Bria Of Elmwood Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Elmwood Park, Illinois.
- Location
- 7733 West Grand Avenue, Elmwood Park, Illinois 60707
- CMS Provider Number
- 145419
- Inspections on file
- 55
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 21 (2 serious)
Citation history
Health deficiencies cited at Bria Of Elmwood Park during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and complex medical conditions, including dependence on G-tube feeding for all or most nutrition, did not receive enteral nutrition and hydration as ordered. For one resident, hospice and the POA agreed to stop G-tube feeding due to emesis and perceived respiratory distress, but no alternative interventions were tried, the RD was not notified, and the existing POLST directing artificial nutrition and hydration by any means was not revised. For the other resident, surveyors found the feeding pump alarming, the formula carton and tubing completely dry, and the carton dated two days earlier, even though the ordered rate meant it should have been replaced the previous day; there was no documentation explaining the lack of feeding or any provider notification. Facility policies on tube-feeding management, documentation, and adherence to advance directives were not followed.
Surveyors found that staff failed to follow professional standards for medication storage, labeling, and controlled substance documentation, and did not properly document or communicate a major change in a resident’s enteral feeding order. Multiple open insulin vials and pens on several medication carts lacked required open dates, had expired beyond-use dates, or were left in active stock for residents who had been discharged or were deceased. Some insulin and an albuterol inhaler were stored without pharmacy labels or resident names, and loose pills and an expired stock allergy medication were found mixed with active medications. Controlled substance count sheets on several carts had missing nurse signatures for shift counts, and the documented remaining doses for several controlled medications did not match blister card counts; in one case, an oxycodone card had an altered label and was tracked on plain copy paper instead of an individual controlled drug record. In addition, a resident with severe malnutrition, anoxic brain damage, tracheostomy, and gastrostomy status, care planned as NPO and dependent on tube feeding, had the G-tube feeding order discontinued without any documentation in the record or notification of the physician or dietitian by the LPN who received the order.
The facility failed to provide sufficient RN staffing on a high-acuity respiratory unit, resulting in widespread late administration of scheduled medications. Two RNs, including an agency RN who arrived late to the shift, were assigned to 32 residents, many with ventilators, trachs, G-tubes, wounds, epilepsy, diabetes, quadriplegia, and other complex conditions. One RN reported that medications were late every day and that the volume of G-tube medications made timely administration impossible, while a floor manager RN confirmed that most medications scheduled for the morning were not given by the due time. Medication audits showed that half of the unit’s residents received morning medications late, in some cases more than three hours past the scheduled time. The DON acknowledged that such delays constitute timing medication errors but maintained that two nurses were sufficient, while other staff, including an RN, an LPN, and the Infection Preventionist, stated that the unit needed a third nurse due to the acuity and workload.
A resident with severe cognitive impairment, multiple complex medical conditions, and a POLST directing provision of artificial nutrition and hydration via surgically placed tubes was care planned as NPO with enteral feeding for all nutrition needs, yet had no active tube feeding orders and was observed on multiple occasions without any feeding infusing. An RN reported that hospice had discontinued the feeding, the POA stated she had been told feeding could not be restarted despite wanting it continued, and the DON was unaware the feeding had been stopped. The MD acknowledged hospice stopped the feeding due to aspiration risk and stated that the POLST should be revised if G-tube feeding is discontinued, while facility policy affirms residents’ rights to determine life-sustaining treatments, including artificial hydration and nutrition.
A resident with acute respiratory failure, tracheostomy, schizoaffective disorder, epilepsy, and a high fall-risk score had a care plan intervention requiring the bed to be kept in the lowest position. Despite this, nursing documentation and leadership interviews confirmed that the resident’s bed was left in a high position, after which the resident was found on the floor and sent to the hospital. The DON, Restorative Nurse, and Administrator each stated that staff are responsible for implementing care plan interventions and are expected to follow the care plan, consistent with the facility’s policy that the comprehensive care plan drives the care and services provided.
The facility failed to ensure effective nurse-to-nurse handoff communication and documentation during hospital transfers for two residents with complex medical conditions, including ventilator dependence, hospice care, ESRD, and heart failure. In multiple transfers, hospital transfer forms lacked the name of the receiving hospital nurse, progress notes did not document any nurse-to-nurse report, and SBAR forms omitted critical information such as hospice status. The DON stated that nurses are expected to obtain MD orders, complete transfer and SBAR forms, notify family, call and give report to the hospital, and send a face sheet and POS, but staff interviews and record review showed that these steps, particularly the verbal handoff and its documentation, were not consistently completed.
Two residents with high fall-risk scores and multiple comorbidities experienced falls that were not properly documented or evaluated according to facility policy. In both cases, nursing staff documented that the residents were found on the floor and sent to the hospital, but did not complete required fall reports, risk management entries, or post-fall and pain assessments. The DON and Administrator stated that any fall risk score greater than 10 indicates high fall risk and that staff are expected to complete fall risk evaluations and update care plans after each fall, as outlined in the facility’s fall prevention and management policy.
A resident with complex medical conditions, including ventilator dependence and anoxic brain damage, was enrolled in hospice, but the facility did not add hospice orders to the physician order sheet or indicate hospice status on the face sheet. When the resident later had tachycardia and seizure-like activity, an agency RN obtained an order to send the resident to the hospital and provided face sheets and physician orders to EMTs, but was unaware the resident was on hospice and did not communicate hospice status during the transfer. Review of the transfer form showed no documentation of hospice, and leadership acknowledged hospice status should appear in the POS and on the face sheet, in contrast to facility hospice policy and CMS requirements for coordinated hospice care.
The facility failed to honor residents’ rights to receive visitors at any time by enforcing fixed visiting hours ending at 8 p.m., despite a written policy allowing 24-hour open visitation with only quiet hours. Two nonverbal, fully dependent residents with complex conditions, including anoxic brain damage, chronic respiratory failure, tracheostomy and gastrostomy status, had family members who were told by staff, including an LPN, that visiting hours were over and they had to leave at 8 p.m., even when one family member was addressing concerns about tube feeding and another was waiting for incontinence care. Staff consistently described visiting hours as ending at 8 p.m., and the DON acknowledged the use of visiting hours and the need for administrative approval for overnight stays, while there was no documentation that these visitation limits were based on individualized clinical need, resident preference, safety, or roommate rights.
The facility failed to ensure that three nonverbal, fully dependent residents with PEG/GT tubes received enteral nutrition as ordered and that tube feeding intake was accurately documented. A resident’s spouse repeatedly found the feeding pump off or inactive during ordered continuous feeding times, with staff and telehealth documentation confirming missed hours of feeding. For two other residents, surveyors observed that the volume of formula remaining in the feeding containers and the total volume displayed on the pumps did not match the prescribed rates, labeled start times, or ordered daily volumes, and one container lacked a start time label altogether. The DON acknowledged that pumps might not have been reset when new bottles were hung and that there was no dedicated flow sheet to track bottle changes, while records lacked documentation of feeding interruptions, restarts, and total daily volumes despite facility guidelines requiring pump clearing each shift and documentation of tube feeding delivered.
A resident with complex medical conditions was treated for hypokalemia and received potassium supplementation, but staff failed to ensure timely laboratory monitoring and did not act upon a critically high potassium result. An LPN reviewed a critical potassium value of 8.4 mEq/L but did not initiate emergent intervention or escalate the situation as required by facility policy. The lack of timely response and failure to follow protocols resulted in the resident not receiving necessary medical care and subsequently experiencing cardiac arrest and death.
A resident with significant cardiac and vascular conditions had a critically high potassium level identified by lab testing, but the LPN who received the result did not ensure timely provider notification or initiate appropriate clinical intervention. The LPN documented an attempt to notify the NP but did not escalate the issue or provide further care, and the critical result was cleared from the EMR, preventing further action. The resident was later found unresponsive and died, with the facility's failure to follow its policy for critical lab notification resulting in Immediate Jeopardy.
A resident with multiple comorbidities was treated for hypokalemia and received potassium supplementation, but the facility failed to ensure ongoing assessment and timely laboratory monitoring. Orders for potassium were entered incorrectly, resulting in prolonged administration, and there was no documentation of follow-up labs or clinical intervention after a critically high potassium level was identified. The resident was later found unresponsive, with the death certificate listing cardiopulmonary arrest as the cause of death.
A CNA failed to follow infection prevention protocols by not changing gloves or performing hand hygiene while providing care to two residents. The CNA used soiled gloves to handle personal items, clean linens, and touched multiple surfaces, including a linen cart, without proper glove removal or hand hygiene. This breach of protocol was confirmed by facility leadership and was inconsistent with established infection control policies.
A resident with multiple medical conditions left the facility without proper discharge planning or documentation, including the absence of required AMA education, physician notification, and completion of forms. The resident departed without medications or belongings, and the facility was unable to confirm the resident's location or condition after discharge.
A resident with significant cognitive and physical impairments, identified as high risk for falls, experienced multiple unwitnessed falls, including one resulting in a hip fracture. The facility did not implement effective fall prevention interventions or follow proper post-fall procedures, as staff moved the resident after a suspected injury and care plan changes did not address the actual causes of the falls.
Two residents who required staff assistance with personal hygiene did not receive adequate ADL care, as evidenced by observations of poor grooming and resident reports of ignored requests for help. Both residents had documented needs for assistance in their care plans, and facility guidelines required such support.
The facility did not properly transcribe and implement hospital nutrition support orders for a resident readmitted with severe underweight and pressure ulcers, resulting in delayed initiation of prescribed supplements and tube feeding. Additionally, two other residents requiring tube feeding were observed without feedings running during ordered times, with staff confirming interruptions for care and medication that were not promptly resumed. These actions led to significant weight loss and inadequate nutrition support, contrary to physician orders and facility policy.
A resident with paraplegia and multiple diagnoses, who requires maximal assistance for transfers, fell after staff failed to respond to her call light for bathroom assistance. The incident was not documented in the fall log, and no fall risk assessment was completed as required by facility policy. Staff believed the resident's behavior was typical, but there was no supporting documentation or care plan evidence.
A resident with multiple risk factors and a history of abuse allegations did not have their Abuse/Neglect Care Plan updated after a new sexual abuse allegation was reported. Despite facility policy requiring care plan updates after significant changes, including abuse allegations, the care plan remained unchanged following the incident.
A resident with moderate cognitive impairment reported to an LPN that his roommate had inappropriately touched him during the night. The allegation was relayed to the Social Service Coordinator and Administrator, but the Administrator did not immediately report the incident to state authorities or law enforcement as required by facility policy, instead concluding the claim was fabricated. The incident was only reported to authorities several weeks later, despite staff acknowledging that immediate reporting was necessary.
A respiratory technician/student, not yet certified, independently provided respiratory care to residents, including tracheostomy care and ventilator checks, without proper supervision. This occurred despite the residents' complex medical needs and the facility's awareness of the technician's unlicensed status.
A facility failed to provide care according to professional standards, resulting in a resident's prolonged distress due to pneumonia and influenza A. Despite the resident's request for hospital transfer, the nurse on duty refused to call 911. Additionally, unlicensed respiratory technicians were observed performing tasks independently without direct supervision, contrary to the Respiratory Care Practice Act.
A resident with COPD, asthma, and influenza experienced a significant change in condition, feeling unwell and having difficulty breathing. Despite her requests for hospitalization, the facility staff failed to assess her condition or notify her physician, resulting in a delay of care. The resident eventually called 911 herself and was admitted to the hospital with pneumonia and influenza.
The facility failed to employ credentialed respiratory staff, allowing a respiratory technician to perform tasks independently without certification. The technician, initially hired as a student, was observed providing tracheostomy care and administering medications without the necessary supervision. Despite awareness of the lack of certification, the facility did not take corrective action, violating state law requirements for licensed respiratory care practitioners.
