Avenues At Royal Oak
Inspection history, citations, penalties and survey trends for this long-term care facility in Kewanee, Illinois.
- Location
- 605 East Church Street, Kewanee, Illinois 61443
- CMS Provider Number
- 145418
- Inspections on file
- 48
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Avenues At Royal Oak during CMS and state inspections, most recent first.
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 cognitively intact resident with psychiatric diagnoses had a $900 check cashed by social services and chose to keep the cash on her person after being advised to secure it. After an outing to Walmart and other locations with another cognitively intact resident, she reported that her wallet, containing approximately $400–$450, went missing from her bed. A CNA reported the loss, and staff searched both residents’ rooms, finding the wallet on top of the other resident’s dresser with the cash missing. The other resident denied taking the money or knowing how the wallet got into his room. The facility’s investigation substantiated a theft, constituting misappropriation of resident property under the facility’s abuse prevention policy.
Two residents engaged in a physical altercation when a cognitively impaired male resident wandered into a roommate’s room from a shared bathroom and the cognitively intact roommate reacted by placing an arm around his neck while both were on the floor, with shouting and hair-pulling observed by staff. In a separate event, a cognitively intact male resident with multiple psychiatric and medical diagnoses repeatedly directed racial slurs at a dietary staff member, who responded by yelling profanities back, moving toward the resident as if to strike, and verbally challenging him, requiring other staff to intervene to separate and de-escalate the situation.
A bariatric resident with diabetes and bipolar disorder, weighing 426 lbs and requiring specialized equipment, was discharged to another nursing home without proper verification, documentation, or discharge instructions. Social services did not clearly document or confirm the receiving facility, and the administrator of the intended facility reported the resident was never admitted there. Upon arrival, the intended facility lacked a bariatric bed and wheelchair, leading to the resident being sent to the ER, where a different nursing home was found. The discharging LPN provided only medications without written discharge papers, contrary to the DON’s expectations and facility policy requiring documented communication of necessary information and DME needs to the receiving institution.
The facility failed to follow its abuse prevention and reporting policy when a CNA reported finding a transportation aide alone in a resident’s room with the door closed, the resident’s shirt pulled up exposing her bra, and the aide behind the door repeatedly saying, “don’t say anything.” The aide later stated he was delivering a sandwich related to a football bet and denied inappropriate behavior, and the resident gave the same account. The Administrator, who is the aide’s sibling, was informed of these details by the DON and CNA but concluded the CNA was making trouble, did not treat the event as potential abuse, and did not report the incident to the state agency or local law enforcement.
The facility failed to report a potential allegation of sexual abuse involving a resident and a transportation aide to the state agency and local law enforcement, despite a policy requiring immediate reporting of any abuse allegations. A CNA reported finding the aide behind the door in the resident’s room with the door closed, while the resident had her shirt up covering her face and her bra exposed, and the aide allegedly provided the resident a sandwich over a football bet. The Administrator, who acknowledged awareness of the incident and that the aide is her brother, stated she was informed by the DON and CNA, but after consulting corporate staff, decided the CNA was making trouble and did not consider the situation potential abuse, resulting in no report being made to authorities.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report does not specify further details about the individuals involved or the exact nature of the hazards.
A resident with severe cognitive impairment and a history of hip surgery experienced a fall resulting in a hip fracture. Despite repeated complaints and signs of pain observed by staff, there was inadequate pain assessment, lack of documentation of pain complaints, and no recorded administration of ordered pain medication. The facility did not follow its pain management policy, leading to unrelieved pain for the resident while awaiting further evaluation and treatment.
Two residents experienced physical abuse from peers when staff were not present to supervise or intervene. In one case, a resident with a history of aggression struck another after a hallway altercation, and in another, a resident swatted at a peer's hand during a dining room incident. Both events involved individuals with behavioral health histories, and neither aggressor had documented aggression screening, highlighting lapses in supervision and risk assessment.
A resident with a history of chronic health conditions and major depressive disorder struck another resident with a crutch, causing a laceration. The incident occurred due to agitation over noises made by the victim, who has paranoid schizophrenia. The facility failed to prevent this abuse, despite having a policy on abuse prevention.
A facility failed to update a PASARR screen for a resident after a new diagnosis of severe recurrent major depression with psychotic features. Despite the resident's significant behavioral changes and the facility's policy requiring a PASARR Level 1 screen with any significant change of status, no updated screen was performed.
A high-risk resident with multiple mental health conditions was involved in a physical altercation with another resident, both having traumatic brain injuries. The incident occurred in the dining room, where one resident punched the other in the face. Despite immediate separation and no injuries reported, discrepancies in staff accounts and the facility's investigation raised concerns about the adequacy of supervision and preventive measures.
The facility failed to monitor and document food temperatures, leading to meals being served at inadequate temperatures. Residents expressed dissatisfaction with cold meals, and the Dietary Manager acknowledged issues with staff not documenting temperatures and delays in serving trays. This affected all 132 residents receiving meal trays.
The facility failed to provide residents access to their personal funds following a change in ownership, affecting 100 residents. The previous company took all funds, leaving the new management without sufficient resources. Residents reported being unable to access their money, with some receiving as little as four dollars a week, and banking hours were reduced. The administration acknowledged the issue, attributing it to the transition and insufficient funds from the new company.
A resident reported being inappropriately touched by an LPN during a search for missing hand sanitizer. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the State Agency or Law Enforcement until three days later. The DON and Interim Administrator were informed of the incident but did not act on it as a reportable abuse incident until prompted by a State Surveyor.
