Bella Terra Morton Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Morton Grove, Illinois.
- Location
- 8425 Waukegan Road, Morton Grove, Illinois 60053
- CMS Provider Number
- 145198
- Inspections on file
- 35
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bella Terra Morton Grove during CMS and state inspections, most recent first.
A bedbound, cognitively impaired male resident with multiple comorbidities, including COVID-19 and atrial fibrillation, was care planned and assessed as high fall risk, requiring his bed to be kept in the lowest position with partial side rails and hourly monitoring while on strict isolation. On a morning shift, an agency CNA received incomplete handoff, did not conduct room-to-room checks, and, upon finding the resident’s bed empty and not in low position with no side rails up, assumed he was out for an appointment without checking the bathroom or around the bed. The assigned RN, who had not physically seen the resident since the start of her shift, incorrectly told the CNA the resident might be at dialysis and did not verify his location, despite facility expectations for hourly checks of isolation residents. More than two hours after the resident was last seen in bed, a staff member discovered him unresponsive under the bed; the bed was still not in the lowest position, required fall-prevention interventions were not in place, and there was no documentation of the required hourly monitoring prior to his being found and later pronounced deceased.
A resident with severe cognitive and visual impairment was subjected to rough handling and disrespectful treatment by two CNAs during in-bed care, including being forcefully pushed down, threatened to stop screaming, and slapped on the face while visibly distressed and resisting care. The incident was not fully documented in the facility's internal report, and staff interviews revealed a lack of specific training on dementia care and de-escalation techniques. Facility leadership acknowledged the actions did not meet standards, but did not clearly identify them as abuse.
A resident with severe cognitive and visual impairment was physically restrained and slapped by two CNAs during care, resulting in emotional and physical harm. The staff involved lacked adequate training in behavior de-escalation and dementia care, and the facility's incident report failed to accurately document the abuse or the resident's distress.
A resident with severe cognitive impairment and behavioral challenges was subjected to rough handling and a face slap by two CNAs during personal care, despite a care plan outlining specific behavioral management interventions. Video evidence showed the resident in distress, with staff failing to follow care plan strategies or seek supervisory assistance. Staff interviews revealed a lack of training on dementia care and de-escalation techniques, and the incident was not fully documented in the facility's internal report.
A resident with severe cognitive impairment and behavioral challenges was subjected to physically rough handling by two CNAs during personal care, including being pushed, restrained, and slapped, despite a care plan outlining person-centered interventions. Video evidence showed the resident in distress, and interviews revealed staff lacked specific training in dementia care and de-escalation techniques. The incident was not fully documented in the facility's internal report, and staff did not follow established protocols for managing care-resistant behaviors.
Two CNAs failed to demonstrate competency in dementia care and behavior management when providing care to a resident with severe cognitive impairment, resulting in physical restraint, rough handling, and a slap to the resident's face during an episode of care resistance. The CNAs did not follow the resident's care plan interventions, and interviews revealed a lack of specific training in dementia care or de-escalation techniques.
Multiple residents and family members reported prolonged call light response times, especially on weekends, due to insufficient nursing staff. Delays ranged from 30 minutes to several hours for assistance with toileting and personal care, with some residents left unattended or forced to seek help independently. Staff interviews confirmed frequent complaints about slow responses, and the DON acknowledged receiving such reports, particularly on weekends.
The facility did not follow its own policy allowing 24-hour visitation, instead requiring all visitors to leave by 8:00PM each day. This practice was confirmed by a family member, multiple residents, and staff, and had the potential to affect all residents in the facility.
Several dependent residents were not provided with scheduled showers or grooming, as observed by surveyors and confirmed by staff interviews and documentation review. Residents were found with matted hair, dirty skin, and long, untrimmed nails, and records showed inconsistent or missing documentation of hygiene care. Facility policy requiring regular showers and documentation of refusals or alternative care was not followed, and some care plans lacked bathing and grooming interventions.
A resident with complex medical needs experienced emotional and psychosocial harm when a CNA threatened to leave her naked and soiled during incontinence care. The incident, witnessed by another resident and a family member and confirmed by video, resulted in the resident becoming hysterical and distressed. The facility administrator viewed the video but did not indicate any follow-up, and staff training on managing behavioral challenges was unclear.
A resident with complex medical needs was subjected to a threatening statement by a CNA during incontinence care, as witnessed by a cognitively intact roommate and captured on video. The facility's investigation was incomplete, failing to interview key witnesses and omitting critical details about the verbal threat, contrary to its abuse policy requirements.
A resident with multiple chronic conditions and hand contractures did not receive physician-ordered palm protectors, as staff failed to apply the splints and were unaware of the order. Observations showed worsening contractures, poor hygiene, and unmet restorative care needs, despite facility policy and care plans requiring these interventions.
A facility failed to notify a resident's family and physician about the discontinuation of Amlodipine and subsequent increased blood pressure. The resident, with a history of hypertension and heart issues, had their medication stopped without proper consent or notification, leading to increased blood pressure episodes. The nurse practitioner involved was not informed of these changes, contrary to facility policy.
A resident with a language barrier experienced inadequate care following a fall, as the LTC facility failed to document and communicate her refusals of a restorative walking program and scheduled showers, and her severe pain was not addressed in a timely manner. The facility's staff did not utilize translators or communication aids effectively, leading to a lack of timely intervention and inadequate documentation of the resident's condition and care.
