Bella Terra Schaumburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Schaumburg, Illinois.
- Location
- 675 South Roselle Road, Schaumburg, Illinois 60193
- CMS Provider Number
- 145678
- Inspections on file
- 29
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Bella Terra Schaumburg during CMS and state inspections, most recent first.
A resident with brain cancer, dysphagia, and broken teeth was observed eating a mechanical soft meal while lying in bed with the HOB declined and the room curtain pulled, leaving him not visible from the hall. Staff later confirmed he ate in bed and needed to be upright during meals. In a separate finding, a second-floor medication cart was left unlocked in the hallway with no staff nearby until an LPN returned and locked it.
Bedtime snacks were not offered to 5 of 5 residents reviewed for snacks. During a resident meeting, all 5 said they do not receive or are not offered HS snacks, and one cognitively intact resident who served as Resident Council President said she could not even get an extra cookie or dessert to take back to her room. The Dietary Manager said snacks are only provided to residents on a dietitian list and that no other residents are offered snacks, despite facility policies stating HS snacks and between-meal snacks are to be made available.
A resident’s medication information was left visible on a cart-mounted computer in a hallway outside a resident room when an LPN stepped away from the cart and no staff were nearby. The DON stated the screen should have been closed and that exposing resident information was a HIPAA violation. The facility policy states residents have a right to secure and confidential personal and medical records, including electronic records.
A resident with severe cognitive impairment and total dependence for toileting and personal hygiene was found incontinent of stool during wound care, but staff did not fully clean the perineal and vaginal area on the first attempt. Visible stool remained on the resident and on the brief after care, and multiple wipes used during the encounter contained stool. The DON stated stool must be fully removed during care to prevent infection and skin breakdown.
A resident with severe cognitive impairment and total care needs had bruising and steri-strips on both shins with drainage visible under the strips, but staff did not identify, assess, or initiate treatment for the new skin condition. The wound care nurse and nursing supervisor were unaware of the issue, and there were no orders in place for the bilateral shins despite the resident being high risk for altered skin integrity.
Insulin Pen Not Disinfected Before Needle Attachment: An RN prepared and administered Humalog from an insulin pen to a resident with dementia and type II DM without disinfecting the rubber top before attaching the needle. The RN and an LPN stated alcohol was not needed, while the Nurse Manager and DON stated the pen should be disinfected for infection control. The facility policy did not address disinfecting insulin injector pens before needle attachment.
The facility failed to prevent cross contamination during incontinent care for two residents and failed to ensure required PPE was worn during IV access for another resident. A CNA used the same wipes across multiple areas during perineal care for a resident who was incontinent and dependent on staff, and during wound/incontinent care for another resident, staff tossed stool-soiled wipes onto the floor and then handled them while standing over the contaminated area. An RN also accessed a resident’s IV antibiotic without wearing the gown required under EBP, despite a posted sign indicating gown use for device care.
The facility failed to monitor and assess a resident who lost 21 lbs in 14 days without re-weighing or assessment. Another resident under hospice care did not receive physician-ordered supplements, risking further weight loss. The facility lacked a weight loss/prevention policy, contributing to these deficiencies.
The facility failed to ensure residents and their representatives understood the Health Care Arbitration Agreement (HCAA) they signed, affecting four residents. A resident and a POA signed the HCAA without clear explanations of its implications, such as waiving legal rights. Staff responsible for presenting the HCAA were not formally educated on how to explain the agreement, and the facility lacked a policy on the arbitration agreement.
The facility failed to prevent resident-to-resident abuse involving two residents, where one resident verbally and physically assaulted another by grabbing his wrist, causing skin breakage. The incident was reported to the administrator and documented by an LPN, who found the residents in a heated exchange. The facility's policy mandates an abuse-free environment, which was not maintained.
The facility failed to provide written notices of hospital transfers to two residents or their representatives. Staff communicated verbally but did not send written notices, and the facility lacked a policy for such notifications.
The facility failed to notify residents or their representatives of the bed hold policy in writing during hospital transfers. In three cases, staff gave paperwork to EMTs but did not inform families, and there was no documentation of written notices. Interviews revealed a consistent practice of not informing families, despite the facility's policy requiring written notification.