A resident reported being inappropriately touched by an LPN during a search for missing hand sanitizer. Despite the facility's policy to protect residents by removing accused staff, the LPN returned to work the next day due to a scheduling error. The incident was reported to the Ombudsman and the State, highlighting a deficiency in the facility's response to the allegation.
A resident with multiple diagnoses, including bipolar disorder and obesity, reported verbal abuse by a night shift CNA, who made derogatory remarks about her weight and menstrual condition. Other CNAs confirmed the resident's complaints, but the facility failed to address the issue, despite having a policy against such abuse.
A resident with multiple diagnoses, including bipolar disorder, reported verbal abuse by a night shift CNA, who allegedly made derogatory comments and refused assistance. Despite the resident's complaints, staff failed to report these allegations to the CNA supervisor or administrator, violating the facility's policy on immediate reporting of abuse.
A resident with multiple health conditions was injured during a transfer using a mechanical lift due to a CNA attempting the procedure alone, contrary to the care plan requiring two to three staff members. The incident led to a hospital visit for a back contusion and ongoing fear of transfers. The facility's failure to ensure proper staffing and equipment maintenance contributed to the incident.
A resident did not receive prescribed medications for several days due to a failure in transcribing hospital orders to the Medication Administration Record. The LPN used paper prescriptions instead of the hospital transfer sheet, leading to a lapse in medication administration, as confirmed by the Assistant Director of Nurses.
The facility failed to implement Enhanced Barrier Precautions and Contact Precautions, as staff were observed performing catheter and wound care without proper PPE. The Infection Preventionist confirmed that precautions were not implemented for several residents with wounds or medical devices, risking MDRO transmission.
The facility failed to implement its Antibiotic Stewardship Program, lacking protocols to review clinical signs and symptoms before administering antibiotics. The Assistant Director of Nursing/Infection Preventionist admitted that the facility does not use assessment tools or management algorithms, affecting all 132 residents by potentially exposing them to unnecessary antibiotic use.
The facility's Infection Preventionist, also the Assistant DON, failed to implement necessary infection control measures, including Enhanced Barrier Precautions and Contact Isolation Precautions, due to insufficient time and guidance. Additionally, the facility lacked protocols for antibiotic use, relying on doctor orders without assessment tools, affecting all 132 residents.
The facility failed to respond to resident call lights in a timely manner, affecting multiple residents. Residents reported excessive wait times, particularly during the third shift, with some waiting over an hour for assistance. The call light system lacks an audible alert, contributing to delays. A staff member was terminated for sleeping on the job, which was expected to improve response times.
The facility failed to ensure that the electronic medical records and care plans of two residents matched their POLST regarding CPR code status. One resident's records indicated a Full Code status, while the POLST indicated DNAR. Another resident's records showed a Full Code status, but the POLST indicated DNR with comfort-focused treatment. These discrepancies were confirmed by facility staff.
A facility failed to implement a baseline care plan for a newly admitted resident with complex mental health diagnoses, including Borderline Personality Disorder and PTSD. Despite the facility's policy requiring a care plan within 48 hours of admission, the Care Plan Coordinator confirmed that no such plan was developed for the resident, who has a history of self-harming behaviors and substance use.
A resident with MRSA in a right ankle wound did not receive proper wound care due to a failure in hand hygiene by an LPN. The LPN did not wash hands after glove removal and before donning new gloves, and placed contaminated scissors on a bedside table. The resident was on Contact Precautions, but the LPN did not adhere to the facility's infection control policies, risking cross-contamination.
A facility failed to implement ROM exercises for a resident with limited mobility due to a stroke. The resident, non-ambulatory and dependent on caregivers, had a Passive ROM Program order incorrectly entered as PRN instead of every day, every shift. This error was confirmed by the administrator, leading to a deficiency in providing necessary restorative care.
A facility failed to provide proper care for a resident with an indwelling urinary catheter. The catheter tubing and drainage bag were found on the floor without a privacy cover, and during a transfer, a CNA improperly raised the catheter bag above the resident's bladder. Staff acknowledged these errors.
A facility failed to coordinate care and communicate with a dialysis center for a resident with End Stage Renal Disease. The care plan lacked essential elements like dialysis schedule, medication changes, and emergency protocols. Staff did not send required communication forms with the resident to the dialysis center, as confirmed by the DON. This led to a deficiency in providing appropriate dialysis care.
A facility failed to provide necessary psychosocial therapies and psychiatric support to a resident with Adjustment Disorder and Major Depressive Disorder, leading to repeated ER visits for suicidal ideations. Despite the care plan and PASRR recommendations, the resident did not receive required psychiatric counseling or therapy services, with only one telehealth session documented. The facility lacked documentation of any refusals by the resident for these services.
Two residents in a LTC facility were involved in a physical altercation, resulting in one resident receiving a black eye. The incident, which was not witnessed by staff, occurred during an argument over a boyfriend. Both residents have mental health disorders, and the facility's failure to prevent the altercation indicates a deficiency in their Abuse Prevention Program.
The facility failed to follow physician orders and have Speech Therapy services assess the swallowing needs of two residents after choking incidents. One resident choked on a biscuit and was sent to the emergency room, while another choked on lettuce and was also hospitalized. Despite physician orders for Speech Therapy evaluations, neither resident received the mandated assessments, constituting a deficiency in the provision of specialized rehabilitative services.
