Allure Of Galesburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Illinois.
- Location
- 1145 Frank Street, Galesburg, Illinois 61401
- CMS Provider Number
- 145987
- Inspections on file
- 43
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 13 (5 serious)
Citation history
Health deficiencies cited at Allure Of Galesburg during CMS and state inspections, most recent first.
The facility failed to prevent multiple episodes of resident-to-resident physical abuse among alert, oriented residents, despite policies prohibiting abuse. In one case, two roommates engaged in a verbal dispute that escalated to one resident striking or poking the other with a cane, leading to reported chest and side pain and an ED evaluation. In another incident in the dining room, a disagreement over cookies and a soft drink led one resident to strike another in the head with a coffee cup or tray, after which the injured resident, who had a prior neck fusion, reported neck pain and went to the ED. In a separate roommate incident, each of two residents reported that the other started an argument and hit him, with one describing being awakened by being hit in the legs and responding by hitting the other in the stomach. These events show that the facility did not effectively prevent physical altercations between residents.
A resident with hypertension, depression, anxiety, hyperlipidemia, and schizoaffective disorder went on a therapeutic leave and was not provided with all ordered morning medications, including antihypertensive, antidepressant, antipsychotic, lipid-lowering, and anxiolytic drugs, despite a facility policy requiring adequate medications for leave. The resident later reported receiving only evening medication packets, called the facility to report missing morning doses, and stated he could not return due to lack of transportation. On return, the resident’s BP was markedly elevated compared to baseline, and the resident reported increased anxiety, dizziness, headaches, and worsened depression and anxiety. Documentation showed no record that medications were sent, the MAR did not reflect home-pass medications, and a nurse consultant confirmed that only p.m. shift medications appeared to have been packed by an agency nurse, leading surveyors to cite a significant medication error.
Surveyors found that a resident’s returned medications from a home pass were kept in white paper envelopes in a nurse’s med cart instead of in original packaging, and these envelopes were not dated or signed by a nurse and contained unidentified pills. The resident, who was cognitively intact and had multiple psychiatric and medical diagnoses with corresponding prescriptions, reported previously bringing back unused medications from leave, which was confirmed by an LPN. An RN consultant acknowledged that staff had left these returned medications in the cart and had not destroyed them according to facility policy, and she was unable to determine what the medications were or when they were from.
The facility failed to maintain accurate and complete electronic clinical records for multiple residents. One cognitively intact resident’s care plan did not reflect a history of making false allegations, and his record lacked documentation of departure and return from therapeutic leave, including whether medications were provided, while the MAR conflicted with the resident’s report of receiving morning medications after elevated BP was noted. In addition, another cognitively intact resident’s record contained no documentation of a physical altercation with his roommate, even though an incident report described a verbal dispute that became physical, involved police response, and resulted in court fines for both residents.
A resident with multiple comorbidities, including dysphagia and dementia, experienced repeated emesis and respiratory distress; staff attempted to respond but found that both crash carts lacked essential items such as an Ambu bag, yankauer suction, and a backboard, and the suction machines were inoperable due to missing or improperly connected tubing. Nurses and CNAs reported they could not recall receiving training on crash cart contents or operation, there were no completed daily crash cart checklists, and the DON could not document when the carts were last checked. During the emergency, staff were unable to suction the resident before she became unresponsive and pulseless, leading to CPR and EMS involvement, and the physician later identified aspiration pneumonia as the immediate cause of death and stated that immediate suctioning could possibly have prevented it. The administrator and DON did not investigate the unplanned death or report it to the state agency, and surveyors determined these failures created Immediate Jeopardy for all residents due to delayed or ineffective emergency response.
A resident with multiple chronic conditions, including COPD, dementia, and dysphasia, experienced several episodes of emesis after supper, with staff noting gurgling respirations and pallor. An RN and an LPN responded, 911 was called, and CPR was initiated after the resident became unresponsive and pulseless; EMS later pronounced the resident deceased, and the death certificate listed aspiration pneumonia as the immediate cause. The RN reported the crash cart suction equipment was not connected and inoperable and stated she could not recall training on its contents. The DON and the Administrator both acknowledged that no investigation into this unplanned death was conducted and that the death was not reported to the state agency as required.
A resident with significant psychiatric diagnoses and a plenary guardian, documented as having impaired social interaction and poor decision-making with men, engaged in ongoing romantic and sexually explicit electronic communication with a dietary aide who had been trained on abuse prevention and was later allowed to resign due to "growing feelings" for the resident. Despite policies prohibiting staff–resident sexual relationships and abuse via technology, the resident’s care plan was not updated to include recommended supervision of phone use, restrictions on contacts, or any assessment of capacity to consent to sexual activity, and did not reflect increased supervision measures discussed in internal meetings. The aide continued to communicate with the resident, meet her at church without staff supervision, and, according to the facility’s investigation and a police report, engaged in multiple non-consensual sexual encounters with her in his vehicle during church services, while also verbally abusing her roommate during sexually explicit calls. Sign-in/out records for community outings lacked documentation of who accompanied the resident, and staff knowledge of the resident “sneaking around” with the aide at church did not result in timely protective interventions, leading to staff-to-resident sexual and verbal abuse and failure to safeguard the resident’s rights and safety.
A facility failed to immediately report multiple abuse, neglect, and exploitation allegations to the State Agency and local police as required by its abuse policy. An administrator learned that a dietary aide was pursuing a romantic relationship with a resident under plenary guardianship, including boyfriend/girlfriend-type texts and sexually explicit electronic communications, but did not notify authorities when this was discovered. The same resident later reported non-consensual sexual encounters with the former staff member off-site, while another resident reported repeatedly witnessing sexually explicit video calls between them and being cursed at and threatened by the former staff member when she asked them to stop. Additionally, a resident’s report of being physically assaulted by other residents, documented in ED records, was not reported to authorities after the facility became aware. Staff interviews showed that several employees knew of the inappropriate relationship and sexually explicit video interactions, yet there was no timely reporting or documented assessment of the resident’s capacity to consent to sexual activity.
A cognitively impaired resident with a plenary guardian, lacking any documented assessment of capacity to consent to sex, became involved with a dietary aide who, while employed, engaged in boyfriend/girlfriend-type texting, sexually explicit video chats, and attempts to form an intimate relationship, and later allegedly sexually assaulted the resident on multiple occasions off-site. Facility staff, including the administrator, DON designee, psychosocial staff, and a CNA, became aware over time of the aide’s inappropriate communications and excessive time with the resident, but the aide was allowed to resign without an abuse investigation, no report was made to the State Agency, and no care plan interventions or enhanced supervision were implemented. The resident’s roommate reported repeatedly witnessing sexual acts and conversations via phone video and being subjected to profane verbal abuse and threats by the former aide, yet there was no documented investigation, no State report, and no care plan updates for her safety. Additionally, when the resident reported in an ED visit that she had been physically assaulted by other residents, the facility did not immediately investigate or report this allegation, contributing to an Immediate Jeopardy finding.
A cognitively intact resident with multiple behavioral health and pain-related diagnoses had an active PRN order for Norco 10/325 mg. Pharmacy records and video evidence confirmed that an agency RN received a 30-tablet card of this controlled substance and placed it in the med cart, with no discrepancies noted at the end of her shift. Two days later, staff discovered the Norco card was missing when a refill request was denied because the prescription had already been filled. Review by the DON found that multiple nurses were not performing required beginning- and end-of-shift controlled-substance counts, and video surveillance did not consistently capture the med cart, preventing clear identification of who removed the medication.
The facility failed to follow its own controlled-substance storage and accountability policies, resulting in a missing card of 30 tablets of Hydrocodone-APAP (Norco) for a resident. Pharmacy records and video showed that an agency RN received the controlled medication and placed it in the med cart, but the medication was later found to be missing. Review of controlled-substance inventory sheets revealed that multiple nurses did not perform required shift-to-shift controlled-drug counts or verify controlled-substance cards, leading to unaccounted-for loss of the resident’s controlled medication.
A nurse pre-prepared and stacked multiple residents' medications, resulting in a resident with complex medical conditions receiving another resident's medications. The error was not immediately reported, and the resident required emergency hospitalization and intubation due to overdose. Ongoing pre-popping and stacking of medications by staff was observed, in violation of facility policy.
Nursing staff were observed pre-preparing and stacking medication cups, including those containing controlled substances, on and inside medication carts rather than keeping them secured and under direct observation as required by facility policy. Both a registered nurse and an LPN confirmed this practice, which involved multiple residents and included controlled drugs such as Clonazepam, Ativan, and Tylenol with Codeine.
Surveyors observed that multiple servings of mixed fruit, applesauce, and cooked chicken breasts were stored in refrigeration units without proper covering or dating, contrary to facility policy. The Dietary Manager confirmed these items should have been labeled and covered.