A resident was diagnosed with schizophrenia without proper assessment, as required by professional standards. The diagnosis appeared on her face sheet two years after admission, despite not being listed in her admission hospital records. Interviews with facility staff revealed a lack of clarity and testing regarding the diagnosis, with the primary care physician and psych nurse practitioner both acknowledging the absence of a full psychiatric evaluation.
The facility failed to provide adequate ADL care for three residents requiring extensive assistance. A resident was found in the same clothes for four days with a saturated diaper, despite needing substantial assistance due to chronic conditions. Two other residents were left in reclining wheelchairs for extended periods without being toileted, contrary to their care plans and facility policy requiring regular incontinence checks.
A facility failed to implement a resident's skin preventive treatment as ordered by the physician. During a bed bath, a CNA found the resident's diaper saturated with urine and the coccyx red with a small open area, noting the absence of a usual dressing. Wound care nurses later confirmed the condition as MASD, with preventive treatment orders in place to prevent skin breakdown. The resident, on hospice care and bedridden, had orders for calamine-zinc oxide lotion, duraseptine with xeroform, and xeroform oil emulsion gauze to be applied every shift.
Two residents developed significant pressure injuries due to the facility's failure to report and identify skin alterations in a timely manner. One resident developed an unstageable pressure injury on the coccyx, while another developed a stage 2 ulcer on the heel, despite having protective measures in place. Both residents required assistance with personal care and had care plans indicating potential skin integrity issues.
A resident with a high fall risk was left unattended on the toilet, leading to a deficiency in safety supervision. The resident, not alert and oriented, was heard calling for help with no staff present. An agency CNA admitted to leaving the resident alone, and both a CNA and an LPN confirmed that the resident should not be left unattended due to her fall risk. The resident's fall risk score was 15, indicating a high risk according to the facility's evaluation.
A resident with a history of UTI did not receive prescribed catheter care, including Betadine application and catheter flush, as documented in their Treatment Administration Record. The DON confirmed these interventions were necessary to prevent infection, but documentation was missing for specific dates, indicating a lapse in care.
A discrepancy was found in the inventory of controlled medications for a resident, where 22 doses of methadone were available instead of the 23 documented. A nurse incorrectly documented the administration, skipping an entry. The facility's policy requires accurate counts and immediate reporting of discrepancies, which was not followed.
A facility failed to implement pharmacy recommendations for a resident's psychotropic medications after the physician agreed to a gradual dose reduction. Despite the consultant pharmacist's recommendation and the physician's agreement, the resident's medication orders were not adjusted. The psychotropic nurse admitted that clarification on the specific dose was needed but not obtained.
A facility failed to implement a gradual dose reduction (GDR) for a resident's psychotropic medications, despite a consultant pharmacist's recommendation and physician agreement. The resident continued receiving the same dosages of sertraline and quetiapine for several months, contrary to federal regulations and the facility's policy. The psychotropic nurse admitted that the necessary dosage adjustments were not clarified or implemented in a timely manner.
A resident with multiple diagnoses, including Parkinson's disease and major depressive disorder, was found holding a medication cup with 7-10 pills and a pill on her bed, indicating improper medication administration and storage. The RN acknowledged the resident's habit of taking medications slowly and stated that staff should monitor until all medications are ingested, as per facility policy.
The facility failed to follow proper infection control practices during perineal care for two residents. CNAs did not change gloves or perform hand hygiene after cleaning soiled areas, violating the facility's policies. These actions were observed during care for a resident with a history of COVID-19 and another resident after a bowel movement.
A resident was prescribed Keflex for recurrent UTI prophylaxis without proper documentation or physician notes until several months after the medication was started. The Assistant DON confirmed the prescription, but the facility failed to provide documentation justifying the use of the antibiotic, despite having an infection surveillance checklist in place.
A resident with dementia and severe cognitive impairments sustained a laceration requiring 13 sutures during a transfer with a mechanical lift. The incident occurred when the resident kicked her leg, hitting the lift, while two CNAs were assisting. The resident's care plan required two staff for transfers due to poor safety awareness.
