Aperion Care Wilmington
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Illinois.
- Location
- 555 West Kahler, Wilmington, Illinois 60481
- CMS Provider Number
- 145316
- Inspections on file
- 37
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aperion Care Wilmington during CMS and state inspections, most recent first.
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.
A resident kicked another resident in the leg, causing a fall and subsequent hip pain that required assessment and an X-ray. Multiple residents and CNAs witnessed the aggressor resident grabbing and shaking the victim’s leg, then kicking it, and staff, including an LPN, DON, and ADON, acknowledged this as physical abuse. The LPN reported the incident to the administrator, but the administrator did not notify the state surveying agency or law enforcement, and no ambulance was called for the victim, despite facility policy requiring immediate reporting of any abuse allegation or injury to the state health department.
Surveyors found that shared resident restrooms were not maintained in a safe, sanitary, and comfortable condition, despite a policy requiring daily toilet and lavatory cleaning. In multiple bathrooms, inspectors observed toilet paper and stained footprints on floors, stained cloth pads placed at the base of leaking toilets, black-stained and peeling floor tiles, chipped toilet seats, heavy black buildup inside toilet bowls, and dirty plungers stored on the floor. Several residents reported that housekeeping cleaned their bathrooms only once a week or a few times per week, that toilets were persistently dirty or clogged, and that they had informed staff about these issues over a long period. The Environmental Manager and Maintenance Director acknowledged awareness of leaking toilets, urine-damaged flooring, and the need for tile and toilet seat replacement, while the DON stated that plungers are unsanitary and should not be left in resident restrooms.
A resident with psychiatric diagnoses and an abuse risk care plan was in a dining room when another resident, who had been pacing nearby, approached in a threatening manner and forcefully pushed the resident in the wheelchair, as later confirmed on video review. No staff were present in the dining room at the time, and the affected resident reported feeling attacked and stated that a nurse refused a request to call the police, while a nurse later documented that the aggressor admitted to pushing the other resident. The facility’s abuse policy prohibits physical abuse, yet the incident occurred without staff supervision and involved resident-to-resident physical contact that was characterized by leadership as abuse.
The facility failed to timely and accurately report an allegation of resident-to-resident abuse to the state surveying agency and law enforcement. A resident in a w/c told an RN that another resident had hit him, while the other resident admitted to pushing him away, and the RN notified the administrator and other leadership that morning. The administrator and social services director reviewed camera footage showing one resident approaching and yelling at another, followed by the second resident pushing him, and this was documented in the EMR. Despite a policy requiring abuse allegations, including a resident pushing another resident, to be reported within two hours, the initial abuse report was not submitted until the next day and was inaccurately documented with the wrong occurrence date and description, characterizing it as a behavior reported to a surveyor rather than the original allegation.
The facility failed to follow its abuse policy by not promptly investigating an allegation of resident-to-resident physical abuse. A resident reported that his roommate pushed him out of his wheelchair in the dining room, and a nurse assessed both residents, found no injuries, and notified the administrator, recognizing the event as an abuse allegation. The administrator and social services director reviewed camera footage showing one resident approaching another and then being forcefully pushed, but no abuse investigation or grievance report was initiated at that time, and the incident was treated as a behavioral event rather than an allegation of abuse, contrary to facility policy requiring documentation and investigation of all alleged or suspected abuse.
The facility failed to notify law enforcement and the state surveying agency after an RN discovered two Norco bingo cards for two residents inside another RN’s personal bag, despite only those two nurses having keys to the medication room. The DON removed the narcotics from the bag, and the RN admitted placing them there and stated she was addicted to drugs and had recently been in rehab. The Administrator confirmed the medications belonged to two residents with multiple medical conditions and pain management orders but chose not to report the incident externally because the medications had not left the building, the narcotic count was accurate, and no doses were missed, contrary to facility policy requiring notification of appropriate agencies for suspected diversion.
Controlled substances (Norco) prescribed for two residents with multiple chronic conditions were not securely stored when an RN left two bingo cards on a cabinet in the medication room instead of in a double-locked narcotic storage area. After the RN returned from break, the Norco cards were missing from the cabinet and were later found inside another RN's unzipped personal bag, with narcotic sheets still attached and visible. Leadership staff confirmed that narcotics in the medication room should be double locked in the narcotic drawer of the med cart, consistent with the facility’s medication storage policy.
A resident with dementia, psychiatric disorders, and multiple medical comorbidities told staff that a female staff member with a specific first name had punched him months earlier and stated he had previously informed others. A CNA reported that, months before, the resident disclosed during a shower that a CNA with that same first name had beaten him, but she did not notify the abuse coordinator or administration because she believed it was an old, already resolved case. Another CNA with that first name stated she had never cared for the resident and did not take the allegation seriously when she heard it secondhand. The facility’s abuse policy required employees to immediately report any incident, allegation, or suspicion of abuse to the administrator or designated channels, but this internal reporting did not occur as required.
A resident with intact cognition and a psychiatric history reported to the PRSC that a nurse inappropriately touched her during wound care, which was promptly reported internally. However, the DON was not informed until three days later, and the facility delayed reporting the sexual abuse allegation to the state agency and police for seven days, contrary to policy requiring notification within two hours.
A resident with intact cognition and a history of mental health conditions reported that a nurse inappropriately applied cream to her genital area during wound care, which she perceived as sexual abuse. The incident was promptly reported internally, but the nurse was not suspended until eight days later, and the DON was not informed until three days after the initial report. The facility also failed to notify the state agency within the required timeframe, delaying the report by seven days.
