Arcadia Care Kewanee
Inspection history, citations, penalties and survey trends for this long-term care facility in Kewanee, Illinois.
- Location
- 144 Junior Avenue, Kewanee, Illinois 61443
- CMS Provider Number
- 145968
- Inspections on file
- 37
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Arcadia Care Kewanee during CMS and state inspections, most recent first.
Surveyors identified that staff failed to accurately document and account for controlled substances, including missing signatures on shift-change narcotic counts, pre-signing controlled medications before administration, and unresolved discrepancies in liquid morphine volumes and records. An LPN did not sign the narcotic count at shift change as required, another LPN pre-signed hydrocodone/APAP and pregabalin doses before actually giving them, and a resident’s liquid morphine record showed inconsistent volumes, missing MAR entries, and a count correction without documented administration. Leadership acknowledged that controlled substance records and MARs are required to match and that staff are not permitted to pre-sign medications.
A resident with morbid obesity and depression, who required a WC for mobility and staff assistance for transfers and showers, was not provided with an appropriately sized WC or safe shower equipment. Despite care plan goals for the resident to get out of bed and socialize, records showed only one shower over several weeks and no documented WC assessment by therapy or nursing. The administrator and ADON confirmed that two bariatric WCs obtained did not fit, no additional WC was secured, and no suitable shower chair was available. CNAs reported the resident could not access the shower room, was bathed in bed, and had to sit on the side of the bed to eat, and observation showed the resident could not sit safely or comfortably in the available bariatric WC.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage each day and did not employ a full-time DON. The Administrator confirmed multiple days with no RN coverage and reported ongoing difficulty securing RNs, noting that the company prohibited use of agency RNs. A Regional Nurse functioned as an interim DON but was only physically present one to two times per week, as shown on a work log, while reviewing 24-hour nursing reports remotely. At the time of the survey, 53 residents lived in the facility.
Surveyors found that dietary staff failed to follow facility policies for labeling, dating, and discarding food, as well as for cleaning and maintaining kitchen cabinets and equipment. Open and undated food items were observed in the refrigerator, freezer, and dry storage, including sliced meats, cheese, scrambled egg mix, bread, stuffing mix, and various condiments and sauces, along with several items that were past their expiration dates. Clean dishes were stored in a cabinet without a door that contained debris and loose wood pieces, and other cabinets were in disrepair with visible dirt and food debris. The dietary aide and dietary manager confirmed these conditions and acknowledged that foods should be labeled, dated, and discarded when expired, and that cabinets should be kept clean and in good repair, affecting all 53 residents receiving meals from this kitchen.
Surveyors found that the facility failed to follow its own COVID-19 vaccination guidelines for staff by not maintaining required documentation of employee vaccine education, vaccination status, and refusals. The Infection Preventionist reported there was no log of which employees had received or refused the COVID-19 vaccine, and the Administrator confirmed that the facility did not use refusal forms or track education provided to new employees who declined vaccination, despite policies requiring this documentation for all staff while 53 residents were in care.
The facility failed to ensure that multiple residents’ POLST orders for scope of treatment were accurately reflected in their EMR face sheets, physician order sheets, and care plans. For several residents, documentation listed only DNR status, while their signed POLST forms included additional directives such as selective or limited additional interventions, use of CPAP/BiPAP, IV fluids, antibiotics, vasopressors, antiarrhythmics, cardiac monitoring, hospital transfer parameters, and a time-limited trial of tube feeding. These detailed treatment preferences were not incorporated into the care plans or EMR, even though an LPN reported relying on the EMR status board to determine code status in emergencies, and facility leadership acknowledged that POLST instructions should match and be reflected in the medical record and care plans.
The facility did not ensure that bedtime snacks were consistently offered and documented for multiple residents, despite a policy requiring provision of bedtime snacks and/or fluids before sleep. Residents reported that staff did not routinely come around to offer snacks, with some stating they had to request snacks and that staff sometimes forgot to bring them, while others were unaware they could request snacks but wanted them offered. The Dietary Manager indicated that dietary staff only delivered a sealed snack box to the nurses’ station each evening, and the Interim DON stated CNAs were responsible for offering snacks to appropriate residents but acknowledged there was no documentation that these residents received bedtime snacks.
A resident who was cognitively intact and at moderate risk for pressure ulcers used a CPAP device and developed a painful, bright red, dime-sized area on the bridge of the nose that the resident reported had been present for over a week and had been reported to staff. The only action taken, per the resident, was application of a bandage, and the area was attributed by the resident to CPAP mask pressure without a cushion. Facility policy required regular skin assessments, daily observation for skin breakdown, and prompt documentation and assessment of any pressure injuries, but the admission and subsequent skin assessments did not note this area, the EMR contained no documentation of the nasal wound or bandage, and the ADON, though having seen a bandage previously, was unaware an ulcer had developed.
A resident with Type 2 DM and long-term insulin use was admitted with physician orders and a hospital discharge list specifying 30 units of Insulin Aspart after meals, including an evening dose that had been missed in the hospital, as well as bedtime blood glucose monitoring. Facility policy required medications to be administered per physician orders and documented on the eMAR. The resident reported that her medications and scheduled insulin were not available on admission and that it took two days before she received them. Review of the eMAR showed no documentation that the ordered evening insulin dose or bedtime blood sugar check were provided on the admission date, and the ADON confirmed that these evening and bedtime medications, including the 30 units of Insulin Aspart, were not administered.
Surveyors found that a resident was receiving risperidone without a documented psychosis diagnosis, identified target behaviors, or a care plan addressing antipsychotic use, despite facility policy requiring these elements for psychotropic medications. The physician’s order linked risperidone to vascular dementia with behavioral disturbance, but staff, including CNAs and an LPN, described the resident as generally pleasant, non-aggressive, and mainly impatient with frequent call light use and occasional yelling for help. The interim DON acknowledged that the record lacked a psychosis diagnosis, behavior tracking, and a care plan related to the antipsychotic, and could not provide evidence to justify the medication.
A resident with documented diagnoses of Bipolar Disorder, MDD, and ADHD was admitted with these conditions present, but the Level I PASRR screening incorrectly indicated that no mental health diagnosis was known or suspected and that no Level II PASRR was required. The staff member responsible for PASRR review at the time of admission did not ensure the resident’s mental illness diagnoses were reflected on the Level I screen, and an LPN/MDS coordinator later confirmed that no Level II PASRR had ever been completed for this resident.
A resident receiving PRN O2 via nasal cannula at 2–4 L had in-use O2 tubing and a humidifier bottle that were not changed and dated weekly as required by facility policy and physician orders. On multiple observations, the nasal cannula tubing remained dated from a prior week and the humidifier bottle in use had no date, while humidified O2 was being administered. The interim DON acknowledged that O2 tubing and humidifiers are supposed to be changed weekly, typically on Sunday nights, and could not explain why this resident’s equipment had not been changed.
The facility did not ensure that multiple-occupancy rooms met the minimum 80 square feet per resident requirement, despite housing two residents in several rooms identified as undersized. A CMS census form documented the total number of residents, and a state health department letter granted a waiver for specific rooms, subject to annual review. The administrator acknowledged that certain rooms were below the required size, provided a floor plan listing these rooms, and stated that the waiver is submitted annually while confirming that two residents are placed in these waived rooms and that any resident may be assigned there with a roommate.