A facility failed to maintain infection control in a common shower room, where soiled clothing and towels were left on the floor. A family member had previously reported the issue, and the CNA responsible admitted to not following proper aftercare procedures. The facility lacked a written policy on maintaining a clean environment after resident showers.
The facility failed to provide adequate CNA staffing in two units, affecting residents' care. Despite a staffing plan requiring 1 CNA per 11 residents, only one CNA was assigned per unit, with 14 and 15 residents respectively. Residents experienced delays in care, and staff struggled with workloads, especially with agency CNAs unfamiliar with residents' needs. The facility's staffing data indicated a concern related to the One Star Staffing Rating.
Two residents in a LTC facility suffered injuries due to inadequate fall prevention measures. One resident, with cognitive impairments, fell and sustained a subdural hematoma after attempting to walk unassisted, lacking nonskid footwear and floor mats. Another resident, with a history of alcohol abuse and neuropathy, fell while transferring from a wheelchair to a bed without assistance, resulting in a laceration. Both incidents were due to insufficient supervision and failure to implement necessary interventions for high fall risk residents.
Two residents at high risk for falls were not provided with effective interventions in an LTC facility. One resident experienced multiple falls due to improper use of a walker and lack of supervision, while another resident's bed alarm was not functioning, increasing fall risk. Staff were unaware of the residents' needs and the status of safety equipment, leading to deficiencies in care.
The facility failed to implement pressure ulcer prevention measures for two residents at high risk, as they were observed without their prescribed bilateral heel protectors while in bed. This led to skin impairment in one resident and inconsistent application of preventive measures.
The facility failed to follow physician orders and implement care plan interventions for two residents with contractures. One resident was observed without the prescribed hand splint, and the restorative assessment inaccurately reflected the resident's condition. Another resident was observed without the prescribed bilateral palm splints, and the restorative aide denied the observation. The facility's policies on restorative nursing programs and physician orders were not followed, leading to the deficiencies observed.
A facility failed to ensure the safe keeping of a resident's smoking materials, as the resident was found with his cigarette and lighter in his possession, contrary to the facility's policy. The resident, who smokes outside without staff assistance, had likely had his smoking materials since the previous day, and the staff were unaware of this.
The facility failed to position a resident in Fowler's position while infusing enteral feeding and did not hold the feeding during incontinence care. Two CNAs performed incontinence care on a resident lying flat with a gastrostomy tube connected to Jevity 1.5 tube feeding. The CNAs did not inform the nurse to turn off the feeding machine, and the resident's medical history includes Multiple Sclerosis and Gastrostomy status. The RN and DON acknowledged the mistake.
The facility failed to document the reason for not attempting a gradual dose reduction (GDR) for a resident on an antidepressant medication. Despite quarterly reviews indicating that a GDR was contraindicated, the nurse practitioner did not provide specific reasons in the progress notes, contrary to facility policy.
The facility failed to ensure daily refrigerator temperature checks were completed, affecting two residents. The housekeeping aide responsible for monitoring and recording the temperatures admitted to forgetting to document them, despite the facility's policy on sanitary food practices.
The facility failed to perform proper hand hygiene during incontinence care for a resident. Two CNAs were observed changing gloves without performing hand hygiene after cleaning fecal matter, contrary to facility policy and CDC guidelines. The DON confirmed the correct procedure was not followed.
Failure to Monitor High Fall-Risk COVID Isolation Resident and Maintain Bed Safety
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention interventions for a bedbound, high fall-risk resident on strict COVID-19 isolation. The resident was an older male with multiple diagnoses including Type 2 diabetes with hyperglycemia, COVID-19, prior head injury with surgical aftercare, syncope and collapse, and paroxysmal atrial fibrillation. His MDS showed moderate cognitive impairment (BIMS 11), he used a wheelchair, and did not attempt to walk due to medical or safety concerns. A fall risk evaluation scored him as high risk (score 9). His care plan and fall coordinator documentation required the bed to be kept in the lowest position, use of two partial side rails, call light and personal items within reach, no clutter on the floor, and hourly checks for residents on isolation. Facility policy on routine resident checks required initial rounds at the start of the shift and at least every two hours thereafter, and the infection control/designee and DON stated that COVID isolation residents were to be monitored every hour, with nurses and CNAs alternating. On the morning of the incident, the night nurse reported seeing the resident at 6:30 a.m. in bed, in the lowest position, sleeping comfortably, with no signs of distress. The night nurse stated that hourly monitoring was done but not documented, and that report was given to the day nurse. The day RN assigned to the resident began her shift at 7:00 a.m., received report that the resident had slept comfortably, and then passed morning medications until about 9:00 a.m. She acknowledged that she had not physically seen the resident at any time after starting her shift and assumed the CNA had seen him when passing breakfast trays. The agency CNA assigned to the resident stated that when she arrived for her 7:00 a.m.