During an influenza outbreak, the facility failed to provide appropriate masks, leading to the use of non-medical masks by staff and residents. The Infection Preventionist recommended N95 masks, but non-medical masks were still available and used, contributing to the spread of influenza among residents. The outbreak began on the fourth floor and spread to the first, with several residents testing positive for influenza and other respiratory illnesses. Observations confirmed the presence of non-medical masks throughout the facility, contrary to CDC guidelines for infection control.
Residents with intact cognition reported dissatisfaction with food quality, describing it as uncooked, cold, and bland. Despite complaints to the Dietary Manager, the grievance committee did not effectively address their concerns. A test tray observation revealed food served below proper temperature standards, highlighting the facility's failure to resolve food quality issues.
The facility failed to document the administration of controlled substances for several residents, as required by its policies. An LPN did not record doses of Oxycodone, Clobazam, and Lacosamide on the controlled substance record, despite administering them. Additionally, a newly admitted resident's Oxycodone was not documented on an individual controlled substance form, and the LPN did not inform the DON about the missing documentation.
A respiratory technician/student, unlicensed, administered a medicated breathing treatment to a resident with chronic respiratory failure, violating the facility's policy that requires medications to be administered by licensed personnel. The technician had been working independently without a license, and the facility failed to verify licenses beyond the initial hiring process.
The facility failed to comply with medication storage and labeling policies, affecting several residents. Unlabeled and expired medications were found in medication carts, and insulin was improperly stored, leading to the administration of expired doses. Additionally, expired Tuberculin solutions were not removed from the medication refrigerator, potentially impacting new admissions. These deficiencies highlight lapses in adherence to established protocols.
A facility failed to follow its mechanical lift policy by not keeping the lift's base in the widest position during a resident transfer. The resident, who was morbidly obese and required assistance, was being moved to a dialysis chair when the lift's legs were closed, contrary to policy. The resident became nervous and fidgeted, leading to a fall that resulted in an acute subdural hematoma.
A resident in an LTC facility was physically abused by another resident, resulting in facial lacerations. The altercation began as a verbal argument over the television and escalated when one resident hit the other with a remote control. Both residents were moderately cognitively impaired. Staff intervened, and the aggressor was sent for psychiatric evaluation.
A resident alleged being attacked by another resident over a TV volume dispute, leading to hospitalization for psychiatric evaluation. Despite an investigation by the social service director, the facility failed to report the abuse allegations to the state agency as required. Conflicting accounts from residents and staff, along with missing documentation, highlight the deficiency in compliance with abuse reporting regulations.
A resident did not receive the correct dose of Oxycodone as prescribed, due to an LPN administering it every four hours instead of the ordered eight-hour interval. The resident was not in the facility when the medication was signed out, and there was a lack of documentation in the medication administration record. The LPN did not review the orders or report the error, and the facility failed to adhere to its narcotic medication policy.
A facility failed to follow its narcotic medication policy for a resident prescribed Oxycodone 5 mg. The resident reported not taking the medication every four hours, yet records showed discrepancies, including administration times when the resident was not present. An LPN admitted to administering the medication more frequently than ordered and did not report the error. The facility's documentation was inconsistent with its policy, leading to a deficiency.
The facility failed to provide palatable meals to several residents, who reported the food as flavorless, overcooked, or undercooked. Meals were often served late, with some residents receiving dinner after 9:45 pm. Dietary staff acknowledged the complaints and frequently sent replacement trays or substitutes, indicating a failure to adhere to the facility's policy on providing nourishing and palatable meals.
A facility failed to provide timely dinner meals to 14 residents, with meals being served after 10:00 pm instead of the scheduled 6:30 pm. Residents, including those with diabetes and respiratory issues, expressed dissatisfaction with the late and poor-quality meals. Staff acknowledged the failure to meet the expected meal delivery times.
A resident with multiple health issues missed an oncology appointment due to the facility's failure to provide an escort, despite being aware of the need. The transportation was arranged, but no escort was available, and the facility lacked a specific policy for such situations.
A facility failed to document the administration of narcotic medication in the EMAR for a resident with multiple medical conditions. Despite being signed out on the individual narcotic sign-out sheet, five doses of Hydrocodone-Acetaminophen were not recorded in the EMAR. Interviews revealed that a lapse in following documentation procedures occurred, with a nurse admitting to sometimes forgetting to sign medications under the EMAR. The facility's policies require documentation in both the individual narcotic sign-out sheet and the EMAR.
A resident experienced mental abuse when an activity aide pulled off her wig during a disagreement over a borrowed speaker. The resident, who was alert and oriented, felt humiliated and embarrassed by the incident, which escalated into a physical altercation. The facility's abuse prevention policy was not upheld, leading to a deficiency report.
The facility failed to ensure that all CNAs have current CPR training and certification, as required by its policy. Interviews revealed that CPR training is encouraged but not mandatory, contradicting the facility's policy that all staff are responsible for performing CPR. The Director of Nursing confirmed that some aides lack CPR training, and they are instructed to inform a nurse if a resident is unresponsive, rather than performing CPR themselves.
A respiratory therapy student administered care unsupervised after the licensed therapist left early, affecting 11 residents. The facility lacked policies for student supervision, violating the Respiratory Care Practice Act's proximate supervision requirement.
A resident with multiple health issues experienced diarrhea and weakness, but the facility failed to notify the physician or conduct a proper assessment. The resident was later found unresponsive and deceased, with signs of rigor mortis. The facility's policy requires notifying the physician of significant changes, but this was not done, contributing to the deficiency.
A resident with multiple medical conditions developed untreated diarrhea, leading to cardiac arrest. The CNA reported the issue to the RN, but no further action was taken due to the absence of a medication order. The LPN was unaware of the resident's condition, and no nursing assessment or physician notification occurred. The facility lacked a care plan for diarrhea, contributing to the deficiency.
A deficiency was identified involving the delayed response of nursing staff to a resident with a tracheostomy, who had a complex medical history including Acute and Chronic Respiratory Failure, Dysphagia, and COPD. Despite the resident's Full Code status, there were documented delays in providing necessary suctioning and monitoring. The resident showed signs of distress, such as gesturing towards the tracheostomy, but received inconsistent and delayed care. Conflicting accounts from staff and discrepancies in monitoring and assessment contributed to the adverse outcomes.
The facility failed to provide timely respiratory tracheostomy care, did not respond to a resident's request for suctioning, and lacked staff with the necessary skills to meet the needs of a resident in respiratory distress, leading to a life-threatening situation.
A male resident with a complex medical history, including respiratory failure and COPD, experienced a critical incident due to lapses in respiratory care. Despite established care plans for ventilator settings and suctioning, the nursing staff and respiratory therapist did not respond promptly to the resident's distress signals. Staffing challenges, including reliance on a single respiratory therapist for over 20 residents with tracheostomies, and unclear protocols regarding suctioning responsibilities contributed to the delay. The resident's distress, including a dislodged tracheostomy tube, led to cardiac arrest and subsequent passing.
A facility failed to follow abuse prevention policies, resulting in a resident being physically abused by a respiratory therapist. The resident, who has a tracheotomy and chronic respiratory failure, reported being slapped and forcibly restrained. Despite reporting the incident, the resident continued to see the therapist, leading to feelings of fear and frustration.
A facility failed to follow abuse prevention procedures by not conducting a thorough investigation of an alleged abuse incident involving a staff member and a resident. The resident reported being slapped by the respiratory therapist on two occasions and expressed fear of the staff member's return. The facility did not ensure the staff member was kept away from the resident and did not provide adequate training to staff on abuse prevention and response.
The facility failed to follow their policy for tracheotomy suctioning and did not adhere to physician orders for providing adequate respiratory care for a resident with a tracheotomy. The resident experienced pain and fear due to harsh suctioning by a respiratory therapist, and documentation showed inconsistencies in care. The medical director acknowledged the incident and confirmed that physician orders should always be followed.
Failure to Provide Ordered Enteral Nutrition and Honor POLST for Artificial Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered enteral nutrition and hydration, to follow tube-feeding policies, and to honor an existing POLST directive for artificial nutrition and hydration. One resident (R11) had a history of anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status, and was assessed as severely cognitively impaired and dependent for all ADLs. His care plan documented NPO status with enteral feeding for all nutrition needs, including monitoring tolerance, weight, labs, skin, hydration, and providing additional fluids via feeding tube as ordered. Physician orders included a nutritionist consult after emesis and instructions to check residuals and hold feeding if residuals were ≥100 ml, with MD notification if residuals remained high. However, at the time of surveyor observations, R11 had no active G-tube feeding order, only water flush and medications, and was repeatedly observed in bed with a G-tube plunger at bedside, no feeding pump, and no feeding infusing. Staff interviews revealed that R11’s feeding had been stopped by hospice on a prior date due to episodes of emesis and perceived respiratory distress. The hospice RN stated that R11 had been on 2 cal formula at 50 ml/hr with a total volume of 425 ml and that hospice discussed with the family that feeding could cause respiratory distress; no other interventions such as reducing rate or volume were attempted before stopping feeding entirely, and hospice believed the resident was near end of life. The hospice RN acknowledged telling the POA that at end of life the resident did not need feeding. The POA reported having no clinical experience, relying on hospice’s explanation, and believing that because the resident was at end of life he did not need feeding; she also stated the resident did not receive water except with medications and was not being turned and repositioned every two hours as care-planned. The facility dietitian reported she was not notified that feeding had been stopped, described not feeding at all as “extreme,” and stated that the facility should be following the resident’s POLST form when determining care. R11’s Illinois Department of Public Health POLST form, signed by the POA, documented in section D that artificial nutrition and hydration should be provided by any means, including new or existing surgically placed tubes. The DON stated she was not aware that R11’s feeding had been discontinued and agreed the facility should follow the POLST. The attending physician/medical director acknowledged being aware that hospice had stopped the feeding due to aspiration risk and that the longer the resident was fed, the longer he would live, and stated that if the G-tube feeding was discontinued, the POLST should be readdressed and a new form obtained. The facility’s advance directive/DNR policy stated that life-sustaining treatments include IVs, tubes, and artificial hydration and nutrition to maintain life unless there are specific directions from the resident or family not to, and that changes to advance directives require voiding the old form and initiating a new one. No documentation was presented showing that R11’s POLST had been revised to reflect a decision to withhold artificial nutrition and hydration. A second resident (R1) with acute and chronic respiratory failure, type 2 diabetes, protein-calorie malnutrition, dysphagia, a stage 3 pressure ulcer, traumatic brain injury, epilepsy, encephalopathy, tracheostomy, and gastrostomy status was also affected. R1’s MDS documented severe cognitive impairment and that more than 51% of nutrition was via enteral feeding. The care plan indicated R1 was NPO due to dysphagia, that tube feeding would provide approximately 100% of estimated needs, and that staff should monitor tube-feeding tolerance; it also noted R1’s increased risk of abuse due to fragility, poor cognition, and poor communication, with a goal to remain free from mistreatment. Physician orders specified continuous enteral feeding of 2 Cal HN at 40 ml/hr for 20 hours daily (on at 2 pm, off at 10 am) via G-tube, with Jevity 1.5 as a substitute at 52 ml/hr for 21 hours if needed. During observation, R1 was found in bed, unarousable, with the enteral feeding pump alarming “FEED ERROR.” The feeding carton was completely desiccated, with only a quarter-sized amount of dried, cracking formula inside, and the tubing contained dry residual formula occupying less than 10% of its length. The carton was labeled with a date indicating it had last been hung two days earlier, with no time noted. Nursing staff and the DON confirmed that at the ordered rate of 40 ml/hr, the 1-liter carton would last approximately 25 hours and that another carton should have been hung the previous day. The DON acknowledged that R1 was completely dependent on staff for enteral feeding and hydration. There was no documentation in the medical record between the date the carton was hung and the survey date indicating that feeding had been held, that a provider had been notified, or that any rationale existed for not administering the feeding. Progress notes for R1 documented on a later date that the resident was in bed with head of bed elevated, vital signs stable, medications given, and “GTF ongoing, on at 2pm off at 10am,” with trach and G-tube sites intact and no signs of infection, and that the resident was repositioned every two hours. This documentation did not reflect the observed absence of active feeding or the dry feeding set. The dietitian confirmed that R1 was NPO and that 100% of nutritional needs were delivered via tube feeding, and explained that the current order met 100% of estimated needs. The medical director stated that a patient with diabetes who does not receive ordered enteral feeding could be expected to develop hypoglycemia, dehydration, or electrolyte imbalances. Nursing staff assigned to the unit on the relevant shifts either denied being assigned to R1, did not recall the resident, or stated they did not change tube-feeding cartons, indicating that night shift was responsible for changing sets at midnight and dating them accordingly. The facility’s Tube Feeding Management policy required continuous tube feedings to be based on a 22-hour consumption period or other time frame per RD assessment, with the health care provider notified if the ordered amount was not infused, and required labeling of tube feedings with resident name, rate, total volume, date, and time hung. The policy also required that the pump be cleared at the end of each shift, that tube feeding delivered be documented, and that the health care provider be alerted to any issues or concerns. In R1’s case, the feeding set remained in place well beyond the expected infusion period without replacement, the pump alarmed without effective response, and there was no documentation of the interruption or of provider notification. In R11’s case, enteral feeding was discontinued without updating the POLST or notifying the dietitian, despite the existing POLST directive to provide artificial nutrition and hydration by any means.