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 Protect Resident From Misappropriation of Money
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from misappropriation of property, specifically the wrongful use of her money. The resident, who had diagnoses including bipolar disorder, borderline personality disorder, and major depressive disorder, had a check for $900 cashed by social services, with staff advising her to keep the money safe or allow the business office to secure it; the resident chose to keep the cash on her person. After going on an outing to Walmart with another resident and spending a portion of the funds, she reported having approximately $400–$450 remaining in her wallet, which she last recalled seeing on her bed. On a subsequent morning, she discovered the wallet missing and reported this to a CNA, who then notified the nurse. Staff searched her room and the room of another cognitively intact resident who had accompanied her on the outing. During the search, staff found the missing wallet on top of the other resident’s dresser, but the cash was no longer inside. The resident whose wallet was taken reported that only the other resident had been in her room and that he knew she had the money. The other resident stated he did not know how the wallet ended up in his room and denied taking the money, though he acknowledged having gone out with the resident to Walmart and other locations before returning to the facility. The facility’s internal financial abuse report documented that the theft was substantiated, and the facility’s abuse prevention and reporting policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. The events demonstrate that the resident’s money was misappropriated while under the facility’s care, in violation of the policy requirement to protect residents from misappropriation of property.
Failure to Protect Residents From Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse. In one incident, a male resident with dementia, anxiety, chronic pain, and moderate cognitive impairment wandered from a shared bathroom into his roommate’s room during the night. The cognitively intact roommate, who was new to the facility, reacted by placing his arm loosely around the first resident’s neck while both ended up on the floor. Staff heard shouting and found the two residents on the floor, with one resident’s arm around the other’s neck in a choke hold and the other resident pulling hair and yelling to be released. Staff separated and assessed the residents, and the administrator later confirmed that the physical altercation was substantiated and that the cognitively impaired resident had wandered into the roommate’s room. In a separate incident, the facility failed to prevent verbal abuse and threatening behavior between a cognitively intact male resident and a dietary staff member. The resident, who had diagnoses including edema, type 2 diabetes, antisocial personality disorder, bipolar disorder, and major depression, admitted to calling the dietary staff member racial slurs. Multiple staff witnesses reported that the resident was screaming racial slurs at the staff member, who responded by shouting back, using profanity, and moving toward the resident as if to strike him, while verbally challenging the resident and stating that nobody talks to him like that. Another staff member intervened by stepping between them with hands raised to keep them separated and de-escalate the situation. The facility’s abuse policy affirms residents’ rights to be free from abuse, including physical and verbal abuse, but the described events show that residents were subjected to both physical and verbal mistreatment.
Failure to Safely Coordinate and Document Bariatric Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to safely discharge a resident with significant medical and equipment needs. The resident had diagnoses including diabetes and bipolar disorder, no documented cognitive impairment, and a recorded weight of 426 lbs, requiring bariatric equipment. The face sheet listed the discharge destination only as an unknown nursing home, and the facility assessment and records did not clearly document the receiving facility. The social services staff member reported that the resident was transferred approximately 145 miles away to a nursing home that accepted bariatric residents, but she did not verify the resident’s status after transfer, could not recall whom she spoke with at the receiving facility, and did not document this communication in the medical record. The administrator of the intended receiving nursing home stated that the resident was never admitted there. The resident and a family member reported that upon arrival at the intended nursing home, the facility did not have a bariatric bed or bariatric wheelchair available, and the resident became anxious with palpitations and was sent to the ER. The hospital then arranged placement at a different nursing home that had the needed equipment. The LPN who discharged the resident stated she sent only the resident’s discharge medications and did not provide any additional discharge papers because she was not instructed to do so. The DON stated that discharge to another nursing home should include written discharge instructions such as a medication list, equipment needs, and a copy retained in the medical record to ensure continuity of care and safety. The facility’s own policy on notice of transfer and discharge required documentation of the transfer in the medical record, communication of appropriate information to the receiving institution, and review of necessary items including DME, prescriptions, appointments, and treatments, which was not followed in this case.
Failure to Recognize and Report Potential Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse Prevention and Reporting policy when presented with a situation that met criteria for a potential sexual abuse allegation. The facility’s policy, effective 12/2025, states that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property, and that staff will be oriented and trained on what constitutes abuse and how to recognize and report incidents or allegations. A Resident Grievance form dated 12/8/25 documented that a CNA reported finding a transportation driver in a resident’s room with the door closed; when the CNA partially entered, the resident had her shirt pulled up, covering her face, and her bra exposed. Once the CNA was able to fully enter the room, the transportation driver was found behind the door, facing the resident, and he repeatedly stated, “don’t say anything.” The grievance also documented the driver’s explanation that he was delivering a sub sandwich to the resident over a football bet and that he denied any inappropriate behavior, and that the resident gave the same account when questioned. During an interview, the Administrator confirmed awareness of the situation between the resident and the transportation aide and stated she had been called at home by the DON, with the CNA present, and informed of what the CNA had witnessed. The Administrator acknowledged that the CNA had reported seeing the resident with her shirt up and bra exposed, and the transportation aide behind the door, and that the aide had repeatedly told the CNA not to say anything. The Administrator stated she consulted with corporate staff and they concluded that the CNA was making trouble because she knew the aide was the Administrator’s brother and wanted to get him in trouble. The Administrator stated she did not consider the situation to be potential abuse, did not report it to the state agency, and did not notify local law enforcement, despite the facility’s policy requiring recognition and reporting of occurrences and allegations of abuse. This failure to recognize and report a potential sexual abuse allegation for one of four residents reviewed for abuse led to the cited deficiency.
