Arc At Sangamon Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Illinois.
- Location
- 3400 West Washington, Springfield, Illinois 62711
- CMS Provider Number
- 146026
- Inspections on file
- 47
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Arc At Sangamon Valley during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff to meet residents’ daily needs, resulting in delayed responses to call lights, toileting, medication administration, and other essential care. Staff reported chronic short staffing, with CNAs caring for up to 16 residents each and nurses up to 32, particularly on certain halls and shifts. A resident who required a full-body mechanical lift sometimes was transferred by only one staff member due to lack of help, another waited many hours for a requested stool softener, and another waited about an hour for assistance to use a bedpan. Surveyors observed residents left waiting for transport to meals and unanswered call lights while staff were tied up with multiple two-person lift transfers. Resident council minutes documented ongoing concerns about call light times, shower schedules, medications, and timeliness of services, and leadership acknowledged there was no formal staffing policy beyond following federal guidelines.
Two residents did not receive wound and skin treatments as ordered by their physicians. For one resident with dementia and diabetes, an RN/DON observed a bright red groin but did not apply the ordered Venelex ointment every shift as prescribed. For another resident with cellulitis, chronic leg ulcers, venous insufficiency, CHF, CKD, and diabetes, the care plan and wound clinic orders required specific treatments including Santyl to the right lower leg/foot and Betadine between the toes. During observed wound care, the DON instead applied xeroform to the right foot despite the resident presenting wound clinic orders for Santyl, and later confirmed that the Santyl order was active but the prior xeroform order had not been discontinued, leading to use of the wrong treatment.
The facility failed to maintain an adequate supply of working batteries for mechanical lifts, causing delays and difficulties in transferring a resident who required a Hoyer lift for all transfers and needed timely transport to dialysis. CNAs reported that lift batteries were often dead, that they had to leave the unit to search for batteries, and that typically only one or two batteries were available for all halls. The Administrator confirmed there were more lifts than batteries, that some batteries needed fuses, and that there was no specific equipment maintenance policy, despite an expectation to follow manufacturer guidelines.
A resident with severe cognitive impairment and a history of falls was transferred by a CNA using a mechanical lift without the required second staff member and without removing a floor mat from the bedside. The lift tipped over the mat, causing the resident to fall and sustain a forehead laceration requiring sutures. Facility policy and the resident's care plan required two-person assistance and a hazard-free environment during transfers, but these were not followed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A newly admitted resident with a recent hip replacement and osteoarthritis did not receive prescribed pain medications as ordered, due to delays in pharmacy delivery and limited staff access to the medication distribution machine. The resident experienced significant pain and poor sleep until the medications were administered the following day, despite facility protocols for effective pain management.
A resident with recent joint replacement, COPD, and osteoarthritis did not receive prescribed pain, anticoagulant, and antibiotic medications on the evening of admission due to delays in pharmacy delivery and limited staff access to the medication machine. The resident experienced significant pain and poor sleep as a result, and staff confirmed that medications were not available or administered as ordered.
A resident with severe cognitive impairment sustained a hand injury after getting her finger caught in a door. Although the incident was documented by staff, the responsible party was not notified as required. The resident's private caretaker discovered the injury and informed the resident's daughter/POA, who had not been contacted by facility staff. The DON confirmed that the required incident report and notification were not completed.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes insufficient safety measures and supervision but does not specify further details.
A resident was found using a wheelchair with dried debris on the seat, wheels, and frame. The resident, who is cognitively intact, stated that staff are supposed to clean her wheelchair monthly but was unsure if this occurs. Facility policy requires weekly cleaning of wheelchairs, but this was not followed, resulting in the resident's wheelchair not being properly maintained.
A resident with dementia and a history of falls, who was dependent on staff for transfers and used a wheelchair, experienced a fall in the dining area after pushing herself away from the table. The care plan required the wheelchair to be locked and tilted back, but at the time of the incident, only one wheel was locked and the resident was not properly supervised, resulting in a head injury and transfer to the ER.
A resident with a complex medical history experienced significant unmonitored weight loss after repeated intolerance and refusal of enteral nutrition. Facility staff failed to obtain required weekly weights, did not promptly notify the RD of the weight loss or supplement changes, and did not reassess the resident’s nutritional needs in a timely manner. Communication lapses and confusion over dietary orders led to inadequate nutrition being provided.
Multiple residents with complex medical needs experienced significant delays in call light responses, missed showers, and prolonged periods on bedpans due to insufficient CNA and nursing staff. Staff interviews confirmed that recent staffing cuts led to only one CNA per unit, resulting in increased workloads, missed care tasks, and a decline in care quality.
A resident with complex medical needs was not provided with a baseline care plan or involved in care planning discussions within 48 hours of admission, as required by facility policy. The care plan was not given to the resident until 23 days after admission, despite documentation and staff confirmation of the delay.
Three residents with significant medical needs did not receive showers or baths as frequently as required, with some receiving only one shower in several weeks or none at all. Documentation and interviews confirmed that insufficient CNA staffing led to missed showers, and the facility's policy of offering bathing at least once per week was not met.
The facility failed to provide and document required pressure ulcer care for multiple residents, including missing wound treatments, incomplete skin assessments, and not following physician orders. As a result, a resident developed a severe, infected stage 4 pressure ulcer that required surgical debridement and hospitalization. Staffing shortages and lack of adherence to facility policies contributed to the deficiencies.
The facility did not ensure consecutive 8-hour RN coverage on several occasions, as shown in staffing schedules, which could have impacted all 122 residents. The administrator confirmed staffing shortages and acknowledged the absence of required RN coverage.
A resident with severe cognitive impairment and multiple medical conditions developed skin tears on her arm and hand, with family members reporting possible rough handling by a CNA. Staff were unaware of the injury's cause, and no incident report or documentation was completed until prompted by a surveyor, contrary to facility policy requiring timely reporting and investigation of unknown injuries.
A resident with severe cognitive impairment and total dependence on staff developed multiple skin tears, including a significant wound on the upper arm, during her stay. Family members reported the injuries and suggested they occurred during transfers or showers, possibly due to rough handling by CNAs. Staff were unaware of the injuries, and no incident report or documentation was completed at the time, resulting in a delayed investigation and failure to follow facility policy for injuries of unknown origin.
Three residents with cognitive impairment and complex medical histories experienced repeated skin tears and falls. Staff failed to complete incident investigations, root cause analyses, and did not implement or maintain care plan interventions such as motion alarms, non-slip pads, and signage. Documentation and reporting were inconsistent, and staff were often unaware of required precautions, resulting in unaddressed injuries and hazards.
The facility did not provide enough nursing staff to meet residents' needs, resulting in delayed meal service, cold food, and long wait times for care. Multiple residents reported consistently late and inadequate service, while staff confirmed ongoing staffing shortages. Documentation showed that a resident with pressure ulcers did not receive all prescribed wound care treatments, and an LPN described worsening conditions and lack of management support. The DON stated there was no formal staffing policy in place.
Three residents reported receiving cold or lukewarm meals, with food temperatures measured below the facility's preferred standard by the time trays reached them. Staff confirmed that food temperatures were not checked at the point of service, and frequent complaints about cold food were noted. Ongoing equipment issues and inconsistent adherence to food temperature monitoring policies contributed to the deficiency.
A resident admitted with a stage 2 pressure ulcer did not receive a documented admission skin assessment, and weekly skin assessments were inconsistently recorded. The physician was not promptly notified for treatment orders, and there was confusion among staff about documentation procedures, resulting in delayed and incomplete pressure ulcer care.
A resident with severe cognitive impairment and multiple health conditions developed a hematoma with a skin tear on the right inner knee, which was discovered by a CNA. Despite facility policy requiring documentation and investigation of injuries of unknown origin, the injury was not reported to the state agency, and no investigation was initiated. The LPN was unable to document the injury due to system access issues, and the Director of Nursing did not complete an incident report, considering it a change of condition.
The facility experienced significant staffing deficiencies, resulting in delayed care and inadequate supervision for its 109 residents. Residents reported long wait times for assistance, with one waiting over two hours for help to use the bathroom. Observations during meal times revealed a lack of supervision in dining areas, affecting residents with specific dietary needs. Staff interviews confirmed insufficient aides and reliance on non-direct care staff to fill gaps, highlighting systemic staffing issues.