Medication Storage, Controlled Substance Documentation, and Enteral Feeding Order Communication Failures
Penalty
Summary
The deficiency involves multiple failures in medication storage, labeling, pharmacy services, and documentation, as well as failure to document and communicate a significant change in a resident’s enteral nutrition order. Surveyors observed numerous open insulin vials and pens on multiple medication carts without required open dates or beyond-use dates, including products for residents who had been discharged or were deceased. Several insulin vials and pens had stickers indicating “Do Not Use After” dates that had already passed, yet remained in the active medication drawers. An albuterol inhaler and several insulin products were found on the carts without pharmacy labels or resident names, and 24 loose pills were scattered in the top drawers of one cart. An expired stock bottle of Geri-Dryl liquid allergy relief was also stored with active medications. Staff interviewed on the units acknowledged that these medications were expired, lacked open dates, or were unlabeled and stated they should not be in use. Record review showed that some of the insulin products belonged to residents who had been discharged or had died weeks earlier, and those medications had not been removed from the active supply or returned to the pharmacy. Current physician orders for several residents confirmed ongoing insulin therapy, yet the corresponding insulin vials or pens on the carts were either expired or missing required dating. Pharmacy and facility policies required that multidose injectable vials be dated upon opening, that shortened expiration dates be applied and observed, that all medications be stored in containers with pharmacy labels, and that expired medications be removed from active stock and destroyed. The DON confirmed that insulin should be dated when opened, discarded after the appropriate time frame, and that medications without labels should not be used. Despite these policies, surveyors found expired, undated, unlabeled, and stock medications commingled with active medications on multiple carts. Additional deficiencies were identified in controlled substance documentation and handling. On several medication carts, controlled substance count sheets had multiple missing nurse initials for shift-to-shift counts on various dates. For several residents, the number of controlled medication doses documented as remaining on the monitoring/control records did not match the actual blister card counts, and nurses stated they had administered doses but had not yet signed them out. One resident’s oxycodone blister card had the original pharmacy label name blacked out and the resident’s name handwritten in marker, and the controlled medication was being documented on a handwritten sheet of copy paper instead of an individual controlled substance record. Facility and pharmacy policies required that each controlled dose be recorded at the time of administration on both the MAR and the controlled substance count sheet, that shift counts be completed and signed by oncoming and off-going nurses, and that controlled medications be dispensed with and tracked on individual controlled drug records. The DON stated it was not appropriate to document controlled counts on blank copy paper and that each controlled medication should have a proper count sheet. The deficiency also includes failure to ensure professional standards in documenting and communicating changes in a resident’s diet order. One resident with anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status was care planned as NPO and dependent on enteral feeding for all nutrition needs. The resident previously had an order for continuous tube feeding with 2 CalHN, with a substitution order for Jevity 1.5 if needed, but this feeding order was discontinued. At the time of review, the resident had no active G-tube feeding order, only water flush and medication orders. The dietitian reported that she last saw the resident while on G-tube feeding and hydration therapy and stated she was not notified that the feeding had been stopped. The DON stated that hospice orders should be clarified by the floor nurse, who should verify with the physician, notify the dietitian, and document the order in the record. The LPN who received the order to discontinue feeding stated he simply stopped the feeding, did not document the change in the resident’s record, did not write a progress note, and did not notify the physician or dietitian, despite job descriptions requiring nurses to document nursing care and pertinent data according to facility policies and procedures.
Insufficient RN Staffing on Respiratory Unit Leading to Widespread Late Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on the third-floor respiratory (ventilator) unit to meet resident needs, resulting in widespread late medication administration. The third floor housed 32 residents, all dependent on staff for all or some daily needs, including 16 residents on ventilators, 29 with tracheostomies, 22 with gastrostomy tubes, and 15 with wounds. Facility staffing records from 3/9/26–3/25/26 show that only two licensed nurses were scheduled per shift on this high-acuity respiratory unit, consistent with the facility assessment and staffing plan that identified two licensed nurses per unit and per shift. On the date reviewed, the schedule showed two RNs (one agency) assigned to the third floor, and the DON confirmed there had been a call-off and that one RN came in to cover until the agency nurse arrived. On the morning in question, one RN reported still having several residents left to receive their medications and stated that medications would be late, explaining that the volume of residents with gastrostomy tubes made medication administration time-consuming due to required checks and preparation. This RN stated that medications were late every day on that floor and that a third nurse was needed. A floor manager RN reported being asked to come in temporarily to help until the agency RN arrived and acknowledged that most residents’ medications, scheduled for 9:00 a.m. and due by 10:00 a.m., were not given by the due time; the floor manager passed medications for only two residents and then stayed to help the agency nurse. The agency RN stated that they had just arrived, were receiving report, had 19 residents assigned, and still had 17 residents needing their morning medications after the due time, confirming that these medications would be late. Medication Administration Audit reports for the third floor on the same date showed that 16 of 32 residents received medications late, affecting residents assigned to both RNs. Multiple residents with complex conditions, including respiratory failure, ventilator dependence, tracheostomies, gastrostomy tubes, epilepsy, diabetes, pressure ulcers, quadriplegia, hemiplegia, anoxic brain damage, COPD, and other serious diagnoses, had scheduled morning medications administered from 21 minutes to more than three hours past the scheduled times. The DON acknowledged that medications are expected to be given within one hour before or after the scheduled time, affirmed that administration more than one hour past the scheduled time is a timing medication error requiring physician notification, and nonetheless stated a belief that two nurses were sufficient for the unit. Additional staff who regularly worked on the respiratory unit, including an RN, an LPN, and the Infection Preventionist, reported that there were not enough nurses on the third floor, described the residents as very acute with extensive ventilator, trach, and tube-feeding needs, and stated that the workload made it difficult to do more than pass medications and impeded timely completion of other nursing tasks. These observations and records demonstrate that the facility did not ensure sufficient nursing staff with appropriate competencies to meet the assessed needs of all residents on the respiratory unit, contrary to its own staffing, medication administration, and resident rights policies.
Failure to Follow POLST Regarding Artificial Nutrition and Hydration
Penalty
Summary
The facility failed to follow a resident’s advance directive, specifically the Illinois POLST form, regarding the provision of artificial nutrition and hydration. The resident, who had anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, a stage 4 sacral pressure ulcer, tracheostomy and gastrostomy status, and a history of sudden cardiac arrest, was cognitively severely impaired and dependent on staff for all ADLs. The POLST form directed that artificial nutrition and hydration be provided by any means, including new or existing surgically placed tubes. The resident’s care plan documented NPO status with enteral feeding for all nutrition needs, with interventions to adjust tube feeding as needed and monitor tolerance, weight, labs, skin, and hydration. However, record review showed that the resident had no active G-tube feeding orders, only water flushes and medications, and that a prior continuous tube feeding order had been discontinued on a specified date. During observations on two separate days, the resident was seen in bed, unresponsive to questions, with a G-tube plunger at the bedside but no feeding pump or feeding infusing. When questioned, an RN stated she was unsure of the feeding orders and later reported that hospice had discontinued the feeding. The resident’s family member/POA reported being told by hospice that feeding could not be restarted because the resident was at end of life and, lacking clinical experience, accepted this explanation, although she stated she wanted the resident to continue receiving feeding. The DON stated she was unaware that the feeding had been discontinued and affirmed that the facility should follow the POLST. The physician acknowledged knowing that hospice had stopped the feeding due to aspiration risk and that the resident’s wife was said to be okay with it, and further stated that if G-tube feeding is discontinued, the POLST should be readdressed and a new one obtained. The facility’s advance directive/DNR policy states that residents have the right to determine in advance what life-sustaining treatment will be provided, including artificial hydration and nutrition, and that such directions enable staff to know how to treat residents in advance of an emergency.
Failure to Implement Fall-Prevention Care Plan Intervention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident assessed as high risk for falls. The resident is an adult male with medical diagnoses including acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, and a BIMS score of 10/15. A fall assessment dated 5-17-2025 scored the resident at 15, indicating high fall risk. The resident’s care plan dated 7-3-2025 included an intervention to keep the bed in the lowest position. However, nursing notes dated 12-25-2025 documented that the resident’s bed was left in an elevated position, and the nurse observed the resident lying on his left side, after which he was sent emergently to a local hospital for evaluation. During interviews, the DON stated that on 12-25-2025 at 5:50 AM, the resident was observed on the floor after the bed had been left in a high position, and that the care plan required the bed to be in a low position due to the resident’s high fall risk. The DON reported not knowing who left the bed in the high position and stated an expectation that nursing staff implement care plan interventions. The Restorative Nurse confirmed that staff are responsible for implementing care plan interventions and did not know why the bed was left high. The Administrator also stated an expectation that nursing staff follow and implement the care plan to ensure the resident’s safety. The facility’s Comprehensive Care Plan policy dated 3-2025 states that the comprehensive care plan should drive the care and services provided for the resident.
Failure to Ensure Effective Nurse-to-Nurse Handoff Communication During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective nurse-to-nurse communication and documentation during resident transfers to an acute care hospital, contrary to professional nursing standards and facility policy. For one resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest, the record for a transfer for a GI bleed showed no documentation of a report being called to the hospital. The Hospital Transfer Form completed by the DON left blank the section for documenting to whom report was called, and the DON stated she did not call the hospital but only helped fill out forms. When requested, the facility could not provide any documentation or other evidence that a nurse-to-nurse report or verbal handoff occurred for that transfer. For the same resident’s later transfer for tachycardia and seizure-like activity, the RN who initiated the transfer stated she believed she had called report to the receiving hospital but could not recall to whom she gave report, and there was no documentation in the medical record of a nurse-to-nurse report or verbal handoff. The RN documented notifying the family and giving information to paramedics, including face sheets and physician orders, but did not document communication with the hospital. The resident had a hospice consent signed several days prior to this transfer, but the SBAR form completed by the RN did not indicate that the resident was on hospice and did not document any communication to the hospital. The facility was unable to provide evidence that a verbal handoff or nurse-to-nurse report was completed at the time of this transfer. A second resident with end stage renal disease, dialysis dependence, acute pulmonary edema, heart failure, hypoxemia, anemia in chronic kidney disease, type 2 diabetes, and peripheral vascular disease was transferred to the hospital on two occasions without documented nurse-to-nurse communication. For one transfer, the hospital transfer sheet completed by an RN did not document who received report at the hospital, and there were no nurse progress notes or other nursing documentation regarding handoff or hospital transfer. For a later transfer, initiated when the resident called 911 stating he did not feel well, the LPN documented that the resident was escorted to the emergency room and that a message was left for the next of kin, but the hospital transfer sheet did not document to whom report was called. The LPN stated she typically did not call the hospital when the resident self-initiated 911 calls, relied on paramedics and the hospital’s prior familiarity with the resident, and did not send physician orders in those situations. The DON described an expectation that nurses obtain physician orders, complete transfer and SBAR forms, notify family, call and give report to the hospital nurse, send a face sheet and physician orders, and document these actions in progress notes, which was not demonstrated in these cases.