A resident with dementia and major depression disorder physically assaulted two other residents in the dining room. The incident, witnessed by a CNA, involved the resident slapping one resident multiple times and hitting another in the head with a fist. The facility's records confirmed the aggressive behavior, and the resident was sent to a hospital for increased aggression. The facility's policy mandates an environment free from abuse, but it failed to prevent this incident.
Unsupervised meal positioning and unlocked medication cart
Penalty
Summary
The facility failed to ensure that a resident's head of the bed was upright during meals. R9 had diagnoses including brain cancer, palliative care, heart disease, skin cancer, and protein-calorie malnutrition, and his facility assessment showed he needed supervision for eating and was on a mechanically altered diet. His dietary evaluation documented dysphagia and dental problems with broken or fractured teeth. During lunch, R9 was observed lying in bed with a mechanical soft meal on the over-bed table, his head of the bed declined, and he was trying to spoon food into his mouth while the room divider curtain was pulled and he was not visible from the hall. He remained in the same position for at least 17 minutes until another CNA entered and raised the head of the bed while he was still eating. Staff later stated he ate in bed and needed to be upright, and the DON stated his head of bed should be at least 45 degrees during meals. The facility also failed to ensure a second-floor medication cart was locked when unsupervised. On the second floor, the medication cart was observed in the hallway outside a resident room and was unlocked with no staff present nearby. The surveyor waited until an LPN stepped out of a resident room and immediately locked the cart, stating it should have been locked when she stepped away. The Assistant Administrator later stated the medication cart should be locked whenever staff step away for safety. The facility's medication storage policy stated medications will be stored safely and secured in a locked storage area.
Bedtime snacks were not offered to residents
Penalty
Summary
The facility failed to ensure bedtime snacks were offered to 5 of 5 residents reviewed for snacks in a sample of 47. During a group resident meeting, all 5 residents present stated they do not receive and are not offered bedtime snacks. One resident, who was the Resident Council President and had no cognitive impairment, said she could not even get an extra cookie or dessert to take back to her room to eat later and reported that staff told her no when she asked for something to eat later. Another cognitively intact resident responded, "That is a BIG NO," when asked about bedtime snacks. Record review showed the residents involved were admitted to the facility between 2019 and 2025 and had facility assessments indicating no cognitive impairment or were cognitively intact. The Dietary Manager stated snacks are provided only to residents identified by the dietitian, that there is a list of residents who receive snacks, and that snacks are delivered to the nursing station on each floor labeled with the resident name and room number. The Dietary Manager also stated no other residents are offered snacks and there is nothing available to send up if residents ask for it at bedtime. The facility's policies stated bedtime snacks are to be offered daily and that between-meal snacks/nourishments shall be made available three times per day unless otherwise indicated in the resident's plan of care.
Resident Medical Information Left Visible on Medication Cart
Penalty
Summary
The facility failed to keep a resident’s medical records private and confidential when, on 1/15/26 at 7:40 AM, the medication cart on the second floor was left in the hallway outside a resident room with the mounted computer screen open to R105’s medications and no staff present nearby. The surveyor waited by the cart until V16 LPN stepped out of a resident room and stated she had been called away, but that the screen should have been closed. Later, on 1/15/26 at 12:12 PM, V2 DON stated that when a nurse steps away from the cart the computer should be closed and no resident information exposed, and identified the situation as a HIPAA violation. The facility’s 12/8/25 policy for Notice of privacy practices states that the resident has a right to secure and confidential personal and medical records, including electronic records.
Incomplete Incontinence and Perineal Care
Penalty
Summary
The facility failed to ensure staff thoroughly cleaned a resident who was dependent on staff for incontinent care. The resident had diagnoses including dementia, osteoarthritis, diverticulosis of the small intestine, pressure ulcer of the sacral region, acute kidney failure, urine retention, and altered mental status. The resident’s assessment showed severe cognitive impairment and dependence on staff for all cares, and the care plan identified the resident as high risk for skin breakdown with interventions to keep skin clean and dry. The resident also had an ADL care plan showing dependence on staff for toileting and personal hygiene needs. During wound care, two nursing staff members found the resident incontinent of stool and began cleaning her while she was positioned on her side. Visible stool remained in the perineal area after the initial cleaning, and when the surveyor asked them to check the front area, additional stool was found on the vaginal and perineal area. Multiple wipes used during the care had visible stool on them, and the brief placed on the resident after care also had visible stool on it. The DON stated it is important to make sure all stool is cleaned off residents during care to prevent infection and skin breakdown. The facility policy stated perineal care is to ensure cleanliness and comfort, prevent infection and skin irritation, and observe the resident’s skin condition.