A facility failed to educate a resident on safety protocols, resulting in the resident leaving without notifying staff. Additionally, the facility did not provide adequate supervision during meal times, leaving residents with cognitive impairments and dietary needs unsupervised. Staffing issues were cited as a contributing factor.
The facility failed to respond promptly to call lights, impacting the dignity and care of three residents. One resident waited over an hour for assistance, leading to distress, while another's sister had to intervene due to delayed response. A third resident experienced incontinence after waiting two hours for help. Staffing issues were acknowledged by the DON, and the facility's policy requires prompt call light responses.
The facility failed to respond to call lights promptly, affecting three residents who experienced delays in receiving assistance for toileting needs. One resident, with Multiple Sclerosis, reported waiting up to an hour for help, leading to accidents and feelings of diminished self-worth. Another resident, dependent on staff for transfers, had an accident after being left waiting, resulting in humiliation. A third resident also reported long wait times, leading to accidents and distress. These incidents reflect ongoing issues with call light response times, as noted in Resident Council Minutes.
The facility failed to prevent and monitor significant weight loss in two residents, both severely cognitively impaired. One resident, with dementia, was not assisted or encouraged to eat, resulting in a 9.5% weight loss over three months. Another resident, on hospice care, experienced an 11.94% weight loss from July to September, despite care plan interventions. The facility lacked a feeding assistance policy, and staff did not consistently provide necessary help.
The facility failed to properly store, label, and date food items, and staff did not adhere to hand hygiene policies during food service. Unlabeled and outdated food items were found in the kitchen, and staff were observed using bare hands to handle food, violating facility policies.
The facility failed to assist five residents with dining needs, despite their cognitive impairments and documented requirements for supervision or assistance. Residents were observed struggling to eat without help, leading to inadequate food intake. The facility lacks a feeding assistance policy, contributing to this deficiency.
The facility failed to follow infection control protocols, with staff not wearing appropriate PPE and neglecting hand hygiene. A CNA assisted a resident on Enhanced Barrier Precautions without proper PPE, and two CNAs provided catheter care without gowns. Additionally, a CNA did not perform hand hygiene between assisting residents, and another passed meal trays without hand hygiene. These actions violated the facility's infection control policies.
The facility failed to provide the SNF/ABN form CMS 1055 to two residents before the termination of their Medicare Part A services. One resident had diagnoses including a vertebra fracture and chronic kidney disease, while another had osteoarthritis and spinal stenosis. Both had benefit days remaining. A social services staff member did not complete the forms due to a lack of training, and the DON expected the facility to complete ABNs.
The facility failed to provide complete incontinent care for two residents, as observed during a survey. A CNA did not dry the cleansed areas for one resident and missed cleansing certain areas for another. Both residents had care plans requiring clean and dry skin maintenance and were dependent on staff for personal hygiene. Interviews confirmed that all areas should be cleansed and dried during incontinent care, as per the facility's policy.
A resident with Parkinson's, Depression, Dementia, and Anxiety had delayed responses to pharmacy recommendations for dose reductions of clonazepam and quetiapine. The Medical Director did not review and sign the recommendations until months later, due to the previous Director of Nurses not keeping up with them. The current Director of Nurses had to resend the recommendations, but the Medical Director did not respond despite multiple requests. The facility's policy did not address physician replies to pharmacy recommendations.
A resident with severe cognitive impairment was placed on antibiotics without proper culture review, leading to inappropriate treatment. Despite recommendations for a wound culture and negative urine culture results, the facility continued antibiotic use without necessary follow-up. Staff interviews revealed gaps in communication and adherence to antibiotic stewardship protocols.
A resident's call light was found on the floor, out of reach, on two occasions. The resident's care plan noted attempts to self-transfer, with an intervention to call for assistance. The Executive Director confirmed call lights should be within reach, as per facility policy.
A facility failed to report a verbal abuse incident between two residents, one with severe cognitive impairment and the other with a history of verbal aggression. Despite staff witnessing and documenting the altercation, the administrator did not classify it as abuse, leading to a deficiency in resident protection.
The facility failed to implement its abuse policy for a cognitively impaired resident dependent on staff for care. An allegation of abuse was not reported as required, despite acknowledgment from the Executive Director. Another resident, who was cognitively intact, had requested a room change due to poor roommate compatibility, but the facility did not follow its policy to report and investigate the incident.
A facility failed to report an abuse allegation involving a cognitively impaired resident who was verbally threatened by another resident. Despite staff awareness, the incident was not reported as abuse, and no immediate action was taken to investigate or document the event, violating the facility's abuse prevention policy.
A facility failed to investigate an abuse allegation involving two residents, one with severe cognitive impairment. The incident involved verbal abuse and threats, but the administrator treated it as a customer service issue, failing to conduct a thorough investigation or report it as required by policy. The executive director later acknowledged the need for reporting, highlighting a lapse in following abuse investigation procedures.
An LPN in an LTC facility improperly borrowed a Lidocaine patch from one resident to administer to another after dropping the original patch on the floor. The facility's DON confirmed that this practice violates the policy, which prohibits borrowing medications between residents. The LPN cited issues with medication reordering as a reason for this action.
An LPN in a facility failed to verify medications against the e-MAR during administration, leading to a medication error for three residents. One resident received an incorrect dosage of Clonazepam due to an unreported change in the physician's order. The facility's policy requiring a triple check of the five rights of medication administration was not followed.
The facility did not post the current nurse staffing information as required, with outdated or missing reports observed on two occasions. The administrator acknowledged the issue, which could impact all 117 residents.
The facility failed to provide timely assistance to residents, resulting in incontinence and use of soiled linens. One resident waited over 20 minutes for help, leading to soiled clothing, while another with MS experienced similar delays. An advocate reported a resident's bed being made with soiled linens, which the facility initially dismissed as stains. These actions violated the facility's policies on prompt assistance and maintaining a dignified environment.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and insufficient assistance for transfers. A resident requiring substantial assistance with toileting waited over 20 minutes for help, leading to soiling of clothes. Another resident with MS, needing a mechanical lift and two staff for transfers, reported a fall due to insufficient staffing. Additional residents experienced long waits for treatments, with staff confirming inadequate staffing levels, contrary to facility policies.
The facility did not follow its mechanical lift policy, requiring two staff members for transfers, affecting two residents. One resident with MS fell due to improper wheelchair footrest positioning, while another faced delays and insufficient staffing for bathroom transfers. Both residents were cognitively intact and reported these issues, highlighting a breach in the facility's policy.
The facility failed to prevent and manage pressure ulcers for two residents, resulting in facility-acquired pressure ulcers. One resident, with a high risk for pressure ulcers, developed a Stage 3 ulcer on the left heel and a deep tissue injury on the right heel due to inadequate repositioning and lack of documentation of education on pressure relief. Another resident, also at risk, developed deep tissue injuries on both heels and a Stage 3 ulcer on the buttock, with insufficient repositioning and documentation of wound care interventions. The facility's pressure ulcer policy lacked guidance on treating actual ulcers.