The facility did not notify the state mental health authority for reevaluation when PASRR short-term approvals ended for six residents. Medical records lacked documentation of required referrals or reevaluations after the expiration of PASRR Level II approvals, as confirmed by the Social Services Director.
Surveyors found that the facility did not implement or maintain required fall prevention interventions for several residents who had experienced falls, as documented interventions such as non-skid strips and perimeter mattresses were not in place during inspection. Additionally, a resident with psychiatric diagnoses repeatedly possessed and used prohibited smoking materials, and the facility failed to update assessments or enforce its smoking safety policy.
Surveyors found that four residents receiving oxygen therapy did not have their oxygen humidification bottles and tubing changed or dated according to facility policy, despite staff confirming the requirement for weekly changes. This failure to follow established procedures affected residents with orders for oxygen therapy, including those with chronic respiratory conditions.
The facility did not ensure that flu and pneumonia vaccines were offered or properly documented for several residents, as required by policy. Immunization records lacked evidence that these vaccines were administered, declined, or even offered, and this lapse was confirmed by the facility's regional nurse consultant.
Two residents with psychiatric diagnoses were not timely assessed for walking pass privileges after requesting participation in the program, resulting in significant delays. One resident's assessment was not initiated for months, while another experienced a prolonged gap between request and reinstatement of privileges, contrary to facility policy.
A resident was subjected to verbal abuse when a CNA yelled and cursed at him, as confirmed by both staff witnesses and the resident. The incident was documented, and the resident reported feeling that the staff member's conduct was unprofessional and inappropriate.
Staff did not follow enhanced barrier precautions during wound care for a resident with open wounds, as gowns and gloves were not available and not used, and no signage was present. Infection surveillance records were incomplete, with missing monthly logs and insufficient documentation in antimicrobial therapy reports. Additionally, an LPN failed to properly disinfect a blood glucose meter between residents, using an alcohol wipe instead of the required disinfectant, potentially affecting several residents.
Nurse staffing information was not posted daily or made accessible, as the displayed sheet was outdated and hidden behind another document. The administrator confirmed the required posting was not done at the start of each shift, potentially affecting all residents.
A resident with severe mental illness physically assaulted another resident by throwing a canister and punching the individual in the chest near the drink station. The incident was witnessed by another resident, partially captured on video, and promptly reported to the administrator and physician. The victim was assessed and found to have no injuries, and staff responded immediately after being notified.
A resident with a history of serious mental illness was subjected to sexual and mental abuse by a CNA over six months. The CNA bribed the resident with alcohol and drugs in exchange for sexual favors, leading to fear, depression, and the need for STD prophylaxis. The facility failed to prevent this abuse, resulting in Immediate Jeopardy.
The facility failed to provide mandatory annual QAPI in-service training to its staff, as revealed by a review of training logs and confirmed by the Corporate Nurse. This oversight, which was not listed as a required yearly training, has the potential to affect all 93 residents in the facility.
A facility failed to report an allegation of staff-to-resident sexual abuse to the State Agency within the required timeframe. A resident reported inappropriate sexual encounters with a CNA, who had resigned. The Administrator was informed by an LPN but delayed reporting to the State Agency until the resident stated the encounters were non-consensual, violating the facility's Abuse Policy.
Two residents were involved in separate incidents of physical abuse by another resident, who smacked them during altercations. The resident responsible for the abuse was cognitively intact and admitted to the actions, which were influenced by misunderstandings and personal perceptions. The facility failed to prevent these incidents, despite being aware of the resident's history of conflicts with roommates.
The facility failed to document significant incidents in resident records, including a physical altercation and an allegation of inappropriate behavior during a home visit. Despite investigations and interventions, such as police involvement and 1:1 supervision, these events were not recorded in the residents' medical records.
A facility failed to identify, monitor, and treat pressure wounds on a resident's feet, resulting in unstageable wounds. Despite having a pressure reduction boot and instructions for offloading, the resident's feet were observed in contact with the mattress multiple times. The care plan did not document the wounds or interventions, and staff were unaware of the wounds, indicating a breakdown in communication and care planning.
The facility failed to properly dispose of kitchen waste by leaving the lids open on the outside trash receptacle, contrary to its policy requiring tightly fitting lids. This was confirmed by the Head Cook and has the potential to affect all 90 residents.
The facility failed to ensure a pest-free environment in the kitchen, as gnats were observed on and around the juice dispenser spigot/handle. This was confirmed by the Head Cook during a kitchen tour, despite the facility's policy requiring food service areas to be free from pests.
The facility failed to maintain a clean and functional women's shower room, affecting all female residents on the E Wing. Observations revealed broken shower heads, minimal water pressure, non-functional toilets, and a lack of privacy. Residents reported long-standing issues, with one stating the problems have persisted for three years. The maintenance director noted plans for a remodel, but the current state includes missing faucets, broken fixtures, and no soap in dispensers.
A disposable razor was found on the counter in the women's shower room, accessible to residents on the E-Wing. An LPN confirmed that razors should be locked up and only given to residents by staff, highlighting a failure in maintaining a hazard-free environment.
The facility failed to develop comprehensive care plans for two residents, resulting in unaddressed medical needs. One resident had skin discoloration and lesions not included in their care plan, despite a physician's assessment. Another resident had skin conditions and foot wounds that were not addressed in their care plan, with necessary interventions like offloading boots not being utilized. The facility's ADON and DON acknowledged these oversights.
A facility failed to address skin care concerns for a resident with discoloration and lesions on both upper extremities. Despite policies requiring regular skin assessments, the resident's records lacked documentation of treatments or physician orders. Staff confirmed the absence of treatment orders and protective measures. A subsequent evaluation diagnosed the resident with Actinic Keratosis, highlighting the facility's failure to provide necessary care.
A facility failed to provide physician orders for oxygen administration and did not change oxygen tubing and humidifier bottles per policy for a resident. The resident was observed receiving oxygen at 3.5L over three days without a physician order, and the equipment was not changed weekly as required. An LPN confirmed the policy, and the ADON was unaware of the continuous oxygen use.
A resident on hospice care with multiple diagnoses was prescribed Seroquel, an antipsychotic, without documented indication or target behaviors. Despite no signs of psychosis or identified behaviors over three months, the medication was administered. The DON could not provide a reason for its use, highlighting a deficiency in medication management.
The facility failed to provide rooms with at least 80 square feet per resident, affecting multiple residents. The Maintenance Director confirmed the deficiency, and a previous waiver was submitted to the State Agency. However, the current administrator was unaware of any recent waivers. A letter from the State Agency confirmed that certain rooms were waivered for not meeting the requirement.
The facility failed to protect two residents from verbal abuse by an RN, who was overheard cussing and yelling at one resident and blaming another. The incident was substantiated through an investigation, and the RN was terminated.
The facility failed to revise care plans for three residents who had their smoking privileges revoked due to non-compliance with smoking rules. Despite the revocations being in place for several months, the care plans were not updated to reflect these changes, as confirmed by the DON. The Social Service Director was responsible for the revisions, but they were not completed.
Failure to Prevent Multiple Resident-to-Resident Physical Altercations
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse despite having written policies prohibiting abuse, neglect, and exploitation. The facility’s Abuse, Neglect, and Exploitation policy states that abuse includes the willful infliction of injury and can include resident-to-resident altercations, and that the facility will develop and implement policies and procedures to prevent and prohibit all types of abuse. In practice, multiple resident altercations occurred among cognitively intact, alert, and oriented residents, resulting in physical contact and reports of pain and injury, indicating that abuse prevention measures were not effective in protecting these residents from physical abuse. In one incident, two alert and oriented roommates became involved in a verbal altercation that escalated into physical contact involving a cane. One resident reported that his roommate hit him across the chest with a cane while he was asleep, waking him and causing side pain; he was sent to the ED for evaluation. The other resident reported that there was a verbal altercation and that he poked the first resident with a cane after being struck in the side, stating he did not poke hard and only wanted the other resident to get away. Police were notified, and both residents later appeared in court and were fined, but the incident itself reflects a failure to prevent a physical altercation between roommates. In a separate incident in the dining room during a meal, two alert and oriented residents argued over cookies and a promised soft drink. One resident reported that he traded cookies for a Mountain Dew, but the other resident then stated he had neither the drink nor the money, laughed, and dismissed repeated requests, leading the first resident to state that he “snapped” and struck the other in the head with a coffee cup. Nursing documentation described the event as the resident getting up from the table, moving chairs, and pouring coffee on another resident’s back in an apparently unprovoked incident. The struck resident reported being hit in the back of the head with a tray, experiencing neck pain, and going to the ED due to a prior neck fusion. In another roommate incident, two alert and oriented residents each reported that the other started an argument and hit him, with one stating he was awakened by being hit in the legs and responding by hitting the other in the stomach; police were called, but no charges were pressed. These multiple episodes of resident-to-resident physical contact demonstrate that the facility did not effectively prevent physical abuse among residents.