–3:00 p.m. shift, the night CNA was not present, she received no room-to-room report, and the nurse on duty said she was not familiar with the group. The CNA reported that she did not go room to room with the nurse and that the only information she received about the resident was that he needed to be checked and changed and that he had COVID. The agency CNA stated that between approximately 8:00 and 8:15 a.m., she went to deliver the resident’s breakfast tray, found the bed empty, and assumed he was out for an appointment. She did not check the bathroom, did not look around the room or on the other side of the bed, and noted that the bed was not in a low position and that no side rails were up. She left the tray and continued passing other trays. About an hour later, she returned and found the tray untouched, asked the nurse about the resident’s whereabouts, and was told he might be at dialysis; she accepted this explanation, although the resident was not a dialysis patient, and left the tray to warm later. The day RN confirmed that she mistakenly told the CNA the resident might be at dialysis, confusing him with another resident, and did not verify his presence in the room despite his being on strict isolation and requiring monitoring every one to two hours. Between 9:00 and 10:00 a.m., the social services director entered the resident’s isolation room after knocking and receiving no response, did not see him in bed, and then observed his feet and legs protruding from under the bed between the bed and the window. Most of his body was under the bed, and he was unresponsive. The social services director called for nursing staff. The rehab LPN and the day RN responded and found the resident lying between the heater and the bed, more under the bed, unresponsive, with no visible chest rise, no eye opening, and no communication. The bed was not in the lowest position. A code was called, CPR was initiated, oxygen was applied, and paramedics were summoned. Progress notes documented that at 9:12 a.m. the resident was found on the floor, unresponsive and not breathing, with blood pressure 106/66, pulse 171, respirations 0, and oxygen saturation 54% on room air. CPR and AED use were documented, and the resident was pronounced dead at 9:58 a.m. The death certificate listed cardiac arrhythmia, atrial fibrillation, and cerebrovascular disease as causes of death. Interviews with multiple staff confirmed that the resident was bedbound, unable to walk, on strict COVID isolation in a private room with the door to be closed, and identified as high fall risk by the fall coordinator, who specified that the bed should always be in the low position with both quarter-length side rails up. The DON, medical director, infection preventionist, and other nurses described expectations that staff perform initial physical checks at the start of each shift, conduct at least every-two-hour rounds for all residents, and hourly checks for isolation residents, with documentation in progress notes for COVID residents. However, review of the resident’s progress notes showed no documentation of hourly monitoring from the time he was placed on isolation. Staff interviews revealed that the day RN did not physically verify the resident’s presence after receiving report, the agency CNA did not thoroughly search the room or verify his location when he was not in bed, and the nurse gave incorrect information that he might be at dialysis. The bed was observed not to be in the lowest position and side rails were not in use when the CNA first entered the room and when the resident was later found under the bed, indicating that required fall-prevention interventions were not consistently implemented. As a result, the resident was not visually observed or assessed for over two hours while on strict isolation and high fall risk status, culminating in his being found unresponsive on the floor under the bed and subsequently pronounced deceased in the facility.
Resident Subjected to Rough and Disrespectful Care During ADL Assistance
Penalty
Summary
A cognitively and visually impaired resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia was subjected to rough and disrespectful care by two CNAs during an in-bed change. The resident, who was non-verbal and dependent for activities of daily living, was observed on video being physically handled in a rough manner, including having their head and torso forcefully pushed down while actively resisting and crying out. The CNAs were also heard threatening the resident to stop screaming and one was seen slapping the resident's face during care. The resident was visibly frightened, screaming, and resisting throughout the incident, but care continued without intervention from a nursing supervisor. The facility's internal incident report did not accurately document the full extent of the resident's distress, including the audible screams, resistance to care, threats, and the slap to the face. Interviews with staff revealed a lack of specific training on managing behaviors associated with dementia or de-escalation techniques. The CNAs involved did not recognize the resident's resistance as a behavioral response and did not employ appropriate interventions to address the resident's distress. One CNA admitted to being too rough and not receiving dementia-specific training, while the other acknowledged pushing the resident's head down and tapping the resident's cheek, later admitting this was inappropriate. Facility leadership, including the administrator and director of nursing, reviewed the video and acknowledged that the actions did not meet facility standards, but did not clearly identify the actions as abuse. The facility's policy emphasizes the right of residents to be treated with respect and dignity and to be free from mistreatment, but these standards were not upheld during the incident. The lack of appropriate assessment, intervention, and documentation contributed to the failure to ensure the resident's right to a dignified existence and respectful care.
Failure to Protect Resident from Abuse and Inadequate Staff Training on De-escalation
Penalty
Summary
A cognitively and visually impaired resident with severe dementia, major depressive disorder, and anxiety was subjected to physical and emotional harm during care provided by two CNAs. The resident, who was assessed as high risk for abuse and dependent in activities of daily living, was observed on video footage being physically restrained and slapped by one CNA while the other CNA assisted in changing the resident. The resident was visibly distressed, screaming, and resisting care, yet the CNAs continued with the care without seeking assistance from a nursing supervisor or employing de-escalation techniques. The facility failed to ensure that staff were adequately trained or monitored in behavior de-escalation and dementia care. Interviews with the involved CNAs revealed that they did not recall receiving specific training on managing behaviors associated with dementia or de-escalation techniques. One CNA admitted to not being trained in dementia care and only signing in on an inservice sheet, while the other could not recall any relevant training. Both CNAs minimized the resident's resistance, with one stating that the resident always cried out during care and the other describing the physical contact as a "love tap." The facility's internal incident report did not accurately document the severity of the incident, omitting details such as the resident's audible screams, resistance, threats made by staff, and the slap to the resident's face. The report also failed to reflect the emotional harm experienced by the resident. Staff interviews indicated a lack of understanding of appropriate interventions for residents exhibiting distress or resistance to care, and there was no evidence that the facility provided staff with the necessary training or guidance to prevent abuse or respond appropriately to challenging behaviors.