Two residents in an LTC facility received inadequate incontinent care. A CNA failed to properly cleanse a resident with a broken ankle and weakness, using insufficient periwash cloths. Another resident, with a pacemaker and diabetes, was not thoroughly cleaned after being found with liquid stool. The DON stated that all soiled skin should be cleansed during care.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a daily basis to meet residents’ needs and to ensure timely care. The DON reported a standard staffing pattern for nurses and CNAs on each shift, but multiple interviews and observations showed that actual staffing was frequently inadequate, with CNAs caring for up to 16 residents each and nurses responsible for as many as 32 residents. Staff, including CNAs, a CNA supervisor, and an LPN, consistently stated that staffing was “terrible,” “horrible,” and “always” short, especially on certain halls and shifts, and that they were unable to respond promptly to call lights or complete needed care. The CNA supervisor stated she was given a fixed number of CNAs per shift and could not increase staffing unless census increased and it was approved, and the administrator stated there was no staffing policy and that they followed federal guidelines. Residents reported and surveyors observed delays in care and unmet needs directly related to insufficient staffing. One cognitively intact resident who was intermittently incontinent stated that call light response times varied depending on who was working and that nights and weekends were usually short-staffed. Another cognitively intact resident reported requesting a stool softener in the morning and not receiving it until evening because the CNA had to locate a nurse. A cognitively intact resident who required a full-body mechanical lift reported that staff sometimes transferred her with only one person because there were not enough staff. Another resident’s oxygen tank was found empty; the LPN stated the resident had been back in his room “a while” and had not been reported as low on oxygen, and explained that CNAs had 16 residents each and she had 32, contributing to such issues. Surveyors also observed prolonged delays in response to call lights and assistance with toileting and transfers. One cognitively intact resident waited approximately an hour from the time she first activated her call light requesting a bedpan until two CNAs using a full-body mechanical lift finally transferred her to bed and placed her on a bedpan; during this time, her call light was answered once only to be told she must wait for a CNA to return from break, and staff were occupied assisting other residents requiring two-person lift transfers. On another occasion, both CNAs and a nurse were in one resident’s room for 30–45 minutes, leaving other residents waiting to be taken to the dining room and at least one call light unanswered for an unknown period. Staff reported that many residents on the 300- and 400-halls required two-person or full-body mechanical lift transfers and close observation for behaviors, and that with only two CNAs on a hall they could not be “everywhere” or get to all residents when needed. Resident council minutes documented ongoing concerns about call light response times, shower schedules, medications, and timeliness of service, further evidencing persistent staffing-related problems.
Failure to Follow Physician Orders for Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for wound and skin care for two residents. For one resident with Type 2 diabetes mellitus and unspecified dementia, a physician order dated 2/5/2026 directed that Venelex ointment be applied to the groin and buttocks every shift for a rash, and the care plan instructed staff to administer all treatments as ordered and monitor for effectiveness. On 2/9/2025 at 10:32 AM, the DON, an RN, removed the resident’s blankets and pulled back the incontinence brief, revealing a bright red right groin area, but did not apply any ointment to the groin despite the active order. When interviewed shortly afterward, the DON acknowledged that if the order specified cream to the groin, it should have been applied. The second resident had multiple diagnoses including cellulitis of the right lower limb, chronic ulcer of the right lower leg, venous insufficiency, atrial fibrillation, CHF, chronic kidney disease stage 3, pulmonary hypertension, Type 2 diabetes mellitus, and hypertension. The care plan documented cellulitis and chronic pressure ulcers of both lower legs, with interventions to administer treatments as ordered, follow facility policies for skin breakdown prevention and treatment, and have the wound doctor assess and treat as needed. Physician orders included daily cleansing and dressing of the left lower extremity with NS, xeroform, dry rolled gauze, and ace wraps; elevation of lower extremities; application of Santyl to right lower leg/foot slough every dayshift; and cleansing of the right foot with NS and wound cleanser followed by Betadine-soaked gauze between the toes. On the date of observation, the DON performed wound care for this resident in the absence of the wound nurse. The DON cleansed and dressed the left foot with xeroform, gauze, and ace wrap consistent with orders. The right lower leg and foot were observed to be very swollen, reddened, oozing serosanguinous fluid and blood, with white patches and open sores. The DON cleansed the right toes, foot, and ankle with NS, applied Betadine between the toes and on the top of the foot, and then applied xeroform to the top of the right foot before covering and wrapping it. During the procedure, the resident stated that the wound clinic had changed the treatment to Santyl and showed the DON the wound physician’s orders specifying Santyl to the right lower leg/foot. The DON responded that she would have to correct the orders but continued using xeroform. Later, the DON acknowledged that a Santyl order dated 2/2/2026 was already in the record and that the original xeroform order had not been discontinued, resulting in the continued use of xeroform instead of Santyl as ordered for the right lower leg/foot.
Insufficient Mechanical Lift Batteries Delaying Resident Transfers
Penalty
Summary
The facility failed to maintain enough working batteries for mechanical lifts, resulting in delays and difficulties in transferring residents who required full-body lift assistance. One resident, who was in bed with a mechanical lift sling underneath him, reported that a CNA told him the mechanical lift did not work and that she would inform therapy. The resident stated he was supposed to get up and needed to be at dialysis at 11:00 AM. Later that morning, two CNAs entered the room with a mechanical lift and transferred the resident from bed to wheelchair. The resident’s face sheet documented end stage renal disease, dependence on renal dialysis, congenital complete absence of the left lower limb, and other conditions, and his care plan specified that he required a Hoyer lift for transfers between two surfaces. Multiple CNAs reported that there were not enough batteries available for the mechanical lifts. One CNA stated another CNA had to go upstairs to get a battery because the lift battery was dead and further stated that the lifts were not broken, but the facility did not have enough batteries. Another CNA reported that most of the time there were only one or two batteries available and that, a couple of weeks prior, no one could find a battery and there were only one or two batteries for all the halls to share. The Administrator confirmed the facility had 14 mechanical lifts and 12 batteries, with 2 of the 12 batteries needing fuses, and acknowledged there was no specific policy for maintenance of equipment, though she expected the facility to follow manufacturer guidelines.
Failure to Follow Safe Transfer Procedures Resulting in Resident Fall and Injury
Penalty
Summary
A resident with severe cognitive impairment, a history of falls, and dependence on staff for transfers was involved in an incident where proper transfer procedures were not followed. The resident's care plan required the use of a full mechanical lift with two staff assisting for all transfers, and the environment was to be kept free of hazards, including removing the floor mat prior to transfers. Despite these requirements, a CNA attempted to transfer the resident alone using the mechanical lift and did not remove the floor mat from beside the bed. During the transfer, the CNA operated the lift over the floor mat, which caused the lift to tip over. As a result, the resident fell and sustained a laceration to the forehead, which required suture repair. The incident was unwitnessed by other staff, and the CNA admitted to performing the transfer alone and not moving the mat, despite knowing the correct procedure. Documentation and interviews confirmed that the resident was care planned for two-person assistance and that the floor mat should have been removed prior to the transfer. The facility's policies also required that mechanical lifts be used according to the care plan and that the environment be free of hazards during transfers. The failure to follow these procedures directly led to the resident's fall and injury.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Timely Pain Medication to Newly Admitted Resident
Penalty
Summary
A newly admitted resident with a history of osteoarthritis and recent right hip joint replacement surgery did not receive prescribed pain medications as ordered upon admission. The resident's care plan identified a risk for pain related to osteoarthritis and reverse total hip arthroplasty, with physician orders for Hydrocodone-Acetaminophen and Tramadol to be administered every six hours as needed for pain. However, medication administration records and controlled substance logs show that neither medication was given on the evening of admission, and the first documented administration occurred the following morning. Interviews with facility staff revealed that the pain medications were not available when needed, with an LPN stating that the pharmacy delivery was late and that only certain staff had access to the medication distribution machine. The resident reported experiencing significant pain and poor sleep due to the lack of timely pain management. The Director of Nursing confirmed that newly admitted residents are expected to receive their medications on time and that staff have the ability to access medications from the distribution machine. The facility's pain management program emphasizes effective pain control to promote healing and wellness, but this was not achieved in this instance.
Failure to Provide Timely Medication on Admission
Penalty
Summary
The facility failed to provide prescribed medications to a newly admitted resident with multiple medical conditions, including aftercare following joint replacement surgery, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and osteoarthritis. The resident was admitted with physician orders for several medications, including Apixaban for anticoagulation, Doxycycline for infection, and two pain medications (Hydrocodone-Acetaminophen and Tramadol). According to the Medication Administration Record, none of these medications were administered on the evening of admission. Interviews with staff revealed that the medications did not arrive at the facility until late, and only certain staff had access to the Medication Distribution Machine. The resident reported not receiving pain medication on the evening of admission, resulting in significant pain and poor sleep. The Director of Nursing confirmed that medications should be administered on time for new admissions and that staff have access to the medication machine. The facility's policy requires medications to be administered according to physician orders, including at the right time.