Failure to Provide Required Medications During Therapeutic Leave Resulting in Elevated BP and Increased Anxiety
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during a therapeutic leave, specifically by not providing required morning medications for multiple days. The facility’s own Therapeutic Leave policy states that staff will coordinate with the resident or representative regarding the length of time away to ensure adequate amounts and appropriate medications are ready for administration while on leave. For this cognitively intact resident with diagnoses including schizoaffective disorder bipolar type, suicidal ideations, major depressive disorder (recurrent), essential hypertension, mixed hyperlipidemia, restlessness and agitation, and anxiety disorder, the medical record showed standing orders for several daily morning medications: Amlodipine/Benazepril for hypertension, Cariprazine for schizoaffective disorder, Fenofibrate for hyperlipidemia, Wellbutrin XL for depression, and Hydroxyzine for anxiety. The record contained no documentation that all of these medications were sent with the resident for the therapeutic leave. The resident went on therapeutic leave from a Friday to the following Monday. On the morning after leaving, the resident called the facility and reported he had not received his morning medications and that they had not been packed for the remainder of the home visit. An LPN documented this call, apologized, told the resident he could return so staff could check what medications were missing, and noted that the resident stated he would try to stay on the home visit but would go to the ER if he had problems. The LPN reported notifying the Administrator. The resident later produced white envelope medication packets labeled with his name and specific dates and times to take at 5 p.m., indicating he had evening medications for several days, but he stated he did not receive any morning medication packets for the three days he was away. The facility’s nurse consultant confirmed there was no note in the chart indicating medications were sent, that the MAR did not show he was sent home with his medications, and that an agency nurse on the p.m. shift had packed the medications. Upon the resident’s return, his blood pressure was documented as significantly elevated at 198/101 compared to 126/84 on the morning before he left. The resident reported that this was the highest his blood pressure had ever been and attributed it to not receiving his blood pressure medications for three days. He also reported increased anxiety, dizziness, and headaches after the weekend, and voiced increased depression and anxiety upon return. A subsequent medication regimen review noted that the resident’s elevated blood pressure upon return could have been secondary to missing his Amlodipine/Benazepril, and described the half-lives and potential effects of abruptly missing his other medications, including Cariprazine, Fenofibrate, Wellbutrin XL, and Hydroxyzine. The review also noted that Hydroxyzine had been ordered twice daily during the home visit period and that abrupt discontinuation could result in rebound anxiety. The resident’s care plan did not document any history of false allegations or untruthfulness, and staff acknowledged that he had not previously complained of missing medications on home visits. These documented omissions and resulting clinical changes formed the basis of the cited significant medication error.
Improper Storage and Failure to Destroy Returned Medications
Penalty
Summary
The deficiency involves the facility’s failure to store and manage medications in accordance with its own medication storage policy and accepted professional standards. The facility policy states that all medications housed on the premises will be stored in the pharmacy and/or medication rooms to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security, and that unused medications with worn, illegible, or missing labels are to be destroyed per policy. Surveyors found medications belonging to one resident (R3) stored in white paper medication envelopes in the nurse’s medication cart, rather than in original packaging. These envelopes were labeled only with the resident’s name and the times the medications were to be taken, but were not dated or signed by a nurse, and the RN consultant (V9) was unable to identify what pills were in the envelopes, what day they were from, or why they remained in the cart. R3’s record documented multiple diagnoses, including schizoaffective disorder bipolar type, suicidal ideations, major depressive disorder (recurrent), essential hypertension, mixed hyperlipidemia, restlessness and agitation, and anxiety disorder, with multiple prescription medications ordered for these conditions. The MDS documented that R3 was cognitively intact, and the current care plan did not document any history of false allegations or untruthfulness. R3 stated that he had previously brought back medications when he forgot to take them while out on leave, and an LPN (V8) confirmed that R3 had brought back medications from home leave that he had not taken. The RN consultant (V9) further confirmed that staff reported R3 had returned medications from a home pass, that these returned medications were still in the cart in envelopes, and that they had not been destroyed as required by facility policy.
Failure to Maintain Accurate Electronic Records for Therapeutic Leave, Medications, and Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate electronic clinical records for residents in accordance with its own policy and accepted professional standards. For one resident, the current care plan did not document a history of making false allegations or not being truthful, despite the resident being assessed as cognitively intact on the MDS. The resident’s electronic medical record contained no documentation of when he left or returned from a therapeutic leave, even though the facility’s sign in/out sheet showed he left with his brother at a specific time and date but did not record his return. The April MAR documented that the resident was out on therapeutic leave and did not receive his morning medications on a particular date, while the resident reported that he did receive his morning medications that day after a nurse noted his high blood pressure. An LPN confirmed that the electronic record should document when a resident leaves and returns, with whom they left, and whether medications were sent for the duration of the leave, and a nurse consultant verified that this resident’s record and MAR were not accurate or complete. The deficiency also includes the lack of documentation in another cognitively intact resident’s electronic medical record of a physical altercation with his roommate. An incident report submitted to the state by the Administrator documented that two alert and oriented residents, both able to make informed decisions, were involved in a verbal altercation that became physical on a specific date. One of these residents later stated he had been roommates with the other at the time, that the other resident claimed he was hit with a cane, and that police were called, court proceedings occurred, and both residents were ordered to pay a fine. Despite these events and the resident’s cognitive intactness as documented on the MDS, there was no corresponding documentation of the physical altercation in his electronic medical record.
Failure to Maintain Functional Crash Carts and Train Staff in Emergency Equipment Use
Penalty
Summary
The deficiency centers on the facility’s failure to ensure that emergency medical equipment was present, functional, routinely checked, and available for use during a medical emergency, and that nursing staff were trained and competent in its use. Facility policy required that the emergency crash cart contain supplies critical to basic life support, be stored in a readily accessible location, be checked every 24 hours and after each use, and that clinical staff be educated on the cart’s location and contents. However, surveyors found that both the front and back nurse’s station emergency carts lacked key items such as a manual resuscitator (Ambu bag), oral airways, Normal Saline, yankauer suction catheters, suction kits, flashlight, alcohol wipes, lubricating jelly, blood pressure cuff, stethoscope, and the required backboard. The suction machines on both carts were inoperable due to missing or improperly connected tubing and canisters, and there was no documentation of daily crash cart checks. The events leading to the deficiency involved a resident with frontotemporal neurocognitive disorder, malignant neoplasm of the right breast, dysphagia, diabetes mellitus, COPD, and dementia, who experienced multiple episodes of emesis. Nursing notes and staff statements document that the resident initially had a small emesis, was cleaned, and reported feeling okay. Shortly thereafter, the resident had additional emesis, appeared pale, and staff noted gurgling respirations. A CNA reported the gurgling to the RN, who sought assistance from another nurse to assess lung sounds. When the nurses returned to the room, the resident was pale and vomiting from the mouth and nose. Staff attempted to obtain the crash cart and suction the resident but were unable to do so because the suction equipment on the cart was not functional and lacked proper yankauer suction and tubing. During this period, the resident’s condition deteriorated from responsive with a pulse to unresponsive without a palpable pulse, and CPR was initiated. Subsequent review of the emergency carts and staff interviews further demonstrated systemic inaction and noncompliance with the facility’s own emergency cart policy. Surveyors observed that the carts were dusty, missing required equipment, and had no completed emergency cart checklists. The DON stated she was responsible for checking the carts after each use and periodically but did not complete checklists, could not state when the carts were last checked, and was unable to provide crash cart check documentation for the past year. Multiple nurses and CNAs reported they could not recall ever receiving training on the contents of the emergency crash cart or how to operate the equipment. The administrator and DON also stated they did not conduct an investigation into the resident’s unplanned death, and the administrator did not report the unplanned death to the state agency. The physician later stated that the resident’s immediate cause of death was aspiration pneumonia occurring within hours and that immediate suctioning when the resident began vomiting repeatedly could possibly have avoided the death. These combined failures resulted in staff being unable to provide timely life-saving interventions during the resident’s unplanned medical emergency and placed all residents at risk for delayed or ineffective emergency response. The situation was determined to constitute Immediate Jeopardy beginning when the resident experienced the medical emergency and staff were unable to access functional emergency equipment or demonstrate competency in its use.