Failure to Implement Behavioral Care Plan Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement care plan interventions related to behavioral management for a resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. The resident was care-planned as high risk for mistreatment and had documented behaviors of screaming and resistance during care, with specific interventions outlined to address these behaviors, such as speaking calmly, avoiding escalation, and taking steps to help the resident feel safe. Despite these interventions, two CNAs did not follow the care plan strategies during an incident where the resident was being changed. Video evidence provided by the resident's family showed the CNAs restraining the resident by pushing his head and chest down, removing clothing in a rough manner, and slapping the resident's face after he screamed in distress. The resident was visibly frightened, screamed audibly, and resisted care, but the CNAs continued the interaction without calling a nursing supervisor or stopping to address the resident's distress. The facility's internal incident report did not document the audible screams, resistance, threats, or the slap observed in the video. Interviews with staff revealed a lack of specific training on managing the resident's behaviors or dementia care, with both CNAs unable to recall receiving relevant training or in-service education. The LPN who assessed the resident after the incident did so the following day and did not observe physical signs of injury. The DON and other facility leaders acknowledged that the actions did not meet facility standards but did not classify them as abuse. The resident was later observed to be withdrawn and non-verbal, with staff not engaging him in activities.
Failure to Follow Care Plan and Professional Standards for Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, major depressive disorder, anxiety disorder, and dementia was dependent on staff for activities of daily living and exhibited behaviors such as screaming and resistance during care. The resident's care plan included specific interventions for managing care-resistant behavior, such as using calm, soft tones, avoiding escalation, and employing person-centered approaches to ensure the resident felt safe and respected. Despite these directives, two CNAs failed to follow the established plan of care during an incident in which they attempted to change the resident's incontinence brief. Video evidence provided by the resident's family showed the CNAs engaging in physically rough handling, including pushing the resident's head down, restraining his chest, and removing clothing in a swift and rough manner, which caused the resident to shriek audibly and appear visibly frightened. One CNA was observed slapping the resident's face after telling him to stop screaming. The care was continued despite the resident's clear distress, and no nursing supervisor was called during the incident. The facility's internal incident report did not document the audible screams, resistance, threats, or the slap captured in the video. Interviews with the involved CNAs revealed a lack of specific training on managing dementia-related behaviors and de-escalation techniques. One CNA stated she did not receive training specific to the resident or dementia care, and both CNAs did not recognize the resident's resistance as a behavioral issue requiring specialized intervention. The DON and other staff acknowledged that the actions did not meet the facility's standards, but did not classify them as abuse. The incident demonstrated a failure to provide care in accordance with professional standards and the resident's individualized care plan.
Failure to Ensure CNA Competency in Dementia Care and Behavior Management
Penalty
Summary
Two Certified Nursing Assistants (CNAs) failed to demonstrate appropriate competency in dementia care and behavior management for a resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, and anxiety disorder. The resident, who was non-verbal and exhibited care-resistant behaviors, had a care plan that required staff to use de-escalation strategies and ensure the resident felt safe during care. However, during an observed incident, the CNAs did not follow these interventions. A video provided by the resident's family showed one CNA repeatedly telling the resident to put his head down, physically restraining the resident's head and chest, and another CNA removing the resident's clothing in a rough manner. The resident was visibly distressed, screaming, and resisting care, but the CNAs continued without calling for a nursing supervisor. The video also captured one CNA slapping the resident's face after telling him not to scream. Interviews revealed that the CNAs could not recall receiving specific training on dementia care or de-escalation techniques, and one CNA stated she was floated between assignments without dementia-specific training. The facility's internal incident report did not accurately document the resident's distress or the physical actions taken by staff, omitting key details such as the slapping and audible screams. Staff interviews further indicated a lack of understanding of appropriate interventions for care-resistant behaviors.
Insufficient Nursing Staff Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the needs of all residents, resulting in prolonged call light response times and delays in assistance with activities of daily living, including toileting and personal care. Multiple residents reported that on weekends, staffing was particularly inadequate, with only one nurse and one CNA assigned to their unit. One resident described waiting five hours for a diaper change, timing the delay from 4:00 PM to 9:00 PM, and noted that no staff communicated the reason for the delay. Another resident reported waiting forty to sixty minutes for staff to respond to call lights on several occasions, especially during the evening shift, and expressed concern about the lack of communication from staff regarding delays. Family members also reported difficulty reaching staff to request assistance for residents, with one family member making multiple unsuccessful attempts to contact the nurse's station about a soiled diaper. Residents and family members described hallways being empty and staff unavailable, particularly on weekends. One resident stated she had to walk to the bathroom unassisted due to unanswered call lights. Staff interviews confirmed that complaints about delayed call light responses were common, especially on weekends, and that agency staff required additional supervision. The DON acknowledged receiving complaints about prolonged response times, mainly from family members over the weekend. During a resident council meeting, all present residents unanimously expressed concerns about long wait times for staff to respond to call lights, with reported delays ranging from 30 minutes to over three hours, again noting weekends as the worst. The facility's own policy requires prompt response to resident calls for assistance, but the evidence gathered from resident, family, and staff interviews, as well as direct observations, demonstrates a consistent failure to meet this standard.