Failure to Notify Responsible Party of Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's responsible party of an injury sustained by a resident with severe dementia, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, suffered a hand injury after getting her finger caught in a door. Documentation showed that the CNA reported the incident to the nurse, and the nurse documented that the Power of Attorney (POA) and physician were updated. However, interviews revealed that the resident's private caretaker discovered the injury the following day and was told by staff that they were unaware of the incident. The caretaker later learned from an evening shift CNA about the incident and subsequently informed the resident's daughter/POA, who had not been notified by the facility. Further investigation found that the POA/daughter only learned of the injury through the private caretaker and not from facility staff. When questioned, the Director of Nursing (DON) confirmed that the night nurse did not complete an incident report and admitted to not calling the POA, despite charting that the call was made. The facility's policy requires that incident/accident reports be completed for all injuries and that the physician and legal representative or interested family member be notified within 24 hours. The administrator confirmed that nurses are expected to complete incident reports and notify the POA when a resident sustains an injury, but this protocol was not followed in this case.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific details regarding the actions or inactions of staff, or the condition of residents at the time, are not provided in the report. No further information about the individuals involved or the exact nature of the hazards is included.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
A deficiency was identified when a resident was observed in the dining room seated in a wheelchair that had dried debris on the edges of the seat, wheels, and frame. The resident reported that staff are supposed to clean her wheelchair once a month but was unsure if this was being done. Review of the resident's Minimum Data Set indicated she was cognitively intact. Facility policy requires that wheelchairs and other medical equipment be cleaned and sanitized weekly or more often if needed, when used by the same resident. The presence of debris and uncertainty about cleaning frequency demonstrate that the facility failed to ensure the resident's wheelchair was maintained in a clean condition, as required by policy.
Failure to Implement Fall Prevention Interventions and Supervision
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for a resident with dementia, a history of falls, and chronic kidney disease. The resident was dependent on staff for transfers and used a wheelchair for mobility. The care plan specified that the resident's reclining wheelchair should be locked and tilted back when not eating, and that reminder signs should be in place to ensure these interventions were followed. Despite these measures, the resident experienced a fall in the dining area after pushing herself away from the table, resulting in a head laceration and pain, and required transfer to the emergency room for evaluation. Family interview and record review indicated ongoing concerns about inadequate supervision in the dining area, with insufficient CNA or nurse presence and reliance on dining staff. Documentation revealed that at the time of the fall, only one wheel of the wheelchair was locked, and the resident was able to push herself away from the table, leading to the incident. The facility's fall prevention policy required individualized interventions and supervision, but these were not effectively implemented for this resident, resulting in the fall and injury.
Failure to Monitor and Address Enteral Nutrition Intolerance and Weight Loss
Penalty
Summary
A resident with a history of esophageal laceration, gastrostomy status, and other complex medical conditions was admitted to the facility and required enteral nutrition via G-tube. The facility failed to consistently monitor the resident’s weight, with only two documented weights taken over a six-week period, despite policy requiring weekly weights for new admissions. During this time, the resident experienced a significant weight loss of 24.8 pounds, equating to an 11.98% loss, which was not promptly identified or addressed by staff. The resident repeatedly reported intolerance to the prescribed enteral nutrition, including symptoms of nausea, diarrhea, and dizziness, leading to frequent refusals of tube feedings. Although the dietitian and medical providers were intermittently notified of these issues, there was a lack of timely and coordinated reassessment of the resident’s nutritional needs. Communication breakdowns occurred between nursing staff and the dietitian, with messages not being received or acted upon, and the dietitian was unaware of key changes such as the discontinuation of supplements and the resident’s significant weight loss until weeks after they occurred. Additionally, there was confusion and lack of documentation regarding dietary orders, with discrepancies between physician orders for a full liquid diet and the facility’s implementation of a clear liquid diet. The resident reported receiving only minimal nutrition, such as broth and a protein supplement, and expressed that her concerns were not being addressed. The facility’s policies for monitoring significant weight changes and ensuring dietitian involvement for high-risk residents were not followed, resulting in the failure to provide adequate nutrition and prevent further weight loss.
Failure to Provide Adequate Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews involving four residents. One resident with a history of acute osteomyelitis, diabetes, chronic kidney disease, and recent partial foot amputation reported waiting 20 to 40 minutes for call lights to be answered, especially when needing assistance with transfers and toileting. The resident and her spouse stated that dirty laundry remained in the room for days, and showers were missed or delayed due to inadequate CNA staffing. Documentation confirmed infrequent showers, and the resident reported ceasing to request help due to long wait times. Another resident, dependent on staff for toileting following a recent shoulder replacement, described waiting 15 to 30 minutes for call lights to be answered and being left on a bedpan for extended periods. Direct observation by the surveyor confirmed a call light was left unanswered for 28 minutes. Staff interviews revealed that only one CNA was assigned to the unit, who was also responsible for meal tray delivery, leaving no one to answer call lights during meal service. Staff expressed confusion and concern about how to manage both responsibilities simultaneously. Additional residents, including one with quadriplegia and another dependent on staff for all ADLs, reported similar issues with delayed responses to call lights, missed showers, and being left on bedpans for prolonged periods. Staff interviews consistently indicated that recent staffing cuts by new facility ownership resulted in only one CNA per unit, increased workloads, and an inability to provide timely care. Staff and residents reported increased complaints, missed care tasks, and a decline in quality of care. Nursing staff also noted an increase in resident falls and pressure ulcers since the staffing reductions.
Failure to Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and provide a baseline care plan within 48 hours of admission for one resident. Specifically, a resident with multiple medical diagnoses, including laceration of the esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia, was admitted to the facility. Documentation showed that the resident was cognitively intact and dependent on staff for all activities of daily living (ADLs). Despite facility policy requiring the baseline care plan to be developed and provided to the resident or their representative within 48 hours of admission, the care plan was not given to the resident until 23 days after admission. During an interview, the resident confirmed that no staff had discussed the care plan, provided a copy, or invited her to a care plan meeting within the required timeframe. The facility's own records indicated that the baseline care plan was completed and provided to the resident and her Power of Attorney well after the 48-hour window. The Regional Nurse confirmed that the Social Service department is responsible for providing the baseline care plan within 48 hours, but acknowledged that this did not occur in this case.
Failure to Provide Regular Showers or Baths to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living (ADLs), specifically bathing or showering, received care according to their needs and facility policy. Three residents with significant medical conditions, including diabetes, chronic kidney disease, heart disease, and lymphedema, were identified as not receiving showers or baths as frequently as required. Documentation and resident interviews revealed that showers were missed or provided less than once per week, with some residents receiving only one shower in several weeks or none at all. One resident reported refusing a shower due to it being offered late in the evening, but was not offered another opportunity as expected. Another resident, dependent on staff for all ADLs, had not received a shower in over two weeks, and documentation confirmed the lack of regular bathing. Staff interviews indicated that insufficient staffing contributed to the inability to provide showers as scheduled, with CNAs reporting being overwhelmed and unable to complete all assigned showers. The facility's policy requires that residents be offered a shower, tub bath, or bed/sponge bath at least once per week or according to their preference, but records and staff statements confirmed that this standard was not met. The administrator acknowledged the lack of documentation for missed showers and confirmed that only the available records were provided.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, as evidenced by incomplete documentation of wound treatments, lack of weekly skin assessments, and failure to follow physician orders for pressure ulcer management. For one resident, the care plan identified a risk for skin breakdown due to impaired mobility and incontinence, with interventions such as weekly skin checks and administration of treatments as ordered. However, the Medication/Treatment Administration Records (MAR/TAR) showed multiple missed or undocumented wound care treatments on specified dates, and there was no evidence that weekly skin assessments were consistently performed. Another resident, who was readmitted without any pressure injuries and identified as high risk for pressure ulcer development, developed a facility-acquired unstageable/stage 4 pressure ulcer. Documentation revealed that skin assessments were not consistently completed, and the wound was only identified after a certified nursing assistant reported it to a nurse. Subsequent wound assessments and physician notes detailed the progression of the wound, including the presence of necrotic tissue, infection, and the need for surgical debridement. There were also discrepancies in documentation regarding antibiotic administration and wound cultures, as well as evidence that the resident did not consistently receive ordered wound care treatments. Interviews with facility staff indicated that staffing shortages and lack of management support contributed to missed wound care and declining wound conditions. The facility's own policies required licensed nurses to document medication and treatment administration, and to follow physician orders for wound care, but these procedures were not followed. The surveyor determined that these failures resulted in significant harm, including the development of a severe, infected pressure ulcer that required hospitalization.
