Casey Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Casey, Illinois.
- Location
- 100 N.e. 15th, Casey, Illinois 62420
- CMS Provider Number
- 146117
- Inspections on file
- 34
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Casey Rehab And Nursing during CMS and state inspections, most recent first.
Staff failed to immediately report two separate abuse-related incidents as required by facility policy and training. In one case, a CNA delayed reporting an allegation that another CNA struck a cognitively impaired resident with a positioning cushion and used hateful language, despite having been trained to report suspected abuse immediately to a supervisor and the administrator. In another case, a CNA and an RN witnessed a verbal altercation in which one resident threatened to beat another, but did not promptly notify facility leadership or the on-call manager, and the incident only came to the attention of the administrator and DON when they later reviewed documentation in the electronic medical record.
A resident with diabetic polyneuropathy and muscle weakness experienced frequent severe pain and received more than the prescribed amount of PRN acetaminophen without required physician notification. When stronger pain relief was needed, there was an 18-hour delay in obtaining Tramadol due to prescription processing issues, resulting in prolonged discomfort despite staff efforts to provide comfort.
A resident with mild dementia and high elopement risk repeatedly attempted to leave the facility, triggering alarms and requiring staff intervention. Staff responses were limited and not always documented, and some staff lacked required dementia training and were unfamiliar with elopement prevention procedures, resulting in inadequate care and monitoring.
A resident with dementia, agitation, and impaired decision-making experienced multiple falls after the facility failed to consistently implement documented fall prevention interventions, such as non-slip strips, safety checks, and hourly toileting. Observations showed missing safety equipment and incomplete documentation, while a change in the resident's condition was not fully addressed due to a missed blood test order.
A resident with a urostomy showing signs of infection experienced a delay in starting prescribed antibiotics for a UTI because the ordered dose was not available in the backup medication system. Staff did not notify the provider about the delay, and the antibiotic was not administered until two days after it was ordered, contrary to facility policy.
A resident with a diabetic ulcer on the left heel experienced worsening of the wound due to the facility's failure to prevent cross-contamination and adhere to physician orders for wound care. The resident's dressing changes were not completed as prescribed, and incontinence care was not provided timely, leading to the dressing being saturated with drainage and urine. Observations showed improper wound care procedures, and facility policies were not followed, resulting in the need for antibiotics due to infection.
The facility failed to maintain their survey results book in an accessible manner, affecting all 51 residents. During a resident meeting, none of the residents could locate the book. It was found positioned too high for wheelchair-bound residents, without signage indicating its location, as confirmed by the Administrator and Regional Representative.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 51 residents. The Dietary Manager, in charge since February 2024, lacks necessary qualifications, having only completed a one-day ServSafe course. The Registered Dietician works one day per month and was misled about the manager's qualifications. The facility's assessment requires a full-time qualified professional, which is unmet.
A facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness, including Delusional Disorder and Affective Mood Disorder, to assess the need for specialized mental health services. The resident, admitted in 2006, was observed with hyper-manic speech and lacked a documented Level 2 screening after the 2021 diagnoses. The administrator confirmed the absence of a recent screening.
A facility failed to complete a discharge summary for a resident who wished to move to another SNF. The resident, who required verbal cues and medication management due to cognitive deficits, had no supportive family or caregivers. The facility's policy mandates a discharge summary for each resident, but the medical record lacked this, along with a physician order and nurse progress notes. The administrator cited a change in facility ownership as the reason for missing documentation.
A facility failed to secure an E type oxygen cylinder, leaving it freestanding in a resident's room. The resident was approximately 10 feet away from the unsecured tank. The facility's policy requires oxygen tanks to be secured in a holder, in line with NFPA regulations. The resident had a previous episode of low blood oxygen levels, but no documented oxygen use since then.
A facility failed to properly label medications and monitor expiration dates, leading to errors in medication administration for a resident. An LPN administered expired Pantoprazole, Ibuprofen without a label, and Zinc Sulfate instead of Zinc Gluconate without questioning the discrepancy. The DON confirmed these were labeling errors, and the pharmacist noted the importance of adhering to labeling policies.
A facility failed to maintain a complete medical record for a resident due to a recent change in ownership. The resident's EMR was missing critical documentation, including physician and nurse progress notes, vital signs, and ADL charting. The administrator acknowledged the incomplete record and the lack of a policy to address such issues.