Failure to Complete Fall Documentation and Post-Fall Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy for two high fall-risk residents by not completing required fall risk evaluations and post-fall assessments, and by failing to document at least one fall event. One resident, a male with acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, had multiple fall risk assessments with scores greater than 10, indicating high risk for falls. His fall risk scores included 15, 13, 25, 25, and 23 on various dates. A progress note documented that he rolled out of bed and was sent to a local hospital for evaluation, but there were no fall or pain assessments completed after this fall, despite the facility policy requiring a fall risk evaluation after each fall. The second resident, a male with hemiplegia, hemiparesis, diabetes, vascular dementia with anxiety, and tracheostomy, also had multiple fall risk assessments with scores greater than 10, indicating high risk for falls, including scores of 14, 22, 24, and 22. A progress note documented that he was found sitting on his buttocks on a floor mat next to the bed and was sent to a local hospital for evaluation. The DON stated there was no completed fall report for this fall and no documented post-fall assessments for falls on two separate dates. The restorative nurse confirmed that the nurse documented the resident on the floor but did not complete a fall report, risk management, or fall assessment. The Administrator and DON both stated their expectation that staff complete risk management, fall assessments, and required documentation after every fall, consistent with the facility’s Fall Prevention and Management policy, which requires a fall risk evaluation on admission, readmission, quarterly, and after each fall, and completion of a fall incident report in the risk management portal.
Failure to Integrate and Communicate Hospice Status in Resident Care and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and integrate hospice services into a resident’s plan of care after hospice enrollment. A male resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest had a hospice consent signed on 12/27/25 initiating hospice services. Despite this, review of the resident’s most current physician order sheet (POS) showed no physician orders for hospice, and the resident’s face sheet contained no indication of hospice status. The facility was unable to provide documentation demonstrating that hospice enrollment was incorporated into the resident’s active orders or clearly communicated to nursing staff responsible for the resident’s care. On 01/02/26, the resident experienced a change in condition characterized by a heart rate between 130–150 and seizure-like movements or activity. The RN on duty, working through an agency, notified the manager on duty, contacted the MD, obtained a telehealth consultation, and received an order to send the resident out via 911. The resident was transported to the hospital by EMTs. The RN documented that three copies of the face sheet and the physician orders were printed and given to the paramedics. The RN later stated she did not know the resident was on hospice at the time of transfer and indicated that hospice status would have been important to communicate to the hospital. Review of the SNF to Hospital Transfer Form for the 01/02/26 transfer showed that report was called in to the ER, but there was no indication on the form that the resident was on hospice. The DON stated that if a resident is on hospice, this should be reflected in the POS and on the face sheet, and that once hospice consent is signed, social services should enter the hospice order into the POS and usually inform the nurse on the unit. The facility’s hospice policy requires a documented communication process between the facility and hospice provider and specifies that the facility must immediately notify hospice of a need to transfer the resident. CMS regulations cited in the report require the facility to coordinate hospice services with the hospice provider and ensure hospice care is integrated into the resident’s plan of care, which did not occur in this case.
Failure to Honor 24-Hour Visitation Rights and Improper Enforcement of Visiting Hours
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to receive visitors of their choosing at the time of their choosing, as required by resident rights regulations and the facility’s own visitation policy. The facility maintained and enforced fixed visiting hours, generally from either 8 a.m. or 10 a.m. until 8 p.m., and staff reported that visitors were expected to leave after 8 p.m. Staff, including CNAs and LPNs, consistently described visiting hours ending at 8 p.m., and one LPN stated that no one was allowed after 8 p.m. except for hospice or critically ill patients. The DON stated that, for the sake of residents and to have some normalcy, the facility had visiting hours and that overnight stays required approval from the administrator or DON, usually for hospice, new admissions, or family comfort. Two residents who were nonverbal and fully dependent on staff for care were directly affected by this practice. One resident, an older adult admitted in March 2025 with anoxic brain damage, acute and chronic respiratory failure, severe protein-calorie malnutrition, a stage 4 sacral pressure ulcer, tracheostomy status, anemia, and gastrostomy status, was unable to self-advocate. The resident’s family member reported typically visiting around 5:45–6 p.m. and stated that on one evening staff told her at 8 p.m. that visiting hours were over and it was time for her to leave. She reported refusing to leave until the resident’s tube feeding was turned back on, and stated that being asked to leave at 8 p.m. was consistent with how visiting hours had “always been.” Another resident, an older adult admitted in November 2025 with anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, was also nonverbal and fully dependent on staff. This resident’s family member reported that at 8 p.m. “on the dot” staff came and told her she had to leave because visiting hours were over, even though she was waiting for staff to come and clean the resident. She identified the LPN who told her to leave as the nurse working that evening. The family member also stated that the roommate’s wife had no objection to her presence and had even shared her phone number. No documentation was found to show that the visitation limits imposed on these residents’ visitors were based on individualized clinical need, resident preference, safety concerns, or the rights of others. The facility’s written visitation guidelines, last reviewed in September 2025, stated that residents have the right to receive visitors 24 hours a day and that open visitation is permitted at all times, with only “quiet hours” between 8 p.m. and 8 a.m., and that any restrictions must be reasonable, temporary, least restrictive, explained, and documented.
Failure to Provide Ordered Enteral Nutrition and Accurately Document Tube Feeding Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to maintain adequate nutrition independently received enteral nutrition as ordered and that accurate records of daily enteral intake were maintained. Three nonverbal, fully dependent residents with gastrostomy tubes and significant medical conditions, including anoxic brain damage, respiratory failure, severe protein-calorie malnutrition, tracheostomy status, and pressure ulcers, were affected. For one resident, the spouse reported that the feeding tube pump was off when she arrived around 6:00 PM, despite orders for continuous tube feeding from 2:00 PM to 11:00 AM. Nursing documentation and an incident narrative confirmed that the feeding tube had been turned off for several hours, resulting in missed scheduled tube feeding, and that the issue was brought to staff attention by the spouse. The telehealth physician note further documented that the spouse was upset that feeds were not running between 2:00 PM and 6:00 PM and that feeds were only started once the notification was made. The same resident’s family member reported that this problem had occurred multiple times over a period of weeks, including around Thanksgiving and Christmas, stating that the resident had not been fed for 6 to 8 hours on separate occasions. The family member also reported another recent visit when the pump was beeping and displayed “INACTIVE,” and the nurse present, identified as agency staff, could not explain why the feeding was not running. A CNA stated that when he goes in to provide care, the feeding is often paused and the nurse is notified to turn it back on. At the time of surveyor observation, the resident’s feeding pump was running at the ordered rate of 50 mL/hr with a labeled start time of 6:00 AM, but the amount of formula remaining in the container and the total volume displayed on the pump did not match what should have infused based on the documented start time and rate. For the second resident, who was also nonverbal and fully dependent with diagnoses including respiratory failure, hemiplegia, severe protein-calorie malnutrition, anoxic brain damage, tracheostomy status, and gastrostomy status, the physician’s order specified Jevity 1.5 at 80 mL/hr continuous for 20 hours, on at 2:00 PM and off at 10:00 AM or until 1600 mL was infused, with water flushes every 6 hours. During surveyor observation, the feeding pump was running at 80 mL/hr, but the feeding container lacked a start time label, and approximately 900 mL remained in a 1000 mL container when, based on the ordered rate and start time, only about 100 mL should have remained. The total fed volume on the pump (209 mL) also did not correspond to the actual volume in the container, and the absence of a start time made it unclear when the feeding had been started or whether it had been running continuously as ordered. For the third resident, who was nonverbal, fully dependent, and had diagnoses including anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, the physician’s order specified Vital 1.5 at 70 mL/hr continuous for 21 hours, on at 2:00 PM and off at 11:00 AM, with a total daily volume of 1470 mL and water flushes every 6 hours. Surveyors observed the feeding pump running at 70 mL/hr with a labeled start time of 3:00 AM, and approximately 600 mL remaining in a 900 mL container. Based on the ordered rate and the labeled start time, the container should have contained about 480 mL, but the observed volume did not match this calculation. The total fed volume displayed on the pump was 2836 mL, which exceeded the ordered daily volume of 1470 mL and did not correspond to the labeled start time. The DON acknowledged that staff may not have reset the pump when hanging a new bottle and confirmed that nurses should reset the machine at that time. Across all three residents, review of the medical records showed no documentation of when tube feedings were interrupted, stopped, or restarted, and there was no accurate record of the total daily volume of tube feeding delivered. The DON stated that there was no flow sheet to track bottle changes and that documentation was limited to the MAR, which for one resident showed tube feedings as administered but without times for when feedings were started or total volume received. The facility’s own tube feeding guideline required that the pump be cleared at the end of each shift and that tube feeding delivered be documented, but the observed discrepancies between ordered rates, labeled start times, pump volumes, and actual formula remaining, along with missing documentation of interruptions and total intake, demonstrate that these procedures were not followed for the residents reviewed.
Failure to Monitor and Respond to Critical Potassium Levels
Penalty
Summary
A resident with multiple complex medical diagnoses, including chronic obstructive pulmonary disease, hypertension, heart disease, and aortic aneurysms, was admitted to the facility and was being treated for hypokalemia (low potassium). The resident's potassium levels were monitored through laboratory testing, which revealed several critically low values. Orders were given for potassium supplementation, but there was inconsistent documentation regarding the administration of these supplements and a lack of timely repeat laboratory monitoring to assess the effectiveness of the interventions. Despite ongoing potassium supplementation, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice. Subsequently, a laboratory result indicated a critically high potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The nurse who reviewed this result documented that the lab was relayed to the nurse practitioner via phone and that they were awaiting a response. However, there was no further documentation of any actions taken, no confirmation that the provider was made aware of the critical value, and no evidence of nursing assessment or clinical intervention. The nurse did not initiate emergent medical care or escalate the situation as required by facility policy, and the critical lab result was cleared in the electronic medical record, preventing further follow-up by subsequent staff. Interviews with facility staff revealed that the nurse failed to follow established protocols for reporting and acting upon critical laboratory values, including contacting the provider, medical director, or telehealth services when a response was not received. The facility's policy required that critical lab results be communicated to a licensed practitioner within one hour and that escalation procedures be followed if the provider could not be reached. The lack of timely intervention and failure to act upon the critically abnormal potassium level resulted in the resident not receiving necessary medical intervention. Four days after the critical lab result, the resident was found unresponsive and subsequently expired in the facility.
Removal Plan
- The DON checked and verified all residents with time sensitive critical medication, recognizing therapeutic laboratory level, conducting routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- All Nurses staff were provided with education by the DON/Designee. The training included ensuring time sensitive critical medication have therapeutic laboratory level, have routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- The Medical Director, Administrator and DON reviewed the facility's policies which include Policy of Critical Lab Result Reporting, Critical Medications Requiring Laboratory Monitoring.
- New hires will be in-serviced by the DON, ADON or Designee. All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. The staff members will also be provided with the same educational materials.
- The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. The Administrator/DON will send the same training materials to the staffing agency. Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first.
- The DON/ADON/designee will conduct audits to identify any potential concerns related to this plan of removal.
- The DON/ADON/Designee will also conduct staff (nurses and agency) interview, with at least five employees, to gauge knowledge retention and determine if additional training is required.
- During the weekends, the assigned Nursing Supervisor/Designee will conduct the audit, ensuring time sensitive critical medication, recognizing therapeutic laboratory level, conduct routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the clinical leadership which includes the DON, ADON, MDS, IP, Restorative, and the Administrator/Designee.
- Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, DON and Designee will monitor completion of this plan of removal.
Failure to Communicate Critical Lab Result Leads to Resident Death
Penalty
Summary
A facility failed to ensure that laboratory results, specifically a critical potassium level, were communicated to the ordering provider in accordance with its policy and procedures. One resident, an elderly female with multiple cardiac and vascular comorbidities, had a laboratory result indicating a critically elevated potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The result was reviewed by an LPN, who documented that the lab was relayed to the nurse practitioner via phone and that a response was awaited. However, there was no further documentation of actions taken, confirmation that the provider was made aware, or evidence of nursing assessment or clinical intervention in response to the critical value. Interviews with facility staff revealed that the LPN may have attempted to notify the provider by text or voicemail but did not receive a response and subsequently cleared the lab notification in the electronic medical record. This action prevented other staff from seeing the critical result. The LPN did not escalate the issue to the medical director or telehealth, as required by facility policy, nor did she initiate emergent care or further monitoring. Other nurses and leadership confirmed that the expectation was for critical labs to be communicated immediately and for escalation if the provider could not be reached, especially for life-threatening values such as a potassium of 8.4 mEq/L. The resident was found unresponsive in the facility four days after the critical lab result was obtained and subsequently expired. The death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required that critical lab results be communicated to a licensed practitioner within one hour, with repeated attempts and escalation to the medical director if necessary. The failure to follow these procedures resulted in the deficiency and was cited as Immediate Jeopardy.
Removal Plan
- DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call; in-services are ongoing. V4 termed.
- DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation; in-service is ongoing.
- DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order.
- The Medical Director was made aware and in agreement with the abatement and an in-service was conducted with her Nurse practitioner regarding critical labs.
Failure to Monitor and Respond to Potassium Supplementation
Penalty
Summary
A resident with multiple significant medical diagnoses, including chronic obstructive pulmonary disease, hypertension, and heart disease, was admitted to the facility and treated for hypokalemia (low potassium). The resident initially had a potassium level of 3.0 mEq/L, which was flagged as abnormal, and was prescribed a one-time dose of potassium. However, there was no documentation that this dose was administered, nor was there any evidence of follow-up laboratory orders or monitoring after this intervention. Subsequent labs showed a critically low potassium level of 2.0 mEq/L, prompting a new order for potassium supplementation over three days and a repeat basic metabolic panel (BMP) the following morning. Despite these interventions, there was a lack of consistent documentation and follow-up regarding the administration of potassium and the monitoring of potassium levels. The resident continued to receive potassium supplementation, with orders entered incorrectly, resulting in the resident receiving potassium for a longer duration than intended. The medication administration record showed that the resident received 34 doses of potassium over an extended period, rather than the intended three days. During this time, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels, nor was there ongoing assessment for the continued need for potassium supplementation. Repeat potassium levels were not obtained until 13 days after the initial critical low value, at which point the resident was found to have a critically high potassium level of 8.4 mEq/L. Upon discovery of the critically elevated potassium level, there was no documentation of nursing assessment, clinical intervention, or initiation of emergent medical care. The nurse who reviewed the lab result documented relaying the information to the nurse practitioner but did not document any further actions or confirmation that the provider was made aware of the critical value. The resident was found unresponsive in the facility four days after the critically high potassium result was obtained, and the death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required ongoing laboratory monitoring and prompt reporting of critical values for medications like potassium, but these procedures were not followed in this case.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to follow standard infection prevention and control protocols during the provision of morning care for two residents. The CNA was observed assisting one resident with a bed bath, using gloved hands to wash the resident and then using the same soiled gloves to handle the resident's personal items, such as a phone, and to touch various surfaces in the room, including pillows that had been on the floor and the door knobs. The CNA also used the same soiled gloves to pick up clean linen from the hallway linen cart and to handle clean clothing and apply lotion to the resident, without performing any hand hygiene or changing gloves throughout the entire care episode. The CNA continued to use the same soiled gloves to handle soiled linens, which were placed on the bare floor, and to interact with the roommate's belongings and bed linens. At no point during the observed care did the CNA remove the soiled gloves or perform hand hygiene, despite moving between different residents' belongings and clean and soiled items. The CNA acknowledged after the observation that gloves should have been changed and hand hygiene performed, and that soiled linens should have been contained in plastic bags rather than placed on the floor. Interviews with the Infection Control Nurse and the Director of Nursing confirmed that facility policy requires staff to perform hand hygiene before and after resident contact, change gloves between tasks, and avoid touching clean linen carts or moving between residents with soiled gloves. The facility's infection control policies, reviewed and current, specify these requirements for all staff to prevent the spread of infection. The observed failure to adhere to these protocols affected the two residents involved and had the potential to impact all residents on the floor.
Failure to Follow Discharge and AMA Policies for Resident Leaving Facility
Penalty
Summary
The facility failed to follow its discharge and Against Medical Advice (AMA) policies when discharging a resident who left the facility without proper documentation or preparation. The resident, who had multiple medical diagnoses including epilepsy, dysphagia, anxiety disorder, and depression, was cognitively intact but required staff supervision or assistance for all activities of daily living. Despite the resident expressing a desire to leave and being denied a community pass due to not following curfew rules, the facility did not ensure that the discharge process was properly documented or that the resident was adequately prepared for a safe transition. There was no evidence that the resident or their responsible party was educated on the risks of leaving AMA, nor was there documentation that the attending physician was notified and given the opportunity to educate the resident as required by policy. The facility was unable to provide a signed AMA form or documentation that the form was presented and refused, as outlined in their procedures. Additionally, the resident left without his medications or personal belongings, which were instead packed and sent to storage. Attempts to contact the resident after discharge were unsuccessful, and the facility did not know the resident's current location or condition. Interviews with staff confirmed that the required steps for AMA discharge, including documentation of education, physician notification, and proper completion of forms, were not followed. The lack of adherence to policy resulted in the resident being discharged to an unknown location without assurance of safety or continuity of care.
Failure to Prevent Falls and Follow Post-Fall Protocols for High-Risk Resident
Penalty
Summary
A resident with multiple diagnoses, including muscle weakness, abnormal posture, profound intellectual disabilities, dementia, and osteoarthritis, was assessed as high risk for falls. Despite this, the facility failed to prevent multiple fall incidents for this resident. The resident experienced two unwitnessed falls, one of which resulted in a closed right hip fracture. The care plan interventions following the first fall included promoting call light use and therapy evaluation, but the root cause of the fall was not clearly identified, and the intervention did not address the actual cause, as the resident was unable to use the call light effectively due to her condition. During the second fall incident, staff found the resident on the floor next to her bed, exhibiting pain and inability to extend her right leg. The nurse performed a head-to-toe assessment and range of motion, noting facial grimacing and abnormal leg positioning. Despite the resident's nonverbal status and clear signs of injury, staff assisted in transferring her back to bed using a Hoyer lift and a blanket, contrary to facility expectations for handling suspected injuries. The resident was later sent to the hospital and diagnosed with a right hip fracture. The facility's post-fall procedures were not properly followed, as staff moved the resident before paramedics arrived, potentially exacerbating her injury. Additionally, the interventions added to the care plan after the first fall were not effective in preventing subsequent incidents, and the root cause analysis did not result in meaningful changes to the resident's environment or supervision. The lack of effective fall prevention strategies and failure to adhere to post-fall protocols contributed to the resident's repeated falls and injury.
Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were dependent on staff for personal hygiene. One male resident with severe cognitive impairment was observed with an unkempt and dirty beard, discolored facial hair around his mouth, food debris in his beard, and long, dirty fingernails. His Minimum Data Set (MDS) indicated a need for substantial to maximal assistance with personal hygiene, and his care plan documented the requirement for staff assistance with ADLs. Another male resident, who was cognitively intact but unable to walk, was observed with long facial hair and reported that he had repeatedly requested assistance with shaving during his two-month stay, but his requests were ignored. His MDS documented a need for partial to moderate assistance with personal hygiene, and his care plan also indicated the need for staff support with ADLs. The Director of Nursing confirmed that CNAs are responsible for providing hygiene care to residents requiring assistance. The facility's ADL guidelines require a care-planned and implemented program of assistance and instruction in ADL skills.
Failure to Follow Nutrition Support Orders for Tube-Fed Residents
Penalty
Summary
The facility failed to properly transcribe and implement hospital nutrition support orders for one resident who was readmitted, and did not follow physician orders for three residents requiring nutrition support. For the readmitted resident, hospital discharge records specified a continuous tube feeding regimen and nutritional supplements, but the facility delayed starting the supplements and did not initiate the continuous feeding as ordered. This resident, who was severely underweight and had multiple pressure ulcers, experienced a significant weight loss over a short period. For two other residents, observations revealed that tube feedings were not running during times when physician orders indicated they should be. Staff interviews confirmed that tube feedings were sometimes stopped for ADL care or medication administration and not always restarted promptly. One resident experienced a severe weight loss over six months, and the dietitian recommended increasing tube feeding to promote weight stability, but the feeding schedule was not consistently followed as ordered. Facility policy required that physician orders be followed as written and that continuous tube feedings be administered according to the specified schedule or as assessed by the dietitian. However, staff practices, including stopping feedings for care or medication and not resuming them as required, led to residents not receiving adequate nutrition support as ordered. These failures were confirmed through observation, record review, and staff interviews.
Failure to Provide Adequate Supervision and Follow Fall Policy
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and follow its fall prevention policy for one resident with paraplegia, PTSD, conversion disorder with seizures, depression, UTI, and osteoporosis. The resident, who is cognitively intact and requires maximal assistance for transfers and toileting, reported that after a medical procedure, she was in pain and felt weak. She activated her call light to request assistance to use the bathroom, but no staff responded for an extended period. As a result, she attempted to go to the bathroom independently, became weak, and fell in the bathroom. She then crawled to her wheelchair and pushed it into the hallway to get staff attention. The facility's fall report log did not document this incident, and no fall risk management assessment was initiated until prompted by the surveyor. The agency LPN and other staff believed the resident's behavior of placing herself on the floor was typical, but there was no documentation or care plan evidence to support this claim. The facility's fall prevention policy requires that all falls be reviewed and a fall risk evaluation be completed, which was not done in this case. The DON confirmed that the expected procedure following a fall was not followed, and there was a lack of documentation regarding the resident's alleged behaviors.
Failure to Update Abuse/Neglect Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update and revise the Abuse/Neglect Care Plan for a resident after a sexual abuse allegation was reported. Interviews with the Social Service Director, MDS Coordinator, and Social Service Coordinator confirmed that the care plan should be updated whenever there is an allegation of abuse, and that the Social Service Department is responsible for these updates. Despite this, the resident's abuse/neglect comprehensive care plan was last updated over a year prior to the reported incident, and was not revised following the new allegation. Record review showed that the resident had multiple risk factors, including diagnoses of aphasia, dementia, bipolar disorder, and a history of cerebrovascular disease. The care plan did note previous allegations of verbal aggression and sexual abuse from a peer, but was not updated to reflect the most recent incident. Facility policy requires that care plans be reviewed and updated quarterly, annually, and with any significant change, including abuse allegations, but this was not followed in this case.
Failure to Immediately Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of resident-to-resident sexual abuse to the Illinois Department of Public Health (IDPH) and local law enforcement. The incident involved a resident who reported to an LPN that his roommate had inappropriately touched him in the lower back and buttocks area during the night. The LPN relayed this information to the Social Service Coordinator, who then informed the Administrator. Despite being made aware of the allegation on the same day it was reported, the Administrator did not notify IDPH or the police at that time, as he concluded after interviews that the allegation was fabricated. Interviews with facility staff, including the Director of Nursing and Social Service Director, confirmed that the proper protocol for such allegations is to report them immediately to the state and law enforcement. The Social Service Coordinator documented the allegation in a progress note and reported it to the Administrator, but no external reporting occurred until several weeks later, when the facility finally contacted the police and submitted an initial report to IDPH. The police confirmed that they were not notified at the time of the alleged incident. The resident involved had a history of cognitive impairment, with a Brief Interview for Mental Status (BIMS) score indicating moderate impairment, and diagnoses including aphasia, dementia, and bipolar disorder. The facility's own abuse prevention policy requires immediate reporting of any abuse allegations to both state authorities and law enforcement, particularly in cases of sexual abuse between residents. Despite these requirements, the facility delayed reporting the incident, failing to follow established protocols.