Two residents with severe cognitive impairment and behavioral histories were involved in a physical and emotional altercation, resulting in one resident sustaining scratches, a bite mark, and emotional distress. Despite known risk factors and prior incidents, the facility did not implement effective interventions to prevent abuse, and staff were not present at the time of the incident. The facility's failure to protect vulnerable individuals led to physical and emotional harm.
Surveyors found multiple failures in kitchen sanitation and food safety, including a malfunctioning dishwasher, improper food holding temperatures, unlabeled and undated food items, open containers in storage, dirty utensils, and staff not using required beard guards. The Dietary Director acknowledged these lapses and inconsistent adherence to facility policies.
Multiple residents at risk for falls did not receive appropriate fall prevention measures, including improper mattress fit, missing floor mats, and beds left in high positions after care. Staff and care plans indicated these interventions were required, but observations and interviews confirmed they were not consistently implemented.
Surveyors identified that several vials of Lorazepam, labeled by pharmacy for refrigeration, were stored unrefrigerated in a narcotic box within a medication cart instead of in a locked refrigerator as required. This affected multiple residents with seizure and anxiety disorders who had physician orders for IM Lorazepam. Staff interviews revealed confusion about proper storage, and the medication refrigerator was found to lack a lock, leading to the improper storage practice.
A resident with limited ROM due to multiple medical conditions did not receive the prescribed active assisted ROM program, as there was no documentation of the program being carried out and the resident was not included on the restorative list. The restorative nurse confirmed the absence of a program to guide staff on exercises or frequency, and the resident reported not receiving restorative assistance.
Two residents received improper catheter care, including unsanitary technique, lack of a catheter securing device, and failure to keep the catheter bag off the floor. One resident's catheter care was performed using the same washcloth for multiple wipes and without cleaning between the labia, while another resident's catheter bag was found on the floor instead of being hung on the bed frame, contrary to facility policy.
Two residents did not receive their prescribed medications due to the facility's failure to reorder medications in a timely manner. One resident missed doses of Tramadol for pain management, while another missed a scheduled dose of Aripiprazole for schizophrenia. Nursing staff confirmed that medications were not reordered according to policy, leading to unavailability during medication passes.
The facility did not ensure that CNAs completed the required 12 hours of annual competency training, as documentation for several CNAs showed only 1.5 to 4 hours of in-service training. The administrator was unable to provide proof of compliance due to a recent change in the training platform, affecting all residents receiving care from CNAs.
Several residents repeatedly requested access to the facility's grievance policy and information on filing grievances, but did not receive it. Staff interviews revealed confusion about who was responsible for providing the policy, and a review of bulletin boards showed the policy was not posted. Resident council meeting minutes documented ongoing requests for the policy to be made available.
A resident with cognitive impairment was bitten by another resident in a dementia unit due to inadequate monitoring. The facility was short-staffed, and the resident, known for wandering, entered another resident's room, leading to the incident. Previous similar incidents had occurred, but effective measures were not implemented to prevent further occurrences.
The facility failed to maintain effective infection control during a norovirus outbreak, affecting 165 residents. Surveyors found inconsistencies in isolation protocols, with symptomatic residents not properly isolated and staff not adhering to PPE and hand hygiene guidelines. Housekeeping staff did not consistently use bleach-based cleaning products due to supply shortages, and the Maintenance Director was unsure of the correct bleach-to-water ratio. The facility's Norovirus Outbreak Measures policy was not fully implemented, contributing to the deficiency.
A resident with urinary retention and urethral issues had a 20FR catheter inserted instead of the ordered 16FR, due to a nurse's oversight in checking the physician's order. The facility had the correct catheter size available, but the nurse did not verify the order before insertion.
During a kitchen renovation, a facility failed to maintain safe food handling practices, leading to the revocation of its food preparation permit. The facility continued food preparation without proper refrigeration or sanitation, affecting all residents. Observations showed inadequate equipment and lack of handwashing stations, with meals served in disposable containers. The Dietary Manager did not document food temperatures, violating facility policy.
A resident experienced a delay in receiving a physician-ordered X-Ray after a fall, resulting in a late diagnosis of fractures. The Quality Assurance Nurse acknowledged the delay, which was noticed when the X-Ray service was needed for another resident. The facility's agreement with the X-Ray company requires services within 24 business hours or notification if this cannot be met.
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.
Failure to Report Resident-to-Resident Physical Abuse to State Agency and Police
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident physical abuse to the state surveying agency and to law enforcement, despite multiple witnesses and staff acknowledging the event as abuse. According to interviews, one resident (R2) stated that another resident (R1) attacked him by kicking him in his left knee, causing him to fall. A third resident (R3) reported witnessing R1 become aggressive with R2, grabbing R2’s legs in an attempt to push him down, and then kicking R2’s left knee when he did not fall, resulting in R2 landing on his left hip. R1 admitted to kicking R2. Two CNAs (V8 and V9) also reported witnessing R1 aggressively grabbing and shaking R2’s leg, then kicking R2’s left leg when R2 did not move, which caused R2 to fall. Both CNAs characterized the incident as physical abuse. Staff interviews confirmed that the incident met the facility’s definition of physical abuse and should have been reported. The LPN (V7) who assessed R2 after the incident stated that R1 kicking R2 was a reportable incident and that she immediately notified the Administrator (V1). The Administrator acknowledged being aware that R1 kicked R2, that R2 fell, and that an assessment and a hip X-ray were ordered for R2 due to hip pain. However, the Administrator stated that the facility did not call the police or an ambulance for R2 and did not report the incident to the state surveying agency. The DON (V2) and ADON (V3) both stated that one resident kicking another resident is physical abuse and should be reported to the state surveying agency. This failure to report occurred despite a written facility policy requiring that any allegation of abuse or any incident resulting in injury be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse.