The facility failed to use proper PPE for two COVID-19 positive residents on isolation precautions. A CNA did not wear a gown or gloves while assisting a resident with eating, and an LPN did not wear an N95 mask, gloves, or gown while administering medications. Both staff members were aware of the residents' isolation status, and the DON confirmed the need for PPE to prevent the spread of infection.
A resident with severe cognitive impairment and a history of elopement left an LTC facility unnoticed due to inadequate supervision. Despite being identified as high risk for elopement, the resident's care plan was not updated with necessary interventions. The resident exited the Dementia unit and was found 0.9 miles away, having crossed multiple streets in extreme heat. Staff interviews revealed a history of elopement and failure to follow facility policies.
The facility failed to provide mandatory training on the QAPI program to all staff, affecting the quality of care for 44 residents. Interviews revealed that an RN and CNAs had not received any QAPI training, with some staff unaware of the program. The administrator admitted that QAPI meetings occur quarterly, but information is only shared by word of mouth, leading to a lack of implementation of new interventions and policy updates.
The facility did not ensure that CNAs received the required twelve hours of annual training, affecting all 44 residents. Records showed that five CNAs completed fewer than the mandatory training hours. The Lead CNA confirmed the deficiency and the absence of documentation for these CNAs.
A resident with dementia and a high fall risk experienced multiple falls due to inadequate interventions and unsafe footwear. The resident wore slip-on shoes and sandals without back straps, contributing to falls. A mechanical lift left in the hallway posed an additional hazard. Staff were aware of the resident's wandering and unsafe footwear but did not take timely action. A urine analysis ordered after a fall was delayed, indicating a lack of prompt response.
The facility failed to protect residents from physical abuse by peers, as incidents involving three residents were reported. A resident with a history of inappropriate behavior made contact with another resident's forehead, while another resident with cognitive disorders and aggressive tendencies made contact with the same resident's face. Despite the facility's abuse prevention policy, these incidents highlight a failure to prevent abuse.
The facility failed to follow physician orders for two residents, resulting in delayed care. A urinalysis for a resident was not obtained promptly after a fall, and a repeat EGD was not scheduled within the recommended timeframe for another resident. Communication and order management issues contributed to these deficiencies.
Failure to Timely Report Alleged Staff Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to timely report multiple allegations of abuse and a resident-to-resident altercation within the required immediate, not more than 24-hour timeframe. In the first incident, a CNA (V3) reported that another CNA (V4) hit a cognitively impaired resident (R2) with a positioning cushion and stated, "I hate you." The facility’s investigation report shows the alleged event occurred on 10/27/25, but the allegation was not brought to facility leadership until 11/10/25. V3 later stated she witnessed the incident on 10/27/25 but delayed reporting it for about a week because she was a new employee and feared backlash from other staff. V3 had previously signed a Training Acknowledgement Form stating it was her responsibility to immediately report any signs of abuse, neglect, or mistreatment to her supervisor and the administrator, and to report any observed, heard about, or suspected mistreatment immediately. In the second incident, staff failed to immediately report a resident-to-resident verbal altercation in which one resident (R3) threatened to beat another resident (R4). The facility’s investigation report documents that the altercation occurred on 11/29/25 and was witnessed by a CNA (V5) and an RN (V6). The administrator (V1) and DON (V2) did not learn of the incident until they read an RN progress note in the electronic medical record on 12/1/25. V5 acknowledged witnessing the altercation, separating the residents, and reporting it only to the nurse on duty, and did not notify the administrator or the on-call manager. V2 confirmed that neither V5 nor V6 contacted her over the weekend to report the incident. V5 had also signed a Training Acknowledgement Form stating that any alleged violations involving mistreatment, neglect, or abuse must be reported immediately to a supervisor and the administrator. The facility’s abuse prevention policy states that all allegations or suspicions of abuse will be reported in the proper timeframe.