Failure to Report Allegation of Potential Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report a potential allegation of sexual abuse to the state agency or local law enforcement as required by its Abuse Prevention and Reporting policy. The policy, effective 12/2025, states that any allegation of abuse will be reported to the state agency immediately and that local law enforcement will be contacted in situations involving sexual abuse of a resident by a staff member. A Resident Grievance form dated 12/8/25, signed by the Assistant Administrator, documents that a CNA reported attempting to enter a resident’s room and finding the transportation driver behind the door while the resident had her shirt up and bra exposed, with the driver allegedly giving the resident a sub sandwich over a football bet. During an interview on 01/10/2026, the Administrator stated she was aware of the situation between the resident and the transportation aide, who is her brother. She reported being called at home by the DON, with the CNA present, and was informed that the CNA had witnessed the transportation aide in the resident’s room with the door closed, the resident with her shirt up covering her face and exposing her bra, and the aide behind the door facing the resident. The Administrator stated that when the CNA entered the room, the aide raised his arms and repeatedly said, “don’t say anything.” The Administrator further stated that after conferring with corporate staff, it was decided that the CNA was making trouble because she knew the aide was the Administrator’s brother, and the Administrator concluded the situation was not potential abuse. Based on this conclusion, she did not report the situation to the state agency and did not notify local law enforcement, contrary to facility policy.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals involved is included.
Failure to Assess, Document, and Manage Pain Following Resident Fall
Penalty
Summary
The facility failed to follow its pain management policy and procedure by not adequately assessing, documenting, or treating a resident's pain following a fall that resulted in a significant injury. The resident, who had a history of dementia, neurocognitive disorder, and a right artificial hip joint, experienced a fall and subsequently showed signs of pain, including vocalizations and physical resistance during care. Despite these indications, there was a lack of consistent pain assessments, documentation of pain complaints, and administration of pain medication as ordered. Multiple staff interviews revealed that the resident expressed pain throughout the night after the fall, particularly when being moved or touched, and staff observed bruising and other signs of injury. However, the medical record did not reflect these complaints or the interventions taken, such as administration of acetaminophen or use of non-pharmacological measures like ice packs. The medication administration record showed no documented administration of pain medication during the relevant period, despite orders for as-needed acetaminophen and documented pain scores. The facility's pain management policy required documentation of pain assessment and monitoring, but this was not followed. The Director of Nursing confirmed that there were no new pain management orders post-fall and that documentation of pain complaints and medication administration was expected. The lack of timely and thorough pain assessment, documentation, and intervention resulted in the resident experiencing unrelieved pain while awaiting further evaluation and treatment for a hip fracture.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two vulnerable residents from resident-to-resident physical abuse. In the first incident, one resident in a wheelchair attempted to move past another resident in a hallway, making physical contact. The standing resident, who had a history of bipolar II disorder, anxiety, PTSD, and prior verbal/physical aggression, responded by hitting the resident in the wheelchair on the head. Both residents were assessed as having no cognitive impairment, and both had documented histories of behavioral issues and high risk for abuse/neglect. No staff were present to witness or intervene during the altercation, and there was no documented aggression screening for the resident who initiated the physical contact. Staff were supposed to monitor the area but were not present at the time of the incident. In the second incident, a resident with severe cognitive impairment reached for another resident's drink at the dining table. The other resident, who had no cognitive impairment but a history of major depressive disorder and prior peer conflict, reacted by swatting the first resident's hand. This incident was witnessed by the Assistant Director of Nursing, who observed that no other staff were nearby, as aides were occupied picking up trays in the vicinity. The resident who initiated the physical contact had no documented aggression screening in their medical record, despite a history of behavioral issues. Both incidents involved residents with documented behavioral and psychiatric histories, and in both cases, staff were either not present or not actively monitoring the areas where the altercations occurred. The lack of staff supervision and absence of aggression screening for residents with known behavioral risks contributed to the facility's failure to prevent resident-to-resident physical abuse.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved two residents, one of whom struck the other with a crutch, resulting in a 2 cm laceration to the left forearm of the victim. The altercation occurred because the aggressor was agitated by noises made by the victim. The facility's policy on abuse prevention and reporting was not effectively implemented to prevent this incident. The aggressor, who has a history of chronic health conditions and major depressive disorder, admitted to hitting the victim due to being disturbed by the victim's noises. The victim, who has paranoid schizophrenia and other mental health issues, was injured during the altercation. The facility's investigation revealed that there were no witnesses to the incident, and the residents were in their room when the altercation occurred. The facility's response included separating the residents and notifying relevant parties, but the deficiency lies in the failure to prevent the abuse from occurring in the first place.
Failure to Update PASARR Screen After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to perform a PASARR rescreen for a resident after the emergence of a newly diagnosed severe mental illness. The facility's policy requires a PASARR Level 1 screen to be completed annually and with any significant change of status. This includes reporting any changes to the state mental health authority or the state intellectual disability authority promptly. However, the facility did not adhere to this policy for one resident who was diagnosed with severe recurrent major depression with psychotic features. The resident, who was admitted with diagnoses including right above the knee amputation, chronic diastolic heart failure, chronic obstructive pulmonary disease, and alcohol abuse, exhibited significant behavioral changes. These changes included responding to internal stimuli, verbal outbursts, and an attempt to attack another resident. Despite these developments and the psychiatric note indicating a serious mental illness, the facility did not update the PASARR screen as required. The administrator confirmed that no updated PASARR screen had been performed following the documented diagnosis.