Unlicensed Respiratory Care Provided by Technician/Student
Penalty
Summary
The facility failed to provide credentialed certified respiratory staff as required by state law, resulting in unlicensed personnel performing respiratory care for residents. Specifically, a respiratory technician/student, who was not yet certified, was observed independently providing tracheostomy care and other respiratory treatments to residents. This included tasks such as suctioning, tracheostomy care, ventilator checks, assessments, and medication administration, which should have been performed by a licensed respiratory therapist. The deficiency involved three residents who required respiratory care. One resident, a female with chronic respiratory failure and other complex medical conditions, had physician orders for tracheostomy tube care and oxygen therapy. Another resident, also a female with chronic respiratory failure and tracheostomy status, had similar orders. The third resident, a male with respiratory failure and other health issues, was on ventilator settings that required professional oversight. Despite these needs, the unlicensed technician/student was assigned to provide care without proper supervision or certification. Interviews with facility staff revealed that the respiratory technician/student had been working independently since January 2023, despite not having completed the necessary certification program. The facility's respiratory therapy director and human resources director were aware of the technician's unlicensed status but did not take appropriate action to ensure compliance with state regulations. The facility's records and staff lists inaccurately represented the technician as a licensed respiratory therapist, further contributing to the deficiency.
Removal Plan
- Affected resident corrective actions: R67, R79, and R149 were provided with respiratory care and assessment by a licensed RT. Respiratory assessments on all current 18 residents were completed by a licensed RT with no concerns identified.
- The Medical Director and responsible parties of ventilator residents were notified of the alleged deficiency.
- The two unlicensed respiratory staff (Staff A and Staff B) were immediately removed from the schedule and will be terminated from their role as respiratory aides.
- Education was provided to the Respiratory Program Director, Director of Human Resources, and Administrator to ensure newly hired credentialed staff have a valid and active license.
- Verification of valid and active licenses for all respiratory therapists was completed by the Regional Director of Operations and the President of Clinical Services.
- Quarterly review of RT licenses by the Human Resources Director to ensure compliance.
- Development of a biweekly schedule and on-call schedule by the Director of RT and/or Regional RT to ensure a licensed RT is available.
- Review of the Respiratory Therapist to Patient ratio on a daily basis by the facility Administrator and Director of Nursing.
- Education provided to the Director of Nursing and Director of Staffing to ensure outside agency staff have valid and active licenses before working.
- Administrator will review newly hired licensed professional staff employee files to ensure valid and active licenses before the first day of work.
- Human Resource Director will send out communication on renewing licenses and remove any RT from the schedule if not renewed one week prior to expiration.
- Director of Human Resources will conduct audits on newly hired licensed professionals to identify non-compliance, with results reported to the QAPI committee.
- Administrator and Director of Human Resources will monitor the completion of the plan of removal.
Failure to Provide Professional Standards of Care and Supervision
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident experiencing a change in condition. A resident, who had a history of chronic obstructive pulmonary disease, acute respiratory failure, and other respiratory issues, experienced physical distress and anxiety due to a lack of appropriate medical intervention. Despite the resident's request to be taken to the hospital, the nurse on duty refused to call 911, insisting that the resident could be treated at the facility. The resident eventually called 911 herself and was diagnosed with pneumonia and influenza A at the hospital. The facility also failed to ensure that respiratory care was provided by licensed professionals. Two unlicensed respiratory technicians, who were still students, were observed independently performing tasks such as tracheostomy care, administering medications, and conducting assessments without direct supervision. The facility's administration was aware of the technicians' unlicensed status but allowed them to continue working independently, contrary to the requirements of the Respiratory Care Practice Act. The facility's failure to adhere to professional standards of care resulted in prolonged distress for the resident and potential risks to other residents receiving respiratory care. The lack of proper documentation and oversight of unlicensed personnel further contributed to the deficiencies identified during the survey.
Failure to Timely Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to timely assess and respond to a significant change in condition for a resident, resulting in a delay of care. The resident, an elderly female with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, asthma, and influenza, experienced a significant change in her condition. On the night of January 12, 2025, she began feeling unwell, experiencing drowsiness and difficulty breathing due to excessive phlegm. Despite her requests to be sent to the emergency room, the nurse on duty refused to call 911, stating there was nothing wrong with her and that she could be treated at the facility. The following morning, the resident continued to feel unwell and again requested to be sent to the hospital, but the nurse refused once more. The resident eventually called 911 herself and was taken to the hospital, where she was admitted with pneumonia and influenza. The facility's Director of Nursing (DON) mentioned that the resident frequently called 911, and the local emergency services had warned the facility about potential fines for abusing the service. However, there was no documentation of a head-to-toe physical assessment or monitoring of the resident's respiratory status on the days in question, nor was there any notification to the resident's physician or nurse practitioner about her change in condition. The facility's failure to assess the resident's condition and notify her physician was a violation of their Change in Resident Condition policy. The resident's care plan specifically noted the need to monitor her respiratory status due to her existing medical conditions, yet no such monitoring was documented. The lack of timely assessment and response to the resident's significant change in condition resulted in prolonged physical distress, pain, and anxiety for the resident before she was admitted to the hospital for treatment.
Unlicensed Respiratory Care Staff Performing Independent Duties
Penalty
Summary
The facility failed to employ credentialed certified respiratory staff as required by state law, impacting the care provided to residents requiring respiratory care. Observations and interviews revealed that a respiratory technician, identified as V5, was performing tasks independently without the necessary certification. V5 was observed providing tracheostomy care, administering medications, and conducting assessments for residents, despite not being a certified respiratory therapist. V5 has been working independently since January 2023, although initially hired as a student in January 2022. The facility's Human Resources Director, V6, acknowledged that V5 does not have a respiratory therapy license and was aware of this since October 2024. Despite this knowledge, no action was taken to rectify the situation. The Regional Respiratory Program Director, V7, stated that V5 was supposed to work under supervision, but observations indicated otherwise. V5's responsibilities included tasks typically performed by licensed respiratory therapists, such as suctioning, tracheostomy care, and responding to respiratory emergencies, without the required supervision. The facility's job description for respiratory therapists requires a graduate of an accredited program and a current license, which V5 and another technician, V10, do not possess. The Respiratory Care Practice Act mandates that individuals performing respiratory care must be licensed and supervised, which was not adhered to in this case. The facility's failure to ensure that V5 and V10 were appropriately credentialed and supervised poses a risk to the residents requiring respiratory care.
Inadequate Mask Provision During Influenza Outbreak
Penalty
Summary
The facility failed to adequately protect its residents during an influenza outbreak by not providing appropriate masks to individuals entering the facility. The Infection Preventionist (V3) recommended that staff wear face shields and N95 masks for contact and droplet precautions, but noted that non-medical masks were being used instead. Despite informing the Director of Nursing (V2) and the Administrator (V1) about the issue, non-medical masks continued to be available on every floor, and some staff were observed wearing them. The outbreak began on the fourth floor and spread to the first floor, with 34 residents testing positive for influenza, two residents positive for pneumonia and influenza, and two residents positive for RSV. The facility's Control Supply Director (V11) ordered non-medical masks instead of surgical masks, possibly due to a supply issue, and was unsure who directed him on what type of masks to order. The Medical Director (V9) stated that N95 masks were necessary to completely prevent an influenza outbreak. Observations by the surveyor revealed numerous boxes of non-medical masks throughout the facility, and staff were seen wearing them, including a respiratory therapist providing care to a resident. The facility's contact tracing list confirmed the spread of influenza among residents, and the CDC guidelines emphasize the importance of using appropriate PPE, such as surgical masks, to prevent transmission in healthcare settings. The use of non-medical masks, which are not suitable for healthcare environments, contributed to the deficiency in infection control during the outbreak.
Failure to Address Food Quality Complaints
Penalty
Summary
The facility failed to implement an effective grievance council to address residents' complaints about food quality, affecting four residents and potentially impacting 128 out of 150 residents. The residents, who have intact cognition, expressed dissatisfaction with the food, describing it as uncooked, cold, and bland. They reported that when they requested alternatives, they were told it was not in the budget. Despite these complaints, the grievance committee did not address their concerns effectively. During a resident council meeting, several residents voiced their dissatisfaction with the food quality, stating that their complaints to the Dietary Manager, V14, were not adequately resolved. Although V14 offered substitutes or reheated meals, residents felt that the food quality had declined since their arrival at the facility. The Medical Director, V9, and the Social Service Director, V18, were unaware of the specific grievances related to food quality, indicating a lack of communication and follow-up on resident concerns. A test tray observation revealed that the food served did not meet proper temperature standards, with burgers at 105 degrees Fahrenheit and other items also below recommended serving temperatures. The Dietary Manager, V14, was unaware of the proper serving temperatures for food safety, further highlighting the facility's failure to address food quality issues. The facility's grievance policy requires prompt resolution of grievances, but this was not effectively implemented, potentially affecting all residents receiving meal trays.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to adhere to its medication administration and documentation policies, affecting four residents. Specifically, the staff did not properly document the administration of controlled substances on the controlled substance record for three residents. For instance, the controlled substance record for one resident's Oxycodone was left blank, despite the medication administration record indicating it was administered. Similarly, another resident's Clobazam and Lacosamide doses were not documented on the controlled substance record, although the medication administration record showed they were given. Additionally, the facility did not ensure that a newly admitted resident's Oxycodone controlled medication was documented on an individual controlled substance form. Instead, the medication was handwritten on a piece of paper, and there was no formal controlled substance record for this resident. The LPN responsible for administering the medication acknowledged the lack of documentation and indicated that the necessary forms might be in the nursing office, but did not inform the Director of Nursing about the missing controlled substance form. The facility's policies require that all controlled substances be documented at the time of administration, including the date, time, and signature of the administering nurse, as well as the number of doses remaining. These policies are in place to ensure safe and accurate medication administration, yet the facility failed to comply with these guidelines, leading to incomplete and inaccurate records for the affected residents.