Failure to Provide Required 8-Hour RN Coverage
Penalty
Summary
The facility failed to provide consecutive 8-hour Registered Nurse (RN) coverage within a 24-hour period on multiple dates in March 2025, as documented in the facility's schedule. This deficiency was identified through interview and record review, revealing that there was no RN present for a full 8-hour shift on specific dates, potentially affecting all 122 residents in the facility. The administrator confirmed ongoing staffing challenges and acknowledged the lack of required RN coverage during the cited periods.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the administrator for one resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident, who had multiple complex medical diagnoses including a stage 4 pressure ulcer, dementia, and a vertebral fracture, developed skin tears on her left upper arm and left hand during her stay. Family members reported that the resident stated a CNA was rough with her during a shower, which may have caused one of the skin tears. The skin tear was observed uncovered for several days before being dressed, and this was the third such injury since the resident's admission. Staff interviews revealed that the CNA and nurse on duty were either unaware of the injury or did not know its cause, and no incident report was completed at the time the injury was discovered. Further review showed that the facility had no documentation of the skin tear and only initiated an investigation after the surveyor requested it. The facility's policy requires that injuries of unknown source be reported to the administrator, documented, and investigated, with notification to the Department of Public Health. However, the initial report of the injury was not made until prompted by the surveyor, indicating a failure to follow established procedures for reporting and investigating injuries of unknown origin.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident developed multiple skin tears during her stay, including a 2x2 inch skin tear on her left upper arm and a quarter-sized skin tear on her left hand. Family members reported these injuries to staff, with the resident and her family indicating that the injuries may have occurred during transfers or showers, possibly due to rough handling by certified nurse assistants (CNAs). Despite these reports, there was no initial documentation or incident report completed for the skin tears, and staff members interviewed were either unaware of the injuries or did not know how they occurred. Nursing staff, including CNAs and LPNs, demonstrated a lack of awareness regarding the resident's injuries, with one CNA stating she informed a nurse who was unable to address the issue at the time, and the subsequent nurse was unaware of the injury. The facility's regional nurse consultant confirmed that there was no documentation of the skin tear and that an investigation would be initiated only after the surveyor's inquiry. The facility's policy requires that all injuries of unknown origin be reported, documented, and investigated, but this process was not followed in the case of this resident. The final abuse investigation report indicated that the skin tear was ultimately attributed to a CNA accidentally causing the injury during a transfer after a shower, but this was only determined after the fact and not at the time of the incident. The initial lack of documentation, failure to complete an incident report, and delayed investigation represent a failure to respond appropriately to an alleged violation and to follow the facility's own policies regarding injuries of unknown origin.
Failure to Investigate, Document, and Implement Interventions for Skin Tears and Falls
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For one resident with multiple diagnoses including stage 4 pressure ulcer, dementia, and a history of fractures, there were repeated incidents of skin tears during her stay. Family members reported that the resident sustained skin tears during care, including while being assisted with a shower and when a handrail was lowered onto her hand. Staff interviews revealed a lack of awareness about the injuries, and there was no documentation or incident report completed at the time of the injuries. The facility only initiated an investigation after the surveyor's inquiry, and the required assessments and documentation were not completed as per facility policy. Another resident with severe cognitive impairment and multiple comorbidities experienced several skin tears over a period of time. Progress notes documented new skin tears, but neither the resident nor staff could consistently identify the cause. Despite these incidents, the care plan was not updated with new interventions to prevent further skin tears, and the Director of Nursing confirmed that no additional interventions were added after the injuries occurred. A third resident, identified as high risk for falls due to a history of fractures and other medical conditions, experienced multiple falls within a short period. Documentation showed that the resident was found on the floor several times, sometimes with injuries such as a swollen and bruised ankle. Although the care plan included specific fall prevention interventions, direct observation revealed that these interventions, such as a motion alarm, non-slip pad, and signage, were not in place. Staff present in the room were unaware of the required fall precautions, and the Director of Nursing was uncertain about which interventions should be in use. Facility policies required prompt reporting, assessment, and implementation of interventions for skin conditions and falls, but these were not consistently followed.
Insufficient Nursing Staff Resulting in Delayed Care and Missed Treatments
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed and inadequate care. Certified Nurse's Assistants (CNAs) and residents reported that food was frequently served late and cold, with staff having to use microwaves to reheat meals due to insufficient staffing. Residents described long wait times for meals and care, with one resident stating that food was not hot and was served well after the scheduled time, and another resident reporting that it could take up to an hour to receive care or food. Staff confirmed ongoing staffing problems, noting that tasks took longer to complete and that there were not enough staff members to meet residents' needs in a timely manner. Additionally, documentation revealed that a resident with stage III pressure ulcers did not consistently receive prescribed wound care treatments, with several dates lacking evidence of treatment administration. An LPN reported that staffing shortages had worsened since a change in ownership, with management not assisting on the floor and wound care deteriorating as a result. The facility's Director of Nursing acknowledged the absence of a formal staffing policy, stating that they follow CMS guidelines. These findings collectively demonstrate a pattern of insufficient staffing leading to unmet resident needs and lapses in required care.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable and safe temperature for three out of five residents reviewed for food palatability. Residents reported that their meals were consistently served cold or lukewarm, with one resident stating that food was never hot and another noting that food was always cold and late. Observations confirmed that food temperatures on the steam table were within acceptable ranges prior to meal service, but by the time trays reached the residents, temperatures had dropped significantly below the facility's preferred standard of 120°F for palatability. A surveyor test tray measured food temperatures as low as 111.3°F for mashed potatoes and 116.3°F for carrots, and the food was described as cold when tasted. Staff interviews revealed that food was not temped after being placed on the steam table or upon arrival at the serving hall, and that complaints about cold food were frequent. A dietary aide/cook confirmed that food temperatures were only checked in the kitchen, not at the point of service. A CNA reported that food was often late and that staff frequently used microwaves to reheat meals for residents. The administrator acknowledged ongoing electrical problems with the steam table on the affected hall, which contributed to the issue. Facility policies required monitoring and documenting food temperatures at the point of service, but these procedures were not consistently followed.
Failure to Assess, Document, and Treat Pressure Ulcer on Admission
Penalty
Summary
The facility failed to properly assess and document a resident's skin condition upon admission, as well as to conduct and record weekly skin assessments as required. The resident was admitted with a diagnosis that included a stage 2 pressure ulcer, but there was no documentation of an admission skin assessment in the medical record, and the initial progress note referenced an admission assessment that could not be located. The CNA Skin Attention Form and the Director of Nursing's signature indicated awareness of the pressure ulcer, but the physician was not notified for treatment orders at the time of admission, and no pressure ulcer treatment was present on the physician's order sheet. Further review of the resident's records showed inconsistent documentation of weekly skin assessments, with some entries made in the Treatment Administration Record and others missing from the computer system. Staff interviews revealed that agency nurses sometimes skipped the admission assessment or documented it inconsistently, and there was confusion about where to record weekly skin assessments. The wound nurse and DON both described expectations for timely and thorough skin assessments, but these were not consistently met, and the wound nurse did not document or assess pressure ulcers after a facility-wide skin sweep. The facility's own policy required a skin assessment at admission, weekly licensed nurse assessments, and prompt physician notification and documentation when pressure ulcers are identified. Despite these requirements, the resident's pressure ulcer was not properly assessed, measured, or documented upon admission, and there was a delay in initiating appropriate treatment orders. The lack of consistent documentation and communication among staff contributed to the deficiency in pressure ulcer care and prevention.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple health conditions, including Type 2 Diabetes Mellitus, congestive heart failure, chronic kidney disease, and atrial fibrillation. The resident required substantial assistance with activities of daily living and was at risk for bleeding due to anticoagulant therapy. On February 26, 2025, a CNA discovered a hematoma with a skin tear on the resident's right inner knee while providing care. The CNA notified a nurse, who assessed the injury and noted the presence of the resident's family, who did not request hospital transfer at that time. However, the injury was not reported to the state agency, and no investigation was initiated to determine its cause. The Director of Nursing stated that unknown injuries should be entered into risk management for investigation, but this was not done in this case. The LPN involved was unable to document the injury in the system due to issues with accessing the new ownership's system. The facility's policy requires that injuries of unknown source be documented and reported to the state agency, but this protocol was not followed. The Director of Nursing did not complete an incident report or initiate an investigation, considering the injury a change of condition rather than an injury of unknown origin.