A resident with multiple neurological and metabolic diagnoses was not provided with the prescribed carbohydrate-controlled, low concentrated sweet (LCS) diet, as he was served apple juice instead of a sugar-free beverage. Staff interviews revealed confusion about dietary orders, and the dietary manager confirmed the error, noting that the resident's care plan and physician orders required strict adherence to a carb-controlled, no added sweets diet.
A facility failed to label and date a multidose insulin pen and a tuberculin vial, as observed by an LPN during a survey. The insulin pen, used for a resident's daily insulin administration, and the tuberculin vial, used for any resident, were both found without open date labels. The Director of Nursing confirmed that these items should have been labeled according to the facility's policy and manufacturer guidelines.
A facility failed to conduct a PASARR Level II evaluation for a resident who developed new severe mental illness diagnoses after admission. Initially admitted with depression, the resident later received diagnoses including bipolar disorder and vascular dementia with severe psychotic disturbance. Despite these changes, the facility did not perform the necessary PASARR re-screening or Level II evaluation, as confirmed by an LPN who was unaware of the requirement.
A facility failed to follow hand hygiene protocols during catheter care for a resident with an indwelling urinary catheter. Two CNAs assisted the resident to bed and removed clothing with gloved hands. One CNA changed gloves without washing or sanitizing hands and performed catheter care. The lapse was confirmed by the CNAs and the Assistant Director of Nursing/Infection Preventionist.
The facility failed to obtain physician orders and develop care plans for oxygen use for two residents. One resident was receiving oxygen at 4.5L without a physician order or care plan, while another was receiving oxygen at 4L despite an order for 2L. These actions did not comply with the facility's policies on medication administration and care planning.
The facility did not ensure rooms for multiple residents met the 80 square feet per resident requirement, affecting 31 rooms. A waiver was granted for specific rooms, allowing them to be smaller, subject to annual review. The administrator confirmed the deficiency and provided a floor plan highlighting the affected rooms.
The facility failed to provide timely access to personal funds for 18 residents, as required by its policy. Residents reported being unable to access their money due to the facility waiting on a corporate check, with no cash available since early December. The LPN managing the business office confirmed the issue, despite the administrator's denial of any hold on the resident trust.
The facility failed to notify the health care power of attorney for two residents of significant changes in their conditions. One resident with CHF was transferred to the ER and evaluated for hospice without notifying their power of attorney due to unreachable contact information. Another resident was transferred to the hospital for pneumonia and CHF exacerbation, but their power of attorney was not informed because the facility overlooked the contact information in the medical record.
A resident experienced a fall resulting in a wrist injury, but the facility failed to notify the physician and the resident's representative promptly. The incident was not reported by the CNA who found the resident on the floor, and the LPN did not communicate the injury to the necessary parties. The DON confirmed the lapse in notification, which is against the facility's policy.
The facility failed to complete physician-ordered treatments and monitoring for three residents with wounds. A resident with a left stump and buttock wounds had multiple missed treatments and infection monitoring. Another resident with Peripheral Vascular Disease had missed skin checks and wound care for a right ankle wound. A third resident with a history of pressure ulcers had missed daily skin checks. The DON confirmed the missing treatments, citing the use of agency nurses as a potential cause.
The facility failed to provide a varied activity program for its 43 residents due to the absence of an Activity Director since October 2023. The interim director, a CNA without formal training, only assisted occasionally, leading to repetitive activities and no weekend staff. Residents reported a lack of engagement, with some unable to participate in the limited activities offered.
The facility failed to employ a qualified Activity Director, impacting the activities program for 43 residents. The interim director, a CNA/Activity Aide, lacked formal training and certification, serving in the role for four months without meeting the facility's policy requirements. The facility has been without a certified Activity Director since late 2023.
The facility failed to verify the Nurse Aide Registry for five CNAs before hiring, potentially affecting all 43 residents. Due to staffing issues, the Administrator in Training had no documentation of registry checks prior to January 2024 and had to perform these checks retrospectively. Specific instances include CNAs hired between October 2023 and May 2024, with registry checks delayed by days to months.
The facility lacks sufficient qualified dietary staff, affecting all 43 residents. The Food Service Manager is not certified and lacks a nationally recognized certification in food service management. The facility does not employ a full-time dietician, relying on a dietician who visits twice a month.
The facility did not provide a posted alternatives or always available menu for residents during mealtimes, affecting all 43 residents. Only the main meal and one alternative, usually leftovers, were displayed. The Dietary Manager confirmed the absence of additional posted options, leaving residents unaware of available choices like cottage cheese, cold sandwiches, and soups.
The facility failed to serve palatable food at lunchtime, affecting all 43 residents. The meal included a pork fritter that was described by residents as overcooked, rubbery, tasteless, and difficult to chew. Observations confirmed these issues, and the Dietary Manager acknowledged receiving complaints, suggesting the cook may have overcooked the meat.
The facility failed to maintain a clean kitchen environment, lacking a cleaning schedule and dishwasher detergent. Observations revealed unclean ovens and an empty detergent container, confirmed by the Dietary Manager and Aide. This deficiency potentially affects all 43 residents, as meals are prepared in this kitchen.
The facility failed to monitor infections, identify necessary precautions, and provide PPE for staff. The DON and Infection Preventionist did not track infections, and multiple residents lacked PPE and disposal bins for infection control. Additionally, the supply room was inadequately stocked, with restricted access to necessary PPE, affecting all 43 residents.
The facility failed to implement its Antibiotic Stewardship Program, as neither the DON nor the Infection Preventionist tracked resident infections or used standards to define infections. The logs from January to May 2024 lacked documentation of infection signs, symptoms, and culture results, affecting all 43 residents.
A resident experienced a malfunctioning bathroom light that had been an issue for a couple of months. The light was dim and flickering, requiring multiple attempts to turn on. The maintenance staff was aware of the problem but had not yet repaired it, causing inconvenience to the resident.
A facility failed to report an injury of unknown origin for a resident to the state agency, as required by their Abuse Prevention Program. The Administrator in Training did not investigate the resident's injuries, which included purpura and a scratch, believing them to be non-concerning due to the resident's history of easy bruising. The resident's spouse expressed concerns about improper handling by aides and reported communication issues with the administrator.
A resident's injury of unknown origin was not investigated by the facility, violating their Abuse Prevention Program. The Administrator in Training dismissed the need for an investigation into the resident's arm injuries, despite previous similar incidents being investigated. The resident's spouse raised concerns about improper handling by aides, which were not addressed by the facility.
A facility failed to implement a restorative walking program for a resident recommended to participate in a walk-to-dine program to prevent functional decline. The resident was not observed walking with his walker, and he reported not walking due to insufficient assistance. The DON was unaware of the walking program, and a CNA noted the resident usually propels himself in a wheelchair and can walk with a walker in his room.
A resident with a history of urinary retention and sepsis was found with their catheter bag and tubing on the floor, contrary to facility policy and CDC guidelines. Despite being relatively independent, the resident's preference for a low bed may have contributed to this improper placement. Staff confirmed the catheter bag should not touch the floor, but the issue persisted.
A resident with COPD and acute respiratory failure was found to have oxygen therapy administered incorrectly, with undated tubing and equipment resting on the floor. The facility's policy requires weekly changes and proper documentation of oxygen equipment, which was not adhered to. Staff noted the resident often adjusted his oxygen flow independently.