Failure to Provide Timely and Adequate Pain Management
Penalty
Summary
A resident with Type II Diabetes Mellitus, Diabetic Polyneuropathy, and muscle weakness was admitted to the facility and had physician orders for Acetaminophen 650 mg every six hours as needed for mild pain, with instructions to notify the physician if more than three doses were given in 48 hours. The resident also had an order for Tramadol 50 mg as needed for pain. Review of the Medication Administration Record showed that the resident received more than three doses of Acetaminophen in 48-hour periods on multiple occasions, but there was no documentation that the physician or advanced practice provider was notified as required. The resident consistently reported high pain levels, rating her pain at eight or higher for most doses administered during this period. On one occasion, the resident experienced unbearable pain and requested stronger pain medication. The DON attempted to contact the nurse practitioner, but did not receive a response, leading the overnight RN to contact the Medical Director, who ordered Tramadol. However, the new prescription could not be sent to the pharmacy immediately, resulting in an 18-hour delay before the resident received the medication. During this time, the resident remained tearful and uncomfortable, and staff attempted non-pharmacological interventions to provide comfort. The delay in medication administration and failure to notify the physician as required by the standing order contributed to inadequate pain management for the resident.
Failure to Provide Appropriate Dementia Services and Elopement Prevention
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate services for a resident diagnosed with mild dementia, agitation, and anxiety disorder, who was assessed as high risk for elopement. The resident repeatedly attempted to leave the facility, triggering personal alarms on multiple occasions and requiring staff intervention to prevent elopement. Despite the resident's ongoing exit-seeking behavior, staff responses were limited to escorting the resident back inside and attempting to re-educate him, which was noted as unsuccessful due to cognitive impairment. Documentation indicated that the resident's exit-seeking had increased in frequency, yet interventions remained largely unchanged and were not consistently documented. Further contributing to the deficiency, not all staff had received dementia training as required by facility policy, and some were unfamiliar with the location or use of the elopement logbook, which is essential for tracking and preventing unsafe wandering. The facility's own policy mandates a multi-faceted approach to elopement prevention, including staff education and awareness of procedures, but interviews revealed gaps in staff training and knowledge. These failures resulted in inadequate implementation of interventions and monitoring for a resident at high risk for elopement.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and maintain fall prevention interventions for a resident with multiple risk factors, including dementia, agitation, delusional disorders, impaired decision-making, and frequent incontinence. The resident's care plan and bedside Kardex included several fall prevention measures such as visible signage, hourly toileting, non-slip strips in key areas, 15-minute safety checks, and assistance with transfers. Despite these documented interventions, observations and record reviews revealed that many of these measures were not in place or not consistently implemented. For example, non-slip strips were missing from the bathroom and recliner, the 'Call Don't Fall' sign was not visible, and non-slip material was absent from the wheelchair and recliner seats. Additionally, the resident's room was not moved closer to the nurse's station as planned, and required safety checks and hourly toileting were not documented or observed during the survey period. The resident experienced multiple falls over a three-month period, with documented incidents occurring in various locations such as in front of the recliner and in the bathroom. Progress notes indicated that the resident often attempted to move independently, including trying to use the toilet or brush teeth, which led to falls. Staff interviews confirmed that required 15-minute safety checks were not accurately documented or performed, and that interventions such as non-slip strips and materials were not consistently maintained. The resident also had a change in condition, including pitting edema and a diagnosis of hyponatremia, which was not fully addressed due to a missed blood test order that was neither completed nor followed up with the provider. Facility policy required thorough investigation of all falls, evaluation for changes in condition, provider notification, and implementation of new interventions as needed. However, the facility did not ensure that these protocols were followed, as evidenced by the lack of documentation, incomplete implementation of care plan interventions, and failure to complete ordered diagnostic tests. These lapses contributed to the resident's repeated falls and unaddressed changes in medical condition.
Delay in Initiation of Antibiotic Therapy for UTI Due to Medication Unavailability
Penalty
Summary
A resident with a urostomy experienced increased weakness, lethargy, and confusion following a fall. Nursing notes documented that the resident's urine was dark amber and cloudy, prompting notification of the nurse practitioner and orders for urinalysis and culture. Laboratory results showed significant abnormalities, including elevated leukocyte esterase, increased white blood cells, and high bacterial counts, indicating a urinary tract infection (UTI). Despite these findings, there was a delay in initiating antibiotic therapy. The nurse practitioner ordered Augmentin, but the specific dose was not available in the facility's backup medication system, and the medication was not started until two days after the order was written. Facility records and interviews revealed that staff did not notify the provider of the delay in starting the antibiotic, as required by facility policy. The backup medication system did not stock the ordered dose, and although the pharmacy was contacted, there was no documentation of provider notification regarding the unavailability of the medication. The facility's pharmacy guide instructs staff to notify the provider if a medication is not available, but this step was not documented or carried out, resulting in a delay in treatment for the resident's UTI.