Failure to Protect High-Risk Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a high-risk resident from physical abuse, as evidenced by an incident involving two residents with traumatic brain injuries. Resident 1, who has a history of bipolar disorder, anxiety, depression, and other conditions, was identified as high risk for abuse. Despite this, an altercation occurred in the dining room where Resident 2, who also has a traumatic brain injury and other mental health issues, approached Resident 1 and made physical contact with their face. The incident was initially described as a slap, but later accounts from staff indicated that Resident 2 punched Resident 1 with a closed fist. Both residents were separated immediately, and no injuries were reported. The facility's investigation concluded that the incident did not constitute abuse, as there was no intent to harm. However, discrepancies in staff accounts of the event suggest a lack of clarity in the facility's response and documentation. The facility's policy requires that resident-to-resident altercations be reviewed as potential abuse situations, yet the investigation did not substantiate abuse. The report highlights the impulsive behavior of both residents due to their medical conditions, but it does not address the adequacy of supervision or preventive measures in place to protect high-risk residents from such incidents.
Failure to Monitor and Document Food Temperatures
Penalty
Summary
The facility failed to monitor and document food temperatures to ensure meals were served at a palatable temperature, affecting all residents. The facility's policy, last revised in September 2023, mandates that food temperatures be taken and documented before serving to prevent foodborne illness and ensure palatability. However, food temperature logs were incomplete for several weeks, with no documentation for the evening meals from December 4 to December 28, 2024, and missing records for B and C Halls between November 13 and December 18, 2024. This lack of documentation and monitoring led to residents receiving meals at inadequate temperatures. Residents expressed dissatisfaction with the temperature of their meals during Resident Council Meetings, noting that food was often served cold. On December 17, 2024, a resident reported that their food was cold and staff refused to reheat it. Another resident's meal was found to be at a low temperature, with mashed potatoes at 108 degrees Fahrenheit and carrots at 110 degrees Fahrenheit. The Dietary Manager acknowledged issues with staff obtaining but not documenting temperatures and noted that delays in serving trays, especially on weekends, contributed to the problem. The facility roster indicated that all 132 residents received meal trays, highlighting the widespread impact of this deficiency.
Facility Fails to Provide Residents Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds, affecting 100 out of 100 residents reviewed for personal funds management. The facility's policy stated that residents should have access to petty cash and be able to arrange for access to larger funds, with specific timelines for accessing different amounts. However, since the facility changed ownership on November 1st, 2024, residents have been unable to access their funds as needed. The previous company took all the resident funds from the cash box, leaving the new management without sufficient funds to meet residents' requests. Residents reported being unable to access their money, with some only receiving as little as four dollars in a week. The facility's banking hours were reduced from twice a week to once a week, and residents were limited to withdrawing ten dollars at a time. This situation left residents unable to purchase personal items or gifts, particularly during the holiday season. The Business Office Manager and Social Service Director confirmed the lack of funds and the inability to fulfill residents' requests, attributing the issue to the transition in ownership and the insufficient funds provided by the new company. The facility's administration acknowledged the problem, stating that the new company did not account for the number of residents and their financial needs. The facility was still in the process of resolving the issue, but in the meantime, residents continued to experience restricted access to their personal funds, causing frustration and dissatisfaction among them.
Failure to Report Alleged Sexual Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of employee-to-resident sexual abuse to the State Agency and Law Enforcement in a timely manner. The incident involved a resident who reported that an LPN entered his bathroom and inappropriately touched his groin area during a search for missing hand sanitizer. The resident reported the incident to the Ombudsman and the State, and it was noted that all the nurses were aware of the situation. Despite the resident's report, the facility did not notify the State Agency or Law Enforcement immediately as required by their policy. The facility's policy mandates that any allegation of abuse must be reported to the State Agency immediately, but not more than two hours after the allegation. However, the report to the State Regional Office was not made until three days after the incident. The facility's Director of Nursing (DON) was informed of the incident on the night it occurred but focused on the medical aspect of the resident potentially ingesting hand sanitizer rather than the abuse allegation. The Interim Administrator was also informed of the nature of the allegation on the day it occurred but did not act on it as a reportable abuse incident until prompted by a State Surveyor. The report indicates that the facility's failure to report the incident promptly was due to a misinterpretation of the situation as a behavioral issue rather than a serious allegation of sexual abuse. Written statements from staff were obtained, but the facility did not provide evidence that Law Enforcement was notified. The delay in reporting the incident to the appropriate authorities constitutes a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Protect Resident After Allegation of Sexual Abuse
Penalty
Summary
The facility failed to protect a resident after an allegation of sexual abuse by an employee was reported. The incident involved a Licensed Practical Nurse (LPN) who allegedly entered a resident's bathroom while the resident was on the toilet and inappropriately touched the resident's groin area during a search for missing hand sanitizer. The resident reported the incident to the Ombudsman and the State, and it was noted that the LPN was initially removed from the facility but returned the following day and was assigned to the same resident. The facility's policy on abuse prevention and reporting requires immediate protection of residents involved in such allegations, including removing the accused employee from resident contact until the investigation is complete. However, the LPN returned to work the next day due to a scheduling mistake, which was acknowledged by the Director of Nursing (DON). The incident was reported to the Interim Administrator, and the LPN was eventually removed from the facility, but the initial failure to prevent the LPN's return to work constituted a deficiency in protecting the