Unsanitary and Poorly Maintained Resident Restrooms
Penalty
Summary
Surveyors identified a failure to maintain safe, functional, sanitary, and comfortable resident restrooms for all 18 residents reviewed for restroom environment. The Environmental Manager stated that housekeepers are assigned to clean resident bedrooms and bathrooms daily, including toilets, sinks, and dispensers. However, during inspection of one shared restroom used by six residents, surveyors observed toilet paper on the floor, scattered black stained footprints, and a blue cloth bed pad with large brown stains placed at the base of a leaking toilet. A dirty plunger was stored on the floor next to the toilet. In another shared restroom used by six different residents, the sink had large areas of stale brown stains and toothpaste buildup, the floor had scattered black stains, the toilet seat was chipped in multiple areas, and the inside of the toilet bowl had large areas of black buildup, with a plunger again stored on the floor. The Environmental Manager acknowledged that the floors needed sweeping and mopping, that the plungers were not clean or hygienic, and that the toilet leakage had been discussed in team meetings and reported to Maintenance. Multiple residents reported that housekeeping did not clean the bathrooms daily and described persistent unsanitary conditions. One resident stated housekeeping came every three days, that black buildup in the toilet had been present as long as she could remember, that she hated it, and that the chipped toilet was not hygienic given it was shared with five others; she also reported the toilet clogged at least once a day and that staff were informed each time. Another resident reported the bathroom was cleaned maybe once a week and that the black buildup and chipped toilet seat had always been present, and that staff were aware of the chipped seat. A third resident stated staff cleaned the bathroom three times a week but that it was always dirty, leading her to sometimes use a shower bathroom down the hall instead. In a third shared restroom, surveyors observed another stained blue cloth bed pad on the floor at the front of the toilet base, with black-stained, peeling tiles beneath it. Residents using this restroom reported the black-stained floor had been present for a long time and that they had informed staff, and one resident reported the toilet sometimes leaked and believed facility staff knew because it had been ongoing. The Maintenance Director stated the black-stained tile was from moisture such as urine, that he had requested tile replacement about two months earlier and it remained on his to-do list, and that the toilet seat and black buildup in another restroom needed replacement and cleaning. The DON acknowledged hearing concerns about toilets clogging and stated plungers were unsanitary and should not be left in resident restrooms, despite the facility’s housekeeping policy requiring daily cleaning of toilets and lavatories.
Failure to Prevent and Respond to Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident pushed another resident in the dining room without staff present. One resident (R2) reported that he and his roommate (R1) had a fight in the dining room and that he pushed R1, causing R1 to fall from his wheelchair, although R1 was able to get up on his own. R1 stated that he had been in the dining room when R2 approached, yelled at him, and suddenly pushed him out of his wheelchair, and that there were no staff present and no staff witnessed the incident. R1 reported feeling bad that someone attacked him in his place of residence and said he asked a nurse to call the police, but the nurse refused. R1 denied pain and had no visible injuries or bruising. R1’s EMR showed diagnoses of paranoid schizophrenia and delusional disorder, and his abuse care plan, which identified him as at moderate risk for abuse due to psychiatric issues, included interventions such as observing him when in the company of peers and ensuring safety if he felt unsafe. The Social Services Director (V18) stated he was notified by the Administrator (V1) that there had been an altercation between R1 and R2 and that he and V1 reviewed dining room camera footage. The footage, later reviewed without audio, showed R2 pacing in the dining room, then approaching R1 in a threatening manner with repeated forward upper body movements, and then forcefully pushing R1 with two flat hands; the camera view of R1 was partially blocked and did not show whether he fell. V1 characterized the push as forceful and as abuse of R1. A nurse (V9) reported that R1 came down the hallway saying, “he hit me,” and that after assessing R1 and finding no injuries, she spoke with R2, who admitted, “He got in my face, and I pushed him out of my face,” while demonstrating a flat-handed pushing motion. V9 stated that once a resident says they pushed another resident, it is an abuse allegation that must be reported immediately. The facility’s Abuse and Retaliation Prevention and Reporting Policy affirmed residents’ right to be free from abuse and prohibited physical abuse, including hitting and controlling behavior through corporal punishment, yet the incident occurred in the dining room without staff supervision and resulted in resident-to-resident physical abuse.