Failure to Investigate and Report Unplanned Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to investigate and timely report an unplanned resident death to the state agency. The resident was admitted with diagnoses including frontotemporal neurocognitive disorder, major depressive disorder, dysphasia, COPD, anxiety disorder, and diabetes mellitus, and had a Full Code status. On the evening in question, nursing documentation and staff interviews indicate the resident vomited in their room after supper, was cleaned and reported feeling fine, and then had additional emesis with gurgling sounds noted by a CNA. The RN returned with an LPN to assess the resident, who was pale, gurgling, and had another episode of emesis. The RN called 911 and attempted to suction the resident but reported the crash cart suction cannister was not connected and inoperable, and also stated she could not recall receiving training on the crash cart contents. The resident became unresponsive and pulseless, CPR was initiated, and EMS later pronounced the resident deceased, with the death certificate listing immediate cause of death as aspiration pneumonia, with COPD and dementia also documented. Despite the unplanned nature of the death and the circumstances surrounding it, the DON stated there was no investigation into the resident’s unplanned death and confirmed that the state agency had not been informed. The Administrator likewise stated he did not conduct an investigation into the unplanned death and did not report it to the state agency. At the time of the survey, the facility census was 84 residents, and the surveyors concluded that the facility failed to ensure the unplanned death was investigated and reported within the required time frame.
Failure to Protect Resident From Staff Sexual and Verbal Abuse and to Assess Capacity for Sexual Consent
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident with a plenary guardian from staff-to-resident sexual abuse, failure to assess the resident’s capacity to consent to sexual activity, and failure to protect residents from staff-to-resident verbal abuse. The facility had an Abuse, Neglect, and Exploitation policy prohibiting all forms of abuse, including sexual and verbal abuse and abuse facilitated through technology, and an employee union agreement that specified discharge for any employee maintaining or attempting to maintain a sexual or romantic relationship with a resident. Despite these policies, a dietary aide (V7) developed and pursued a personal, romantic, and sexual relationship with a resident (R3) who had a court-appointed plenary guardian due to inability to manage her person or property and lack of capacity to make and communicate responsible decisions. The facility did not complete or document any evaluation of R3’s ability to consent to sexual activity in her electronic health record and did not incorporate her guardianship status or consent capacity into her care plan. R3’s medical and psychosocial history included Borderline Personality Disorder, ADHD, Major Depressive Disorder (including with severe psychotic symptoms), Anxiety Disorder, suicidal ideation, and impaired social interaction. Her care plan documented that she frequently spoke with, texted, or called men, became easily emotionally involved, made poor decisions related to the opposite sex, manipulated situations and staff to leave the building unsafely, used her cell phone to manipulate men online to pick her up, and made false accusations. However, the care plan was not updated after the facility became aware of sexually inappropriate conversations and video nudity via electronic communication between R3 and V7, nor after the guardian restricted R3’s contacts to specific family and staff. The IDT noted that R3 required assistance to think logically about safety and was at risk of exploitation or abuse related to smartphone and social media use, and recommended supervised phone use with the smartphone secured at the nurses’ station, but these interventions were not added to the care plan. The facility also failed to protect R3 and her roommate (R6) from ongoing inappropriate and abusive interactions involving V7. Progress notes documented that R6 complained about R3 getting completely naked in the room with the door and curtain open while talking or videoing on social media, and a behavior note recorded that R6 reported R3 engaging in sexual conversation with a male on a call, during which the male (identified as V7) cursed at R6 and called her names when R6 asked them to stop. Text messages later obtained from R3’s phone showed ongoing personal, romantic, and sexually explicit communication between R3 and V7, including expressions of love, plans for a future together, and explicit sexual content. The facility’s own abuse investigation and a police report documented that R3 reported at least three non-consensual sexual encounters with V7 in his vehicle in a church parking lot during church services, involving forced intercourse, episodes of feeling woozy or blacking out after consuming food or a pill provided by V7, and threats of harm if she disclosed the events. Although the facility’s QAPI/QAA documentation referenced immediate protection measures and increased supervision for R3, these measures were not incorporated into her care plan, and sign-in/sign-out sheets for community outings did not consistently document who accompanied her, allowing continued unsupervised contact with V7 in the community and ongoing verbal abuse toward R6. The facility’s handling of V7’s employment further contributed to the deficiency. V7 had received multiple in-services on abuse prevention, sexual abuse, personal boundaries, and the facility’s abuse policy, yet he was allowed to resign due to “growing feelings for a resident” without the incident being treated and reported as abuse or exploitation at that time. The guardian reported being told by the Administrator that V7 left on his own and that the facility did not have to complete paperwork or report to the state agency, despite the guardian’s assertion that V7’s conduct constituted exploitation and that R3 could not consent to a relationship. After V7’s resignation, R3 continued to attend church services in the community without staff supervision, and the van driver and a nurse reportedly knew R3 had been “sneaking around” with V7 at church. The facility’s root cause analysis acknowledged that R3 attended church with no staff supervision, met V7 there, and left services to go to the parking lot with him, where sexual relations were reported, yet the care plan and supervision practices were not adjusted in a timely or effective manner to prevent further abuse or protect R3 and R6 from staff-to-resident sexual and verbal abuse.
Failure to Timely Report Staff-to-Resident Sexual Exploitation and Other Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to immediately report multiple allegations of abuse, neglect, and exploitation to the State Agency, local police, and the Administrator as required by policy. The facility’s Abuse, Neglect, and Exploitation policy required all alleged violations to be reported immediately, but not later than two hours, when the events involve abuse or result in serious bodily injury, and within 24 hours for other events. Despite this, when the Administrator became aware in June that a dietary aide was attempting to initiate a personal or romantic relationship with a resident who had a plenary guardian due to disability and lack of capacity to make responsible decisions, the Administrator did not notify the State Agency or local law enforcement. The aide resigned after the Administrator reviewed text messages showing boyfriend/girlfriend-type communications and the aide’s desire for a relationship and to get the resident pregnant, but no report was made at that time. The resident involved in this staff-to-resident situation had been adjudicated a disabled person in need of a plenary guardian of person and estate, with the guardian authorized to make residential decisions and protect the resident’s best interests. The guardian reported being told by the Administrator that the aide had resigned and that the facility did not have to report the matter to the state health department. The guardian stated that she informed the Administrator that the aide’s conduct constituted exploitation and that the state needed to know an employee was trying to have a sexual and boyfriend-girlfriend relationship with her disabled daughter. Staff interviews and documentation showed that the psychosocial rehabilitation coordinator and the prior dietary manager both observed or were informed that the aide was spending excessive time with the resident, expressing romantic feelings, and sending messages such as “I love you” and wanting to get the resident pregnant. A CNA also reported seeing the resident video chatting with the aide at night, and another CNA reported several evenings of sexually explicit video chatting between the aide and the resident, which she said she reported to nurses. The facility also failed to immediately report other abuse allegations involving the same resident and her roommate. On one date, progress notes documented that staff spoke with the resident after the roommate complained that the resident was completely naked in the room with the door and curtain open while talking or videoing on social media with a male. On another date, a behavior note documented that the roommate reported the resident was engaging in sexual conversation via video with a male, identified as the former dietary aide, and that when the roommate asked them to stop, the aide cursed at and called the roommate names. The psychosocial rehabilitation coordinator stated she reported this to the Administrator, but there was no evidence these allegations of sexual exploitation by video or the verbal abuse and threats toward the roommate were reported to the State Agency or local police. The roommate later stated she had watched the resident and the aide having sex on the phone several times and that the aide repeatedly yelled at and threatened her when she asked them to stop, and she reported feeling abused and worried. In addition, the facility did not timely report an allegation of resident-to-resident physical abuse involving the same resident. Emergency department notes documented that the resident presented with suicidal ideation and reported being physically assaulted by two other residents the previous day. The Administrator acknowledged learning of this allegation only after receiving the hospital records months later and confirmed that, as of the survey, he had not notified the local police or State Agency regarding this allegation. The police report and the facility’s own abuse investigation later documented that the resident reported multiple instances of non-consensual sexual contact by the former dietary aide in a church parking lot on Sundays, including episodes where she described feeling woozy and blacking out after eating food provided by the aide. The Administrator did not notify the State Agency or local police about the aide’s initial attempts to initiate a personal relationship with the resident while employed, and the police and State Agency were not notified about the sexual relations at church until several days after the guardian reported the situation to facility staff. The Immediate Jeopardy was determined to have started when the Administrator first became aware that the aide was engaging in behavior indicating an attempt to initiate a personal or romantic relationship with the resident and failed to report this to the police or State Agency. This failure coincided with ongoing sexually inappropriate conversations and video nudity by electronic communication between the aide and the resident, which were not reported. The facility’s records and staff interviews showed that, during this period, there was no documented evaluation of the resident’s capacity to consent to sexual activity in the electronic health record, and staff reported they were never informed whether the resident could consent to sexual relationships or that she required supervision. The combination of unreported staff-to-resident sexual exploitation, unreported staff-to-resident verbal abuse toward the roommate, and unreported resident-to-resident physical abuse formed the basis of the cited deficiency for failure to timely report suspected abuse, neglect, and exploitation.