resident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R9, from verbal abuse by a night shift CNA, V15. R9, who has multiple diagnoses including bipolar disorder and obesity, reported feeling insecure and degraded by V15's comments. R9 stated that V15 made derogatory remarks about her weight and menstrual condition, which made her feel humiliated. Other CNAs, V11 and V12, confirmed that R9 had complained about V15's behavior, including ignoring her call light and making derogatory comments. However, these complaints were not addressed by the CNA supervisor, V10, who claimed not to have received any reports of verbal abuse. The facility's policy on abuse prevention and reporting emphasizes the residents' right to be free from abuse, including mental and verbal abuse. Despite this policy, the facility did not take appropriate action to investigate or address the allegations made by R9. The administrator, V1, acknowledged that such behavior would be considered abuse, yet there was no evidence of any follow-up or corrective measures taken to address the situation. Attempts to contact V15 for her account of the events were unsuccessful, leaving the issue unresolved.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were immediately reported to the administrator for a resident who was cognitively intact and had multiple diagnoses, including bipolar disorder and borderline personality disorder. The resident expressed concerns about a night shift CNA, who allegedly made derogatory comments about her weight and refused to assist her properly during her menstrual period. The resident felt insecure and reported that some staff ignored her call light and grievances, leading to a lack of response to her complaints. Interviews with other CNAs revealed that the resident had complained about verbal abuse involving the same CNA, but these complaints were not reported to the CNA supervisor or the administrator. The CNA supervisor and the administrator both stated they had not received any reports of verbal abuse towards the resident. The facility's policy requires employees to report any incidents or suspicions of abuse immediately to the administrator, but this protocol was not followed, resulting in the deficiency.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a full mechanical lift, resulting in the resident being sent to the hospital with a back contusion. The resident, identified as R84, has multiple diagnoses including Bipolar Disorder, Deep Vein Thrombosis, Neurogenic Bladder, Diabetes Mellitus, Anxiety Disorder, Depression, and Obesity. The care plan for R84 indicated the need for a mechanical lift and two to three staff members for transfers due to limited mobility and morbid obesity. However, on the day of the incident, the resident was transferred by a single Certified Nurse Aide (CNA), V15, which led to the resident slipping out of the sling and sustaining an injury. The incident occurred when R84 requested to use the restroom and was hooked up to the mechanical lift by V15. Despite the care plan's requirement for multiple staff members, V15 attempted the transfer alone due to a lack of available staff. The CNA's personnel file indicated a lack of documented completion of mechanical lift training, and although V15 had received training in the past, the incident report noted that the fall was due to the improper use of the lift without the assistance of additional staff. The manufacturer's guidelines also recommended two assistants for safe operation, although it allowed for one assistant based on professional evaluation. Following the incident, the resident expressed fear of being transferred with the mechanical lift, citing concerns about the equipment's condition, including issues with the lift's legs and the availability of appropriately sized slings. The facility's failure to adhere to the care plan and ensure proper staffing and equipment maintenance contributed to the resident's injury and ongoing psychosocial distress.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer medications as prescribed for a resident, identified as R232, who was reviewed for medication administration. The facility's Medication Administration policy requires that medications be administered according to physician orders and documented accordingly. However, from September 18, 2024, to September 24, 2024, there was no documentation that R232 received their prescribed medications, including Albuterol, Amlodipine, Emtricitabine/Tenofovir, Fluticasone Propionate, and Folic Acid. This lapse occurred because the medications were not transcribed from the hospital transfer sheet to the Medication Administration Record, as confirmed by the Assistant Director of Nurses. The deficiency was identified during an interview with a Licensed Practical Nurse (LPN), who admitted the resident on September 18, 2024. The LPN stated that they used paper prescriptions and pill bottles to create the medication sign-out sheet, rather than following the facility's process of using the hospital transfer sheet. This deviation from protocol resulted in the resident not receiving their prescribed medications for several days, as confirmed by the Assistant Director of Nurses.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact Precautions to prevent the spread of multi-drug resistant organisms (MDROs) among its 132 residents. The facility's EBP policy, dated July 13, 2023, outlines the use of gowns and gloves during high-contact resident care activities, particularly for residents with open wounds, indwelling medical devices, or those colonized with MDROs. However, during a facility tour on September 22, 2024, no residents were observed to be in isolation or have EBP signage on their doors. Additionally, on September 23, 2024, staff members were observed performing catheter and wound care on residents without wearing gowns or other personal protective equipment (PPE), despite wearing gloves. The Infection Preventionist confirmed that EBP had not been implemented for several residents with wounds or indwelling medical devices. Furthermore, procedures related to Contact Isolation Precautions were not implemented for a specific resident. The facility's failure to adhere to its own policies and procedures for infection prevention and control was confirmed by the Infection Preventionist, highlighting a significant lapse in protecting residents from potential MDRO transmission.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which is designed to improve antibiotic use and reduce antibiotic resistance. The program's policy outlines several core elements, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. However, the facility did not adhere to these elements, as evidenced by the lack of protocols to review clinical signs, symptoms, and laboratory reports before administering antibiotics. The Assistant Director of Nursing/Infection Preventionist admitted that the facility does not use assessment tools or management algorithms to determine the necessity of antibiotics, relying instead on obtaining a doctor's order based on belief rather than documented criteria. The deficiency was identified during an interview and record review, revealing that the facility's staff did not complete forms detailing McGeer's protocol, which is intended to guide antibiotic use. This oversight affects all 132 residents in the facility, as there is no systematic approach to ensure antibiotics are used appropriately. The facility's failure to implement the Antibiotic Stewardship Program as per its policy potentially exposes residents to unnecessary antibiotic use and the associated risks of antibiotic resistance.