The facility failed to use non-pharmacological interventions before administering psychotropic medications and did not identify target behaviors for two residents. One resident was given Seroquel without prior behavior tracking or documentation of non-pharmacological attempts. Another resident was on Quetiapine for psychotic disorder and dementia, but behavior monitoring showed no observed behaviors, and the consent form lacked a diagnosis or target behaviors. The DON admitted to not knowing the resident's behaviors, and a pharmacy report highlighted the need for updated records.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN administered incorrect dosages of Carbidopa-Levodopa and Gabapentin to two residents, affecting their treatment for Parkinson's Disease and polyneuropathy. The errors were due to a misunderstanding of the correct dosages, as confirmed by the Director of Nursing.
The facility failed to ensure rooms met the required 80 square feet per resident in multiple resident rooms, affecting 16 residents. The Minimum Data Set Coordinator confirmed the deficiency, and the facility submitted a waiver to the State Agency, but the Administrator in Training could not provide the date of the last submission.
Inaccurate Controlled Substance Documentation and Narcotic Count Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely documentation and accountability for controlled substances, including failure to follow its own narcotic counting and documentation policies. During review of the B/C hall Narcotic Book, the Shift Change Controlled Substance Inventory Sheet for a morning shift change was found to be signed only by the oncoming day nurse; the off‑going night LPN did not sign the form as required. The Assistant DON confirmed that both nurses are required to participate in the narcotic count and sign the sheet at shift change to verify the counts are correct. Further review of controlled substance documentation showed that an LPN pre‑signed controlled medications as if administered before actually giving them. For one resident’s hydrocodone/APAP (Norco), the Controlled Substance Proof of Use form was not in the narcotic book but on the nurse’s desk and showed the 11:00 a.m. dose of two tablets signed out, bringing the count to zero, even though the medication had not yet been given. For another resident’s pregabalin (Lyrica), the card contained 16 pills, but the Proof of Use form showed the 12:00 p.m. dose already signed out, reducing the documented count to 15. The LPN confirmed she had signed out these controlled medications ahead of time and acknowledged she knew this was not permitted. For a third resident receiving liquid morphine 100 mg/5 ml, there were multiple discrepancies between the amount documented on the Controlled Drug Receipt/Record/Disposition Form, the actual volume in the bottle, and the MAR and progress notes. At the time of reconciliation, the bottle contained 24 ml, while prior entries showed inconsistent volumes and missing or incorrect subtractions, including an instance where the documented remaining volume did not mathematically match the dose given and no explanation was recorded. Several doses were signed out on the controlled drug record on specific dates but were not documented as administered on the MAR, and in some cases there were no corresponding progress notes. A later “count correction” entry changed the documented volume from 25 ml to 24 ml without any recorded administration between those dates, and staff acknowledged they had attempted to clarify the amount in the bottle due to apparent subtraction errors. The Administrator and Assistant DON confirmed that the MAR and narcotic sheet should match for controlled medication administration and that these discrepancies should have been identified.
Failure to Provide Proper Wheelchair and Shower Equipment for Obese Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not providing an appropriately sized wheelchair and suitable shower equipment. The resident, who has morbid obesity and depression, was documented as cognitively intact, requiring a wheelchair for mobility, two staff for transfers, and one to two staff for showers. The resident’s care plan included a goal that she would not refuse to come out of her room, get out of bed, and socialize with others, and indicated she required staff assistance for showers. However, shower records showed she received only one shower over several weeks, and there was no documentation of a wheelchair assessment in the medical record or therapy notes. An OT treatment note did not include a wheelchair assessment, and the Interim DON confirmed there was no evidence of any such assessment to recommend a proper wheelchair or positioning. The resident reported that the facility did not have a wheelchair that fit her, leaving her confined to her room and mostly in bed, and that she had only been showered once since admission. She stated she brought a shower chair from home because the facility had no way to give her a shower, but staff told her it was not safe to use, and a scheduled shower was canceled because staff were too busy. The Administrator confirmed that two bariatric wheelchairs had been ordered and delivered but neither fit the resident comfortably, and no further wheelchairs had been obtained. The ADON stated the available wheelchair was too tall and uncomfortable, that the facility was limited in wheelchair sizes, and that they were unable to find a safe shower chair for the resident. CNAs confirmed the resident did not have a fitting wheelchair, could not go to the shower room, was bathed in bed, and sat on the side of the bed to eat. During observation, the resident was unable to sit safely and comfortably in the bariatric wheelchair, and the ADON verified it was not safe for her to sit in it alone. The ADON also confirmed that only one shower was documented for the resident and stated that if showers were not documented, they did not occur.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide RN services for at least eight consecutive hours daily, seven days a week, and failed to employ a full-time DON to oversee the nursing department. The facility’s Director of Nursing job description dated 7/2023 states that the DON is responsible for planning, organizing, developing, and directing the overall operation of the nursing department in accordance with applicable regulations to ensure quality care. The facility assessment dated 1/4/2026 documents that a DON is required to meet residents’ needs. A list titled “Days without RN coverage as of 1/5/26,” provided by the Administrator, showed there was no RN coverage on 12/10/25, 12/14/25, 12/25/25, 12/27/25, 12/28/25, and 1/2/26. The Administrator confirmed there was no RN coverage on those dates and acknowledged the requirement for a minimum of eight consecutive hours of RN coverage seven days a week, further stating that the facility was having difficulty obtaining RN coverage and that the company did not allow the use of agency RNs. The facility also did not have a full-time DON. The Administrator identified a Regional Nurse as the current interim DON and stated that this individual was in the building only about twice a week, a practice that had been in place for approximately one to one and a half months while the facility searched for a permanent DON. The interim DON provided a list of days worked in December 2025, documenting presence in the facility on only six specific dates and confirming that they were at the facility only one to two times per week, although they reviewed the 24-hour nursing report daily. CMS Form 671 dated 1/4/26 and signed by the Administrator documented that 53 residents resided in the facility at the time these deficiencies occurred.
Failure to Properly Label, Date, Store, and Sanitize Food and Kitchen Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow policies for labeling, dating, storage, and sanitation of food and equipment. The facility’s policies required all refrigerated and frozen foods, as well as dry goods, to be labeled and dated upon receipt and when opened, and to be discarded according to safe food storage guidelines or manufacturer expiration dates. Policies also required drawers and cabinets in the dietary department to be cleaned weekly or more often as needed. During an initial kitchen visit, surveyors observed a cabinet without a door that contained accumulated debris and loose wood pieces at its base, while clean dishes were stored in this compromised area. Other kitchen cabinets were also in disrepair and had food and debris on their exterior surfaces. The dietary aide confirmed the presence of dirt and debris on cabinets where clean dishes were stored and stated that the manager was aware the cabinets were an issue. Further observations in the refrigerator, freezer, and dry storage revealed multiple opened food items that were not labeled or dated, as well as items that were past their expiration dates. In the refrigerator, surveyors found an open bottle of food and liquid thickener mix, sliced cheese, sliced ham, sliced turkey, and a carton of scrambled egg mix, all opened and undated. They also found an open container of French dressing labeled with an expiration date that had passed, opened bags of carrots with expired dates, several condiment containers with unknown sauces that were unlabeled and undated, and leftover cake labeled with an expiration date that had passed. In the freezer, opened bags of bread sticks, cinnamon rolls, and mixed vegetables were not labeled or dated. In the dry storage room, opened bags of bread and stuffing mix lacked opened dates, and three large containers of cereal were stored without labels or dates. The dietary manager verified each of these observations, acknowledging that the foods were opened and undated, some were expired and should have been discarded, and that all foods should be labeled and dated and cabinets cleaned and in good repair. The CMS Form 671 documented that 53 residents resided in the facility at the time of the survey.