Failure to Timely and Accurately Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report an allegation of resident-to-resident abuse to the state surveying agency and law enforcement. On the morning of March 12, 2026, a nurse (V9) was approached by R1, who propelled his wheelchair down the hallway stating, "he hit me, he hit me." V9 followed R1 to his room, attempted to clarify what happened, and assessed R1 for injuries, finding none and with R1 denying pain. V9 then spoke with R2, who reported that R1 had gotten in his face and that he pushed R1 away, demonstrating a flat-handed pushing motion. Recognizing this as an abuse allegation under facility protocol, V9 notified the Administrator (V1) at approximately 6:40–6:45 AM that R1 alleged R2 had hit him and that R2 admitted to pushing R1. V1, in turn, notified the Social Service Director (V18) and the DON (V2) via text message that morning, describing that R2 allegedly pushed R1 in the dining room because R1 was yelling at him. V1 and V18 reviewed the dining room camera footage later that morning. The view was partially blocked, but they observed R1 approaching R2, yelling and waving his arms, and R2 becoming agitated and pushing R1 away. V18 documented a behavioral progress note in R1’s EMR at 10:11 AM, describing R1 approaching R2, yelling and waving his arms, R2 reporting that R1 grasped his arm, and R2 pushing R1 away. The note also documented that the camera view was partially blocked and they could not verify whether R1 grasped R2’s arm. Despite this information and the facility’s policy that an allegation of abuse, such as a resident pushing another resident, must be reported to the state surveying agency within two hours, V1 did not submit an initial abuse allegation notification or notify the police on March 12, 2026. On March 13, 2026, R1 reported to surveyors that on the previous morning in the dining room, R2 approached him, yelled at him, and suddenly pushed him out of his wheelchair, with no staff present and no staff witnessing the event. R1 stated he felt bad that someone attacked him in his place of residence and that he had asked a nurse to call the police, which he said was refused, and that he had reported the incident to V1 around 11:00 AM on March 12. R2 also told surveyors that he had gotten into a fight with his roommate in the dining room and that he pushed him, causing him to fall out of his wheelchair and get up on his own. When V1 eventually submitted the Facility Reported Incidents form to the state surveying agency on March 13, 2026, the report inaccurately listed the occurrence date as March 13 instead of March 12 and described the event as both residents alleging a resident-to-resident behavior to a surveyor, rather than reflecting the original allegation and occurrence date. The facility’s Abuse and Retaliation Prevention and Reporting Policy required any allegation of abuse to be reported immediately, but not more than two hours after the allegation, which was not followed in this case.
Failure to Investigate Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse and Retaliation Prevention and Reporting Policy by not investigating an allegation of resident-to-resident physical abuse. One resident (R1) reported that another resident (R2) pushed him out of his wheelchair in the dining room, with no staff present, and stated he felt bad that someone attacked him in his place of residence. R1 said he asked a nurse to call the police and reported the incident to the Administrator (V1) later that morning. On the same day, R2 told staff that R1 got in his face and that he pushed R1, and a nurse (V9) recognized this as an abuse allegation per facility protocol, immediately notifying the Administrator. Despite this, the Administrator stated she was unaware that R2 had pushed R1 and believed the situation to be only a behavioral event. The Social Service Director (V18) reported that he was notified by the Administrator early that morning that there had been an altercation between the two residents, and that he and the Administrator reviewed dining room camera footage. The behavioral progress note he entered described R1 approaching R2, yelling and waving his arms, and R2 becoming agitated and pushing R1 away. The camera view was partially blocked, and they could not verify whether R1 fell from his wheelchair. The Director of Nursing (V2) also received a text from the Administrator stating that R2 allegedly pushed R1 because R1 was yelling at him, but V2 was not involved in any investigation. Video footage later reviewed by surveyors showed R2 pacing in the dining room, then moving toward R1 in a threatening manner and forcefully pushing him with two flat hands, with the view of R1 partially blocked so it was unclear if he fell. The Administrator acknowledged that the push was forceful and constituted abuse of R1. However, no abuse investigation or grievance report was initiated at the time of the incident, and the Administrator stated she did not complete an investigation because she considered it only a behavioral event. The facility’s written policy required that all incidents involving alleged or suspected abuse be documented and result in an investigation, but this was not done until more than a day later, after surveyors were informed by R1 that he had been pushed out of his wheelchair by R2.
Failure to Report Attempted Narcotic Diversion to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to notify law enforcement and the state surveying agency of an attempted diversion of narcotic medications involving two residents. A registered nurse (V3) reported that on 08/09/25 he left two bingo cards of Norco, one for resident R7 and one for resident R8, on top of a cabinet in the medication room while he went on break. When he returned, the medications were no longer where he had placed them. V3 stated that only he and another RN (V4) had keys to the medication room. After searching the medication room, V3 found both bingo cards containing Norco inside V4’s unzipped personal shoulder bag. V3 notified the DON (V2), who, along with the Administrator (V1), came to the unit. V2 stated she removed the medications from V4’s bag and that V4 admitted placing the narcotics in her bag and reported she was addicted to drugs and had recently been in rehab. V1 confirmed that the narcotic medications found in V4’s personal bag belonged to R7 and R8 and stated that the police were not called because the medications had not left the facility, the narcotic count was accurate, and no residents missed any medications. V1 also stated that V4 was not reported to the state licensing agency or the state surveying agency for the same reasons. R7 had diagnoses including major depressive disorder, bipolar disorder, anxiety, osteoarthritis, cervicalgia, and a left-hand contracture, and had discontinued orders for Norco 10-325 mg as needed for pain with start dates in July and August 2025. R8 had diagnoses including acquired absence of the right leg below the knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes, and had an order for Norco 5-325 mg every 12 hours as needed for severe pain for five days in August 2025. The facility’s policy on discrepancies, loss, and/or diversion of medications required that all suspected loss or diversion be immediately investigated and that appropriate agencies required by state regulation be notified, but law enforcement and the state surveying agency were not notified in this incident.