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was adequately implementing and performing the duties required for the position, potentially affecting all 132 residents. The IP, who also serves as the Assistant Director of Nursing, confirmed that Enhanced Barrier Precautions were not implemented for residents with wounds or indwelling medical devices. Additionally, procedures related to Contact Isolation Precautions were not followed for a specific resident. The IP had recently received her training certificate but lacked proper guidance and was learning on the job. She reported being unable to dedicate sufficient time to the Infection Prevention Control Program due to other responsibilities, including staff scheduling, working on the floor, and attending meetings. The facility also failed to implement protocols for reviewing clinical signs and symptoms or laboratory reports before administering antibiotics. The IP admitted that the facility does not use assessment tools or management algorithms to determine the necessity of antibiotics, relying instead on calling the doctor for orders. The IP acknowledged that the antibiotic stewardship program was not yet operational. The facility's application for Medicare and Medicaid confirmed the presence of 132 residents, underscoring the potential widespread impact of these deficiencies.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure that resident call lights were responded to in a timely manner, affecting eight residents. During a group meeting with residents who attend Monthly Resident Council Meetings, several residents expressed concerns about excessive call light response times, particularly after meals and during the third shift. One resident reported waiting over an hour for assistance, while another mentioned being left on the toilet for over 20 minutes. The residents described the third shift staff as lazy, and one resident was so distressed by the wait times that it brought her to tears. Another resident reported having accidents and falls due to the long wait times for assistance. Observations confirmed these concerns, as one resident's call light was on for at least 20 minutes before a CNA responded. The CNAs acknowledged the issue, noting that the call lights do not make any noise, requiring staff to constantly look for lights that are on. This lack of an audible alert system contributed to delays in response times, especially during busy periods like after meals. The facility's Administrator in Training acknowledged the problem and mentioned that a staff member on the third shift had been terminated for sleeping on the job, which was expected to improve the situation.
Discrepancy in POLST and Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that the electronic medical records and care plans of two residents matched their Physician's Order for Life-Sustaining Treatment (POLST) regarding their CPR code status. For one resident, the Physician Orders sheet and the current care plan indicated a Full Code status, while the POLST form, signed by both the resident and the physician, indicated a Do Not Attempt Resuscitation (DNAR) status. This discrepancy was confirmed by the Social Services Director, who stated that the electronic chart should match the Physician's Order and the Care Plan, and both should align with the POLST. Similarly, another resident's care plan and Physician Order Sheet documented a Full Code status, whereas the POLST form, signed by the resident, Social Services, and the Medical Director, indicated a Do Not Resuscitate (DNR) status with comfort-focused treatment only. This inconsistency was verified by the Care Plan Coordinator and Social Services, who acknowledged that the care plans and Physician Orders did not match the POLST forms for these residents.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan for a newly admitted resident, identified as R232, within the required 48-hour timeframe. According to the facility's policy on Baseline Care Planning, a care plan should be promptly developed to provide effective person-centered care based on the resident's initial assessment. R232 was admitted with diagnoses including Adjustment Disorder with Depressed Mood, Borderline Personality Disorder, Post-Traumatic Stress Disorder, and Transsexualism. The resident's hospital history indicated a history of mental health issues, self-harming behaviors, and substance use. Despite these complexities, the Care Plan Coordinator confirmed that no baseline care plan was present in R232's medical record, stating that they had not yet addressed it.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with pressure ulcers, specifically for a resident identified as R84. The facility's policies on Preventative Skin Care and Dressing Care require handwashing at specific steps during wound care procedures. However, during an observation, a Licensed Practical Nurse (LPN) did not perform hand hygiene after removing gloves and before donning new ones while treating R84's sacral and right ankle wounds. Additionally, the LPN placed contaminated scissors on the bedside table and used a tube of antibiotic ointment without conducting hand hygiene, further compromising the infection control protocols. R84 had a physician's order for Contact Precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection in the right lower leg wound. Despite this, the LPN failed to adhere to the facility's Contact Precautions policy, which mandates handwashing and disinfection of equipment after glove removal. The LPN also handled personal items, such as a marker, without performing hand hygiene, increasing the risk of cross-contamination. The Assisting Director of Nursing and Infection Preventionist confirmed the breach in protocol, acknowledging that hand hygiene should have been conducted before and after glove changes and that equipment should have been disinfected.
Failure to Implement ROM Exercises for Resident with Limited Mobility
Penalty
Summary
The facility failed to implement and follow through with Range of Motion (ROM) exercises for a resident with functional limited range of motion. The resident, who is non-ambulatory and has difficulty with bed mobility and balance due to a musculoskeletal and neurological disorder, was observed in a wheelchair unable to move his legs or arms, with hands tightly balled up. The resident's care plan indicated a dependency on caregivers for activities of daily living due to a history of stroke, and the Minimum Data Set documented functional limitations in both upper and lower extremities. Despite having an order for a Passive ROM Program due to poor motivation for exercise and a sedentary lifestyle, the program was incorrectly entered into the system as PRN (as needed) instead of being scheduled for every day, every shift. This error was confirmed by the facility administrator, who acknowledged the incorrect entry in the Point Click Care system, leading to the deficiency in providing the necessary restorative care to maintain or improve the resident's range of motion.