Failure to Allow 24-Hour Visitation as Required by Facility Policy
Penalty
Summary
The facility failed to follow its own visitation policy, which allows for 24-hour access for immediate family, other relatives, and authorized persons with the resident's consent. Instead, the facility enforced a policy requiring all visitors to leave by 8:00PM each day. This was confirmed through interviews with a family member/POA, several residents during a resident council meeting, the nursing supervisor, and the receptionist. The family member/POA reported being asked to leave by 8:00PM, with the nursing supervisor monitoring their departure. Residents also confirmed that visitors are routinely made to leave at 8:00PM. Staff interviews further corroborated that the facility's practice was to end visitation at 8:00PM, with the receptionist and nursing supervisor coordinating to ensure all visitors exited the building at that time. This practice was in direct contradiction to the facility's written policy, which permits 24-hour visitation for certain individuals. The daily census indicated that this failure had the potential to affect all 154 residents residing in the facility.
Failure to Provide Scheduled Showers and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). Multiple residents were observed with poor hygiene, including matted hair, dirty skin, long fingernails with debris, and untrimmed beards. Documentation showed that showers and bed baths were not consistently provided as scheduled, and there was no record of resident refusals or preferences for alternative hygiene care. Staff interviews confirmed that some residents had not received showers or grooming for extended periods, and that documentation of care was incomplete or missing. One resident with significant medical conditions, including metabolic encephalopathy, chronic kidney disease, and osteoarthritis, was observed with contractures, matted hair, dry and flaky skin, and long, unclean fingernails. The resident reported not receiving showers and could not recall the last time her hair was washed. Another resident stated he had not received a shower or grooming in over a month, and his last documented shower was several weeks prior. Additional residents were observed with greasy, matted hair, dirty faces, and long toenails, with one resident's care plan lacking any mention of bathing or grooming needs. Facility policy requires that residents receive showers at least once weekly and as necessary, with refusals and alternative care to be documented. However, review of records and staff interviews revealed that these procedures were not followed. There was a lack of documentation for showers, refusals, or alternative hygiene care, and some residents' care plans did not address their bathing and grooming needs, resulting in unmet ADL care for several dependent residents.
Resident Threatened and Emotionally Harmed During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) threatened a resident during incontinence care, resulting in emotional and psychosocial harm. The resident, a female with multiple complex diagnoses including Moyamoya disease, dysphagia, altered mental status, conversion disorder with seizures, and cerebral aneurysm, was being changed after a bowel movement. During the care, the CNA rolled the resident onto her left side, causing pain, which the resident communicated by kicking and swinging her arms. The CNA responded by telling the resident, "No, no, you better stop, or I am going to leave you here like this," while the resident was naked and soiled. This statement was perceived as a threat to leave the resident in a vulnerable and undignified state. The incident was witnessed by another resident and a family member, both of whom observed the resident become hysterical and emotionally distressed. A video recording of the incident confirmed the CNA's threatening statement and the resident's distress. The family member reported the incident to the facility administrator, who viewed the video but did not indicate any follow-up action. The administrator was unable to confirm whether staff received training on managing residents with behavioral challenges. The facility's abuse policy prohibits mental abuse, including threats and humiliation, but the actions of the CNA were inconsistent with this policy, resulting in documented emotional harm to the resident.
Failure to Properly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to properly investigate an allegation of abuse involving a female resident with multiple complex diagnoses, including Moyamoya disease, dysphagia, altered mental status, and conversion disorder with seizures. The incident in question involved a certified nursing assistant (CNA) changing the resident's incontinence brief, during which the resident exhibited signs of pain and distress, such as kicking and banging on the bed. The CNA was heard making a threatening statement to the resident, indicating she would leave the resident in a vulnerable condition if the behavior did not stop. A roommate, who was present and cognitively intact, witnessed the event and later reported not being interviewed as part of the facility's investigation. The facility's investigation was incomplete, as it did not address the verbal statement made by the CNA, failed to interview the eyewitness roommate, and contained inconsistencies regarding the date of the alleged incident. The facility's abuse policy requires thorough investigations, including interviews with all involved persons and witnesses, but these steps were not followed. Additionally, the facility's report did not reflect all relevant details observed in the video evidence or concerns raised by the resident's family member, who had reported the incident and shared the video with the administrator.
Failure to Apply Ordered Hand Splints for Resident with Contractures
Penalty
Summary
Staff failed to provide ordered care for a resident with decreased range of motion by not applying physician-ordered splints to both hands. The resident, who has a history of multiple chronic conditions including metabolic encephalopathy, chronic obstructive pulmonary disease, chronic kidney disease, osteoarthritis, and diabetes, was observed on two occasions without the required hand splints. Observations noted contractures in both hands, with fingernails on the left hand digging into the palm, and the resident was unable to open her hands. Additional observations included matted hair, dry and flaky skin, and long fingernails with brownish substances underneath. The resident's care plan and physician orders specified the use of palm protectors for both hands for at least 2-4 hours daily or as tolerated, with staff responsible for assisting with their application and monitoring for skin concerns. Interviews with staff revealed a lack of awareness and follow-through regarding the splint orders. The assigned LPN was unaware of the need for hand splints, and the restorative aide admitted to not providing restorative care on the day prior to the survey and was unsure of the whereabouts of one of the splints. The restorative aide confirmed that all staff were supposed to assist the resident with the splints, but this was not consistently done. Facility policy required assessment and provision of restorative services, including contracture management and splint use, but these were not implemented as ordered for this resident.