Failure to Securely Store Controlled Substances in Medication Room
Penalty
Summary
The deficiency involves the failure to securely store controlled substances in the medication room, specifically Norco prescribed for two residents. A registered nurse (V3) reported that on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8, on top of a cabinet in the medication room while they were due to be wasted. When V3 returned from break, the medications were no longer where he had placed them. V3 stated that only he and another RN (V4) had keys to the medication room. After searching the medication room, V3 found both bingo cards containing Norco inside V4's unzipped personal shoulder bag, with the narcotic sheets still attached and visible. The Director of Nursing (V2) confirmed that she removed the medications from V4's personal bag and stated that narcotic medications in the medication room should be double locked. The Assistant Director of Nursing (V12) stated that narcotic medications stored in the medication room should not have been left on the cabinet and should have been placed back in the locked narcotic drawer in the medication cart. The Administrator (V1) confirmed that the narcotic medications found in V4's personal bag belonged to R7 and R8. R7 had multiple diagnoses including major depressive disorder, bipolar disorder, anxiety, osteoarthritis, cervicalgia, and a left-hand contracture, and had discontinued orders for Norco 10-325 mg with different dosing frequencies in July and August 2025. R8 had multiple diagnoses including acquired absence of the right leg below the knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes, and had an order for Norco 5-325 mg every 12 hours as needed for severe pain for five days in early August 2025. The facility’s Storage of Medications Policy stated that medications and biologicals are to be stored safely, securely, and properly, but the handling and storage of these Norco bingo cards did not comply with those requirements.
Failure to Report Resident’s Allegation of Physical Abuse per Facility Policy
Penalty
Summary
The facility failed to follow its abuse reporting policy when staff did not report a resident’s allegation of physical abuse to administration. The resident had multiple diagnoses including type 2 DM with hyperglycemia, unspecified dementia with moderate cognitive impairment, psychotic and mood disturbances, anxiety, cognitive communication deficit, recurrent moderate major depressive disorder, alcohol dependence with alcohol-induced disorder, and alcoholic cirrhosis. In December 2025, the resident told an insurance representative that he had been abused by a female staff member months earlier but could not provide a description or details. The administrator reported that this allegation was investigated by the state surveying agency with no findings, and the facility’s social service director and the resident’s case manager spoke with him about it. During that prior investigation, according to the administrator, no staff names were given by the resident. On a later date, during an interview, the resident was lying in bed and answered only closed-ended questions. He stated that months ago a female staff member had physically abused him, saying she punched him, and he believed it was a staff member with a specific first name. He reported that he had told someone at the facility and that a male, whom he believed might be staff, had talked to him about it. When asked if he was afraid the staff member would do it again, he hesitated and said “probably.” The administrator was informed that the resident had now identified a staff first name, and she acknowledged that there were both a CNA and an RN with that first name, noting that the CNA was working that day and the RN was scheduled later. The administrator stated that previously no names had been provided in connection with the allegation. Interviews with staff revealed that a CNA (V6) had been told of the abuse allegation by the resident months earlier but did not report it to administration as required by facility policy. V6 stated that while giving the resident a shower, he reported that months ago a CNA had beaten him and identified the first name shared by the CNA (V5) and RN (V7). V6 responded that she was sorry to hear it and did not notify the abuse coordinator or administration because the resident said it had happened months ago and had already been reported and “taken care of,” and because she believed it was an old, resolved case. V6 also stated she had heard about the allegation about eight months prior, believed it related to the unit where V5 worked, and thought the case was clear since V5 was still working there. V5 reported that she first heard of the allegation when V6 told her, after a shared shift, that the resident said someone with her first name had hit him; V5 said she did not take it seriously because she had never worked with the resident. The facility’s written policy required employees to immediately report any incident, allegation, or suspicion of potential abuse they observe, hear about, or suspect to the administrator or through designated channels, which did not occur in this case.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required timeframes to both the state surveying agency and local law enforcement. The incident involved a resident with intact cognition and a history of major depressive disorder, bipolar disorder, anxiety disorder, and suicidal ideations. The resident reported that a nurse applied cream to her buttocks during wound care and then to her vaginal area and labia, which made her feel violated. The resident disclosed the incident to the Psychiatric Rehabilitation Service Coordinator (PRSC), who immediately informed the Social Service Director, and together they reported it to the Administrator on the same day. Despite the prompt internal reporting, the Director of Nursing (DON) was not informed until three days later, and the facility did not notify the state surveying agency or the police until seven days after the initial report was made to facility staff. The facility's own policy requires allegations of abuse to be reported to the Department of Public Health within two hours and to local law enforcement in cases of sexual abuse. The delay in external reporting constituted a failure to follow both regulatory requirements and facility policy.
Failure to Timely Investigate and Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention and reporting policy by not promptly investigating an allegation of sexual abuse and not immediately suspending the alleged perpetrator. A female resident with intact cognition and a history of major depressive disorder, bipolar disorder, anxiety disorder, and suicidal ideations reported that a nurse inappropriately applied cream to her genital area during wound care, which made her feel violated. The resident reported the incident to the Psychiatric Rehabilitation Service Coordinator (PRSC), who immediately informed the Social Service Director, and both reported the allegation to the Administrator on the same day. Despite the facility's policy requiring immediate removal of employees accused of abuse from resident contact, the nurse continued to work for eight days after the allegation was reported. The Director of Nursing (DON) was informed of the incident three days after it was reported to the Administrator, and the nurse was not suspended until eight days after the initial report. Additionally, the facility did not report the allegation to the state surveying agency within the required two-hour timeframe, instead reporting it seven days after the incident was brought to the facility's attention.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical and emotional abuse by another resident. Both residents involved had severe cognitive impairment and histories of behavioral issues, including dementia and aggressive or agitated behaviors. The incident occurred when one resident physically assaulted the other, resulting in scratches, a bite mark, and emotional distress. Staff found both residents on the floor, with one resident biting the other's fingers and subsequently slapping him on the face. The assaulted resident was observed to be crying, scared, and visibly upset, with multiple minor injuries documented. Prior to the incident, the care plans for both residents identified significant risk factors. One resident had a documented history of childhood abuse, severe cognitive impairment, and a pattern of wandering into peers' rooms, which was known to startle or upset others. The other resident had a history of aggressive behavior, agitation, and resistance to care, as well as recent medication orders for agitation and anxiety. Despite these known risks, the facility did not implement effective interventions to prevent resident-to-resident altercations or address the potential for abuse between these two individuals. Staff interviews revealed that the two residents had a history of negative interactions, with one resident frequently being mean and attempting to exclude the other from their shared room. On the day of the incident, staff were not present in the room at the time of the altercation and were alerted by another resident. Upon intervention, staff observed the aggressor laughing and making statements that the victim "deserved it." The facility's abuse policy affirms the right of residents to be free from abuse and requires the prevention of mistreatment, but the lack of adequate interventions and supervision led to the occurrence of abuse and emotional harm.