Removal Plan
- V7 resigned from the facility.
- V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation into R3 and R6's abuse allegations and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation, notified IDPH, and notified the local police regarding R3's abuse allegation.
- V5 completed assessments on R3's capacity to consent to sexual relations with the involvement of V3, V35, and V36.
- The facility is evaluating R3's capacity to consent to sexual relations and implemented precautions to keep R3 safe.
- The facility developed a plan to ensure R3 has staff supervision while using the facility phones to ensure safe communication with others.
- V3 removed R3's phone and restricted R3's church visits.
- R3's care plan was updated with interventions to increase R3's safety.
- V26 reviewed all residents to ensure no residents suffered from past abuse.
- The Quality Assessment and Assurance Committee met for an emergency QAPI meeting and developed and implemented plans to ensure no further abuse occurred within the facility and all policies and procedures were followed correctly.
- The facility's abuse policies were reviewed by the QA committee prior to educating staff.
- The facility's staff intimate relationships policy was reviewed by the QA committee.
- V1, V2, and V38 educated all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
- V25 educated V1 on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
- V1, V2, and V38 educated all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
- R3 and R6's care plans were updated with safety interventions to protect them from abuse.
Failure to Prevent, Investigate, and Report Staff-to-Resident Sexual and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from staff-to-resident sexual and verbal abuse, to implement safety interventions and adequate supervision, and to promptly investigate and report allegations of abuse to the State Agency. One resident had a plenary guardian due to physical and mental conditions that rendered her unable to manage her person or property or make responsible decisions, and her record lacked any evaluation of her capacity to consent to sexual activity. Despite this, a dietary aide began engaging in boyfriend/girlfriend-type texting, video chatting, and sexually inappropriate communications with her while employed at the facility, including messages expressing love, wanting to get her pregnant, and plans to remove her from the facility. Staff, including the dietary manager, psychosocial rehabilitation coordinator, CNA, and administrator, became aware over time that the aide was spending excessive time with the resident, was texting and video chatting with her, and was attempting to have an intimate relationship, yet the aide was allowed to resign without an abuse investigation or report to the State Agency, and no care plan interventions or supervision measures were implemented to protect the resident. The resident later reported to the administrator and police that the former dietary aide sexually assaulted her on at least three Sundays in a church parking lot, describing non-consensual intercourse, being lured into the aide’s vehicle, feeling woozy after eating food he provided, blacking out, and waking up alone before attending services. Her guardian, who had been told by the administrator that the aide had resigned due to growing feelings for the resident, stated that she had previously informed the facility that the aide was trying to have a sexual relationship with the resident and that this constituted exploitation, and she expected the facility to keep the resident safe and to report the aide’s conduct to the State Agency. The guardian later learned from a van driver that the resident had been sneaking around with the aide at church for weeks and reported that the resident admitted to having intercourse with the aide while he was working at the facility. The resident’s psychotherapy notes documented ongoing stress, fear of the aide approaching her when not with staff or family, night tremors, and a desire to leave town to feel safer, and she told the surveyor she had asked the aide to stop, that the encounters were not consensual, and that she had reported the rapes to both the police and the administrator. The facility also failed to protect the resident’s roommate from verbal abuse and exposure to sexually explicit conduct by the same former staff member and failed to investigate and report these allegations. The roommate reported witnessing the resident and the former aide engaging in sexual conversations and acts via phone video on multiple occasions and stated that when she asked them to stop, the aide cursed at her, called her derogatory names, and threatened that she would get her “a** kicked,” causing her to feel abused and worried. The psychosocial rehabilitation coordinator documented the roommate’s report of sexually inappropriate conversations and acts on video and the aide’s profane verbal abuse, and stated this was reported immediately to the administrator; however, there was no documentation of an abuse investigation, no final report submitted to the State Agency, and no updates to the roommate’s care plan to address safety from the aide’s threats. Additionally, when the resident reported in an emergency department visit that she had been physically assaulted by two other residents, the facility did not initiate an immediate investigation or submit a final report to the State Agency, and the administrator later acknowledged he had not started an investigation into that allegation even after receiving the hospital records. These combined failures led to an Immediate Jeopardy determination related to the ongoing access and exploitation by the former dietary aide and the lack of timely investigation and protective interventions for both residents.
Removal Plan
- Initiate an abuse investigation into R3's abuse allegation and submit the initial report to IDPH, with a final report to follow.
- Initiate an abuse investigation into R3's abuse allegation and submit the initial report to IDPH, with a final report to follow.
- Initiate an abuse investigation into R3 and R6's abuse allegations and submit the initial report to IDPH, with a final report to follow.
- Complete assessments of R3's capacity to consent to sexual relations with involvement of R3's plenary guardian, physician, and psychiatrist.
- Continue evaluating R3's capacity to consent to sexual relations and implement precautions to keep R3 safe.
- Develop a plan to ensure R3 has staff supervision while using facility phones to ensure safe communication with others.
- Update R3's care plan with interventions to increase R3's safety.
- Hold an emergency QAPI meeting and develop and implement plans to ensure no further abuse occurs within the facility and all policies and procedures are followed correctly.
- Review the facility's abuse policies through the QA committee prior to educating staff.
- Review the facility's staff intimate relationships policy through the QA committee.
- Educate all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
- Educate the administrator on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
- Educate all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
- Update R3 and R6's care plans with safety interventions to protect them from abuse.
Failure to Safeguard Resident’s Controlled-Substance Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a controlled-substance pain medication was missing after delivery. The facility’s Abuse, Neglect, and Exploitation Policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. The resident involved was cognitively intact and had diagnoses including major depressive disorder, suicidal ideations, anxiety disorder, alcohol abuse with intoxication, insomnia, and muscle spasms of the back. The resident had an order for Norco (hydrocodone-acetaminophen) 10/325 mg, one tablet by mouth every eight hours as needed for pain. Pharmacy records and a proof of delivery/packing slip show that 30 tablets of this medication were delivered to the facility, and video evidence and a signed statement from an agency RN confirm that she received the delivery in the early morning, signed the pharmacy delivery sheets, and placed the 30 tablets in the medication cart. She also stated that when she left her shift, she counted all controlled medication cards and pills and found no discrepancies. The deficiency arose when the medication card for this resident’s Norco was later found to be missing. The DON learned that an LPN had attempted to reorder the Norco, but the pharmacy denied the request because the prescription had already been filled and sent. By the time the DON became aware that the Norco was missing, two days had passed since delivery. An audit of the controlled substance inventory sheets revealed that numerous nurses were not counting controlled substances and cards at the beginning and end of their shifts as required. Video surveillance could not confirm who took the medication because there were times when the medication cart was not visible. The DON reported that, after reviewing video footage, interviews, and medication records, she concluded that the only nurse who could have taken the Norco was a new agency RN, as all other nurses had worked there previously and there had been no prior issues with missing narcotics.
Failure to Secure and Account for Controlled-Substance Medication
Penalty
Summary
The deficiency involves the facility’s failure to properly store and account for a resident’s controlled-substance medication in accordance with its own policies and procedures. The facility’s Controlled Substance Administration and Accountability Policy requires controlled substances to be stored in locked compartments with access limited to approved personnel, and for areas without automated dispensing systems to use a two-lock storage unit and a paper system for 24-hour recording. The policy and the Controlled Substance Inventory Count Sheets further require that the oncoming nurse verify all controlled substances with the offgoing nurse at each shift change, including counting total cards/containers and reconciling actual drug counts against individual resident count sheets, with any discrepancies reported immediately to the DON or nursing supervisor. Review of the inventory sheets from 12/6/25 through 12/9/25 showed that two nurses did not count or verify the number of controlled substances or controlled-substance cards within the medication cart for six oncoming/offboarding shifts during that period. Pharmacy documentation showed that 30 tablets of Hydrocodone-APAP 10/325 mg for one resident (R8) were delivered to the facility and received by an agency RN, who was seen on video placing the medication card in the medication cart. The DON later learned from an LPN that a refill request for this resident’s Norco was denied by the pharmacy because it had already been refilled and sent, prompting review of video footage and records. By the time the DON discovered that the resident’s Norco card of 30 tablets was missing from the medication cart, two days had passed since delivery. An audit of the controlled substance inventory sheets revealed that numerous nurses had not been performing the required beginning- and end-of-shift controlled-substance counts, contributing to the unaccounted-for loss of the resident’s controlled medication.