Failure to Identify and Treat New Shin Skin Condition
Penalty
Summary
The facility failed to prevent, identify, initiate treatment for, and notify the physician of a new skin condition for one resident with severe cognitive impairment who was dependent on staff for all cares. The resident was admitted with diagnoses including senile degeneration of the brain, dementia without behavioral disturbance, generalized anxiety disorder, insomnia, overactive bladder, hypokalemia, and hypertensive heart and chronic kidney disease without heart failure. Her care plan identified her as high risk for altered skin integrity and directed staff to perform skin checks every shift and report abnormalities to the nurse, but her current physician order sheet had no orders for treatment or monitoring of her bilateral shins. During observation, the resident’s shins were exposed and showed several dark bruises on each shin with steri-strips applied to areas on both shins, with drainage visible under the steri-strips. The resident’s son-in-law stated the bruises and steri-strips had been present on and off for months and that she had bruising or skin tears in various forms for months. The wound care nurse and nursing supervisor were not aware of the skin conditions, and the wound care nurse stated that when a new skin condition is reported she would assess it, notify the wound care company, enter treatment and monitoring orders, and start an investigation. The DON stated staff should report skin alterations right away, the wound care staff should be notified, and the wound should be assessed, documented, and reported to the physician and family; however, none of these actions were in place for the resident’s bilateral shin condition.
Insulin Pen Not Disinfected Before Needle Attachment
Penalty
Summary
The facility failed to ensure an insulin pen was disinfected before the needle was attached for one resident who was reviewed for insulin injections. The resident had diagnoses including dementia and type II diabetes mellitus, and the admission record showed she had severe cognitive impairment and required substantial to maximal assistance from staff, or was dependent on staff for all cares except eating. Her order summary showed an active order for Humalog KwikPen insulin to be given by sliding scale before meals and at bedtime, and her care plan identified her as at risk for fluctuating blood sugars due to diabetes mellitus. During observation on 01/14/2026, an RN checked the resident’s blood sugar, told her she would get the insulin ready, and then returned to prepare the medication. The RN removed the cap from the Humalog injector pen and attached the needle without disinfecting the rubber top of the pen before attaching the needle, then administered the insulin. When asked, the RN stated she did not need to alcohol the end of the insulin pen before attaching the needle. An LPN later stated nurses do not need to alcohol the top of insulin pens before attaching the needle, while the Nurse Manager and DON stated the rubber end of the insulin pen should be disinfected with alcohol wipes before attaching the needle for infection control. The facility policy titled Medication Pass, revised 7/2/2025, did not address disinfecting insulin injector pens prior to attaching the needle.