Failure to Document and Track Staff COVID-19 Vaccination, Education, and Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of COVID-19 vaccination processes for employees. The facility’s own Interim COVID-19 Vaccination Guidelines for Residents and Employees, dated 12/2025, require that staff be provided education on the risks, benefits, and potential side effects of the COVID-19 vaccine, be offered the vaccine or information on obtaining it, and that the facility maintain documentation of staff education, vaccination status, and refusals, including information needed for NHSN reporting. The CMS Form 671 dated 1/5/26 and signed by the Administrator documents that 53 residents reside in the facility. During interviews, the Infection Preventionist stated there was no log of employees who had received the COVID-19 vaccine and no record of employees who refused it. The Administrator confirmed that the facility did not keep COVID-19 vaccination logs for employees, did not have employees sign a refusal form, and did not track education provided to new employees who refused the COVID-19 vaccination. As a result, the facility failed to document and track employee COVID-19 education, vaccine administrations, and vaccine refusals as required by its policy.
Mismatch Between POLST Orders and Documented Advanced Directives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ electronic medical records (EMR), care plans, and physician order sheets accurately reflected and matched their completed Physician’s Orders for Life-Sustaining Treatment (POLST) forms for scope of treatment. The facility’s Advance Directives policy requires that when a resident has an advance directive regarding CPR or scope of treatment (POLST), appropriate forms are completed, a specific physician order is obtained for each directive, and the directives are included in the resident’s plan of care. For four residents reviewed for advance directives, the EMR face sheets and physician order sheets documented only a Do Not Resuscitate (DNR) status and did not incorporate the additional treatment preferences specified on their POLST forms. For one resident, the EMR face sheet and physician order sheet listed “Advanced Directives: DNR,” and the care plan documented that the resident had signed a valid DNR and instructed staff not to resuscitate if there was no breathing or pulse. However, the resident’s POLST, signed by the resident, also directed that if not in cardiac arrest and with a pulse, staff should follow “Selective Treatment,” including limited medical measures such as non-invasive positive airway pressure (CPAP/BiPAP), IV fluids, antibiotics, vasopressors, antiarrhythmics, and hospital transfer if indicated. These additional scope-of-treatment instructions were not reflected in the care plan, EMR face sheet, or physician order sheet. Similarly, three other residents had EMR face sheets and physician order sheets that documented only DNR status, and their care plans addressed only the DNR directive. Their signed POLST forms, however, contained more detailed instructions for care when not in cardiac arrest, including “Selective Treatment” or “Limited Additional Interventions,” specifying use of medical treatments such as antibiotics, IV fluids, cardiac monitoring, non-invasive airway support, hospital transfer with general avoidance of ICU, and, for one resident, a defined six-month trial of artificial nutrition by tube. These POLST directives were not incorporated into the residents’ care plans or reflected on the EMR face sheets and physician order sheets. In interviews, an LPN stated that nurses rely on the EMR status board/face sheet to determine advanced directives in an emergent situation, and the Administrator and Interim DON confirmed that POLST instructions should be reflected in the EMR and care plans and that these documents should match the residents’ wishes.
Failure to Offer and Document Bedtime Snacks for Residents
Penalty
Summary
The facility failed to ensure that bedtime snacks were offered and provided in accordance with residents’ needs, preferences, and the facility’s own policy, which required staff to provide a bedtime snack and/or fluids as appropriate to promote comfort and relaxation before sleep. Review of the electronic health records for six residents showed no documentation that they were offered or received bedtime snacks. During a resident council meeting, all six residents reported that staff did not come around to offer bedtime snacks; several stated they had to specifically request a snack and that staff sometimes forgot to bring it, while others reported they were not aware they could request a bedtime snack but would like to have them offered. The Dietary Manager stated that dietary staff place a sealed box of bedtime snacks on the nurses’ desk each evening and do not offer snacks directly to residents, and the Interim DON stated that CNAs were expected to offer snacks to all appropriate residents but confirmed there was no documentation that these residents received any bedtime snacks. No additional medical history or clinical conditions for the involved residents were documented in the report.
Failure to Assess and Document CPAP-Related Nasal Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its own pressure injury and skin assessment policies for a cognitively intact resident who used a CPAP device and was assessed as being at moderate risk for pressure ulcers on multiple Braden Scale assessments. Facility policy required that pressure ulcers and other ulcers be assessed and measured at least every seven days by a licensed nurse, that each resident be observed daily for skin breakdown by CNAs with changes promptly reported to the charge nurse, and that the earliest sign of a pressure injury be documented in the clinical record and nursing progress notes with notification to the physician and resident or representative. The resident’s admission skin assessment and subsequent Braden Scale assessments did not document any pressure ulcer or skin alteration on the bridge of the nose, despite the resident’s use of a CPAP mask. Surveyor observation found the resident lying in bed with a CPAP device in place and, shortly thereafter, sitting on the edge of the bed with a bright red, dime-sized area on the bridge of the nose. The resident reported that this area had been present for over a week, was painful, and had been reported to staff about a week earlier, with the only response being application of a bandage. The resident stated the breakdown was caused by the CPAP mask due to the absence of a cushion and that the area hurt when touched or when the mask contacted it. The electronic medical record contained no documentation of the nasal area or the application of a bandage. The Assistant DON acknowledged seeing a bandage on the bridge of the resident’s nose previously but stated she was not aware that the resident had developed an ulcer there, confirming that the area had not been identified, assessed, or documented as a pressure injury in accordance with facility policy.
Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered insulin and perform ordered blood glucose monitoring for a resident with Type 2 Diabetes Mellitus and long-term insulin use. Facility policy dated 1/2015 requires medications to be administered in accordance with physician orders and documented on the Medication Administration Record. The resident was admitted with diagnoses including Type 2 Diabetes Mellitus and long-term insulin use, and the physician orders dated 12/11/25 specified Insulin Aspart 100 UNIT/ML, 30 units subcutaneously after meals for Type 2 Diabetes. The hospital discharge medication list for the same date documented that the resident was prescribed 30 units of Insulin Aspart that evening because an evening dose had not been given in the hospital. On interview, the resident reported that upon admission the facility did not have her medications or scheduled insulin and that it took two days before she received her medications. Review of the electronic Medication Administration Record (eMAR) for 12/11/25 showed no documentation that the resident received the scheduled 30 units of Insulin Aspart or that a bedtime blood sugar check was performed. The Assistant DON confirmed that if medications are not marked off on the eMAR, they were not given, and verified that the resident did not receive her evening or bedtime medications on 12/11/25, including the ordered 30 units of Insulin Aspart from the hospital discharge medication list. The resident’s admission time was confirmed as 6:49 PM on that date.