Immediate Jeopardy Due to Medication Administration Error and Failure to Follow Policy
Penalty
Summary
A significant medication administration error occurred when a nurse pre-prepared and stacked multiple residents' medications, resulting in one resident receiving another resident's medications. The nurse failed to follow the facility's medication administration policy, which requires verification of the six rights of medication administration and prohibits pre-popping and stacking medications. The error was not immediately reported by the nurse involved, and the resident was subsequently given their own scheduled medications as well. The affected resident, who had a complex medical history including hemiplegia, bradycardia, Parkinson's disease, and other serious conditions, was found to be lethargic, hard to arouse, and had a heart rate in the 40s after receiving the wrong medications. The error was discovered when another resident reported to a different nurse that he had witnessed his medications being given to the wrong person. Upon assessment, the resident was sent to the emergency room, where he required critical care, including intubation, due to medication overdose and associated complications. Further investigation revealed that the practice of pre-preparing and stacking medication cups was ongoing, as observed by surveyors during their visit. Staff involved in medication administration confirmed that medications, including controlled substances, were being pre-popped and stacked in advance, contrary to facility policy. The incident was not promptly reported to supervisory staff or the physician as required by the facility's medication error policy.
Removal Plan
- R4 was sent to the emergency room for treatment and remained in the hospital.
- V3's employment with the facility was terminated and the incident reported to the State Nursing Board.
- An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to review and interpret all audit findings, review all procedures, review investigation, review root cause analysis, and review all facts surrounding the incident. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. All applicable facility policies and procedures for medication administration were reviewed/revised by the QAPI team.
- V11/Assistant Director of Nursing re-educated licensed nurses on facility policies regarding Medication Administration as well as medication errors and medication administration reconciliation guidelines. All nurses were educated prior to working their next shift including agency nurses. Sign-in sheets were utilized.
- An audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V11 and continued.
- The facility's contracted pharmacy service performed a med cart audit and medication administration audit.
- The DON or designee will audit med carts on all shifts to ensure medications are being prepped and administered accordingly weekly for 4 weeks then bi-weekly for 2 months. The audits will continue until compliance can be maintained for 3 consecutive months.
- The DON or designee will educate all new hire licensed nurses on medication administration and reconciliation guidelines.
- Education on Medication Administration and Medication Error sign in sheets and course material reviewed with no concerns.
- Medication Cart Audit was completed by and observed by the State Agency V12, V13, and V14's med carts. No concerns.
Improper Pre-Preparation and Storage of Medications by Nursing Staff
Penalty
Summary
Nursing staff failed to comply with facility policy and professional standards regarding the storage and preparation of medications. During an early morning observation, a registered nurse and an LPN were found to have pre-prepared and stacked clear medication cups containing both controlled and non-controlled drugs on and inside their medication carts. This practice was confirmed by both staff members, who acknowledged that medications for multiple residents were prepared in advance and left unattended, rather than being administered directly from secured storage at the time of medication pass. The facility's policy requires all drugs and biologicals to be stored in locked compartments and to remain under the direct observation of authorized personnel during medication administration. Among the pre-prepared medications, several cups contained controlled substances such as Clonazepam, Ativan, and Tylenol with Codeine, which had been signed out on the Controlled Drug Received/Record/Disposition Form. The staff involved stated that they resorted to this practice due to time constraints and resident behaviors, but acknowledged it was not in accordance with policy. The administrator confirmed that the pre-preparation and stacking of medication cups was not permitted and that the involved staff would not return.
Failure to Properly Store Refrigerated Food Items
Penalty
Summary
The facility failed to store refrigerated food in accordance with professional standards for food service safety. During observation, surveyors found 11 individual servings of mixed fruit and two cups of applesauce that were uncovered and undated on a shelf in a kitchen refrigeration unit. Additionally, six cooked chicken breast servings were found undated and wrapped in foil with open areas exposing the chicken in another refrigerated unit. The facility's Food Safety Requirements policy requires that refrigerated foods be labeled, dated, and kept covered or in tight containers. The Dietary Manager confirmed that refrigerated foods should not be stored undated or uncovered. At the time of the survey, 91 residents were residing in the facility.
Failure to Refer for PASRR Reevaluation After Short-Term Approval Expired
Penalty
Summary
The facility failed to notify the state mental health authority for reevaluation when the Preadmission Screening and Resident Review (PASRR) short-term approvals ended for six residents. According to the facility's policy, all applicants are to be screened for serious mental disorders or intellectual disabilities, and a PASRR Level II evaluation determines the need for specialized services and the appropriate setting. For each of the six residents, documentation showed that their short-term PASRR approvals had expired, but there was no evidence in their medical records that a referral for reevaluation was made or that the state mental health authority conducted a reevaluation after the approval period ended. This deficiency was confirmed through both interview and record review. The Social Services Director acknowledged that the affected residents were not reevaluated by the state mental health authority as required when their short-term PASRR approvals expired. The lack of timely referral and reevaluation was identified for each resident based on the expiration dates listed in their PASRR Level II Outcome Notices and the absence of corresponding documentation in their records.
Failure to Implement Fall Prevention and Smoking Safety Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for multiple residents who had documented falls. Despite having a Fall Prevention Program that required individualized assessment and intervention, several residents experienced repeated falls, and the interventions documented in their care plans and fall reports were not in place during a subsequent survey. For example, one resident had multiple falls in the bathroom and bedroom, with interventions such as non-skid strips and non-adhesive pads documented but not present during inspection. Another resident who fell in front of a recliner did not have the prescribed non-skid strips in place, and a third resident who fell out of bed did not have the required perimeter mattress in use. The Director of Nursing confirmed during the tour that these interventions were missing and was unable to explain why they had not been implemented. Additionally, the facility failed to accurately assess and enforce smoking safety policies for a resident with significant psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, depression, and a history of suicidal ideation. The resident had multiple documented incidents of possessing and using prohibited smoking materials, such as marijuana vapes, nicotine vape juice, lighters, and edibles, in violation of the facility's smoking policy. Despite these incidents, the resident's Smoking and Safety Assessment was not updated to reflect noncompliance, and there was no documentation that the facility followed its own policy to ensure the resident's safety regarding smoking materials. These deficiencies were identified through record review, staff interviews, and direct observation, which confirmed that required safety interventions and policy enforcement were not consistently carried out for residents at risk of falls and those with smoking-related safety concerns.
Failure to Change and Date Oxygen Supplies per Policy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for four residents who were receiving oxygen therapy. Surveyors observed that oxygen humidification bottles and tubing were not changed according to facility policy, which requires weekly changes and dating of equipment. Specifically, two residents were found with humidification bottles dated over two weeks prior to the observation, and their oxygen tubing was not dated. Another resident was using oxygen equipment that was not dated, and there was no documented physician order for oxygen or for changing the tubing and humidification bottle. A fourth resident had an order to change oxygen supplies weekly, but the humidification bottle was dated a week prior and the tubing was not dated. Interviews with facility staff confirmed that the policy is to change oxygen humidification bottles and tubing weekly, every Sunday by the night shift. However, observations and record reviews indicated that this policy was not consistently followed for the residents reviewed. The affected residents had diagnoses or orders indicating the need for oxygen therapy, including chronic obstructive pulmonary disease and orders for oxygen at specific flow rates. The lack of adherence to the facility's policy for changing and dating oxygen supplies constituted a failure to provide safe and appropriate respiratory care as required.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were properly offered and documented for four out of five residents reviewed for immunization compliance. Specifically, the Immunization Audit Report sheets for these residents did not include any history of receiving the pneumococcal vaccine, nor was there evidence that the vaccine was offered, declined, or administered. In one case, there was also no documentation regarding the influenza vaccine. The facility's policies require annual offering of the influenza vaccine and assessment for pneumococcal immunization upon admission, but these procedures were not followed or recorded for the affected residents. This deficiency was confirmed by the Regional Nurse Consultant during the survey.
Failure to Timely Assess Residents for Walking Pass Privileges
Penalty
Summary
The facility failed to assess two residents for participation in the Walking Pass Program, which is designed to promote resident independence and self-determination. One resident, with diagnoses including depression, schizoaffective disorder, narcissistic and antisocial personality disorders, reported requesting a walking pass multiple times but had not been assessed for eligibility. The Social Service Director confirmed the resident's request was made months prior and acknowledged that no assessment had been initiated due to workload constraints. Another resident, with a history of schizoaffective disorder, depression, bipolar disorder, and suicidal ideations, experienced a significant delay in regaining walking pass privileges after they were rescinded due to a program violation. The resident stated that the process took a long time, and records showed a gap of several months between the request and reinstatement of privileges. The facility's administrator confirmed that assessments should be completed within thirty days of a resident's request, and acknowledged that a three-month delay was excessive.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as required by its Abuse, Neglect, and Exploitation policy. According to interviews and record reviews, a Certified Nurse Aide (CNA) was overheard by a Registered Nurse and another CNA telling a resident to 'shut the f*ck up.' The resident later confirmed that the CNA had yelled and cursed at him, expressing that he did not like the way he was spoken to and felt it was unprofessional. The incident was documented in the facility's Serious Injury Incident Communicable Disease Report, and the resident stated that staff should not be allowed to speak to residents in such a manner.