Infection Control Failures During Incontinent Care and IV Access
Penalty
Summary
The facility failed to provide incontinent care in a manner to prevent cross contamination for two residents. One resident was incontinent of bowel and bladder, had moderate cognitive impairment, and was dependent on staff for toileting hygiene and personal hygiene. During incontinent care, a CNA and a restorative aide removed the resident’s soiled brief, and the CNA used several wipes stacked together to clean the pubic area, right groin area, and middle vaginal area without using a different section of the wipes or folding them between swipes. The facility’s unit manager and DON stated that wet wipes should be discarded after each swipe and a clean wipe should be used when cleaning the vaginal area. Another resident had severe cognitive impairment, was dependent on staff for all care, and was receiving wound care after being incontinent of stool. During the care, an RN in training and an LPN donned PPE, but the LPN tossed three stool-soiled wipes over the bed toward the trash can and they landed on the floor. After care was completed, the RN in training picked the wipes up from the floor and placed them in the trash bag, then lifted the trash bag to tie it off while standing over the area where the wipes had landed. The facility also failed to ensure staff wore the required gown when accessing a resident’s IV antibiotic under Enhanced Barrier Precautions; the RN entered the room to administer the IV medication, brushed against the bedding, and was not wearing a gown even though the posted sign indicated a gown was required for device care or use.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and assess a resident, identified as R137, who experienced significant weight loss. Upon admission, R137 weighed 145.6 lbs, but over a period of 14 days, she lost 21 lbs without being re-weighed or assessed. Despite having a history of weight loss and a diagnosis of dementia, depression, and other conditions, the facility did not conduct weekly weights as required for new admissions. The resident's food intake was inconsistent, and she was not seen by a dietitian until 20 days after admission, despite her poor intake and significant weight loss. Additionally, the facility failed to provide physician-ordered nutritional supplements to another resident, identified as R118, who was under hospice care and had experienced a significant weight loss of 10.5% over six months. The resident was supposed to receive a magic cup at lunch and dinner as part of their dietary plan, but this was not provided on two observed occasions. The lack of adherence to the dietary plan could potentially exacerbate the resident's weight loss. The facility did not have a weight loss/prevention policy in place, which contributed to the oversight in monitoring and addressing the nutritional needs of residents R137 and R118. The absence of such a policy likely led to the failure in providing necessary interventions and monitoring to prevent further weight loss in these residents.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents and/or their representatives understood the Health Care Arbitration Agreement (HCAA) they were signing, which affected four residents in a sample of 30. Resident R251, who was cognitively intact, signed the HCAA without a clear explanation of its implications, such as waiving the right to legal assistance. Similarly, R20's Power of Attorney (POA) signed the HCAA without understanding its significance due to a lack of explanation and time to review the document. R73, with moderate cognitive impairment, also signed the HCAA without a clear understanding of its terms, and R144, who was cognitively intact, misunderstood the nature of the arbitration agreement, thinking it involved a committee rather than waiving legal rights. The staff responsible for presenting the HCAA, including the Guest Services Director and Admissions Director, were not formally educated on how to properly explain the agreement to residents. The facility lacked a policy on the arbitration agreement, and the staff had not seen the educational materials provided by the facility. The education packet highlighted factors that could render the HCAA unconscionable, such as issues with age, literacy, or the manner in which the contract was presented, emphasizing the importance of ensuring the signer understands the terms without being rushed.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident verbal and physical abuse, specifically involving two residents. On the afternoon of November 19, 2024, one resident reported that another resident cursed at him, rolled over in his wheelchair, and grabbed his left wrist with a strong grip, causing skin breakage without bleeding. An X-ray was conducted, revealing no fractures. The two residents reportedly did not get along well, which may have contributed to the altercation. The incident was reported to the facility administrator by a nurse, who was informed of the yelling and wrist-grabbing incident. A Licensed Practical Nurse (LPN) was alerted by a CNA about the yelling and found the two residents in a heated exchange, with one resident holding the other's wrist. The LPN noted difficulty in understanding the aggressor's speech, but identified words related to the TV being loud. Progress notes for both residents documented the altercation, with one resident's care plan indicating a history of unclear speech and the other being alert and oriented. The facility's Abuse and Neglect Policy, revised in July 2024, mandates an environment free from abuse, which was not upheld in this instance.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify residents or their representatives in writing of transfers to the hospital, as required. This deficiency was identified in two cases. In the first case, a resident was transported to the emergency room, and their Power of Attorney was informed of the hospital admission only after the transfer occurred, with no written notice provided. In the second case, another resident was admitted to the hospital without any documentation of written notice being given to the resident or their representative. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that while verbal communication with families occurred, written notices were not provided. The facility also lacked a policy addressing the requirement for written notification of transfers.