Failure to Notify Family and Physician of Medication Discontinuation and Increased Blood Pressure
Penalty
Summary
The facility failed to notify a resident's family member and physician about the discontinuation of a hypertensive medication, Amlodipine, and the subsequent increase in the resident's blood pressure. The resident, who had a complex medical history including hypertension, heart failure, and dementia, was admitted with an order for Amlodipine to manage essential hypertension. On a specific date, a nurse documented notifying a nurse practitioner about a change in the resident's condition, leading to an order to stop Amlodipine. However, the family member did not consent to the discontinuation and requested the medication be held for four days, which was not communicated to the nurse practitioner. The medication was not administered after this date, and the resident experienced increased blood pressure episodes without the physician or nurse practitioner being notified. The nurse practitioner, who was covering for the resident's primary care physician, stated she only ordered the medication to be held for four days and denied ordering its discontinuation. She was not informed of the discontinuation or the resident's increased blood pressure episodes. The facility's policy requires immediate notification of significant changes in a resident's condition to the resident, their physician, and family members, which was not adhered to in this case. This deficiency affected one of the three residents reviewed for notification of change in condition.
Failure to Provide Timely Care and Address Language Barriers
Penalty
Summary
The facility failed to provide necessary treatment and care in a timely manner to a resident with a language barrier who had been refusing to participate in a restorative walking program, scheduled showers, and was experiencing severe pain following a fall incident. The resident, who has a history of falls and a diagnosis including a fracture of the sacrum, was observed to be lethargic and arousable, with inadequate documentation of her condition and care. The facility's staff, including the receptionist and restorative aides, did not document or communicate the resident's refusals and pain effectively, leading to a lack of timely intervention. The resident's medical records indicated a history of unwitnessed falls and a comprehensive care plan that highlighted her high risk for falls and difficulty in communication due to a language barrier. Despite having a care plan that involved the use of translators and communication aids, these were not utilized effectively by the staff. The resident's pain assessments were inconsistent, and there was a lack of documentation regarding her refusals of care and treatment, which were not communicated to the family or the interdisciplinary team. The facility's policies on pain management and language line solutions were not adequately followed, contributing to the deficiency. The resident's family was not informed of her refusals of care, and there was a miscommunication regarding the decision to send the resident to the hospital for evaluation. The facility was unable to provide a policy on reporting and documenting reasons for resident refusal of treatment and care, further highlighting the gaps in communication and documentation that led to the deficiency.
Infection Control Lapse in Shower Room
Penalty
Summary
The facility failed to ensure appropriate infection control practices in one of the common shower rooms used by residents. During an observation, soiled resident clothing, towels, and washcloths were found on the floor of the shower room. A family member had previously reported the issue of the shower room being dirty and not cleaned, with soiled items left behind. The housekeeping supervisor and an LPN confirmed that the CNA should have placed all soiled items in a plastic bag after the shower, rather than leaving them on the floor. The CNA responsible for the shower admitted to forgetting to place the soiled items in a plastic bag and acknowledged that they should not have been left on the floor. The Director of Nursing confirmed that aftercare procedures require gathering all soiled items and placing them in a plastic bag, but the facility did not have a written policy on this procedure. Despite a previous grievance being filed and addressed, the issue persisted, indicating a lapse in maintaining a clean environment in the shower room.
Inadequate CNA Staffing in Facility Units
Penalty
Summary
The facility failed to provide adequate staffing for Certified Nursing Assistants (CNAs) in two units, Suites North and Suites South, affecting three residents reviewed for staffing and potentially impacting 29 residents residing in these units. The facility's staffing plan, as per the Facility Assessment Tool 2024, requires 1 CNA per 11 residents for the day and evening shifts, and 1 CNA per 13 residents for the night shift. However, the Daily Schedule from 10/6/2024 to 11/3/2024 showed only one CNA working per shift on each unit, despite Suites North having 14 residents and Suites South having 15 residents on 11/4/2024. Interviews with residents and staff revealed concerns about the adequacy of care, with residents experiencing delays in call light responses and personal care, and staff expressing difficulties in managing workloads, especially with agency CNAs unfamiliar with residents' needs. Observations and interviews highlighted specific issues, such as a resident not receiving regular showers and another resident requiring two-person assistance for transfers, which further strained the limited staffing resources. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) on duty reported that they often had to assist CNAs with tasks like transfers and feeding, which impacted their ability to perform other duties, such as medication administration. The Nursing Scheduler/CNA Supervisor confirmed that staffing was based on census numbers, and despite the facility being full, only one CNA was assigned per unit. The facility's Payroll-Based Journal Staffing Data Report for FY Quarter 3 2024 indicated a concern related to the One Star Staffing Rating, underscoring the staffing deficiencies observed during the survey.