Failure to Implement Effective Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, antibiotic stewardship, and adherence to enhanced barrier precautions (EBP). For one resident with a stage 3 sacral pressure ulcer and an open surgical wound, staff did not follow EBP protocols during wound care. Specifically, gowns and gloves were not available near or outside the resident's room, there was no signage indicating EBP was in place, and staff, including an LPN and two CNAs, did not don protective gowns while performing and assisting with wound care. The facility's regional nurse consultant confirmed that EBP should have been in place for this resident due to the presence of open wounds. Additionally, the facility did not maintain complete and accurate infection surveillance records. The Monthly Infection Logs were not completed for several consecutive months, and the Antimicrobial Days of Therapy Reports lacked critical information such as infection site, pathogen, signs and symptoms, resident location, diagnostic reports, and analysis. Several residents who received antibiotics for urinary tract infections were not included in the UTI log, and the infection preventionist acknowledged that while McGeer criteria were reviewed, this was not documented. The facility also failed to follow manufacturer guidelines for disinfecting blood glucose monitors. After performing blood glucose monitoring on a resident, an LPN cleaned the meter with an alcohol wipe instead of the required disinfectant wipe, and the device was returned to the medication cart. The DON confirmed that the correct disinfectant wipes should have been used. This practice potentially affected multiple residents who required blood glucose monitoring from the same medication cart.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily and made accessible to residents and visitors. During an observation, it was found that the nurse staffing sheet displayed was dated 21 days prior and was placed behind another document, making it not viewable. The administrator confirmed that the nurse staffing sheet was not posted at the beginning of each shift and was not visible as required. This deficiency had the potential to affect all 91 residents currently residing in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident-to-resident physical abuse incident occurred when one resident with a history of severe mental illness, but no recent aggressive behavior, threw a canister at another resident, hitting him in the knee, and then punched him in the chest. The incident took place near the drink station by the patio door, and was partially captured on facility camera footage, although the video was blurry and lacked audio. The resident who was struck was assessed for injuries, with no injuries or redness noted, and declined further medical attention. The incident was reported to the facility administrator and physician. Witness accounts confirmed that the aggressor slapped a cup of coffee out of the other resident's hand and then hit him in the chest, accompanied by a verbal statement. Staff, including an LPN, responded immediately after being notified by another resident who witnessed the event. The aggressor refused to be interviewed by the surveyor and was not observed near the victim following the incident. The facility's policy prohibits all forms of abuse, including resident-to-resident altercations, but the event demonstrates a failure to prevent such abuse in this instance.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident sexual and mental abuse involving a resident, identified as R1, and a Certified Nursing Assistant (CNA), identified as V3. Over a period of six months, V3 engaged in sexual activities with R1 on more than 100 occasions, often bribing R1 with alcohol, drugs, and vapes in exchange for sexual favors. R1, who has a history of serious mental illness, including Bipolar Disorder with Psychotic Features and Major Depressive Disorder, was coerced into these encounters under the threat of being cut off from these substances. The abuse occurred within the facility, sometimes in the presence of other residents, and extended to locations outside the facility. R1's mental health history includes suicidal ideation and non-adherence to medication, which were exacerbated by the abuse. The abuse led to R1 experiencing fear, depression, and the need for prophylaxis to prevent sexually transmitted diseases. R1 reported feeling threatened by V3, who claimed she could have R1 removed from the facility if he did not comply with her demands. The situation was further complicated by R1's sharing of videos of the encounters with other facility staff, which were requested by several employees. The facility's policies explicitly prohibit staff from engaging in sexual or romantic relationships with residents, yet V3's actions went unchecked for an extended period. The facility was notified of the abuse after R1 disclosed the encounters to another employee, prompting an investigation. Despite V3's resignation prior to the report, the facility's failure to detect and prevent the abuse resulted in an Immediate Jeopardy situation, highlighting significant lapses in safeguarding resident welfare and enforcing staff conduct policies.
Removal Plan
- The Administrator or designee ensured the safety and well-being of the resident. The staff member was no longer employed with the facility.
- The Administrator initiated an abuse investigation into the resident's abuse allegation.
- Police were notified and the resident was sent to the emergency room for evaluation and examination.
- The Administrator or designee educated all staff on what constitutes all forms of abuse and bribery.
- The Social Service Director completed an Abuse/Neglect/Trauma screening on all residents and any resident who triggered at risk for abuse neglect, or trauma was educated on what to report and who to report to.
- The quality assessment and assurance committee developed and implemented plans to ensure further abuse and bribery of the residents does not continue within the facility.
- The abuse policies were reviewed and revised by the quality assurance committee prior to educating staff.
- A root cause analysis was completed for the alleged sexual relationship that occurred between the resident and the staff member.
- The Administrator received education from the Regional Director of Operations on reporting abuse timely and thoroughly investigating all abuse allegations.
- All newly hired staff and agency staff will be educated by the Administrator, Director of Nursing, or designee prior to the start of their shift on abuse prevention and reporting as well as what constitutes bribery, prohibiting staff from providing contraband to residents, and maintaining professional boundaries with residents, staff not having a physical relationship with residents, and for staff to not request or view photos or videos of residents.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received the mandatory annual Quality Assurance and Performance Improvement (QAPI) in-service training. This deficiency was identified through a review of the facility's Staff Training and Staff In-Service Logs, which covered the period from January 1, 2024, to February 3, 2025. The logs did not contain any documentation indicating that the staff had completed the required QAPI training. During an interview on February 4, 2025, the Corporate Nurse confirmed that no staff at the facility had received the annual QAPI training, as the training program did not list it as a required yearly training. This oversight has the potential to impact all 93 residents currently residing in the facility, as documented in the facility's Resident Roster dated January 31, 2025.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not immediately reporting an allegation of staff-to-resident sexual abuse to the State Agency. The policy mandates that any allegations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In this case, a resident reported inappropriate sexual encounters with a CNA, who had already resigned. The facility's Administrator was informed of the allegation by an LPN but did not report it to the State Agency until two days later, when the resident clarified that the encounters were not consensual. This delay in reporting constitutes a failure to comply with the facility's established procedures for handling abuse allegations.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by two separate incidents involving a resident identified as R2. In the first incident, R2 was involved in a verbal altercation with another resident, R1, which escalated when R2 smacked R1 in the face, causing his glasses to fall off and resulting in a minor injury above his right eye. R1 expressed confusion about why R2 became upset, while R2 admitted to smacking R1 because she perceived him as acting foolishly. R2's cognitive status was assessed as intact, with a BIMS score of 15/15, indicating she was aware of her actions. In a second incident, R2 smacked her roommate, R5, after mistakenly believing R5 was attempting to get into her bed. This misunderstanding occurred because R2's bed had been moved earlier that day, and she forgot about the change. R2 was apologetic after realizing her mistake. R2 acknowledged that having roommates often leads to conflicts, suggesting a pattern of behavior that the facility staff was aware of. These incidents highlight the facility's failure to prevent resident-to-resident physical abuse, as outlined in their Abuse, Neglect, and Exploitation policy.
Failure to Document Significant Incidents in Resident Records
Penalty
Summary
The facility failed to maintain accurate clinical records for four residents, as evidenced by the absence of documentation regarding significant incidents. In one case, two residents were involved in a verbal disagreement that escalated when one resident smacked the other, causing a minor injury. Despite the incident being documented in an abuse investigation, it was not recorded in the medical records of either resident involved. The Licensed Practical Nurse/Assistant Director of Nursing confirmed the lack of documentation and noted that the incident was only recorded in a part of the medical record accessible to managers, not in the general medical records. In another incident, two residents went on a home visit, during which one resident reported inappropriate sexual behavior by the other. This led to an abuse investigation, police involvement, and the implementation of 1:1 supervision for the accused resident. However, there was no documentation in the medical records of either resident regarding the allegation, the intervention, or the decision-making process to discontinue the supervision. The facility's administrator confirmed that the interdisciplinary team discussed the situation but did not document their meeting or the rationale for ending the supervision.
Failure to Identify and Treat Pressure Wounds
Penalty
Summary
The facility failed to properly identify, monitor, and treat pressure wounds on a resident's feet, leading to the development of unstageable wounds on both the right outer lateral foot and the left outer lateral heel. Observations revealed that the resident's feet were not offloaded as required, despite the presence of a pressure reduction boot and instructions to use a pillow for offloading. The resident was observed multiple times with their feet in contact with the mattress, contrary to the care plan. The facility's wound treatment management policy requires evidence-based treatments and adherence to physician orders, but these were not followed in this case. The LPN assisting with the assessment was unaware of the resident's wounds, and the current care plan did not document the wounds or any interventions. The Assistant Director of Nursing also confirmed a lack of awareness regarding the resident's foot wounds, indicating a breakdown in communication and care planning within the facility.