Staffing Deficiencies Lead to Delayed Care and Supervision
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of all 109 residents, leading to delays in care and supervision. Multiple residents reported long wait times for assistance, with one resident waiting over two hours for help to use the bathroom, resulting in distress and incontinence. Another resident's sister had to intervene personally after the resident was unable to get assistance with her catheter tubing, highlighting the lack of available staff to respond to call lights promptly. Observations during meal times revealed inadequate supervision in the dining areas, with no nursing staff present to oversee residents who required assistance. This lack of supervision was acknowledged by a registered nurse, who admitted that staffing issues were affecting the facility's ability to provide continuous care. The absence of staff in the main dining room left residents without necessary oversight during meals, which is critical for those with specific dietary needs and cognitive impairments. Interviews with staff members further confirmed the staffing challenges, with reports of insufficient aides to manage the workload, leading to rushed care and delayed responses to residents' needs. The Assistant Director of Nurses admitted to staffing according to state guidelines but noted difficulties in maintaining adequate staffing levels due to high call-off rates and reliance on agency staff, which was not always available. This situation resulted in non-direct care staff stepping in to assist, indicating a systemic issue with staffing that affected the quality of care provided to residents.
Lack of Resident Supervision and Safety Protocols
Penalty
Summary
The facility failed to educate residents on safety protocols and provide adequate supervision, leading to two significant deficiencies. In the first instance, a resident, identified as R2, left the facility without notifying staff. R2, who is moderately cognitively impaired and requires partial assistance with mobility, called a cab and went to a department store to do banking. The staff was unaware of her departure until informed by her roommate. The facility's Director of Nurses confirmed that R2 was not considered at risk for elopement, and R2 herself stated she was unaware of the need to sign out or inform staff of her departure. In the second deficiency, the facility failed to provide adequate supervision during meal times. Observations revealed that the main dining room, where several residents with cognitive impairments and dietary needs were eating, lacked continuous supervision by nursing staff. The dining room was split into two areas, and staff were only present in the assisted dining room, leaving the main dining room unsupervised. This lack of supervision was acknowledged by a Registered Nurse, who cited staffing issues as a contributing factor. The residents involved in the dining room supervision deficiency had various medical conditions, including dysphagia, Alzheimer's disease, dementia, and diabetes, requiring specific dietary precautions and assistance. The facility's policy on assisted dining considerations did not document the necessity for nursing staff presence in the dining room, contributing to the oversight in supervision.
Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to respond to call lights in a timely manner, affecting the dignity and care of three residents. One resident reported waiting over an hour for assistance, leading to distress and crying due to the inability to access the bathroom. This resident, who is cognitively intact and dependent on staff for toileting, expressed concerns about potential staffing shortages. Another resident, also cognitively intact and reliant on staff for toileting, experienced delays in assistance, which led to her sister intervening after multiple failed attempts to contact the facility by phone. The sister eventually drove to the facility to assist her sibling. A third resident reported waiting up to two hours for bathroom assistance, resulting in incontinence and feelings of discomfort and indignity. This resident, who is usually continent, expressed frustration with the hurried manner of staff at night, leading her to avoid using the call light for assistance. The Resident Council Minutes indicated that staffing issues were acknowledged by the Director of Nurses, who mentioned a transition to a new company that would allow the use of agency CNAs and nurses. The facility's policy on the call light system mandates prompt responses, which was not adhered to in these instances.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, leading to feelings of humiliation and loss of dignity. Resident R58, who is cognitively intact and dependent on staff for all care due to Multiple Sclerosis and functional Quadriplegia, reported waiting up to an hour for assistance to use a bedpan, resulting in accidents and feelings of being less than a person. Similarly, Resident R102, who is also cognitively intact and dependent on staff for transfers and toileting hygiene, experienced a delay in being taken to the bathroom, leading to an accident and feelings of humiliation. The incident was documented in a nurse's note, highlighting the staff's delay in responding to the resident's needs. Resident R17, who is continent but dependent on staff for toileting and transfers, also reported waiting an hour for assistance, resulting in accidents and feelings of distress. The Resident Council Minutes from previous months documented ongoing complaints about long wait times for call light responses, indicating a pattern of inadequate response times by the facility's staff. These deficiencies in timely response to call lights compromised the residents' dignity and quality of life, as outlined in the Illinois Long Term Care Ombudsman Program Resident Rights.
Failure to Prevent and Monitor Weight Loss in Residents
Penalty
Summary
The facility failed to implement necessary interventions to prevent and monitor weight loss for two residents, resulting in significant weight loss for both. Resident 7, who has a diagnosis of dementia and is severely cognitively impaired, was observed during a meal without receiving assistance or encouragement to eat. Despite a dietary note indicating a weight warning and the need for encouragement and monitoring, Resident 7 experienced a weight loss of 9.5% over three months. The resident's meal intake records showed consistently low consumption, with many meals documented as 0-25% consumed. Resident 46, also severely cognitively impaired and on hospice care, experienced a weight loss of 11.94% from July to September. The resident's care plan noted nutritional risk and interventions such as fortified juice and encouragement to eat, but the facility's records did not document any additional dietary orders. The Director of Nurses acknowledged that interventions should have been in place to minimize weight loss, even for a hospice patient. The facility lacked a feeding assistance policy, and staff were not consistently providing necessary assistance to residents who required help with eating.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage, labeling, and hygiene practices, which could potentially affect all 116 residents. During an inspection, it was observed that various food items in the kitchen's stand-up refrigerators were not labeled or dated, including spaghetti and meat sauce, cheese sandwiches, cooked chicken breast, shredded vegetables, pies, shredded lettuce, shredded cheese, and red sauce. Additionally, some food items were found with outdated labels, such as cooked hamburger patties dated 9/15/24, tuna salad dated 9/16/24, and chicken breast dated 9/12/24. Personal beverages were also found in the refrigerators, which is against the facility's policy. The Dietary Manager acknowledged that food should be labeled, dated, and properly sealed, and that employees should not have personal drinks in the refrigerators. Furthermore, the facility's staff failed to follow proper hand hygiene and glove use policies during food service. A Dietary Aide was observed using bare hands to serve a roll from the steam table, and a Certified Nurses Aide (CNA) was seen peeling and feeding an orange to a resident without performing hand hygiene between assisting different residents. Another CNA was observed handling a roll with bare hands while serving a meal to a resident. These actions are in violation of the facility's policy, which mandates no bare hand contact with ready-to-eat food items. The facility's policies on food storage and hand hygiene were not followed, contributing to the deficiency.
Failure to Assist Residents with Dining Needs
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and feeding for five residents who required help with activities of daily living (ADL). Resident 43, who is moderately cognitively impaired and requires supervision while eating, was observed eating with her thumb and flinging food without receiving any staff assistance or redirection. Despite her care plan indicating the need for monitoring and intervention due to behavior problems related to dementia, no staff were present to assist her during the meal. Similarly, residents 46, 60, 7, and 8, all of whom have varying degrees of cognitive impairment and require assistance with dining, were not provided with the necessary help during meals. These residents were not assisted with cutting their food, encouraged to eat, or offered alternative food options. As a result, they consumed little to no food during the observed meals. The facility lacks a feeding assistance policy, as confirmed by the administrator, which contributed to the lack of support provided to these residents.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of staff not wearing appropriate Personal Protective Equipment (PPE) and neglecting hand hygiene practices. For instance, a Certified Nurse Aide (CNA) assisted a resident, R100, with a transfer and clothing change while only wearing gloves, despite the resident being on Enhanced Barrier Precautions due to a dialysis shunt. The CNA did not perform hand hygiene between glove changes, which is a requirement when providing care under such precautions. Another incident involved two CNAs providing catheter care to a resident, R67, who was also under Enhanced Barrier Precautions due to a urinary tract infection and other conditions. The CNAs failed to wear gowns during the procedure, contrary to the facility's documented requirements for high-contact resident care activities. Additionally, a CNA was observed assisting a resident, R43, with eating without performing hand hygiene between assisting different residents, which is a breach of infection control protocols. Further observations included a CNA passing meal trays to multiple residents without performing hand hygiene between each interaction, and another instance where CNAs donned gloves without hand hygiene before and after changing a resident's incontinent brief. These actions were in direct violation of the facility's hand hygiene and infection control policies, which emphasize the necessity of handwashing before and after glove use and between resident interactions to prevent cross-contamination.
