive impairment, reported a new sore on his right leg, but the electronic wound round reports did not reflect any open or active wounds. Despite the resident's concerns about the new sore, the nursing staff did not document the wound or obtain treatment orders in a timely manner. The wound care nurse was unaware of the new blister until it was brought to her attention, and the wound doctor was not notified until two days after the wound was discovered. The Director of Nursing and a Registered Nurse acknowledged awareness of the blister but failed to document the new order or perform an assessment. The facility's Skin Management policy emphasizes the importance of consistent documentation and assessment, which was not adhered to in this case.
Failure to Safely Transport Resident in Wheelchair
Penalty
Summary
The facility failed to safely transport a resident in a wheelchair, leading to a deficiency in ensuring a hazard-free environment and adequate supervision to prevent accidents. On the specified date, a resident, identified as R83, was observed being pushed in a wheelchair by the Social Service Director (V6) without foot pedals attached. During the transport, R83, who was wearing running shoes, attempted to lift his feet but was unable to consistently keep his right foot off the ground, causing his toes to hit the floor multiple times. This incident occurred despite R83's known high fall risk and severe cognitive impairment, as documented in his facility assessment and admission evaluation. Interviews with staff, including a Registered Nurse (V7) and the Director of Nursing (V2), confirmed that R83 was at high risk for falls and required foot pedals on his wheelchair during transport to prevent injury. The staff acknowledged that the absence of foot pedals could lead to potential harm, as R83 had a tendency to put his feet down. Despite the facility's awareness of the resident's condition and needs, a policy for safely transporting a resident in a wheelchair was requested but not provided, indicating a lapse in procedural adherence and safety measures.
Failure to Verify G-Tube Placement Before Water Flush
Penalty
Summary
The facility failed to ensure the proper checking of a gastrostomy tube (G-tube) placement before administering water flushes for a resident with severe cognitive impairment and multiple medical conditions, including chronic respiratory failure, cerebral infarction, dysphagia, and the use of a tracheostomy tube. The resident's physician orders required a 200-milliliter water flush every four hours through the G-tube. However, during an observation, a registered nurse administered the water flush without verifying the tube's placement, which is a critical step to prevent potential complications such as aspiration. The Director of Nurses acknowledged that staff should verify the G-tube's placement before administering any substances, as failing to do so could result in the tube not being in the stomach, increasing the risk of aspiration. Although the facility's policy on enteral tube medication administration emphasizes safe and effective practices, it does not explicitly outline the procedure for checking tube placement. This oversight in practice and policy contributed to the deficiency identified during the survey.
Failure to Follow Insulin Pen Manufacturer Instructions
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for the use of an insulin pen, which was observed during the administration of insulin to a resident with type II diabetes. The resident had an active order for 5 units of rapid-acting insulin to be administered at meals, along with a sliding scale order for additional insulin based on blood sugar levels. On a specific occasion, a registered nurse prepared the insulin pen by dialing in and depressing 2 units of insulin twice without attaching the needle, contrary to the manufacturer's instructions. The nurse then attached the needle and selected 13 units of insulin for administration based on the resident's blood sugar reading. The manufacturer's instructions for the insulin pen specified that the needle should be attached before priming the pen, and the pen should be held vertically to expel air bubbles. The Director of Nursing confirmed that the purpose of priming the pen is to ensure the resident receives the full dose of insulin and that the needle should be attached prior to priming. The failure to follow these instructions could potentially result in the resident not receiving the correct dose of insulin.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as R56, who was observed on multiple occasions without access to water. On the first observation, R56 was found in bed with dry lips and no water available in the room. The resident expressed thirst and consumed an entire cup of water when it was eventually provided by a nurse. Subsequent observations revealed similar conditions, with no water within reach, despite the resident's evident signs of dehydration such as dry lips and mouth. R56's medical records indicated no fluid restrictions or swallowing issues, and the care plan emphasized the importance of keeping water within reach and monitoring for dehydration signs. Despite this, the facility staff failed to ensure water was accessible, as evidenced by the resident's repeated expressions of thirst and physical signs of dehydration. The facility's hydration policy mandates routine monitoring and provision of fluids, which was not adhered to in this case, leading to the deficiency.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound treatment as ordered for a resident with a pressure ulcer. On a specific date, the Wound Care Nurse/Assistant Director of Nursing (ADON) noted that the resident should have received wound care and a dressing change to her coccyx wound two days prior, as the treatment was ordered every other day. However, the dressing in place was dated four days earlier, indicating a lapse in care. A Licensed Practical Nurse confirmed that wound care and dressing changes are supposed to be conducted according to the doctor's orders. The resident's care plan indicated an active stage 4 pressure ulcer on the sacrum, with treatment orders for cleansing, medication, and dressing changes every other day and as needed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. On August 29, 2024, a resident reported to a registered nurse and the local police department that his roommate had used a racial slur against him. The police responded to the call, and the facility moved the accused resident to a different room. However, the facility administrator did not conduct an abuse investigation, as she did not consider the incident an abuse allegation. The facility's abuse policy requires prompt and aggressive investigation of all reports and allegations of abuse. Despite this policy, no investigation was conducted following the incident. Both residents involved were cognitively intact, as indicated by their Minimum Data Set assessments. The facility's failure to investigate the reported incident is a violation of its abuse policy and prevention program, which aims to ensure residents are free from abuse and mistreatment.
Failure in Medication Administration Protocol
Penalty
Summary
The facility failed to ensure proper medication administration for a resident diagnosed with delusional disorder, major depressive disorder, parkinsonism, cervical disc disorder, spinal stenosis, and a history of falling. On multiple occasions, the resident refused to take medications when offered by the nursing staff. The nurse initially attempted to administer the medication at 5:00 PM, but the resident was in the restroom and refused. A second attempt was made at 6:00 PM, which was also refused. At 8:30 PM, the resident took the medication cup from the nurse and placed it on the bedside table, instructing the nurse to leave it there. The Assistant Director of Nursing (ADON) witnessed this interaction but did not ensure the resident took the medication. The Medication Administration Record indicated that the medications were signed out as given, despite the resident not taking them in the presence of the nurse. The ADON confirmed that it was not acceptable to leave medications unattended, as it was unclear if the resident would take them. The facility's policy requires that staff verify medication administration by remaining with the resident to ensure the medication is swallowed. However, this protocol was not followed, and the resident's self-medication assessment was not completed, nor was there a doctor's order or care plan in place for self-administration.
Failure to Provide Necessary Wound Care
Penalty
Summary
The facility failed to provide necessary care and treatment to residents with nonpressure wounds, as evidenced by the cases of two residents. The first resident, R2, was admitted with infectious wounds on her buttocks and lower legs due to necrotizing fasciitis. Despite physician orders for daily wound care, observations revealed that R2's wounds were not dressed, and the resident reported that her dressings had not been changed for a couple of days. The wound nurse confirmed that wound care should be performed daily, and if unavailable, the floor nurse could also perform the treatments. The second resident, R3, had open wounds in the axilla and groin areas due to Hidradenitis Suppurativa. Physician orders required daily cleansing and application of wound care products, but the treatment administration record showed multiple days where no wound care was provided. The facility was unable to provide a policy on the care and treatment of nonpressure wounds when requested by the surveyors, indicating a lack of adherence to established care protocols.
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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