Lack of Diagnosis, Behavior Monitoring, and Care Plan for Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its Behavioral Health Services Program policy for the use of psychotropic medications, specifically antipsychotics, for a resident receiving risperidone. The policy dated 1/2023 requires that psychotropic medication care plans include the indication or rationale for use, specific target behaviors, and monitoring for efficacy and adverse consequences. For this resident, the care plan dated 1/6/2026 did not document a psychosis medical diagnosis, did not identify specific target behaviors, and did not include any care plan interventions related to antipsychotic use. The physician’s order sheet listed risperidone 1 mg as related to vascular dementia, mild, with other behavioral disturbance, but there was no corresponding behavioral documentation or behavior tracking in the record to support the need for an antipsychotic. Surveyor observations and staff interviews further showed an absence of behaviors that would typically warrant antipsychotic use. The resident was observed resting in bed watching a cell phone and later eating lunch peacefully in the dining room, and reported no concerns with the facility. Multiple CNAs and an LPN consistently described the resident as not violent or aggressive toward others, characterizing him instead as impatient, frequently using the call light, and sometimes yelling for help if not assisted quickly. The interim DON confirmed that if there was no psychosis diagnosis, no targeted behaviors, and no care plan addressing antipsychotic use in the record, then the facility did not have the required documentation, and was unable to provide evidence of a mental diagnosis or behavior monitoring to warrant the use of risperidone.
Failure to Complete Required Level II PASRR for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with documented serious mental illness diagnoses received a required Level II PASRR evaluation upon admission. The resident’s Level I PASRR, dated 7/23/25, indicated that no mental health diagnosis was known or suspected and concluded that no Level II PASRR was required, stating there was no evidence of a PASRR condition such as intellectual/developmental disability or serious behavioral health condition. However, the resident’s care plan, dated 1/6/26, shows that at the time of the most recent admission the resident had diagnoses of Bipolar Disorder, Major Depressive Disorder (MDD), and Attention-Deficit Hyperactivity Disorder (ADHD), and the LPN/MDS coordinator confirmed these diagnoses were present on the original admission. The LPN/MDS coordinator also confirmed that no Level II PASRR had been completed for this resident and that the former Social Services Director had been responsible for reviewing records and PASRR results at the time of the original admission, during which the resident’s mental illness diagnoses were not listed on the Level I screening. This discrepancy between the resident’s known mental health diagnoses at admission and the information recorded on the Level I PASRR screening led to the failure to initiate the required Level II PASRR review for a resident with Bipolar Disorder, MDD, and ADHD.
Failure to Change and Date Oxygen Tubing and Humidifier Weekly
Penalty
Summary
The facility failed to follow its own policy for changing oxygen and respiratory equipment for a resident receiving oxygen therapy. The facility’s policy dated 12/2025 required nasal cannulas and oxygen humidifiers to be changed weekly or as needed and to be dated when changed, in order to ensure safety and minimize infection transmission. A physician order dated 1/5/26 directed that the resident receive oxygen at 2–4 L via nasal cannula as needed, with oxygen tubing to be changed weekly and as needed. On 1/5/26 at 11:05 AM, the resident was observed in bed with oxygen running at 2.5 L with humidity; the nasal cannula tubing in use was dated 12/28 and the humidifier bottle in use had no date. On 1/6/26 at 11:25 AM, the same resident was again observed receiving humidified oxygen via nasal cannula, with the tubing still dated 12/28 and the humidifier bottle still lacking a date. The Interim DON confirmed that residents on oxygen should have their tubing and humidity changed weekly and stated they are usually changed on Sunday nights, but could not explain why this resident’s equipment had been missed. These observations, combined with the documented policy and physician orders, show that the facility did not ensure weekly changing and proper dating of oxygen tubing and the humidification bottle for this resident receiving oxygen therapy.
Noncompliance With Minimum Square Footage Requirements in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that multiple-resident rooms provided at least 80 square feet per resident, as required, affecting rooms that could house 31 residents. The CMS Form 671 dated 1/4/26, signed by the Administrator (V1), documented that 53 residents resided in the facility. An Illinois Department of Public Health letter dated 4/1/2025 granted a waiver for specific rooms (107-112, 115-119, 201-209, 301-306, 307-311), with the waiver subject to annual review or review at any time the facility did not meet the conditions under which it was granted. During an interview on 1/4/26, the Administrator acknowledged that the facility had rooms that did not meet the 80 square feet per resident requirement and provided a floor plan highlighting rooms 107, 108, 109, 110, 111, 112, 115, 116, 117, 118, 119, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, and 311 as being under the required size. On 1/5/26, the Administrator further stated that the waiver is sent every year to the State Agency and confirmed that the facility places two residents in the rooms covered by the waiver and that any resident could be moved into those rooms with a roommate. No additional resident-specific medical histories or clinical conditions were documented in relation to this deficiency, and the report focused on the room size measurements, the existence of the waiver, and the Administrator’s statements about room occupancy and use of the waived rooms.
Failure to Provide Prescribed Carbohydrate-Controlled Diet
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral infarction, sleep apnea, multifocal motor neuropathy, and polyneuropathies, was not provided with the prescribed carbohydrate-controlled, low concentrated sweet (LCS) diet. During a lunch observation, the resident was served apple juice, which was not compliant with his dietary order for sugar-free beverages. The resident confirmed he consumed whatever was provided, and the meal ticket indicated he should have received a diet beverage and sugar-free hot chocolate. The certified nursing assistant stated she only checks the name on the meal ticket, while the cook is responsible for assembling the tray based on the ticket. The dietary manager confirmed that the resident should not have received apple juice and that the dietary flowsheet specified diet beverages for those on LCS diets. The cook provided apple juice, mistakenly believing it was high in fiber, despite the resident's physician and spouse preferring sugar-free options. The resident's care plan and physician orders both specified a no added salt/carb-controlled diet with no additional sweets, and the facility's policy required adherence to documented diet orders. The failure to follow the prescribed diet was identified through observation, interview, and record review.
Failure to Label and Date Multidose Medications
Penalty
Summary
The facility failed to ensure proper labeling and dating of a multidose insulin pen injector and a multidose tuberculin vial, which were not labeled with an open date. This oversight was observed during a survey when a Licensed Practical Nurse (LPN) accessed the medication cart and refrigerator in the B and C Wing medication storage room. The insulin pen injector, used for a resident with a physician order for daily insulin administration, was found to be 1/3 full and lacked an open date label. Similarly, the tuberculin vial, which was used for any resident in the facility, was also found to be half full and without an open date label. The facility's Medication Storage Policy requires that once any medication or biological package is opened, the facility should follow manufacturer guidelines regarding expiration dates and record the date opened on the medication container. The Director of Nursing confirmed that the multidose insulin pens and tuberculin vials should have been labeled and dated with an open date, as per the facility's policy and manufacturer guidelines. The failure to adhere to these guidelines has the potential to affect all 56 residents residing in the facility.
Failure to Conduct PASARR Level II Evaluation for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with new diagnoses of mental illness after admission was referred to the state agency for a Level II PASARR evaluation. The facility's policy requires screening all potential admissions on an individualized basis and completing a PASARR Level I for all new and readmissions. This process is meant to determine if the individual meets the criteria for a mental disorder, intellectual disability, or related condition. However, the facility did not conduct a PASARR re-screen or a Level II screening for the resident after new diagnoses of severe mental illness were identified. The resident, identified as R25, was admitted with a diagnosis of depression, which did not initially require a Level II PASARR evaluation. However, subsequent diagnoses included bipolar disorder, psychophysiologic insomnia, vascular dementia with severe psychotic disturbance, unspecified affective mood disorder, delirium due to a known physiological condition, and unspecified psychosis not due to substance or known physiological condition. Despite these significant changes in the resident's mental health status, the facility did not perform the necessary PASARR re-screening or Level II evaluation. A Licensed Practical Nurse confirmed the oversight, stating that they did not realize the need to redo the PASARR after new diagnoses were made.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during the provision of urinary catheter care for a resident with an indwelling urinary catheter. The facility's policy mandates that hand hygiene should be performed before and after touching any part of the urinary catheter drainage system. However, during an observation, two Certified Nursing Assistants (CNAs) were seen preparing to perform catheter care for a resident diagnosed with Retention of Urine, Benign Prostatic Hyperplasia, and Obstructive and Reflux Uropathy. The CNAs assisted the resident to bed and removed the resident's clothing with gloved hands. One CNA, after removing her gloves, reapplied new gloves without washing or sanitizing her hands and proceeded to perform the catheter care. Throughout the procedure, the CNA failed to wash or sanitize her hands, even when changing gloves and moving from dirty to clean areas. This was confirmed by the CNAs themselves, who acknowledged the lapse in hand hygiene. The Assistant Director of Nursing/Infection Preventionist also verified that the CNA should have washed her hands before and during the catheter care procedure. The CNA admitted to not using hand sanitizer due to the inconvenience of bringing a large bottle into the resident's room.