Failure to Provide SNF/ABN Forms to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) form CMS 1055 to residents prior to the termination of Medicare Part A services. This deficiency was identified for two residents, R106 and R315, out of a sample of 51 residents reviewed for Medicare Part A services. R106 was admitted with diagnoses including an unspecified fracture of T9-T10 vertebra, chronic kidney disease, syncope, collapse, and repeated falls. R106's Medicare Part A services began on June 24, 2024, and ended on August 5, 2024, with benefit days remaining, yet the SNF/ABN form was not provided. Similarly, R315, admitted with bilateral primary osteoarthritis of the hip, radiculopathy of the lumbar region, repeated falls, and spinal stenosis, had Medicare Part A services from July 1, 2024, to August 16, 2024, also with benefit days remaining, but did not receive the SNF/ABN form. Interviews revealed that V28, a social services staff member, did not complete the Advanced Beneficiary Notice (ABN) forms due to a lack of training, having started employment at the facility on June 28, 2024. The Director of Nursing (DON), V2, expressed an expectation that the facility should complete ABNs. The facility's undated training notes indicated that Medicare requires notices to be sent to beneficiaries when Medicare services are ending.
Incomplete Incontinent Care for Two Residents
Penalty
Summary
The facility failed to provide complete incontinent care for two residents, R6 and R45, as observed during a survey. For R6, a CNA cleansed the resident's left buttock, inner thigh, and peri-rectal area with wet cleansing wipes but did not dry these areas. Additionally, the CNA did not cleanse R6's left hip, buttock, or back of the left thigh before putting on a clean incontinent brief. R6's care plan required maintaining clean and dry skin and providing incontinence care with each episode. R6 had a history of urinary tract infections, dementia, and anxiety, and was always incontinent of bowel and bladder, requiring staff assistance for personal hygiene. Similarly, for R45, a CNA cleansed the resident's left groin, right groin, and penis with a cleansing wipe but did not dry these areas. The CNA also applied antifungal powder to the buttocks and rectal area without drying them first. R45's care plan also required maintaining clean and dry skin and providing pericare after each incontinent episode. R45 had diagnoses of Alzheimer's, dementia, and Parkinson's disease, and was always incontinent of bowel and bladder, requiring staff assistance for personal hygiene. Interviews with CNAs and the Director of Nurses confirmed that all areas should be cleansed and dried during incontinent care, as per the facility's policy.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for a resident reviewed for medication review. The resident, who was admitted with diagnoses of Parkinson's Disease, Depression, Dementia, and Anxiety, had pharmacy recommendations dated June and July 2024 regarding dose reduction attempts for clonazepam and quetiapine. These recommendations were not reviewed and signed by the Medical Director until September 25, 2024. The Director of Nurses stated that the previous Director had not kept up with the pharmacy recommendations, leading to delays in addressing them. The current Director of Nurses had to resend the recommendations to the Medical Director, who had not responded despite multiple requests. The facility's Pharmacy Consultant Policy did not address physician replies to pharmacy recommendations.
Failure in Antibiotic Stewardship and Culture Review
Penalty
Summary
The facility failed to properly review and act upon culture results for a resident, leading to inappropriate antibiotic use. A resident with a history of urinary tract infection, chronic kidney disease, and other conditions was admitted with severe cognitive impairment and required full assistance for personal care. Despite a recommendation for a wound culture, the facility placed the resident on Tetracycline without completing the necessary cultures. Additionally, a urine culture indicated that the bacteria present were not indicative of a urinary tract infection, yet the resident was subsequently placed on Cephalexin for a UTI without a repeat culture being conducted. Interviews with facility staff revealed a lack of communication and follow-up regarding culture results. The Assistant Director of Nursing admitted that the facility often does not receive or request culture and sensitivity results from hospitals when residents return on antibiotics. The Infection Preventionist was unaware of why the resident continued on antibiotics despite negative culture results and acknowledged that the wound care nurse did not complete the recommended wound cultures. The facility's Infection Prevention and Control Manual emphasizes the importance of antibiotic stewardship, yet these protocols were not followed in this case.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of the residents reviewed for call lights. On two separate occasions, the call light for this resident was observed lying on the floor at the head of the bed, out of the resident's reach. The resident's care plan, dated June 30, 2023, indicated that the resident attempts to self-transfer and included an intervention to remind the resident to call for assistance when help is needed. The Executive Director confirmed that call lights should be within reach of residents. The facility's policy, revised in December 2011, states that staff will ensure the call light is within easy reach of the resident.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents who were cussing at each other. The incident was reported by CNAs to the LPN, who documented that one resident often made verbal threats and abusive statements towards her roommate. Despite being informed of the situation, the administrator did not consider it as verbal abuse, viewing it instead as a behavioral issue and customer service matter, since both residents were involved in the altercation. The resident involved in the incident, identified as having severe cognitive impairment and a diagnosis of unspecified dementia with behavioral disturbances, was dependent on staff for personal care. The other resident, who was cognitively intact, had a care plan indicating a potential for verbal abuse and aggression due to ineffective coping skills, anxiety disorder, and depression. The care plan included interventions such as administering medications, providing a calm environment, and assessing coping skills. Despite the care plan and the facility's policy on the prevention of abuse, neglect, and exploitation, the incident was not reported as abuse. The executive director later acknowledged that the allegations should have been reported. The facility's failure to recognize and report the verbal abuse incident led to a deficiency in ensuring the resident's protection from abuse.
Failure to Implement Abuse Policy for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement its abuse policy for a resident with severe cognitive impairment, identified as R4, who was dependent on staff for various personal care activities. The report highlights that the facility did not report an allegation of abuse involving R4, as required by their policy. The Executive Director acknowledged that the allegation should have been reported, indicating a lapse in following the established procedures for handling such incidents. The report also mentions another resident, R3, who was cognitively intact and had a care plan addressing potential verbally abusive behavior. R3 had requested a room change due to poor compatibility with a roommate, which was agreed upon by the social service director and administration. Despite this, the facility did not adhere to its policy of reporting and investigating suspected abuse, as the abuse prevention coordinator was not notified to begin an investigation or report the incident to the appropriate state agencies.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one of whom has severe cognitive impairment and is dependent on staff for personal care. The incident involved verbal abuse from a cognitively intact resident towards the cognitively impaired resident, with threats of physical harm. Despite being aware of the situation, the facility's staff, including the Administrator and Social Service Aide, did not report the incident as an abuse allegation, considering it a customer service issue instead. The incident was reported to the Licensed Practical Nurse (LPN) on duty by Certified Nursing Assistants (CNAs) who witnessed the verbal abuse. The Social Service Aide attempted to address the situation by suggesting a room change for the verbally abusive resident, but the resident declined the offered room. The Administrator was informed but did not take further action to report the incident as abuse, and no written statements were collected from the staff involved until much later. The facility's policy requires that incidents of suspected or witnessed abuse be reported to the abuse prevention coordinator, who is responsible for initiating an investigation and reporting to state agencies. However, this procedure was not followed, as confirmed by the Executive Director, who acknowledged that the allegation should have been reported. The lack of timely reporting and investigation of the abuse allegation constitutes a deficiency in the facility's adherence to its abuse prevention policy.