Unlicensed Staff Administers Medication
Penalty
Summary
The facility failed to ensure that medications were administered by licensed personnel, as required by their policy. A respiratory technician/student, who was not licensed, independently administered a medicated breathing treatment to a resident with chronic respiratory failure. The resident, an elderly female with multiple complex medical conditions including chronic respiratory failure, neurocognitive disorder, and quadriplegia, was observed receiving the treatment from the unlicensed staff member. The technician had been working independently since January 2023, despite not having completed the necessary respiratory program or obtained a license. The facility's human resources director acknowledged that the technician was unlicensed and that there was no follow-up on license verification after the initial hiring process. The facility's policy clearly states that medications should only be administered by licensed personnel, yet this protocol was not followed. The technician's employee badge did not indicate their student status, and the facility's medication administration guidelines were not adhered to, leading to a significant medication error.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and labeling policies, resulting in several deficiencies. During a review of the medication cart on the first floor, it was found that two open bottles of eye drops, Simbrinza and Gentamycin Sulfate Ophthalmic Solution, were not labeled with a resident's name. The Simbrinza was discontinued by the physician on 11/7/2024, and the Gentamycin was discontinued on 1/17/2025, yet both remained in the cart without proper labeling. The LPN on duty could not confirm the ownership of these medications, indicating a lapse in following the facility's medication labeling policy. On the second floor, an open vial of Novolog insulin with an expiration date of 12/17/2024 was found in the medication cart, along with another expired and unlabeled vial. The LPN admitted to administering doses from the expired vial, which should have been removed from the cart. This oversight highlights a failure to adhere to the facility's policy on medication expiration and storage, as insulin should be used within 28 days of opening and stored in a refrigerator until opened. Additionally, on the third floor, an unopened insulin vial meant for a resident with Type 2 Diabetes Mellitus was found in the medication cart instead of being refrigerated as required. The facility also failed to remove expired Tuberculin testing solutions from the medication refrigerator, which could potentially affect all newly admitted residents on the first floor. These findings demonstrate a pattern of non-compliance with medication storage and labeling protocols, posing a risk to resident safety.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its mechanical lift policy, which mandates keeping the base of the lift in the widest position during transfers. This oversight occurred during the transfer of a resident diagnosed with morbid obesity and requiring assistance with personal care. The resident, who was unable to self-transfer due to decreased muscle tone and comorbidities, was being moved from bed to a dialysis chair using a mechanical lift. During the transfer, the CNAs did not have enough space in the resident's room and moved the resident into the hallway. As the resident was being lowered into the chair, the lift's legs were closed, contrary to the policy. The resident, who was top-heavy and nervous, began to fidget and move his hands outside the sling, causing instability. As the CNAs attempted to position the resident in the chair, the resident's movements led to the chair and the resident falling backward, resulting in the resident hitting his head on the floor. The incident resulted in the resident sustaining an acute subdural hematoma. The CNAs involved could not recall if the lift's legs were open or closed, but the Director of Nursing confirmed that the lift's legs were closed during the transfer, which was against the facility's policy.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent and protect a resident from resident-to-resident physical abuse, resulting in one resident hitting another in the face with a remote control. This incident involved two residents, both of whom were moderately cognitively impaired. The altercation began as a verbal argument over the television in their shared room, which escalated into physical violence. The resident who was struck sustained facial lacerations that required medical attention. The incident was reported by the affected resident, who initially stated that there was no physical altercation, but later confirmed being hit with the remote control. Staff members, including a CNA and LPN, observed the aftermath of the incident, noting blood on the affected resident's face. The facility's Director of Nursing and other staff were notified, and the resident who committed the act of aggression was sent to the hospital for a psychiatric evaluation. The facility's abuse policy emphasizes the right of residents to be free from abuse and outlines measures to prevent such occurrences. However, the incident highlights a failure in implementing these measures effectively, as the altercation was not prevented despite the facility's commitment to creating a secure environment. The report indicates that education on TV volume levels and encouraging residents to participate in activities outside their rooms could have potentially prevented the incident.
Failure to Report Allegations of Resident Abuse
Penalty
Summary
The facility failed to report allegations of physical abuse involving a resident, identified as R1, who claimed to have been attacked by another resident, R3. The incident reportedly occurred when R1 asked another resident to lower the volume of their television, leading to an altercation. R1 was sent to the hospital for a psychiatric evaluation following the incident. Despite the facility's social service director, V7, being aware of the altercation and conducting an investigation, there was no documentation to show that the facility reported the allegations to the state agency as required. Interviews with staff and residents revealed conflicting accounts of the incident. R1 alleged that R3 attacked him from behind, while R3 claimed that R1 was the aggressor and that he intervened to prevent R1 from attacking another resident, R4. R3 stated that he held R1 in a bear hug until staff arrived. The facility's registered nurse, V6, reported that R3 admitted to putting R1 in a choke hold, but there was no evidence that this information was reported to the state agency. The facility's administrator, V1, was out of state at the time of the incident and relied on V7 to handle the investigation and reporting. The facility's policy requires that any allegations of abuse be reported to the state agency within two hours if they result in serious bodily injury, or within 24 hours if they do not. However, there was no documentation to confirm that the initial or final reports were submitted to the state agency. The administrator, V1, acknowledged the lack of documentation and was unable to provide proof of submission. The failure to report the allegations as required constitutes a deficiency in the facility's compliance with abuse reporting regulations.
Medication Administration Error and Documentation Failure
Penalty
Summary
The facility failed to ensure that a resident received the correct dose of medication as prescribed, specifically Oxycodone 5 mg every eight hours as needed. The deficiency was identified when a resident, who was alert and oriented, reported that he did not take Oxycodone every four hours and only took it after returning from being out on pass due to increased pain from movement. The resident's sign-out log confirmed he was not in the facility at the time the medication was signed out, indicating a discrepancy in medication administration. The controlled drug log showed multiple instances where Oxycodone was signed out without corresponding documentation in the medication administration record, suggesting a lack of proper documentation and adherence to prescribed orders. Further investigation revealed that an LPN admitted to administering Oxycodone every four hours without reviewing the medication administration record or physician orders, which specified an eight-hour interval. The LPN acknowledged realizing the error but did not report it to the Director of Nursing. The facility's policy on narcotic medications requires documentation of administration and proper handling, which was not followed in this case. The Director of Nursing confirmed that staff had been in-serviced on documenting controlled substances, but the facility failed to present documentation of proper administration during the survey period.
Failure to Document and Administer Oxycodone Correctly
Penalty
Summary
The facility failed to adhere to its narcotic medication policy, specifically concerning the administration and documentation of Oxycodone 5 mg for a resident. The resident, who was alert and oriented, reported that he did not take Oxycodone every four hours and only used it occasionally, particularly after returning from being out on pass. However, the facility's records showed discrepancies in the administration of the medication. The resident's controlled drug log indicated that Oxycodone was signed out at times when the resident was not present in the facility, such as on 11/18/24 at 4:50 pm, when the resident was out on pass. Additionally, there were multiple instances where the medication administration record lacked documentation of the nurse's initials, indicating that the medication was administered. The Director of Nursing acknowledged that the staff had been in-serviced on documenting controlled substances, but the facility failed to present documentation showing that the resident was administered Oxycodone as per the physician's orders. An LPN admitted to administering Oxycodone every four hours without reviewing the medication administration record or physician orders, which specified administration every eight hours. This LPN also failed to report the medication error to the Director of Nursing. The facility's policy on narcotic medications requires that every dose be accounted for and documented, but this was not consistently followed, leading to the deficiency.
Deficiency in Meal Palatability and Timeliness
Penalty
Summary
The facility failed to provide palatable meals to residents, affecting six individuals who reported dissatisfaction with the food quality. These residents, all with intact cognition as per their BIMS scores, expressed concerns about the food being flavorless, overcooked, or undercooked. Specific incidents included meals being served late, with some residents receiving their dinner trays after 9:45 pm, and the food, particularly chicken, being described as hard and dry. This led residents to supplement their meals with personal snacks or food ordered from outside the facility. Interviews with dietary staff, including the Dietary Manager, cooks, and aides, revealed awareness of the complaints regarding food quality. Staff acknowledged receiving concerns about the food being overcooked or burned and mentioned frequently sending replacement trays or substitutes upon request. Despite these acknowledgments, the facility's policy on providing nourishing and palatable meals was not adhered to, as evidenced by the residents' consistent dissatisfaction and the staff's recognition of the ongoing issues.
Delayed Dinner Service for Residents
Penalty
Summary
The facility failed to provide dinner meals to residents at the designated mealtimes, affecting 14 residents. On the evening of November 13, 2024, several residents reported receiving their dinner trays significantly later than the scheduled time of 6:30 pm, with some not receiving their meals until after 10:00 pm. This delay in meal service was confirmed by multiple residents, who expressed dissatisfaction and distress over the late and poor-quality meals, such as overcooked chicken. The residents involved in this deficiency included individuals with various medical conditions such as diabetes, obesity, respiratory failure, and cognitive impairments. Despite having intact cognition as per their BIMS scores, residents expressed their dissatisfaction with the meal service, highlighting the impact of the delay on their well-being. For instance, one resident mentioned feeling sad and unhappy due to the late meal service, while another had to rely on personal snacks from a roommate due to the inedible state of the provided meal. Interviews with facility staff, including the Dietary Manager, Director of Nursing, and a cook, revealed an acknowledgment of the failure to adhere to the scheduled meal times. The Dietary Manager and Director of Nursing both stated that the expectation was for meals to be delivered between 6:15 and 6:30 pm, which was not met on the specified date. The cook admitted to sending the dinner trays after 9:30 pm, thus failing to maintain the facility's policy of providing meals within a 14-hour window between dinner and breakfast.
Failure to Provide Escort for Resident's Medical Appointment
Penalty
Summary
The facility failed to arrange appropriate transportation for a resident, leading to a missed oncology appointment. The resident, a male with a history of acute respiratory failure, emphysema, malignant neoplasm of the larynx, COPD, severe protein-calorie malnutrition, and behavioral disturbances, required an escort due to his behavior and elopement risk. On the day of the appointment, the transportation was arranged, but no escort was available to accompany the resident, making it unsafe for him to attend the appointment alone. The transportation coordinator, who usually accompanies residents, was on a scheduled day off and had informed the scheduler and the Director of Nursing (DON) about the need for an escort. Despite the transportation being set up, the facility did not provide an escort, resulting in the appointment being missed. The facility's appointment log incorrectly documented that no escort was needed, although the transportation coordinator confirmed that the facility was aware of the requirement. Interviews with the DON and the scheduler revealed that while the facility offers escort services, they do not guarantee them and have no specific policy or protocol for providing escorts. The facility was unable to provide any policy or documentation regarding transportation arrangements during the survey.
Failure to Document Narcotic Administration in EMAR
Penalty
Summary
The facility failed to adhere to its narcotic and medication administration policy by not documenting the administration of narcotic medication in the electronic medical record (EMR) for a resident. This deficiency was identified during a review of medication administration for a resident who had multiple medical conditions, including a history of left perinephric hematoma, intervertebral disc degeneration, hypertension, atrial fibrillation, benign prostatic hyperplasia, chronic myelomonocytic leukemia, monoclonal gammopathy, idiopathic gout, non-Hodgkin lymphoma, b-cell lymphoma, and chronic kidney disease. The resident had physician orders for Hydrocodone-Acetaminophen to be administered as needed for moderate pain, but five doses were not documented in the EMAR, although they were signed out on the individual narcotic sign-out sheet. Interviews with facility staff revealed that there was a lapse in following the established procedures for documenting narcotic administration. A Licensed Practical Nurse admitted to sometimes forgetting to sign medications under the EMAR, only signing the individual narcotic sign-out sheet. The Director of Nursing and the Vice President of Clinical Operations both confirmed that the facility's policy requires documentation in both the individual narcotic sign-out sheet and the EMAR. The facility's policies on narcotic medication and medication administration were provided, which outline the steps for proper documentation, including checking the medication administration record prior to administering medication and documenting each medication as it is prepared.
Staff-to-Resident Mental Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of staff-to-resident mental abuse involving a resident, identified as R5, and an activity aide, identified as V9. The incident occurred after a disagreement over a borrowed portable speaker, during which V9 pulled off R5's wig in a hallway where other staff were present. R5, who was alert and oriented with a BIMS score of 15, reported feeling humiliated and embarrassed by the incident. The altercation escalated with R5 throwing a cup at V9 and grabbing V9's shirt, which required intervention from other staff members to separate them. The facility's abuse prevention policy, dated February 2017, emphasizes the residents' right to be free from abuse and mistreatment by anyone, including facility staff. Despite this policy, the incident occurred, and the facility's administrator, V7, and a nurse, V37, were involved in the investigation. V7 stated that V9's actions were not willful, and V37, who witnessed part of the altercation, did not believe V9 intended to harm R5. However, the incident was reported as a deficiency due to the failure to protect the resident from mental abuse, as outlined in the facility's policy and residents' rights.