Improper Indwelling Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The resident, identified as R92, had a physician's order for an indwelling catheter. During an observation, the catheter tubing and drainage bag were found lying on the floor, and the catheter bag was not covered with a privacy bag. Additionally, during a mechanical lift transfer, a CNA held the catheter bag above the resident's bladder, which is against proper procedure. These actions were verified by the staff involved, including a Licensed Practical Nurse and Certified Nursing Assistants, who acknowledged that the catheter should not have been on the floor and should have been covered, and that the catheter bag should not have been raised above the bladder during the transfer.
Failure in Dialysis Care Coordination and Communication
Penalty
Summary
The facility failed to provide ongoing communication with the dialysis center and did not develop a comprehensive care plan for a resident receiving dialysis services. The facility's policy requires coordination of care with the dialysis provider, including a predetermined schedule, medication changes, meal or snack provisions, fluid restrictions, and emergency protocols. However, the care plan for the resident did not address these elements, such as specific dialysis days, medication schedule changes, or emergency protocols. Additionally, the facility did not send a dialysis communication form with the resident to the dialysis center, which is a requirement according to the facility's policy. The resident, who was admitted with diagnoses including Type 1 Diabetes Mellitus, End Stage Renal Disease, and Kidney Transplant Rejection, attended dialysis three times a week. Despite this, the facility staff, including a Registered Nurse and a Licensed Practical Nurse, confirmed that they did not send a communication form with the resident to the dialysis center. The Director of Nurses verified that the resident's electronic medical record lacked any Dialysis Communication Tools and that the care plan did not include the necessary interventions. This lack of communication and incomplete care planning led to the deficiency identified by the surveyors.
Failure to Provide Adequate Psychiatric Support Services
Penalty
Summary
The facility failed to provide adequate psychosocial therapies and psychiatric support services to a resident diagnosed with Adjustment Disorder and Major Depressive Disorder, who had repeated emergency room visits for suicidal ideations and depression. The facility's assessment indicated that they would provide mental health and behavior support, including individual and group therapies, and psychiatric management. However, the resident, identified as R102, did not receive the necessary psychiatric counseling or therapy services as outlined in their care plan and PASRR recommendations. Observations and interviews revealed that R102 expressed unhappiness and had a history of suicidal ideations, which led to multiple hospital visits. Despite these incidents, there was a lack of documentation showing that R102 received the required psychiatric counseling or therapy services. The facility's records did not reflect any in-person psychiatry visits or group therapies since the resident's admission, except for a telehealth session with a psychiatrist in August. Additionally, there was no documentation of any refusals by the resident for the offered services. The facility's Social Service Director and Administrator in Training confirmed the absence of professional psychiatry notes and the lack of documentation regarding the resident's refusal of community mental health treatment. This deficiency highlights the facility's failure to adhere to its own policies and care plans, resulting in inadequate support for a resident with significant mental health needs.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to prevent physical abuse between two residents, R1 and R2, who were involved in an altercation resulting in R2 receiving a black eye. The incident occurred in the residents' shared room, and no staff witnessed the event. R1 admitted to hitting R2 in the face during an argument, which R2 confirmed, stating that the altercation was over a boyfriend. Both residents have a history of mental health disorders, with R1 diagnosed with Schizoaffective Disorder, Bipolar Disorder, and Paranoid Personality Disorder, among others, and R2 diagnosed with Schizophrenia, Paranoid Schizophrenia, and Dementia with Behavioral Disturbance. The facility's records indicate that the altercation was reported to the Administrator and the local police department, who interviewed both residents. The facility's Abuse Prevention Program, dated 11/28/2016, outlines the commitment to protecting residents from abuse by anyone, including other residents. However, the altercation between R1 and R2 suggests a failure in implementing this program effectively, as the root cause was determined to be related to R1's paranoid personality disorder. The incident reports and interviews reveal that both residents were aware of the altercation, with R1 stating that she would retaliate if hit. Despite the facility's efforts to educate the residents on appropriate behaviors and conflict resolution, the initial failure to prevent the altercation highlights a deficiency in the facility's ability to protect residents from abuse, as outlined in their Abuse Prevention Program.
Failure to Provide Speech Therapy Evaluations After Choking Incidents
Penalty
Summary
The facility failed to follow physician orders and have Speech Therapy services assess the swallowing needs of two residents after choking incidents. One resident, who had a history of poor-fitting dentures and difficulty chewing, choked on a biscuit and was sent to the emergency room. Despite a physician's order to downgrade the resident's diet and a subsequent refusal to attend a dental appointment, there was no documentation of a speech therapy evaluation before or after the choking incident. The facility's Director of Nursing confirmed that the resident had not been evaluated by Speech Therapy, and the Administrator acknowledged the absence of Speech Therapy services for the resident since the incident. Another resident, who had a diagnosis of COPD and was a former smoker, choked on lettuce and was also sent to the emergency room. The resident's diet was downgraded to mechanical soft texture, and a physician's order was issued for a Speech Therapy evaluation. However, there was no documentation of a speech therapy evaluation in the resident's medical record. The Director of Nursing was unsure about the availability of Speech Therapy services due to a new therapy company, and the Administrator confirmed that the resident had not been seen by Speech Therapy since the choking incident. Both residents experienced significant choking incidents that required emergency intervention, yet neither received the mandated Speech Therapy evaluations to assess their swallowing needs. The facility's failure to provide these evaluations, despite clear physician orders and the residents' documented needs, constitutes a deficiency in the provision of specialized rehabilitative services. The lack of Speech Therapy assessments potentially compromised the residents' safety and well-being, as their dietary needs were not adequately addressed following the choking episodes.
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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