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed hold policy in writing during transfers to the hospital or therapeutic leave. This deficiency was identified in three cases out of a sample of thirty residents. In the first case, a registered nurse (RN) caring for a resident who was transferred to the hospital in February admitted to giving the paperwork to the EMTs but could not recall notifying the family about the bed hold policy. The RN also could not find any documentation indicating that the family was informed. In the second case, a resident's progress notes indicated that the resident was transported to the emergency room, and the power of attorney was informed of the hospital admission, but there was no documentation of a written bed hold policy being provided. Similarly, in the third case, the facility was unable to provide documentation of a written notice regarding the resident's transfer to the hospital or the bed hold policy. Interviews with various nursing staff, including RNs and an LPN, revealed a consistent practice of giving bed hold policy paperwork to paramedics upon resident transfer, but not necessarily informing the family about the bed hold policy. The Director of Nursing confirmed that a hard copy of the transfer was not sent to the family, and the facility's policy, revised in July, stated that the resident or family must be informed of the bed hold duration in writing. This lack of documentation and communication with the residents' families regarding the bed hold policy constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Properly Assess Resident for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was properly assessed before being diagnosed with a serious mental illness, specifically schizophrenia, according to professional standards of practice. The resident, identified as R99, was admitted to the facility without a diagnosis of schizophrenia, as confirmed by her admission hospital records. However, two years after admission, schizophrenia was added to her face sheet as a diagnosis. Interviews with the psychotropic nurse and the primary care physician (PCP) revealed a lack of clarity on how this diagnosis was made. The psychotropic nurse, who began handling psychotropics in May of the current year, was unaware of the origin of the diagnosis. The PCP assumed the resident came with the diagnosis and admitted to not conducting any testing to confirm it. Further interviews with the psych nurse practitioner, who has been seeing the resident since February of the current year, indicated that the resident has a diagnosis of dementia, which could explain her behaviors. The nurse practitioner acknowledged that schizophrenia is a significant diagnosis that typically requires a full psychiatric evaluation and extensive testing, which had not been performed for this resident. The resident's face sheet also lists other diagnoses, including dementia, bipolar disorder, psychotic disorder with delusions, generalized anxiety disorder, delusional disorders, and major depressive disorder, none of which were confirmed to include schizophrenia upon her admission.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for residents requiring extensive assistance. Resident R59's family reported that he was not receiving timely care, including changing clothes and adult diapers. Observations confirmed that R59 was in the same clothes for four days, and his diaper was saturated with urine. His care plan indicated he required substantial assistance for dressing and toileting due to multiple chronic conditions, including cognitive impairment and mobility issues. Resident R118 was observed sitting in the same spot in a reclining wheelchair for extended periods without being toileted. His care plan required dependent assistance for toileting due to cognitive impairment and mobility limitations. Similarly, Resident R49 was left in a reclining wheelchair without being toileted, despite needing dependent assistance for toileting due to various chronic conditions. The facility's policy required rounds every two hours to check for incontinence, which was not adhered to, leading to these deficiencies.
Failure to Implement Skin Preventive Treatment as Ordered
Penalty
Summary
The facility failed to ensure that a resident's skin preventive treatment was in place according to physician orders. This deficiency was identified during an observation on November 18, 2024, when a hospice CNA was giving a bed bath to a resident whose adult diaper was saturated with urine, and the resident's coccyx was red with a small superficial open area. The CNA noted that there was usually a dressing on the coccyx, but it was absent that day. On the following day, two wound care nurses confirmed that the resident did not have any open pressure injuries on the coccyx, describing the condition as moisture-associated skin damage (MASD). The resident, who was on hospice care and bedridden, had preventive treatment orders to prevent skin breakdown or pressure injuries. The treatment administration record for November 2024 indicated orders for calamine-zinc oxide lotion, duraseptine with xeroform, and xeroform oil emulsion gauze to be applied to the coccyx/buttocks every shift for skin breakdown prevention.
Failure to Prevent and Identify Pressure Injuries
Penalty
Summary
The facility failed to report and identify a pressure injury in a timely manner for two residents, leading to the development of significant pressure injuries. Resident R137, who had diagnoses including dementia and required assistance with personal care, developed an unstageable pressure injury on her coccyx. The initial wound assessment indicated that the injury was facility-acquired and unstageable, measuring 3 cm by 5 cm. It was noted that the resident was incontinent and should have been changed every shift, which could have prevented the injury from becoming unstageable. The care plan for R137 indicated a potential for skin integrity issues, but the injury was not identified until it was already severe. Resident R118, who also required assistance with personal care and had a history of depression and COPD, developed a stage 2 pressure ulcer on his left heel. The wound assessment showed that the injury was facility-acquired and resulted from the resident's heel resting on the footrest of his wheelchair. Despite having heel protector boots, the injury occurred, indicating a failure to properly offload pressure from the heel. The care plan for R118 included the use of boots to offload heel areas, but this intervention was not effectively implemented, leading to the development of the pressure ulcer.