Failure to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain the kitchen in a manner that would prevent foodborne illness for all residents receiving dietary services. Surveyors observed that the kitchen dishwasher, which is supposed to disinfect by reaching 180 degrees Fahrenheit, only reached 150 degrees during the wash and 160 degrees during the rinse. The dishwasher gauges had not worked properly for over a year, and staff relied on temperature test strips instead of recording gauge temperatures. Additionally, a cook was found holding coleslaw at 48.5 degrees Fahrenheit, above the required 41 degrees or below, and the Dietary Director acknowledged that improper holding temperatures could lead to foodborne illness. Further observations revealed multiple food storage and sanitation issues. Unlabeled and undated containers of food and thickener were found in dry storage and the walk-in cooler, and several large bags of frozen food were left open to air in the freezer. The kitchen and utensils were found dirty with crusted debris, and a bottle of lemon juice requiring refrigeration was left out at room temperature. The Dietary Director admitted that labeling, dating, and proper storage were not consistently followed, and that cleaning responsibilities were not always met due to time constraints. Additionally, the Dietary Director was observed in the kitchen without a beard guard, contrary to facility policy requiring facial hair coverage to prevent food contamination.
Failure to Implement Fall Risk Precautions and Maintain Safe Environment
Penalty
Summary
The facility failed to implement appropriate fall risk precautions for multiple residents identified as being at risk for falls. One resident was observed with a mattress that was significantly larger than the bed frame, causing the mattress to hang off and angle downward. This resident reported ongoing issues with the mattress, including slipping while trying to get out of bed, and stated that complaints about the mattress had been made for months. Both nursing and maintenance staff confirmed that the mattress did not fit the bed frame and acknowledged the risk of falls associated with this improper fit. The resident's care plan documented a risk for falls due to multiple medical conditions, and facility policy required that malfunctioning equipment be reported or removed from service immediately. Another resident, who was severely cognitively impaired and at high risk for falls, was observed in bed without the required floor mat in place. The floor mat, intended to minimize injury in the event of a fall, was found either under the bed or standing against the wall during multiple observations. Staff interviews confirmed that the floor mat should have been positioned at the bedside whenever the resident was in bed, as specified in the resident's care plan and the facility's fall prevention guidelines. The lack of proper placement of the floor mat represented a failure to follow the prescribed fall prevention interventions. Additional deficiencies were noted for other residents at risk for falls, including beds left in a high position after care was provided. Several residents, who were dependent on staff for activities of daily living and unable to adjust their own beds, were found with their beds elevated, contrary to their care plans and facility policy. Staff acknowledged that beds should have been returned to a low and safe position after care to reduce the risk of injury from falls. One resident was also found to lack a care plan with fall prevention interventions despite being assessed as at risk for falls.
Improper Storage of Refrigerated Controlled Medications
Penalty
Summary
Surveyors found that the facility failed to store resident medications, specifically Lorazepam vials, according to pharmacy labeling and manufacturer recommendations. Multiple vials labeled as requiring refrigeration were instead kept unrefrigerated in the narcotic box within the nurse's medication cart. This was observed for four residents with diagnoses including seizure disorders, epilepsy, and anxiety disorder, all of whom had physician orders for Lorazepam to be administered intramuscularly as needed. The medication refrigerator in the medication room was found to lack a lock, and staff reported that this was the reason for storing the vials in the cart rather than in the refrigerator. Interviews with nursing staff revealed a lack of clarity regarding proper storage procedures, with one agency nurse unaware of the requirement to refrigerate the Lorazepam vials. The Director of Nursing confirmed that medications labeled for refrigeration must be stored accordingly and acknowledged that improper storage could affect medication potency. The facility's policy requires refrigerated medications to be kept at specific temperatures in a locked box within the refrigerator, but this was not followed for the Lorazepam vials in question.
Failure to Provide and Document Range of Motion Services
Penalty
Summary
A resident with diagnoses including Parkinson's disease, anemia, slow transit constipation, and osteoarthritis was identified as having limited range of motion (ROM) in both upper and lower extremities. The resident's care plan specified an active assisted ROM (AAROM) program, with a goal of performing one set of five repetitions to all extremities with limited staff assistance one to two times daily. However, there was no documentation in the electronic medical record (EMR) that the ROM program was being implemented. The restorative nurse confirmed that the last restorative assessment was completed several months prior, and although recommendations for active ROM and bed mobility were made, the resident was not included on the restorative list and had no program in place to guide staff on exercises or frequency. The resident also reported not receiving restorative assistance from staff, and the facility's policy required regular screening and implementation of restorative nursing programs.