Improper Disposal of Kitchen Waste
Penalty
Summary
The facility failed to ensure proper disposal of kitchen waste by leaving the lids open on the trash receptacle located outside. This deficiency was observed during an initial kitchen tour, where the outside trash dumpster lids were found to be left open. The facility's policy on the disposal of garbage and refuse requires that refuse containers and dumpsters outside the facility have tightly fitting lids and be kept covered when not being loaded. The Head Cook confirmed that the lids should be closed to prevent animals from accessing the trash. This failure has the potential to affect all 90 residents residing in the facility.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the food service areas, as evidenced by the presence of gnats on and around the juice dispenser spigot/handle in the kitchen. This observation was made during an initial kitchen tour conducted with the Head Cook. The facility's policy on sanitation inspection mandates that all food service areas be kept clean, sanitary, and free from pests such as rodents, roaches, flies, and other insects. Despite this policy, the Head Cook confirmed the presence of gnats, acknowledging that they should not be present and that the facility had attempted extermination efforts.
Deficient Conditions in Women's Shower Room
Penalty
Summary
The facility failed to maintain a clean, functional, and private environment in the women's shower room, affecting all sixteen female residents on the E Wing. Observations and interviews revealed multiple issues, including broken shower heads, minimal water pressure, and non-functional toilets. Residents reported that the showers and toilets have been in disrepair for an extended period, with one resident stating the issues have persisted for three years. The shower room was observed to have black stains, debris, and broken fixtures, with no soap available in the dispensers. The maintenance director acknowledged the age and difficulty in maintaining the bathroom, noting that corporate plans for a full remodel. However, the current state of the facilities includes non-functional sinks, missing faucets, and a lack of privacy due to broken shower curtains. The cabinet labeled for towels contained unrelated items such as broken PVC pipe and shower curtain hangers, further indicating neglect in maintaining a safe and clean environment for the residents.
Hazardous Item Found in Shower Room
Penalty
Summary
The facility failed to ensure the women's shower room was free from hazards, specifically a 2-blade disposable razor left on the counter. This oversight potentially affects all sixteen female residents on the E-Wing who utilize the shower room. During an observation, the razor was found accessible to residents, which contradicts the facility's protocol that razors should be kept locked up and only accessible to residents when provided by staff. An LPN confirmed that the razor should not have been in the shower room, indicating a lapse in supervision and adherence to safety protocols.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. One resident, identified as R30, exhibited discoloration and lesions on their bilateral upper extremities, which were not included in their care plan. Despite the discoloration being noted in a CNA shower sheet and a wound physician identifying a pre-cancerous lesion, the facility's Assistant Director of Nursing (ADON) and Administrator stated that these skin issues did not need to be included in the care plan. The discoloration was attributed to the resident's medication, Plavix, and an order for protective sleeves was only obtained after the physician's assessment. Another resident, R13, had physician orders for antifungal cream due to skin conditions on their lower back, groin, and sacrum, as well as wounds on their feet. Observations revealed bright red, shiny areas on the buttocks and groin, and scabbed areas on the feet, which were not addressed in the care plan. The CNA noted that R13's heels should be offloaded, but the necessary boots were not found in the resident's room. The ADON was unaware of the foot wounds, and the Director of Nursing acknowledged the absence of care plans for R13's skin conditions.
Failure to Address Skin Care Concerns for Resident
Penalty
Summary
The facility failed to address skin care concerns for a resident, identified as R30, who exhibited discoloration and lesions on both upper extremities. Despite the facility's policy requiring regular skin assessments, R30's Treatment Administration Record and Care Plan lacked documentation of skin treatments or physician orders for the affected areas. Observations on 7/9/24 revealed that R30 had not received treatment or protective sleeves for her arms, and the Weekly Skin Assessments consistently noted no skin issues. Interviews with facility staff, including LPNs and the Assistant Director of Nursing, confirmed the absence of treatment orders and the oversight in providing protective measures for R30's fragile skin. Subsequent evaluation by a wound physician on 7/10/24 diagnosed R30 with Actinic Keratosis, a condition that can develop into skin cancer, and noted the presence of purpura due to anticoagulant use and capillary fragility. The physician recommended the use of arm skin protectors to mitigate the extent of purpura. This deficiency highlights the facility's failure to adhere to its own skin assessment policy and to provide necessary care and treatment for R30's skin condition, resulting in a delay in addressing a potentially serious medical issue.
Failure to Provide Physician Orders and Change Oxygen Equipment
Penalty
Summary
The facility failed to provide physician orders for the administration of oxygen and did not change oxygen tubing and humidifier bottles according to facility policy for a resident receiving oxygen therapy. Observations over three days revealed that the resident was in bed with an oxygen cannula administering oxygen at 3.5 liters. The oxygen tubing was dated from a previous date, and the humidification bottle was not dated, indicating they were not changed weekly as required. A Licensed Practical Nurse confirmed that the tubing and bottles should be changed weekly. The Assistant Director of Nursing was unaware that the resident was receiving continuous oxygen and confirmed that a physician order was necessary. No physician order was found until later on the third day of observation.
Deficiency in Antipsychotic Medication Management
Penalty
Summary
The facility failed to identify an appropriate indication for the use of an antipsychotic medication for a resident, leading to a deficiency in medication management. The resident, who is on hospice care and has diagnoses including anxiety disorder, Major Depressive Disorder, Chronic Viral Hepatitis, Cirrhosis of the Liver, Chronic Pain Syndrome, and Emphysema, was prescribed Seroquel, an antipsychotic medication, without a documented diagnosis or indication for its use. The care plan did not reflect the use of an antipsychotic medication or identify target behaviors that would necessitate such medication. Despite the resident's psychiatric evaluation indicating no hallucinations, delusions, or suicidal ideation, and behavior monitoring over three months showing no identified behaviors, the medication was still administered. The Director of Nursing was unable to provide a reason for the resident receiving Seroquel, further highlighting the lack of documentation and justification for the medication's use. This oversight in medication management was observed during a survey, where the resident was seen answering questions appropriately without displaying any inappropriate behaviors or signs of psychosis.
Deficiency in Room Square Footage
Penalty
Summary
The facility failed to ensure that rooms provided at least 80 square feet per resident in multiple resident rooms, affecting fourteen residents in a sample of 53. On July 10, 2024, the Maintenance Director confirmed that some rooms did not meet the required square footage. Observations on July 11, 2024, confirmed that the affected residents occupied rooms identified as less than 80 square feet per resident according to the facility floor plan. A letter from the previous administrator dated January 29, 2019, indicated that a waiver had been submitted to the State Agency regarding the square footage requirement. However, the current administrator stated that this was the last waiver sent to the State Agency. A letter from the State Agency dated April 3, 2019, confirmed that certain rooms were waivered for not meeting the square footage requirement.
Verbal Abuse by RN
Penalty
Summary
The facility failed to ensure that two residents, R1 and R3, were free from verbal abuse by an employee. According to the facility's policy on abuse, neglect, and exploitation, verbal abuse includes the use of oral, written, or gestured communication that includes disparaging and derogatory terms to residents or their families. On 5/10/24, an RN (V5) was overheard being verbally inappropriate with R3, which included cussing and yelling. V5 also yelled at R1, blaming them for the situation. The incident was reported, and an investigation concluded that the allegations were substantiated. V5 was immediately separated from all residents, suspended, and subsequently terminated from employment. Statements from witnesses and the residents involved confirmed the verbal abuse incident.
Failure to Revise Care Plans for Residents with Revoked Smoking Privileges
Penalty
Summary
The facility failed to revise care plans for three residents who smoke, despite their smoking privileges being revoked due to non-compliance with smoking rules. The facility's policy mandates that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, the care plans for these residents were not updated to reflect the revocation of their smoking privileges. Specifically, Resident 1's care plan did not include the revocation of smoking privileges despite the resident's repeated non-compliance and continued attempts to obtain contraband. Resident 3's care plan failed to address non-compliance with smoking rules and the revocation of smoking privileges, even though the resident had been caught giving cigarettes to another resident. Resident 4's care plan also did not reflect the revocation of smoking privileges or the specific incidents of non-compliance, such as taking drags off other residents' cigarettes during smoke breaks. The Director of Nursing (DON) confirmed that the smoking privileges for these residents had been revoked for several months, yet the care plans remained unchanged. The Social Service Director was identified as the person responsible for revising the smoking care plans, but the revisions were not completed. This oversight indicates a failure to adhere to the facility's policy on care plan revisions, potentially compromising the effectiveness of the care provided to these residents.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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