Failure to Supervise High Fall Risk Resident on Toilet
Penalty
Summary
The facility failed to adequately supervise a resident with a known history of falls while she was on the toilet, leading to a deficiency in safety supervision. On November 17, 2024, at 2:20 PM, the resident was heard shouting for help while sitting on the bathroom toilet, holding the grab bar, with no staff present in the room, bathroom, or hallway. An agency CNA admitted to placing the resident on the toilet and acknowledged that the resident was not alert and oriented. Another CNA confirmed that staff should not leave the resident alone on the toilet due to her fall risk, and an LPN reiterated that the resident should not be left unattended because of her fall risk. The resident's Fall Risk Evaluation, dated April 1, 2024, indicated a high fall risk score of 15, where a score of 8 and above is considered high risk according to the facility's reference range.
Failure in Catheter Care for Resident with UTI History
Penalty
Summary
The facility failed to provide appropriate catheter care interventions for a resident with a history of urinary tract infection (UTI). The resident was observed with a urinary catheter in place, and the Director of Nursing (DON) confirmed that catheter care, including catheter flush and application of Betadine, should be performed every shift to prevent infection. However, the Treatment Administration Record (TAR) for the resident showed missing documentation for catheter care, Betadine application, and catheter flush on specific dates, indicating a lapse in the prescribed care routine.
Controlled Medication Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation and inventory of controlled medications for a resident. During a medication administration observation, it was noted that there were 22 physical doses of methadone available for a resident, while the Individual Controlled Substance Record indicated there should have been 23 doses. The discrepancy occurred when a registered nurse administered a dose of methadone and incorrectly documented the entry, skipping the 23rd dose and signing out the administered dose on the next line. The facility's policy requires a physical inventory of all controlled substances by two licensed personnel at each shift change or when keys are transferred, with any discrepancies reported immediately to the Director of Nursing. However, the discrepancy in the methadone count was not immediately addressed, indicating a lapse in adherence to the facility's Controlled Substance Storage Policy.
Failure to Implement Agreed Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed after being agreed upon by the physician for a resident reviewed for psychotropic medications. The consultant pharmacist recommended a gradual dose reduction (GDR) for the resident's psychotropic medications, quetiapine and sertraline, on August 2, 2024. The physician agreed with these recommendations on September 24, 2024. However, the resident's order summary report dated November 20, 2024, showed no orders for the medications at a reduced dose. The psychotropic nurse, responsible for addressing medication recommendations, acknowledged that she or the floor nurse should have clarified the specific dose the doctor intended to prescribe after agreeing to the GDR.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the gradual dose reduction (GDR) of psychotropic medications for a resident, identified as R94, who was part of a sample of 30 residents reviewed for unnecessary psychotropic medication use. The consultant pharmacist recommended a reevaluation and consideration for GDR of R94's medications, quetiapine and sertraline, due to potential side effects such as drowsiness, increased risk of falls, and hypotension. The physician agreed with these recommendations; however, the facility did not implement the GDR in a timely manner. R94 continued to receive the same dosages of sertraline and quetiapine from September through November, despite the physician's agreement to the pharmacist's recommendations. The psychotropic nurse acknowledged that they should have clarified the physician's intended dosage adjustments and implemented them promptly. The facility's policy on psychotropic medications, revised in August, mandates adherence to federal regulations, which was not followed in this instance.