Inadequate Fall Prevention Leads to Resident Injuries
Penalty
Summary
The facility failed to implement adequate fall prevention interventions for two residents, resulting in significant injuries. One resident, who had a cognitive communication disorder and poor safety awareness, fell while attempting to walk unassisted. Despite being known for impulsive behavior and having a history of falls, the resident was left without nonskid footwear or floor mats, and the bed was not in the lowest position. The resident sustained a subdural hematoma and was hospitalized, where they later died from cardiac arrest and aspiration pneumonia. Another resident, with a history of alcohol abuse and neuropathy, attempted to transfer from a wheelchair to a bed without assistance, resulting in a fall and a laceration requiring sutures. This resident was known to refuse assistance and had a high fall risk score. Despite being close to the nurses' station, the resident was not adequately supervised, and the call light was not utilized. The resident's impulsive behavior and poor safety awareness were contributing factors to the fall. Both incidents highlight the facility's failure to provide necessary supervision and interventions for residents at high risk of falls. The lack of appropriate footwear, supervision during transfers, and failure to ensure the use of assistive devices contributed to the accidents. These deficiencies resulted in harm to the residents, with one sustaining a serious head injury and the other requiring medical attention for a facial laceration.
Failure to Prevent Falls Due to Inadequate Supervision and Equipment Monitoring
Penalty
Summary
The facility failed to provide effective resident-centered interventions for residents identified to be at high risk for falls, affecting two residents. One resident, identified as R1, experienced multiple falls, including an unwitnessed fall on 6/28/24, which resulted in a head injury requiring medical glue. R1, who has severe cognitive impairment and a history of impulsive behavior, was observed using a walker improperly and without adequate supervision. Staff members assigned to R1's unit were unaware of his identity and care needs, indicating a lack of communication and supervision. Another resident, identified as R3, was observed walking unassisted in his room despite being at high risk for falls due to cognitive impairment and other medical conditions. R3's bed alarm, intended to alert staff when he attempted to get out of bed, was not functioning properly, and staff were unaware of its status. This lack of awareness and failure to ensure the alarm was operational contributed to the risk of falls for R3. The facility's fall occurrence policy mandates that residents at high risk for falls should have interventions in place, which should be reevaluated and revised as necessary. However, the observations and interviews revealed that these interventions were not effectively implemented or monitored, leading to the deficiencies noted in the report. The lack of proper supervision and failure to ensure the functionality of safety devices like alarms were significant factors in the deficiencies identified by the surveyors.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement interventions to prevent skin impairment in residents at high risk for developing pressure ulcers. Specifically, two residents, R107 and R64, were observed without their prescribed bilateral heel protectors while lying in bed. R107, who has multiple diagnoses including Multiple Sclerosis and altered mental status, was found without heel protectors on multiple occasions, leading to blanchable redness on the right heel. The assigned CNA admitted to forgetting to apply the heel protectors. Similarly, R64, who has a history of pressure ulcers and multiple comorbidities, was also observed without heel protectors on two separate days. The CNA responsible for R64 confirmed the requirement for heel protectors but failed to apply them consistently. Both residents have care plans indicating the need for offloading heels to prevent pressure ulcers, and the facility's policy mandates prompt identification and treatment of skin breakdown. Despite these measures, the facility did not ensure the consistent application of heel protectors, as evidenced by the observations and staff interviews. The wound care nurse confirmed the importance of heel protectors in preventing pressure ulcers and acknowledged the residents' high risk for skin impairment.
Failure to Follow Physician Orders and Implement Care Plan Interventions for Residents with Contractures
Penalty
Summary
The facility failed to follow physician orders and implement care plan interventions for two residents with contractures. One resident, who was totally dependent and had contractures in both hands, was observed lying in bed without the prescribed hand splint. The hand splint was found placed over a fluorescent light cover above the bed, and the resident's left hand was severely contracted. The family member of the resident expressed concerns about the condition of the splint and the lack of action from the facility. The resident's medical records indicated an active order for the left hand splint, but the restorative assessment inaccurately reflected the resident's condition, and no care plan was formulated regarding the restorative program for the left hand contractures. The restorative program log showed no application of the left-hand splint for a week, and the restorative nurse inaccurately completed the assessment and discontinued the care plan without proper justification. The Director of Nursing (DON) acknowledged the concerns and indicated a referral to an occupational therapist would be made. Another resident, who had multiple sclerosis and other significant health issues, was observed without the prescribed bilateral palm splints. The restorative aide responsible for applying the splints denied the observation made by the surveyors and the RN. The resident's medical records and care plan indicated the need for bilateral palm protectors to prevent digging of the palms and to be applied after morning care for at least four hours as tolerated. The restorative program log showed no application of the bilateral hand splints/palm protectors for a week. The facility's policies on restorative nursing programs and physician orders were not followed, leading to the deficiencies observed. The facility's policy on restorative nursing programs and physician orders emphasized the need for comprehensive assessments and adherence to physician orders. However, the facility failed to implement these policies effectively, resulting in the lack of proper care for residents with contractures. The deficiencies were identified through observations, interviews, and record reviews, highlighting the need for accurate assessments, proper documentation, and adherence to care plans to ensure the well-being of the residents.