Failure to Prevent Cross-Contamination and Inadequate Wound Care
Penalty
Summary
The facility failed to prevent cross-contamination during wound care for a resident with a left plantar heel open diabetic ulcer. The resident's wound care was not conducted according to physician orders, leading to the worsening of the wound. The dressing changes were not completed as prescribed, and the resident did not receive timely incontinence care, resulting in the dressing being saturated with wound drainage and urine. This lack of proper care led to the resident requiring antibiotics due to a Staphylococcus infection. The resident, who is cognitively intact, has a medical history that includes acute osteomyelitis of the left ankle, diabetes mellitus type II with foot ulcer, morbid obesity, and polyneuropathy. The resident requires maximum assistance for toileting and moderate assistance for personal hygiene. Despite these needs, the facility's records show that the dressing changes were not documented on several occasions, and the resident's wound showed signs of deterioration, including increased purulent drainage and foul odor. Observations revealed that the resident's dressing was often saturated, and staff failed to follow proper wound care procedures, such as changing gloves and performing hand hygiene. The facility's policies on wound care and skin prevention were not adhered to, as evidenced by the lack of incontinence care and monitoring of the resident's wound. The Director of Nurses and the Administrator acknowledged these failures, noting that the staff did not monitor the wound or document treatments as required, contributing to the resident's wound worsening.
Inaccessible Survey Results Book
Penalty
Summary
The facility failed to maintain their survey results book in a manner accessible to residents, potentially affecting all 51 residents residing in the facility. During a resident group meeting, none of the four residents present were able to state where the survey results book was located. The survey book was found positioned five feet six inches above the floor in a wall caddy outside the facility business office, without any signage indicating its location. This placement made it inaccessible to residents, particularly those in wheelchairs, as confirmed by the facility's Administrator and Regional Representative.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 51 residents. The Dietary Manager, V18, has been in charge since February 2024 but lacks the necessary qualifications, such as being a Certified Dietary Manager or having equivalent training. V18 only completed a one-day ServSafe course, which does not cover clinical nutrition. V18 admitted to not meeting the State of Illinois standards for a food service manager or dietary manager and lacks qualifications in clinical nutrition. The facility's Registered Dietician, V19, works only one day per month and was misled by V18 about their qualifications. The Regional Consultant, V14, reported previous success in reversing similar citations by presenting the one-day course as equivalent to the required clinically focused nutrition course. However, the facility's assessment documents the need for a full-time clinically qualified professional as the Dietary Manager, which is not currently being met. The facility's application for Medicare and Medicaid confirms the presence of 51 residents, all potentially affected by this deficiency.
Failure to Obtain Level 2 Screening for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to obtain a Level 2 screening for a resident who was newly diagnosed with severe mental illness, specifically Delusional Disorder and Affective Mood Disorder, to determine the need for specialized mental health services. This deficiency affected one resident out of two reviewed for pre-admission screening. The resident, admitted to the facility in 2006, was observed speaking in a hyper-manic pattern and unable to maintain the topic of conversation. Despite the new diagnoses made in 2021, there was no documented Level 2 screening in the resident's medical record. The facility's administrator confirmed that the only pre-admission screening available was from 2006, with no subsequent Level 2 screening recorded.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as R48, who was reviewed for discharge among a sample of 27 residents. According to the facility's policy, a discharge summary should be prepared for each resident discharged, especially when moving to a private residence or another nursing care facility. R48's electronic medical record indicates an admission date of 6/30/22 and a discharge date that is unspecified in the report. R48's care plan, initiated on 2/26/24, notes the resident's desire to be discharged despite lacking supportive family or caregivers, and highlights R48's need for verbal cues and medication management due to cognitive deficits. However, the medical record lacks a discharge summary, physician order for discharge, or nurse progress notes documenting the discharge. The facility administrator acknowledged the absence of documentation, attributing it to a change in facility ownership on 11/1/24, during which all resident information was transferred to the previous corporation.