Deficiency in CPR Training for CNAs
Penalty
Summary
The facility failed to ensure that all healthcare personnel, specifically Certified Nursing Aides (CNAs), have current basic life support cardiopulmonary resuscitation (CPR) training and certification. During interviews and record reviews, it was revealed that none of the ten CNAs reviewed had current CPR certification. The facility's Administrator, V7, stated that CPR training is encouraged but not required for CNAs. Similarly, V11 from Human Resources confirmed that not all CNAs are required to be CPR trained, despite the facility's policy indicating that all staff are responsible for performing CPR. The Director of Nursing, V8, acknowledged that some aides working at the facility lack CPR training and certification, and reiterated that they are not required to have it. The facility's CPR policy, dated 2015, mandates that all staff are responsible for performing CPR according to American Heart Association guidelines. However, the current practice contradicts this policy, as CNAs without CPR training are instructed to inform a nurse if they find a resident unresponsive, rather than performing CPR themselves. This discrepancy between policy and practice raises concerns about the facility's preparedness to handle emergencies involving unresponsive residents.
Unsupervised Respiratory Care by Student
Penalty
Summary
The facility failed to have a licensed respiratory therapist on duty for the entire shift on August 8, 2024, affecting 11 residents who required respiratory care. A respiratory aide, who was also a respiratory therapy student, was observed administering respiratory care unsupervised. The aide confirmed that the licensed respiratory therapist left early, a practice that was reportedly common. The respiratory therapy supervisor was unaware of the situation and stated that students should not work unsupervised and must be accompanied by a licensed therapist. The facility did not provide any policy or procedures regarding the supervision of respiratory therapy students. The facility's assessment tool indicated the need for two respiratory therapists per shift but did not include information about respiratory therapy students. The Respiratory Care Practice Act requires proximate supervision, meaning a licensed individual must be physically close enough to assist if needed. The facility's failure to adhere to these requirements led to the deficiency.
Failure to Notify Physician of Resident's Acute Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of an acute change in condition for a resident who experienced loose stools and weakness. The resident, who had a history of osteomyelitis, adjustment disorder, anemia, hypertension, hypotension, lymphedema, stage four pressure ulcer, and adult failure to thrive, was found in cardiac arrest by emergency medical services. The resident had been last checked by a CNA around 2:00 AM, who noted diarrhea and weakness but did not report these symptoms to the nurse or physician. The CNA mentioned the diarrhea to another nurse, who did not take further action as there was no order for Imodium. The resident was found unresponsive and cold to the touch at 4:00 AM, with signs of rigor mortis, indicating they had been deceased for some time. The paramedics confirmed the resident's condition and noted that the facility staff could not provide a timeline of when the resident was last checked. The facility's policy requires notifying the physician of significant changes in a resident's condition, but there was no documentation of such notification or a nursing assessment related to the resident's diarrhea. The Director of Nursing stated that staff are expected to perform rounds every few hours and notify the physician if a resident experiences new or persistent diarrhea. However, the resident's care plan did not include a plan for diarrhea, and there was no record of anti-diarrhea medication being administered. The facility's failure to notify the physician and assess the resident's condition contributed to the deficiency, as the resident's acute change in condition was not addressed in a timely manner.
Failure to Assess and Treat Resident's Diarrhea
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident who developed new loose stools, which remained untreated. The resident, who had a history of multiple medical conditions including osteomyelitis, anemia, hypertension, and a stage four pressure ulcer, was found in cardiac arrest by emergency services. The resident had been left unattended for an extended period, with dried fluids on the linens, indicating a lack of timely care and monitoring. Interviews with staff revealed that the Certified Nursing Assistant (CNA) noticed the resident had diarrhea during the night shift but did not wake the resident for further assessment. The CNA reported the diarrhea to the Registered Nurse (RN) on duty, who did not take further action as there was no standing order for anti-diarrheal medication. The Licensed Practical Nurse (LPN) on the following shift was unaware of the resident's condition and did not conduct an assessment, as she was not informed of any issues during the shift handover. The Director of Nursing (DON) stated that staff are expected to conduct rounds every few hours and assess any new conditions such as diarrhea. However, there was no documentation of a nursing assessment or physician notification regarding the resident's condition. The lack of a care plan for diarrhea and the absence of any as-needed medication orders for diarrhea contributed to the failure to address the resident's symptoms, ultimately leading to the resident's untreated condition and subsequent cardiac arrest.
Delayed Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility nursing staff to provide timely respiratory care to a resident with a tracheostomy, leading to adverse outcomes. The resident in question, R2, had a complex medical history including diagnoses of Acute and Chronic Respiratory Failure, Dysphagia, Chronic Obstructive Pulmonary Disease, and other conditions. Despite the resident's code status being Full Code, there were documented instances where the nursing staff did not respond promptly to the resident's needs, particularly in relation to suctioning and monitoring after tracheostomy care. The events leading to the deficiency included instances where the resident exhibited signs of distress, such as gesturing and pointing to the tracheostomy, indicating the need for suctioning. However, there were delays in providing the necessary care, with conflicting accounts from staff regarding the resident's condition and the actions taken. The report highlighted a lack of consistent monitoring and assessment of the resident's respiratory status, as well as discrepancies in the responses of different healthcare professionals involved in the resident's care.
Failure to Provide Timely Respiratory Tracheostomy Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards of quality by not providing timely respiratory tracheostomy care, not responding to a resident's request for respiratory suctioning, and not having staff with the necessary skills to adequately meet the needs of a resident in respiratory distress. On the morning of 02/19/2024, a resident with a tracheostomy (R2) gestured for suctioning, but the Licensed Practical Nurse (LPN) did not immediately provide the care and instead informed the Respiratory Therapist (RT). The RT did not promptly attend to the resident, and later, the resident was found unresponsive with a dislodged tracheostomy tube, leading to a code blue situation and emergency resuscitation efforts by the staff and EMS. The resident was not connected to a ventilator at the time, which meant no alarms were triggered to alert staff of the distress. The facility's policy did not include specific monitoring protocols for residents with tracheostomies who were not on ventilators, relying instead on physical rounds and checks by nurses, CNAs, and respiratory therapists. Interviews with staff revealed inconsistencies in understanding and executing the responsibilities for suctioning and monitoring residents with tracheostomies. The Director of Nursing (DON) and Respiratory Therapy Director both indicated that nurses and respiratory therapists are expected to suction residents in need, but there was a lack of clear communication and immediate action in this case. The facility's policy on oxygen therapy did not provide adequate guidance on monitoring residents with tracheostomies who are not connected to ventilators, contributing to the failure to prevent the life-threatening situation for R2.
Respiratory Care Deficiency Leading to Critical Incident
Penalty
Summary
The report details a deficiency in the facility's response to a resident (R2) requiring respiratory care, ultimately leading to a critical incident. R2, a [AGE] year old male with a complex medical history including Acute and Chronic Respiratory Failure, Dysphagia, COPD, and Heart Failure, was ventilator-dependent and had a tracheostomy. Despite clear care plans and orders for ventilator settings and suctioning, there were lapses in providing necessary respiratory care. The facility's nursing staff and respiratory therapist failed to respond promptly to R2's distress signals, including agitation and pointing to his tracheostomy, indicating a need for suctioning. The deficiency was exacerbated by staffing challenges, as highlighted by the respiratory therapist mentioning limited resources and high workload. The facility's reliance on a single respiratory therapist during the day for over 20 residents with tracheostomies may have contributed to delays in responding to urgent respiratory needs. Additionally, the lack of clear protocols or policies regarding suctioning responsibilities between nurses and respiratory therapists further complicated the situation. The failure to promptly address R2's respiratory distress, including a dislodged tracheostomy tube, ultimately led to a critical event resulting in cardiac arrest and the resident's passing.
Failure to Prevent Abuse by Staff Member
Penalty
Summary
The facility failed to follow their abuse prevention policy and procedures, resulting in a resident being physically abused by a respiratory therapist. The incident occurred when the respiratory therapist pushed the resident onto the bed, forcibly restrained him, and roughly suctioned him after a physical struggle. The resident reported the incident to his nurse and family member, expressing fear, anger, and frustration with the facility for not preventing further contact with the staff member after the report. The resident, who is alert and oriented, has a diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. He recounted the incident to the surveyor, stating that the respiratory therapist slapped him for coughing on two separate occasions. The resident felt unsafe as he continued to see the respiratory therapist in the facility after reporting the abuse. The administrator confirmed that the incident was reported on Christmas day, and the respiratory therapist was suspended over the phone but was still present in the facility afterward. The respiratory therapist admitted to struggling with the resident and pushing him onto the bed for suctioning, but denied slapping him. The therapist described the resident as uncooperative and difficult to manage. The facility's administration did not take immediate and effective actions to ensure the resident's safety and psychosocial well-being, as the resident continued to see the respiratory therapist after the incident. The facility's failure to act promptly and appropriately led to the resident feeling unsafe and unsupported.
Failure to Follow Abuse Prevention Procedures
Penalty
Summary
The facility failed to follow their abuse prevention investigation procedures by not conducting a thorough investigation of an alleged abuse incident involving a staff member and a resident. The incident was reported to the administrator on Christmas day, but the alleged abuse occurred on Christmas Eve. The administrator interviewed the accused staff member over the phone and suspended him, but did not ensure that the staff member was kept away from the resident. The resident consistently reported being slapped by the respiratory therapist, and the resident's sister requested that the staff member not be allowed to care for the resident again. However, the administrator did not take adequate steps to ensure the resident's safety, stating that the staff member would only enter the resident's room with another person in case of an emergency, despite the respiratory office being in close proximity to the resident's room and no supervisor being present at night to enforce this rule. The resident, who is alert and oriented, reported being slapped by the respiratory therapist on two separate occasions and expressed fear of the staff member's return. The resident's sister also expressed concerns about the staff member's continued access to the resident. The respiratory therapist admitted to struggling with the resident during care, forcibly restraining the resident, and suctioning the resident in a hard manner. Despite these admissions, the facility did not conduct a thorough investigation or provide adequate training to staff on abuse prevention and response. The facility's social service director was not informed of the initial incident and did not conduct a psychosocial assessment of the resident until prompted by the administrator. The medical director acknowledged that the facility's response to the incident was inadequate and that abuse prevention would be included in future quality assurance meetings. The facility's policy on abuse prevention emphasizes the importance of creating a resident-sensitive and secure environment, but the facility failed to adhere to its own procedures in this case, leading to the resident's continued fear and distress.
Failure to Follow Tracheotomy Suctioning Policy and Physician Orders
Penalty
Summary
The facility failed to follow their policy for tracheotomy suctioning and did not adhere to physician orders for providing adequate and appropriate respiratory and tracheal suctioning for a resident. This resulted in the resident not receiving sufficient suctioning to maintain a clear tracheal airway and experiencing pain and fear due to harsh and non-gentle suctioning by a respiratory therapist. The resident, who is alert and oriented, has a diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. Observations revealed the resident's tracheotomy was filled with phlegm, and the resident struggled to communicate due to the mucus accumulation. Staff interviews indicated that suctioning was performed once per shift and as needed, but documentation showed inconsistencies and multiple days without recorded suctioning or tracheal care, contrary to physician orders and facility policy. During an interview, a respiratory therapist admitted to forcibly restraining the resident and performing suctioning in a hard manner, causing the resident to become upset. The therapist did not seek assistance or return at a different time to provide care. Another observation showed the resident's tracheotomy with thick mucus buildup and discolored sponge, indicating inadequate suctioning. The resident confirmed that suctioning was performed only once in the morning and that he needed additional suctioning. The facility's policy on tracheal suctioning emphasizes the importance of gentle and reassuring care, allowing the resident to catch their breath between suctioning episodes and providing oxygenation as needed. However, these standards were not met in the care provided to the resident. The medical director acknowledged the incident and stated that the administration did not act effectively to maintain the resident's safety and psychosocial well-being. The medical director also confirmed that physician orders should always be followed and that the resident had not been examined by a doctor since the original incident. The failure to provide adequate and appropriate respiratory care, as well as the harsh treatment by the respiratory therapist, highlights significant deficiencies in the facility's adherence to professional standards of practice and physician orders for tracheal suctioning 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.
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