Failure to Obtain Physician Orders and Develop Care Plans for Oxygen Use
Penalty
Summary
The facility failed to obtain a physician's order and develop a care plan for oxygen use for two residents, R16 and R21. R21 was observed lying in bed with oxygen flowing at 4.5 liters per nasal cannula, but there was no physician order for this oxygen use, nor was there a care plan addressing it. This was confirmed by both an LPN and the Director of Nursing, who acknowledged the absence of a physician order and care plan for R21's oxygen use. Similarly, R16 was observed with oxygen flowing at 4 liters per nasal cannula, despite having a physician order for oxygen at 2 liters via nasal cannula as needed. An LPN confirmed that R16's oxygen was set higher than the ordered amount. These observations indicate a failure to adhere to the facility's policies regarding medication administration and comprehensive care planning, which require following physician orders and developing care plans that address residents' medical needs.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that rooms housing multiple residents met the required minimum of 80 square feet per resident. This deficiency was identified through observation, interview, and record review, affecting 31 rooms that could potentially house 31 residents. The facility's application for Medicare and Medicaid documented 56 residents residing within the facility. An Illinois Department of Public Health letter granted a waiver for specific rooms, allowing them to be less than 80 square feet per resident, subject to annual review. The administrator confirmed that the facility has rooms not meeting the 80 square foot requirement and provided a floor plan highlighting these rooms. The administrator also stated that the waiver is submitted annually to the State Agency, and rooms with waivers accommodate two residents, with any resident potentially being moved to these rooms with a roommate.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to provide access to personal funds for 18 residents whose money was managed by the facility. According to the facility's Resident Funds policy, requests for access to funds should be honored promptly, with same-day access for amounts less than $100 and within three banking days for larger amounts. However, residents reported being unable to access their funds due to the facility waiting on a check from corporate. This issue was confirmed by the Licensed Practical Nurse (LPN) who was temporarily managing the business office, indicating that there had been no cash available since December 3rd. Residents expressed their frustration, with one resident stating they had been unable to withdraw $150 for Christmas shopping. The facility's Resident Council meeting minutes also reflected ongoing issues with the management of resident funds, noting the absence of a permanent Business Office Manager and limitations on cash availability. Despite the administrator's denial of any hold on the resident trust, the evidence from interviews and records indicated that residents' requests for funds were not being fulfilled in a timely manner, as required by the facility's policy.
Failure to Notify Health Care Power of Attorney of Change in Condition
Penalty
Summary
The facility failed to notify the health care power of attorney of a change in condition for two residents, R5 and R19, as required by their policy. R5, who was admitted with a diagnosis of congestive heart failure, experienced shortness of breath, altered mental status, and tachycardia, leading to a transfer to the emergency room and a subsequent hospice evaluation. Despite these significant changes, there was no documentation of notification to R5's health care power of attorney, V12. The Social Service Director, V7, admitted to being unable to contact V12 and confirmed the absence of any documented attempts to reach him, as the phone number listed was not in use. Similarly, R19, admitted after a fall with a hip fracture and other health issues, was found unresponsive and transferred to the hospital for pneumonia and exacerbation of congestive heart failure. The facility failed to notify R19's health care power of attorney, V11, due to the belief that her phone number was unavailable, despite it being documented in R19's medical record. The Director of Nursing, V2, confirmed the oversight and acknowledged that V11's phone number was not listed on the face sheet as it should have been.
Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician and the resident's representative after a fall with an injury occurred. The incident involved a resident who sustained an unwitnessed injury of unknown origin, first noted at midnight. Despite the resident's vocal complaints of pain and visible signs of discomfort, the practitioner, resident's responsible party, and interested party were not notified at the time of the event. The facility's policy requires immediate notification of changes in a resident's condition, but this protocol was not followed. The deficiency was further highlighted when the resident's representative discovered the injury during a visit and was informed by staff that the resident had fallen the previous day. The LPN acknowledged that the fall and subsequent swelling of the resident's wrist were not communicated to the primary physician or the representative. Additionally, a CNA who found the resident on the floor did not report the incident, mistakenly believing it did not constitute a fall. The Director of Nursing confirmed the failure to notify the appropriate parties immediately after the fall and the injury.
Failure to Complete Physician-Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to ensure that physician-ordered treatments, skin checks, and infection monitoring were completed for three residents with wounds. For the first resident, several treatments for wounds on the left and right inner buttocks, as well as the left stump, were not completed on multiple occasions in June and July 2024. The resident had a history of hospitalizations for infections and other health issues, and the Treatment Administration Record (TAR) showed numerous missed treatments and monitoring for signs of infection. The second resident, who had Peripheral Vascular Disease and was at risk for skin tears, also experienced missed treatments. The TAR indicated that daily skin checks and wound care for a right ankle wound were not completed on several occasions in June 2024. Additionally, monitoring for signs of infection and the application of protective barrier cream were not consistently administered. The third resident, with a history of pressure ulcers and other health conditions, had missed daily skin checks in July 2024. The Director of Nursing confirmed the missing treatments for the second and third residents, acknowledging that the lack of documentation meant there was no proof the treatments were completed. The facility's reliance on agency nurses was suggested as a reason for the missed treatments.
Lack of Activity Program Variety and Staffing
Penalty
Summary
The facility failed to provide an ongoing program of a variety of activities for all residents, affecting the physical, mental, and psychosocial well-being of the 43 residents. The facility's activity policy mandates a diverse program under the direction of an Activity Director, but the position has been vacant since October 2023. The interim Activity Director, a Certified Nurse Assistant without formal training, only assisted with activities three days per month. The activity calendars for April, May, and June 2024 showed little variety, with repetitive card games and Bingo, and lacked activities for residents unable to participate in these games. There were no activity staff on weekends, and residents reported a lack of activities during these times. Specific residents expressed dissatisfaction with the activity program. One resident stated there were no activities on weekends and desired more engagement. Another resident, who primarily stays in bed, reported that no activity staff visited her room, and she relied on television and puzzle books for entertainment. A third resident mentioned that card games in the dining room were not organized by the facility but were resident-directed. The Director of Nursing confirmed the limited activity schedule, with only one activity per day, including weekdays.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to have a qualified Activities professional to direct the provision of activities for all residents, affecting the 43 residents in the facility. The facility's job summary for the Activity Director outlines responsibilities such as planning, scheduling, and implementing an ongoing program of activities to meet the physical, mental, and psychosocial needs of each resident. However, the facility did not have a licensed or certified Activity Director since October 27, 2023, as confirmed by the Administrator in Training. A Certified Nurse Assistant/Activity Aide, who served as the interim Activity Director for four months, admitted to having no formal training, certification, or degree, and only received one day of formal training at another facility. This individual now assists with activities only three days per month. The facility's policy requires the Activity Director to have completed a State-approved Basic Orientation Course, which was not met, leading to the deficiency identified by the surveyors.