Deficient Catheter Care and Improper Catheter Bag Placement
Penalty
Summary
The facility failed to provide proper catheter care for two residents, resulting in deficiencies related to sanitary technique, use of securing devices, and catheter bag placement. For one resident with diagnoses including bipolar disorder, type 2 diabetes, tremor, and neuromuscular dysfunction of the bladder, catheter care was observed to be performed using the same washcloth multiple times for different areas, and the washcloth was re-wetted in the same basin of water. The CNA did not clean between the labia, and no catheter securing device was in place during the procedure. The Director of Nursing confirmed that proper technique requires a fresh washcloth for each wipe, opening the labia for cleaning, and using more than two washcloths for the procedure. In another instance, a male resident with severe cognitive impairment was observed with his indwelling catheter bag placed directly on the floor. A CNA later picked up the bag and acknowledged it should not have been left on the floor, stating it should be hung on the bed frame. The Director of Nursing confirmed that catheter care is provided every shift and as needed, and that catheter bags should not be on the floor. The facility's policy also specifies that indwelling catheters should be secured to prevent trauma and that drainage bags and tubing should not touch the floor.
Failure to Ensure Timely Availability of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were available for administration to residents, resulting in two residents not receiving their prescribed medications as ordered. One resident, who had a history of chronic pain and migraines, reported running out of Tramadol, a pain medication she routinely took twice daily. She stated that it sometimes took days for the facility to obtain her medication and that she was informed the previous night that she was on her last pill. The medication was not available during the morning medication pass, and the nurse confirmed it had last been administered the previous evening. The nurse also indicated that medications should be reordered when there are eight pills remaining, but this was not done in time for this resident. Another resident, with diagnoses including schizophrenia, anxiety disorder, and psychosis, did not receive her scheduled dose of Aripiprazole because the medication was not available during the morning medication pass. The LPN responsible for her care stated she was not notified by the night shift that the medication had run out and only reordered it that morning. The facility's policy requires medications to be reordered according to the pharmacy provider's schedule, but this was not followed, resulting in missed doses for both residents.
Failure to Maintain Annual CNA Competency Training Requirements
Penalty
Summary
The facility failed to maintain the required minimum of 12 hours per year of competency training for Certified Nurse Assistants (CNAs), as mandated for all staff providing care to residents. During the survey, the administrator confirmed that all 164 residents received care from CNAs. When proof of annual CNA competency training was requested for several CNAs, the administrator was unable to provide documentation of the required hours due to a recent change in the computer-based training platform, resulting in incomplete records. The available in-service training hours for the reviewed CNAs ranged from 1.5 to 4 hours, which is significantly below the required 12 hours. The administrator acknowledged the inability to provide proof of compliance with the annual training requirement.
Failure to Provide Grievance Policy to Residents
Penalty
Summary
The facility failed to provide residents with access to the grievance policy, as required. Four residents reported during a resident meeting that they had been requesting copies of the grievance policy and information on how to file a grievance since November 2024, but had not received it. One resident stated that staff only advised them to speak to a staff member if they had a grievance, and that the Social Service Director was invited to explain the policy but did not do so. A review of facility bulletin boards confirmed that the grievance policy was not posted in any location. Interviews with facility staff revealed confusion and lack of clarity regarding who was responsible for providing the grievance policy to residents. The Social Service Director stated that the administrator had given the policy to the resident council, while the administrator said the policy was reviewed with the council but not personally distributed. The Activities Director reported notifying the administrator about the request but did not provide the policy herself. The Director of Nursing confirmed that any policy requested by residents should be provided. Resident council meeting minutes from January and February 2025 documented ongoing requests for the grievance policy to be posted throughout the facility, with responses indicating that the administrator would provide it and that it was posted on each unit, though this was not observed.
Resident Biting Incident Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a resident being bitten by another resident. The incident involved a resident with moderate cognitive impairment who was bitten by another resident with similar cognitive challenges. The biting incident led to the victim being hospitalized and receiving antibiotic treatment for the injuries sustained. The report highlights that the resident who was bitten had a history of wandering into other residents' rooms, which triggered aggressive responses from other residents. On the day of the incident, the facility was short-staffed due to a call-off, which left the dementia unit understaffed. The resident who was bitten was not adequately monitored, allowing him to enter another resident's room, leading to the biting incident. Staff members reported hearing shouting and commotion but were not present in the room to prevent the incident. The lack of sufficient staff coverage and monitoring contributed to the failure to prevent the abuse. The report also notes previous incidents where the same resident had entered other residents' rooms, leading to aggressive interactions. Despite these prior occurrences, the facility did not implement effective measures to monitor and redirect the resident to prevent further incidents. The facility's failure to ensure adequate supervision and protection for residents in the dementia unit resulted in the physical abuse incident.
Inadequate Infection Control During Norovirus Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a norovirus outbreak, which had the potential to affect all 165 residents. Upon entering the facility, the surveyor did not observe any signs indicating a current norovirus outbreak. The Director of Nursing (DON) confirmed the outbreak and mentioned that some residents were on isolation, but there were inconsistencies in the implementation of isolation protocols. Several residents with symptoms were not properly isolated, as evidenced by the lack of contact isolation signs and personal protective equipment (PPE) outside their rooms. The facility's staff, including CNAs and housekeepers, demonstrated a lack of adherence to infection control measures. Some staff members were observed interacting with symptomatic residents without wearing appropriate PPE, and there were instances where hand hygiene protocols were not followed. Additionally, the housekeeping staff was not consistently using bleach-based cleaning products as required, due to a shortage of supplies. The Maintenance Director, who was overseeing housekeeping, was unsure of the correct bleach-to-water ratio for disinfection. The facility's Norovirus Outbreak Measures policy outlined specific guidelines for controlling the spread of the virus, including isolation of symptomatic residents, proper hand hygiene, and the use of bleach solutions for cleaning. However, these measures were not fully implemented, as evidenced by the lack of isolation signs, inadequate PPE usage, and insufficient cleaning practices. The facility's failure to adhere to its own policy and the lack of communication with the health department regarding cleaning practices contributed to the deficiency.