Failure to Investigate Allegation of Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents, one of whom has severe cognitive impairment and is dependent on staff for various activities of daily living. The incident involved verbal altercations between the two residents, with one resident reportedly using abusive language and making threats towards the other. Despite being informed of the situation, the facility's administrator did not consider it an abuse allegation and treated it as a customer service issue, failing to conduct a thorough investigation or report the incident as required by the facility's policy. The administrator was made aware of the verbal abuse but did not interview the cognitively impaired resident, as she was asleep at the time. Instead, the administrator spoke with the other resident and some staff members, concluding that the incident was mutual and not a case of abuse. The administrator's decision was based on the belief that there was no clear victim or perpetrator, despite staff reports indicating that one resident was verbally abusive and had made threats. The facility's policy mandates that all allegations of resident abuse be fully investigated, including interviews with staff and residents, record reviews, and collaboration with appropriate agencies. However, the administrator did not follow these procedures, and the incident was not documented in writing. The executive director later acknowledged that the allegation should have been reported, indicating a failure to adhere to the facility's policies and procedures regarding abuse investigations.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically involving the wrongful use of a Lidocaine patch. During a medication pass, an LPN dropped a resident's Lidocaine patch on the floor and discarded it. Instead of following proper procedures, the LPN borrowed a Lidocaine patch from another resident to administer to the first resident. The LPN admitted to occasionally borrowing medications between residents when supplies run out, attributing this practice to floating staff not reordering medications. The Director of Nursing (DON) stated that the facility's policy prohibits borrowing medications between residents and that medications are prepackaged by the pharmacy. The DON emphasized that if a medication is wasted, it should be replaced from the same resident's supply, and the pharmacy should be notified to send a replacement. The facility's policies clearly state that medications supplied for one resident should never be administered to another, and any misappropriation of resident property is against the facility's policy.
Medication Administration Deficiency Due to Lack of Verification
Penalty
Summary
The facility failed to adhere to Nursing Standards of Practice during medication administration for three residents. An LPN was observed administering medications without verifying them against the electronic medication administration record (e-MAR). The LPN relied on memory and prepackaged medication pouches, which were not cross-checked with the e-MAR, leading to potential medication errors. The LPN admitted to not reporting issues with the computer system and working long shifts, which may have contributed to the oversight. During the medication pass, the LPN administered medications to three residents without verifying the medications against their e-MARs. For one resident, the LPN administered a full tablet of Clonazepam instead of the prescribed half tablet, as the order had been changed following the resident's hospital stay. The LPN was unaware of the change and continued to administer the incorrect dosage, as the medication card was not updated with a change of dose sticker. The resident confirmed receiving the incorrect dosage for an extended period. The Director of Nursing (DON) confirmed that the facility's medication pass policy was not followed, as the LPN did not verify medications against the e-MAR. The facility's policy requires a triple check of the five rights of medication administration, which was not adhered to in this instance. The DON acknowledged the error and noted that the medication error report had been completed regarding the Clonazepam dosage discrepancy.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the current staffing record was posted daily, as required by federal regulations. On two separate occasions, surveyors observed that the Report of Nursing Staff directly responsible for resident care was either outdated or not posted at all. On May 20, 2024, the posted report was dated April 26, 2024, and included a disclaimer from March 29, 2024, indicating non-compliance with federal staffing guidelines. On May 21, 2024, the report was not posted at all. The facility's administrator acknowledged the oversight and mentioned efforts to rectify the situation. The facility's policy mandates that staffing information, including the current date and census, be posted daily in a prominent location, but this was not adhered to, potentially affecting all 117 residents in the facility.
Failure to Provide Timely Assistance and Maintain Dignity
Penalty
Summary
The facility failed to honor residents' rights and dignity by not providing timely assistance to prevent incontinence and by leaving residents in soiled linens. This deficiency was observed in four out of five residents reviewed for dignity. One resident, who is cognitively intact and requires substantial assistance with toileting, reported waiting over 20 minutes for help after activating the call light. The resident was found with feces on her gown and soiled adult briefs. Another resident with Multiple Sclerosis reported a similar delay, resulting in a bowel movement that soiled her clothing and bed. A third resident, also cognitively intact, expressed frustration over long wait times for assistance with toileting, leading to occasional incontinence. Additionally, a resident's advocate reported multiple instances where the resident's bed was made with soiled linens, which the facility initially dismissed as stains. However, the advocate provided photographic evidence and noted a strong odor, contradicting the facility's claim. The facility's grievance log confirmed a complaint regarding soiled linens. The facility's policies on call light response and resident rights emphasize prompt assistance and maintaining a clean, dignified environment, which were not adhered to in these cases.
Inadequate Staffing Leads to Delayed Care and Unsafe Transfers
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of residents, resulting in delayed responses to call lights and insufficient assistance for transfers. One resident, who is cognitively intact and requires substantial assistance with toileting, reported waiting over 20 minutes for help, leading to soiling of clothes. This resident's care plan did not adequately address bowel incontinence, and the lack of timely assistance was observed when two CNAs delayed attending to the resident due to needing a gait belt. Another resident with Multiple Sclerosis, who requires a mechanical lift and assistance from two staff members for transfers, reported waiting four hours for medication and experiencing a fall due to insufficient staffing. The resident's care plan highlighted a history of legs giving out during transfers, yet the facility failed to provide the necessary staff to ensure safe transfers, resulting in a fall and subsequent bruising. Additional residents reported similar issues, including long waits for necessary treatments and assistance, with one resident waiting from early morning until late morning for a breathing treatment. Staff interviews confirmed the lack of adequate staffing, with reports of only one CNA available on certain shifts, contrary to the facility's policy requiring two staff members for mechanical lift transfers. The facility's policies on staffing and call light response were not adhered to, contributing to the deficiencies observed.
Failure to Follow Mechanical Lift Policy Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to adhere to its mechanical lift policy, which requires the assistance of two staff members during transfers, resulting in safety concerns for two residents. One resident, diagnosed with Multiple Sclerosis and cognitively intact, reported that only one staff member was present during transfers, contrary to the care plan that specified assistance from two staff members. This resident experienced a fall while using the sit-to-stand lift, which was attributed to improper positioning of the wheelchair footrest. The incident was documented in the facility's log, and the root cause was identified as the failure to adjust the footrest. Another resident, also cognitively intact, expressed concerns about insufficient staffing, leading to delays in assistance for bathroom transfers using the sit-to-stand lift. This resident reported that typically only one staff member was available, despite the facility's policy requiring two. The facility's mechanical lift transfer policy, dated December 2019, clearly states the necessity of two staff members for such transfers and the importance of ensuring wheelchair leg supports are out of the way before initiating a transfer.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to adequately prevent and manage pressure ulcers for two residents, R2 and R3, resulting in the development of facility-acquired pressure ulcers. R2, who was admitted with a left femur fracture and was at high risk for pressure ulcers, developed a Stage 3 pressure ulcer on the left heel and a deep tissue injury on the right heel. Despite physician orders for a specialized turning schedule and the use of prevalon boots, R2 was observed sitting in a wheelchair for extended periods without repositioning or offloading pressure. The care plan did not address the current pressure ulcers, and there was no documentation of education provided to R2 or his wife regarding pressure relief measures. R3, admitted with a history of pacemaker placement, diabetes, and atrial fibrillation, was also at risk for pressure ulcers. R3 developed deep tissue injuries on both heels and a Stage 3 pressure ulcer on the left buttock. Despite being dependent on staff for mobility and frequently incontinent, R3 was not repositioned adequately, as observed during a period where R3 remained in bed without repositioning. The facility failed to document the initial measurement of R3's right heel pressure ulcer and the development timeline of the buttock ulcer. Additionally, there was a lack of documentation regarding the education provided to R3 and her family about wound care interventions. The facility's pressure ulcer policy did not provide guidance on treating actual pressure ulcers, contributing to the inadequate care provided to R2 and R3. The Director of Nursing acknowledged the lack of documentation and the need for proper measurement and documentation of pressure ulcers. The facility's failure to implement and document appropriate interventions and education for pressure ulcer prevention and management led to the development and worsening of pressure ulcers in both residents.
Inadequate Incontinent Care for Two Residents
Penalty
Summary
The facility failed to provide complete incontinent care for two residents, R1 and R3, who were reviewed for bowel and bladder incontinence. R1, who was admitted with a broken ankle and weakness, was cognitively intact and required substantial assistance for mobility and toileting. During an observation, a CNA was seen providing inadequate cleansing after removing R1's soiled incontinent brief. The CNA used only one pre-moistened periwash cloth to wipe down the labia and another to wipe the buttocks in circles, failing to cleanse the entire area properly. Similarly, R3, who was admitted for aftercare following pacemaker placement and had diagnoses of Diabetes Mellitus and Atrial Fibrillation, was frequently incontinent of bowel and bladder. During care, CNAs were observed inadequately cleaning R3 after removing a pad full of liquid stool. The CNAs wiped the labia once and did not cleanse the periarea thoroughly. The Director of Nurses later stated that staff are expected to cleanse all soiled skin during incontinent care, indicating a failure to meet this standard.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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