Failure to Ensure Safe Keeping of Resident's Smoking Materials
Penalty
Summary
The facility failed to ensure the safe keeping of a resident's smoking materials when not in use, as observed during a survey. On the morning of 4/17/24, a resident was found lying on his bed with his cigarette and lighter in his possession. The resident, who is alert and oriented, stated that he smokes outside the building 2-3 times a day without staff assistance and keeps his smoking materials with him. This observation was contrary to the facility's policy, which mandates that staff should keep the resident's smoking materials for safe keeping when not in use. Further investigation revealed that the Director of Nursing and an Agency RN were unaware that the resident had his smoking materials with him. The Agency RN confirmed that the smoking materials were supposed to be kept in the medication room and provided to the resident only when he goes out to smoke. However, the RN found the plastic pouch meant for the resident's smoking materials empty and realized that the night shift had not endorsed the materials to her. The resident had likely had his cigarette and lighter since the previous day. The resident has a medical history that includes nicotine dependence, acute pulmonary edema, chronic obstructive pulmonary disease, and dependence on renal dialysis.
Failure to Properly Manage Enteral Feeding During Incontinence Care
Penalty
Summary
The facility failed to position a resident in Fowler's position while infusing enteral feeding and did not hold the enteral feeding administration during incontinence care. This deficiency was observed when two CNAs were performing incontinence care for a resident who was lying flat on their right side with a gastrostomy tube connected to Jevity 1.5 tube feeding in progress at 65ml/hr. The CNAs were unaware that the feeding tube should be turned off during such care, and they did not inform the nurse to turn off the feeding machine before starting the incontinence care. The resident's medical history includes Multiple Sclerosis, Altered mental status, Demyelinating disease of the central nervous system, and Gastrostomy status, with active physician orders specifying that the enteral feeding should be turned off during ADLs and the resident should be positioned in Fowler's position while the feeding is running. The CNAs and the RN acknowledged the mistake upon being informed of the observation, and the RN turned off the feeding machine afterward. The Director of Nursing also confirmed that the CNAs should have informed the nurse before performing incontinence care so the feeding tube could be turned off, and the resident should not have been in a flat position while the feeding was running.
Failure to Document Reason for Contraindicated Gradual Dose Reduction
Penalty
Summary
The facility failed to document the reason why a gradual dose reduction (GDR) was contraindicated for one resident (R126) who was on an antidepressant medication. This deficiency was identified during a survey when the psychotropic nurse (V14) was unable to provide a documented reason for not attempting a GDR for R126. The resident's medical records indicated that GDRs were reviewed quarterly, but the notes from the nurse practitioner (V28) did not specify why the dose reduction was contraindicated, despite being marked as such on multiple occasions. R126's medical history includes diagnoses such as Toxic Encephalopathy, Cerebrovascular Disease, Major Depressive Disorder, and Complications of Heart Transplant. The resident was admitted on 6/13/23 and was prescribed Sertraline HCl Oral Tablet 100 MG once per day. Progress notes from 6/28/23, 9/11/23, and 1/30/24 indicated that a dose reduction was not indicated and was contraindicated, but no specific reason was documented. The facility's policy requires that if no GDR is done, there should be a psychiatric note explaining why it is contraindicated, which was not adhered to in this case.
Failure to Complete Daily Refrigerator Temperature Checks
Penalty
Summary
The facility failed to ensure daily refrigerator temperature checks were completed, affecting two residents. On 4/16/24, it was observed that the refrigerator temperature log for one resident was not completed that morning, and the refrigerator contained various food items. The RN confirmed that the housekeeping aide was responsible for monitoring and recording the refrigerator temperature daily. The actual refrigerator thermometer reading was 40°F. Similarly, another resident's refrigerator temperature log was not completed on 4/15/24 and the morning of 4/16/24, with the refrigerator containing multiple food items. The RN again confirmed the housekeeping aide's responsibility, and the thermometer reading was also 40°F. The Director of Nursing was informed of these observations, and it was confirmed that either the housekeeping aide or maintenance was responsible for the daily monitoring and recording of the resident refrigerators. On 4/18/24, the housekeeping aide assigned to the unit admitted that she probably forgot to document the refrigerator temperatures. The facility's policy on food from the outside, revised on 7/28/23, states that the facility will comply with sanitary food practices, including placing food items requiring refrigeration inside the refrigerator.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to perform proper hand hygiene during incontinence care for one of the residents. On 4/18/24 at 9:13 AM, two CNAs were observed performing incontinence care on a resident. One CNA cleansed fecal matter from the resident's sacral area while the other CNA held the resident in a left-sided position. After cleaning the fecal matter, the CNA applied a clean disposable adult brief to the resident and removed the soiled linens. Both CNAs changed their gloves without performing hand hygiene in between, which is against the facility's policy and CDC guidelines for infection control. When informed of the observation, one CNA incorrectly stated that it was not necessary to change gloves after cleaning fecal matter, while the other CNA acknowledged the need to change gloves and perform hand hygiene. The Director of Nursing confirmed that the CNAs should have removed their gloves and performed hand hygiene after handling fecal matter and before handling clean objects. The facility's policies on hand hygiene and incontinence care, revised on 7/28/23, clearly state the importance of hand hygiene in preventing infections and the proper procedures to follow during incontinence care.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