Failure to Follow Catheter Size Order
Penalty
Summary
The facility failed to adhere to its policy regarding the insertion of an indwelling catheter for a resident with specific medical conditions, including urinary retention, urethral stricture, and urethral erosion. The physician's order specified the use of a 14FR or 16FR Foley catheter, but a 20FR catheter was inserted instead. This incident involved a registered nurse who, upon finding the resident's catheter dislodged with the balloon intact, replaced it without verifying the correct size as per the physician's order. The nurse acknowledged the oversight, stating that they did not check the order for the catheter size before proceeding with the insertion. The facility's medical supply storage was adequately stocked with catheters of various sizes, including the ordered 16 French size. The Medical Records/Supply Director confirmed that nurses could access catheters of all sizes and seek assistance if needed. Despite the availability of the correct catheter size, the nurse's failure to follow the physician's order and the facility's policy resulted in the use of a larger catheter than prescribed. The nurse practitioner confirmed that the larger catheter was not in accordance with the order, although no trauma was reported as a result of the incident.
Facility Fails to Maintain Safe Food Handling During Kitchen Renovation
Penalty
Summary
The facility failed to ensure food was stored, distributed, and served to residents in a manner that prevented food contamination during a kitchen renovation. The kitchen was closed for floor repair, but food preparation continued without the ability to maintain safe food temperatures or sanitize dishware and equipment. This led to the local health department revoking the facility's permit to prepare food on site, resulting in an Immediate Jeopardy situation affecting all 161 residents who consumed food from the facility. The Immediate Jeopardy began when the facility's kitchen was closed, and food preparation continued in inadequate conditions. The facility rented a refrigerated storage container, which failed to maintain proper temperatures due to warm weather and frequent door openings. Additionally, there were no handwashing stations available for dietary staff, and the facility attempted to prepare puree and mechanically altered food onsite using inadequate equipment and sanitation methods. The local health department documented the suspension of food service operations due to inadequate refrigeration and lack of handwashing sinks. Observations revealed that the facility was serving meals in take-out containers with disposable cups, and staff were using a single handwashing sink for both hand hygiene and cleaning equipment. The facility's policy required food temperatures to be documented, but the Dietary Manager admitted to not recording them. The facility's actions and lack of planning for the kitchen renovation led to unsafe food handling practices, which were confirmed by interviews with staff and the local health department.
Removal Plan
- Facility will utilize a local organization's kitchen to prepare mechanical and puree diets for residents that are on puree or mechanically altered diets to have their food safely prepared. This will be managed by the Dietary Director/Designee.
- Facility has 1 handwashing sink in each serving room; a total of 1 of operational handwashing sinks since there are two serving rooms in the facility. In addition, the facility will obtain 2 portable hand washing stations to ensure that dietary staff is able to perform appropriate hand washing process. The portables were on site.
- The facility will obtain disposable foil pans. For Utensils, 3 containers will be provided to rinse, wash and sanitize to ensure a method for sanitizing food service equipment and service items between meals to prevent food borne illnesses. This will be on site at local organization's kitchen. Once sanitized the equipment will be transported back to the facility. Facility will utilize test strips to ensure proper Ph for sanitation. This will be managed by the Dietary Director/Designee and monitored by the facility Administrator.
- The facility is only storing milk products in the cooler located in the dining room. The cooler temperature is being monitored to maintain at safe temperatures during holding. A log for temperatures will be maintained by the Dietary Director/Designee and is being checked every shift. The facility will continue to cater food for the residents until the project has been completed. Administrator will maintain documentation of temperatures.
- The facility is having food delivered from vendor in insulated bags via private vehicle to the facility. Food is then transferred back and forth to local organization's kitchen via private vehicle in insulated bags. The facility has developed a temperature tool to monitor and document temperatures of food - pick up time and temps, after transfer time and temps.
- Prior to start of shift, the Dietary Director/Designee will monitor food temperatures and document temperature on the newly developed log. The Administrator will monitor and maintain these logs daily during the kitchen closure and make immediate corrective action if not complete.
- An emergency QA meeting has been conducted with facility medical director and IDT team to review the incident and action plan. The facility has reviewed the policies and procedures and has developed and amendment on how the facility will monitor temperatures during this interim. The QA team will also refer this incident for review of emergency action plan for any changes.
Delay in Completing Physician-Ordered X-Ray
Penalty
Summary
The facility failed to timely complete a physician order for an X-Ray for one resident who experienced a change in condition. On 04/13/2024, the resident had a witnessed fall in the bathroom and later complained of pain and swelling in her right ankle. An X-Ray was ordered by the physician to be completed by the on-call X-Ray service. However, the X-Ray was not performed until 04/17/2024, revealing an oblique fracture of the distal fibula and a distal tip fracture of the medial malleolus. The Quality Assurance Nurse acknowledged that the delay was noticed on 04/16/2024 when the X-Ray service was needed for another resident. The facility's agreement with the portable X-Ray company stipulates that services should be provided within 24 business hours or a scheduled time, and the provider should notify the facility if this timeframe cannot be met.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