Failure to Verify CNA Registry Prior to Hiring
Penalty
Summary
The facility failed to perform registry verification for five Certified Nursing Assistants (CNAs) prior to their hiring, which has the potential to affect all 43 residents residing in the facility. The Administrator in Training (V1) admitted that there was no documentation available to confirm that the Nurse Aide Registry was checked for CNAs V10, V24, V25, V27, and V28 before they were employed. This lapse was attributed to staffing problems, which left V1 without anyone to conduct the verifications, and a lack of documentation prior to January 2024. Consequently, V1 had to retrospectively perform these checks herself. Specific instances include V10 CNA, who was hired on March 22, 2024, but whose registry was not checked until June 4, 2024. Similarly, V24 CNA was hired on May 15, 2024, with the registry checked a day later on May 16, 2024. V25 CNA was hired on January 5, 2024, but the registry was not checked until June 4, 2024. V27 CNA was hired on October 25, 2023, with the registry checked on November 10, 2023. Lastly, V28 CNA was hired on December 15, 2023, and the registry was not checked until June 4, 2024. The facility's CMS Form 671, signed by the Director of Nursing (V2), documented 44 residents currently residing in the facility.
Deficiency in Qualified Dietary Staff
Penalty
Summary
The facility failed to employ sufficient qualified dietary staff, which has the potential to affect all 43 residents. The Food Service Manager, responsible for managing all aspects of the Food Service Department and the nutritional care of all residents, is not certified as a dietary or food service manager, does not have a nationally recognized certification in food service management, and is not currently enrolled in a relevant course. The manager, who started the position in 2024, was previously a dietary aide. Additionally, the facility does not have a full-time dietician employed, relying instead on a qualified dietician who visits twice a month.
Lack of Posted Alternative Menu Options
Penalty
Summary
The facility failed to provide an alternatives or always available menu for residents during mealtimes, potentially affecting all 43 residents. Over several days, the dining room only displayed the main meal and one alternative food choice, which was typically leftovers. The facility did not have a posted menu or list of always available food options for residents who did not prefer the main or alternative meal. The Dietary Manager confirmed the absence of additional posted food options and acknowledged that residents would not know their food choices without them being displayed. Although the facility had items like cottage cheese, cold sandwiches, peanut butter and jelly, soups, and cereal available, these options were not communicated to residents through any posted menu or distributed food menu.
Facility Fails to Serve Palatable Food at Lunchtime
Penalty
Summary
The facility failed to serve palatable food at lunchtime on June 3, 2024, affecting all 43 residents. The menu for that day included a pork fritter with gravy, scalloped potatoes, green beans, and peaches. Multiple residents expressed dissatisfaction with the meal, describing the pork fritter as overcooked, rubbery, tasteless, and difficult to chew. Residents reported that the quality of food was inconsistent and often unappetizing, with some resorting to eating snacks in their rooms instead of the provided meal. Observations confirmed that the pork fritter was hard on the edges, difficult to cut, and lacked flavor. The Dietary Manager acknowledged receiving complaints about the food and suggested that the cook may have overcooked the meat in the convection oven. The manager confirmed that several residents had complained about the meal served at lunchtime on June 3, 2024.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by the lack of a cleaning schedule and the absence of dishwasher detergent in the dishwashing machine. During a kitchen tour, it was observed that the dishwashing machine did not have detergent, which was confirmed by both the Dietary Manager and a Dietary Aide, who were responsible for monitoring and refilling the detergent. Additionally, the facility's ovens were found to have a buildup of a black sticky substance with tin foil stuck in it, indicating that they had not been cleaned as required. The Dietary Manager acknowledged that the ovens needed cleaning and admitted that there was no established cleaning schedule for the dietary employees, necessitating daily written task assignments. The facility's policies, including the Ware-Washing and Kitchen Sanitation policies, require that utensils and dishes be clean and sanitized and that the Food Service Manager develop a cleaning schedule for the dietary department. However, the facility was unable to provide any documentation of a cleaning schedule or completed cleaning tasks. This deficiency has the potential to affect all 43 residents in the facility, as all residents have diet orders and consume meals prepared in the kitchen.
Inadequate Infection Control and PPE Management
Penalty
Summary
The facility failed to effectively monitor and manage active infections, identify the need for transmission-based precautions, and ensure the availability of Personal Protective Equipment (PPE) for staff. The Director of Nursing (DON) and the Infection Preventionist did not track resident infections, as evidenced by the absence of documented signs and symptoms of infection, whether infections were facility-acquired, or if they were cultured. This lack of monitoring was confirmed by the DON and the Infection Preventionist, who admitted to not maintaining an infection tracking log. Multiple residents were affected by the facility's failure to provide necessary PPE and disposal bins for infection control. For instance, a resident with an indwelling catheter had Enhanced Barrier Precautions documented on their door, but no PPE was available outside the room, nor were there disposal bins inside. Similarly, another resident on Contact Precautions for a wound infection had no PPE available, and the Infection Preventionist was unsure if the resident should remain on Contact Precautions or switch to Enhanced Barrier Precautions due to a lack of follow-up culture results. The facility's supply management also contributed to the deficiency, as the clean supply room was inadequately stocked with gloves and gowns, and additional supplies were locked away, accessible only by managers. This restricted access to necessary PPE further hindered staff's ability to adhere to infection control protocols, as they would need to call an on-call manager to access these supplies. The combination of inadequate infection monitoring, unclear precautionary measures, and restricted access to PPE posed a risk to all 43 residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which is crucial for monitoring and assessing antimicrobial use trends. The program's policy, dated November 1, 2017, emphasizes the importance of regularly assessing antimicrobial use to identify gaps in communication, inconsistencies in documentation, and compliance with facility policies and evidence-based recommendations. However, the facility did not adhere to these guidelines, as confirmed by the Director of Nursing and the Infection Preventionist, who admitted to not tracking resident infections or using a set of standards to define infections. Additionally, they did not encourage physicians to wait for culture results before starting antibiotics. The Resident Infection Control and Antimicrobial logs from January 2024 through May 2024 lacked documentation of signs and symptoms of infection, whether infections were acquired within the facility, or if infections were cultured. This oversight has the potential to affect all 43 residents residing in the facility, as documented in the facility's Long Term Care Facility Application for Medicare and Medicaid. The absence of a structured approach to monitoring antibiotic use and infections indicates a significant deficiency in the facility's infection control practices.