Unsafe Storage of Oxygen Cylinder
Penalty
Summary
The facility failed to maintain safe storage of oxygen cylinders, resulting in a deficiency related to accident hazards. During an observation, an unsecured E type oxygen cylinder was found standing freely inside the doorway of a resident's room. The resident was reclining in bed approximately 10 feet away from the cylinder. Both the Administrator and the Director of Nursing confirmed that oxygen tanks should not be left unsecured on the floor. The facility's policy, dated 3/8/22, mandates that E tanks must be secured in a holder and never left unsecured, in accordance with NFPA regulations. The resident's nurse's note indicated an episode of low blood oxygen levels on 1/9/25, but there was no documented use of oxygen since that date.
Medication Labeling and Expiration Monitoring Deficiencies
Penalty
Summary
The facility failed to properly label medications and monitor expiration dates for a resident, leading to several medication administration errors. A Licensed Practical Nurse (LPN) administered Pantoprazole suspension to a resident despite a sticker indicating it should not be used after a certain date. Additionally, the LPN administered Ibuprofen suspension that lacked a medication instruction label and Zinc Sulfate instead of the prescribed Zinc Gluconate, without questioning the discrepancy. The multivitamin administered from a stock bottle also lacked an open date, which is against facility policy. The Director of Nurses (DON) confirmed that all medications should have a label and that expired medications should not be administered. The DON acknowledged that the LPN should have noticed the difference in the Zinc order and questioned the label discrepancy. The Registered Pharmacist/Pharmacy Manager stated that while there is no significant clinical difference between the Zinc formulations, the discrepancy should have been questioned. The pharmacist also noted that administering expired Pantoprazole should have been avoided, and all medications should adhere to the facility's labeling policy.
Incomplete Medical Record Due to Ownership Change
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was reviewed for closed records. The resident was admitted and later discharged to another skilled facility at their request. However, the Electronic Medical Record (EMR) for this resident was incomplete, lacking essential documentation such as Physician Orders, Nurse Progress Notes, Physician Progress Notes, Social Service Progress Notes, the resident's weight and vital signs, Activities of Daily Living (ADL) charting, and Assessments. The facility's administrator acknowledged the incomplete EMR and stated that due to a recent change in ownership, the facility could not provide additional documentation of the resident's stay. There was no paper documentation available, and the administrator confirmed that there was no policy in place to address this issue, although it was understood that complete medical records were expected.
Failure to Use PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols for residents who tested positive for COVID-19 and were on droplet and contact isolation precautions. Specifically, a Certified Nurse Aide (CNA) did not wear a gown or gloves while assisting a severely cognitively impaired resident, who was COVID-19 positive, with eating. The CNA also failed to perform hand hygiene before assisting the resident, who was seated at a table by the nurses' station. The CNA later admitted to not knowing the requirement to wear gloves when assisting a COVID-19 positive resident. Additionally, a Licensed Practical Nurse (LPN) did not wear an N95 mask, gloves, or gown while administering medications to another COVID-19 positive resident on droplet and contact isolation precautions. Despite the presence of signs indicating the need for such precautions and a bin with PPE supplies outside the resident's room, the LPN acknowledged awareness of the resident's isolation status and the necessity of wearing appropriate PPE. The Director of Nurses confirmed that staff should wear proper PPE to prevent the spread of COVID-19 and other organisms.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident with a history of elopement, resulting in the resident leaving the facility unnoticed and unattended. The resident, who has frontal lobe dementia, was able to exit the alarmed Dementia unit and elope 0.9 miles away from the facility. This incident occurred despite the resident being identified as high risk for elopement and having a care plan that required checks every 15 minutes. The resident's medical history includes dementia, major depressive disorder, altered mental status, cognitive decline, colostomy status, a history of cerebral vascular accident, and chronic ulcerative enterocolitis. The resident was admitted to the facility with a documented severe cognitive impairment and a behavior of exit-seeking, which was noted in the social service progress notes. Despite these documented risks, the resident's care plan was not updated to include necessary interventions until after the elopement incident. On the night of the elopement, the resident was left unsupervised in the main nursing home area after a CNA allowed the resident to leave the Dementia unit. The staff failed to monitor the resident as required, and the door alarms did not sound, allowing the resident to leave the facility unnoticed. The resident was later found at a family member's house, having crossed multiple streets in extreme heat and high humidity. Interviews with staff and family members revealed that the resident had a history of elopement and that the facility's policies and procedures were not adequately followed to prevent such incidents.