Medication Administration and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for a resident, identified as R123, who was part of a sample of 30 residents reviewed for medication storage. R123 was admitted with multiple diagnoses, including Parkinson's disease, major depressive disorder, and rheumatoid arthritis, among others. On November 18, 2024, it was observed that R123 was holding a medication cup with 7-10 pills and had a small yellow pill on her bed mattress. R123 reported that these were her morning medications, which she intended to take later with food. This indicates that the medications were not administered at the time they were prepared, as per the facility's policy. The Registered Nurse (RN), identified as V6, acknowledged that R123 often takes a long time to consume her medications, preferring to take them one at a time with food in between. V6 stated that staff should monitor the resident until all medications are ingested and that if a resident requests to take medications later, they should be taken away and re-administered at a later time. The facility's Medication Administration General Guidelines policy requires that medications be administered at the time they are prepared and that the resident is observed to ensure the dose is completely ingested. The failure to adhere to these guidelines resulted in the deficiency noted in the report.
Infection Control Lapses During Perineal Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during perineal care for two residents, R80 and R137. R80, who has a history of COVID-19, urinary tract infection, and is always incontinent of bowel and bladder, was observed receiving perineal care from CNAs V5 and V7. During the procedure, V7 did not change gloves or perform hand hygiene after wiping stool from R80's perineal area before assisting her to turn, which is against the facility's hand hygiene and perineal care policies. These policies require changing gloves and performing hand hygiene to prevent cross-contamination when moving from soiled to clean areas. Similarly, CNA V15 was observed changing R137's adult diaper after a bowel movement and failed to remove gloves or wash hands after cleaning the resident. Instead, V15 continued to adjust the resident's pillow, cover her, and lower the bed without performing hand hygiene. This action also violated the facility's hand hygiene policy, which mandates hand hygiene before and after assisting a resident with toileting and after contact with body fluids. These lapses in infection control practices were confirmed through interviews with the Infection Control Nurse and a review of the facility's policies.
Unnecessary Antibiotic Prescription for a Resident
Penalty
Summary
The facility failed to ensure that a resident was not prescribed an unnecessary antibiotic, specifically affecting one of the five residents reviewed for unnecessary medications in a sample of thirty. The resident, identified as R128, was prescribed Keflex Oral Capsule 250 MG for recurrent urinary tract infection (UTI) prophylaxis, starting on March 29, 2024. However, there were no physician notes or documentation regarding the initiation of this medication until November 20, 2024, when a progress note mentioned recurrent urinary tract issues and the use of Keflex. The Assistant Director of Nursing confirmed that the resident was on the medication for recurrent UTIs, but the facility did not provide any documentation prior to November 20, 2024, to justify the prescription. The facility's infection surveillance checklist, dated August 8, 2024, indicated the use of the McGreer Criteria Checklist for infection prevention and control, but this was not reflected in the documentation for R128.
Resident Injury During Transfer Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a significant injury. The resident, who was diagnosed with dementia, malnutrition, and peripheral venous insufficiency, had severe cognitive impairments and was dependent on staff for transfers. The care plan indicated that the resident required assistance from two staff members for transfers due to poor safety awareness and impulsiveness. During a transfer from a shower chair using a mechanical lift, the resident kicked her left leg, hitting the lift and sustaining a laceration that required 13 sutures. The incident occurred while two CNAs were assisting with the transfer; one was moving the lift, and the other was guiding the resident. The resident's medical history included a previous hematoma on the left leg, which was noted a day before the laceration incident. The hematoma was discovered during a transfer and was attributed to trivial trauma. On the day of the incident, the resident was not following directions and was known to become agitated during care. The wound care nurse confirmed the laceration and hematomas were sustained during the transfer, and the resident was subsequently sent to the emergency room for treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from resident-to-resident physical abuse. On 3/16/24, a resident with dementia and major depression disorder, identified as R1, physically assaulted two other residents, R2 and R3, in the dining room. According to staff interviews, R1 slapped R2 in the head multiple times with an open hand and then hit R3 in the back of the head with a fist. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the contact was not accidental. R1 was subsequently sent to a local hospital for increased aggression. The facility's records, including progress notes and a Change in Condition Note, confirmed the aggressive behavior of R1. The facility's Abuse and Neglect policy, reviewed on 7/14/23, mandates an environment free from any type of abuse, including physical abuse such as hitting and slapping. Despite this policy, the facility failed to prevent the physical abuse incident involving R1, R2, and R3, thereby not ensuring a safe environment for its residents.
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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