Failure to Maintain Working Bathroom Light
Penalty
Summary
The facility failed to maintain a working overhead light in the bathroom for one resident, identified as R20, among a sample of 43 residents. The deficiency was observed when the bathroom light switch was flipped on, and the light did not work properly. The light was dim and flickering, and it required multiple attempts to turn on. R20 reported that the bathroom light had not been functioning correctly for a couple of months and that the maintenance staff was aware of the issue, attributing it to a bad ballast. Despite this knowledge, the light had not been repaired, causing inconvenience to R20, who had to flip the switch multiple times to use the bathroom light for daily activities like brushing teeth. The maintenance staff, identified as V16, confirmed the issue and acknowledged that the light did not come on immediately and flickered when it did. V16 had been employed at the facility since March 2024 and stated an intention to replace the faulty light. However, at the time of the survey, the light remained unrepaired, indicating a lapse in maintaining a safe and comfortable environment for the resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the local state agency, as required by their Abuse Prevention Program. The program mandates that any injury of unknown origin should be investigated as potential physical abuse and reported to the state agency within five working days. However, the Administrator in Training (V1) did not conduct an investigation into the resident's (R11) injuries, which included four scattered areas of open purpura and a superficial scratch on the left upper arm. V1 was notified of the injury on 3/19/24 but did not report it, believing it was not a cause for concern due to the resident's history of bruising easily. The resident's spouse and legal guardian expressed concerns about the bruises, suspecting that the aides were improperly handling the resident by the arms instead of using a gait belt. Despite these concerns and previous investigations into similar bruising incidents, V1 did not investigate the March occurrence or notify the state agency. The spouse also reported difficulties in communicating with V1, who allegedly avoided addressing these concerns. This lack of action and communication contributed to the facility's failure to adhere to its abuse prevention policy and state reporting requirements.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as R11, which is a violation of their Abuse Prevention Program. The program mandates that all injuries of unknown origin should be investigated as potential physical abuse. Despite this, the Administrator in Training, V1, did not conduct an investigation into the injuries sustained by R11 on the left upper arm, which included four scattered areas of open purpura and a superficial scratch. V1 was notified of the injury on 3/19/24 but dismissed the need for an investigation, citing that R11 frequently gets marks on his arm and did not consider it a concern. R11's spouse and legal guardian expressed concerns about the bruises, suspecting that the aides were improperly handling R11 by the arms instead of using a gait belt for transfers. The spouse reported these concerns to V1, who allegedly avoided addressing them. The facility's records show that V1 had conducted two previous investigations into similar bruising incidents on R11's arms, but she could not articulate why the incident on 3/19/24 was treated differently. This lack of investigation into the injury of unknown origin constitutes a failure to adhere to the facility's abuse prevention policy.
Failure to Implement Restorative Walking Program
Penalty
Summary
The facility failed to implement a restorative walking program for a resident, identified as R43, who was recommended to participate in a walk-to-dine program to prevent decline in function and mobility. Despite the recommendation documented in the resident's physical therapy discharge summary dated 5/30/2024, R43 was not observed walking with his walker during the survey period. On 6/2/24, R43 expressed that he no longer walks because there is not enough help to assist him. On 6/4/24, the Director of Nursing (V2) was unaware of R43's walking program and confirmed that to her knowledge, R43 does not walk to or from meals. Additionally, on 6/5/24, a Certified Nurse Assistant (V11) stated that R43 usually propels himself in his wheelchair and can walk with his walker in his room to the toilet.
Improper Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency in infection prevention. The resident, who has a history of urinary retention, urinary device use, and sepsis, was observed on two occasions with their catheter collection bag and tubing resting on the floor. This placement is contrary to the facility's Catheter Care policy and the CDC guidelines, which state that the collection bag should be kept below the bladder level and not rest on the floor. The resident's care plan included interventions to prevent catheter-related trauma and infection, such as positioning the catheter bag and tubing below the bladder level and monitoring for signs of infection. Despite these guidelines and care plan interventions, the resident's catheter bag was found on the floor, and staff members, including a CNA, the MDS Assessment and Care Plan Coordinator, and the Director of Nursing, confirmed that the catheter bag should not touch the floor. The resident was described as being relatively independent and often moved the catheter bag themselves. The Director of Nursing noted that the resident preferred their bed to be lowered to the floor, which may have contributed to the improper placement of the catheter bag. Staff were aware of the issue but had not effectively ensured compliance with the catheter care policy.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R40, by not ensuring that oxygen was infused correctly, that oxygen tubing was dated, and that the tubing was not resting on the floor. The facility's Oxygen Therapy policy requires a physician's written order for oxygen therapy, specifying the liter flow per minute, the type of delivery method, and the time frame. Additionally, the policy mandates that oxygen tubing, masks, and cannulas be changed weekly, with the changes documented on the treatment sheet. However, observations revealed that R40's oxygen concentrator was infusing at 3 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula as needed. Furthermore, the oxygen tubing was not dated, and it was observed resting on the floor. R40, who has a medical history of acute respiratory failure with hypoxia, COPD with acute exacerbation, and centrilobular emphysema, was noted to be oxygen-dependent. The resident was observed multiple times with undated oxygen tubing while using both an oxygen concentrator and a cylinder tank. Interviews with staff indicated that R40 often adjusted his oxygen flow and switched between the concentrator and the tank independently. Despite being educated on the proper handling of oxygen equipment, the resident's tubing and nasal cannula were found on the floor, and the Director of Nursing confirmed that the tubing should be changed weekly, dated, and not placed on the floor.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions before administering psychotropic medications and did not identify target behaviors for the use of antipsychotic medications for two residents. For one resident, identified as R19, the facility's records showed an order for Seroquel due to a diagnosis of psychosis. However, there was no behavior charting or documentation of non-pharmacological interventions attempted prior to starting the medication. The Director of Nursing confirmed the absence of behavior tracking before the medication was administered. Observations of R19 showed the resident interacting appropriately with others, yet the medical record lacked documentation of targeted behaviors for the antipsychotic medication. Another resident, identified as R39, was on Quetiapine for stimulant-induced psychotic disorder with hallucinations and dementia with behavioral disturbance. The care plan indicated the use of psychotropic medication for behavior management, but behavior monitoring records showed no observed behaviors. The consent form for the medication was incomplete, lacking a diagnosis or target behaviors. The Director of Nursing admitted to not knowing the resident's psychosis or behaviors and acknowledged the need for a new consent form. A pharmacy consultation report highlighted the need for updated medical records to include specific diagnoses, target behaviors, and documentation of non-pharmacological interventions, which were not adequately addressed.
Medication Error Rate Exceeds 5% Due to Incorrect Dosages
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during a medication pass review. This deficiency affected two residents out of ten reviewed. The first incident involved a Licensed Practical Nurse (LPN) administering an incorrect dosage of Carbidopa-Levodopa to a resident with Parkinson's Disease. The medication card indicated a dosage of 2.5 tablets, but the LPN administered only 1.5 tablets, mistakenly believing it to be the correct dosage. The Director of Nursing confirmed that the correct dosage was indeed 2.5 tablets. The second incident involved the same LPN administering an incorrect dosage of Gabapentin to another resident with polyneuropathy. The physician's order required two capsules of Gabapentin, but the LPN administered only one capsule, along with two Tylenol tablets. The LPN later stated that she thought she had given the correct dosage of Gabapentin. These errors highlight a failure to adhere to the facility's medication administration policies, which emphasize the importance of following the six rights of medication administration.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide rooms that meet the required minimum of 80 square feet per resident in multiple resident rooms. This deficiency affected 16 residents out of a sample of 44, as observed during a survey. The Minimum Data Set Coordinator confirmed that some rooms do not meet the square footage requirement. The facility's floor plan indicated that the rooms occupied by these residents were indeed less than 80 square feet per resident. An undated letter from the Administrator in Training revealed that the facility has submitted a waiver to the State Agency regarding this issue, as the rooms are slightly under the required square footage. However, the Administrator in Training was unable to provide information on when the waiver was last sent.
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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