Failure to Train Staff on QAPI Program
Penalty
Summary
The facility failed to provide mandatory training to all staff members on the Quality Assurance and Performance Improvement (QAPI) program, which is essential for ensuring quality care for all residents. The facility's policy mandates that QAPI training should be conducted regularly and involve all employees, departments, and services. However, interviews with staff members, including a Registered Nurse (RN) and Certified Nurse Aides (CNAs), revealed that they had not received any training on the QAPI process. The RN mentioned that they believed QAPI was something managed by the facility's managers, while the CNAs were unaware of the program entirely. The facility's administrator acknowledged that the management team, including the Medical Director, holds QAPI meetings at least quarterly. However, the information from these meetings is not effectively communicated to the staff, as it is only shared by word of mouth. This lack of formal training and communication means that staff are not informed about new interventions for residents or updates to policies and processes, leading to a failure in implementing necessary changes to improve resident care.
Failure to Provide Mandatory CNA Training
Penalty
Summary
The facility failed to provide the required twelve hours of annual training for Certified Nurse Aides (CNAs), which has the potential to affect all 44 residents residing in the facility. The facility's in-service attendance records from August 2023 through August 2024 did not document that five CNAs, identified as V27, V28, V29, V30, and V31, completed the mandatory training hours. Specifically, V27 and V28 each completed six hours, V29 completed four hours, V30 completed eight hours, and V31 completed five hours of in-service training in the past twelve months. The Lead CNA, V21, confirmed that all CNA staff should receive twelve hours of training annually and acknowledged the lack of documentation for the mentioned CNAs.
Failure to Prevent Falls and Maintain Safe Environment
Penalty
Summary
The facility failed to provide appropriate fall interventions and maintain a safe environment for a resident identified as a high fall risk. The resident, who has a history of agitation due to dementia, major neurocognitive disorder, and Alzheimer's disease with behavioral disturbances, experienced multiple falls within a short period. The resident's care plan documented interventions for falls, including ensuring appropriate footwear and keeping hallways clear of clutter. However, the resident was found wearing unsafe footwear, such as slip-on shoes and sandals without back straps, which contributed to the falls. Additionally, a mechanical lift was left in the hallway, posing a hazard that the resident encountered during one of the falls. The facility's staff, including LPNs and CNAs, were aware of the resident's wandering behavior and the unsafe footwear but did not take timely action to address these issues. Interviews with staff revealed that the resident often wore gripper socks or slip-on shoes, which were not suitable for preventing falls. Furthermore, a urine analysis ordered after the resident's second fall was delayed, indicating a lack of prompt response to the resident's fall risk. The facility's fall prevention policy, intended to ensure resident safety, was not effectively implemented, leading to the resident sustaining a laceration that required sutures.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by incidents involving three residents. Resident 8, who has a history of inappropriate behavior and physical aggression, was involved in an incident where they made contact with Resident 7's forehead in the dining room. Resident 8's medical history includes unspecified dementia with psychotic disturbance and depression, and they are not cognitively intact. Despite these known behaviors, the facility did not prevent the incident from occurring. Similarly, Resident 1, diagnosed with mild neurocognitive disorder and unspecified dementia with agitation, made contact with Resident 7's face. Resident 1 has a history of entering rooms uninvited and displaying physically aggressive behaviors. Interviews with staff confirmed that Resident 1 can exhibit aggressive behaviors. The facility's abuse prevention policy emphasizes the importance of protecting residents from abuse by others, yet the incidents involving Residents 1 and 8 indicate a failure to implement effective measures to prevent such occurrences.
Failure to Follow Physician Orders for Urinalysis and EGD
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. For one resident, a urinalysis was ordered after a second fall but was not obtained until several days later. The delay occurred because the resident was unwilling to sit down, and the order was passed through multiple nurses before being executed. The Director of Nursing confirmed that the urinalysis should have been obtained promptly after the order was given. For another resident, the facility did not schedule a repeat Esophagogastroduodenoscopy (EGD) within the recommended four-week timeframe following an emergency department visit for food impaction. The resident was on an antibiotic, which complicated scheduling, but there was no documentation of an appointment being made. The staff member responsible for scheduling appointments was unaware of the need for a follow-up EGD, indicating a breakdown in communication and order management.
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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