Charleston Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, Illinois.
- Location
- 716 Eighteenth Street, Charleston, Illinois 61920
- CMS Provider Number
- 145636
- Inspections on file
- 37
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Charleston Rehab And Nursing during CMS and state inspections, most recent first.
Two residents experienced significant medication errors when staff failed to transcribe, obtain, and update medications as ordered. One resident with epilepsy was discharged from the hospital on a new bedtime phenytoin regimen, but the admitting ADON did not enter the order into the EMR, the DON did not complete clarification with the hospital, and the resident received no antiepileptic medication before having a seizure and being sent to the ED. Another resident with cardiac disease, AFib, CKD, and diabetes missed multiple doses of apixaban, metformin, and empagliflozin because the medications were unavailable and nurses did not consistently notify the DON, pharmacy, or physician, and also received a lower dulaglutide dose for months after dose-increase orders from an endocrinology provider were twice sent to the facility but never updated in the physician orders or MAR.
A resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II DM had a physician order for nursing staff to apply bilateral elastic compression bandages from the dorsum of the feet to below the knees each morning and remove them at bedtime. Review of the Treatment Administration Record for the month showed multiple missed leg wrap treatments, with no corresponding documentation of refusals or physician notification. The DON confirmed that nurses are required to document treatments on the TAR, notify the physician of refusals, and that the resident’s legs were to be wrapped daily per the physician’s order.
A resident with intact cognition, a history of paroxysmal atrial fibrillation, and a recent Covid-19 diagnosis experienced a rapid decline, including extreme weakness, shortness of breath, lethargy, and loss of ability to feed and care for himself. CNAs repeatedly reported these changes and the resident’s complaints of not feeling well to an LPN and an RN, but the LPN stated she was too busy with a med pass and did not promptly assess the resident. An RN documented a new-onset irregular heart rate of 111 bpm, but this abnormal finding was not reported to a provider, and the resident was not sent out for evaluation at that time. The facility’s change in condition policy, which required a full nursing assessment and provider notification for such changes, was not followed, and the resident was later hospitalized with Covid-19, acute renal failure, elevated troponin, hyperkalemia, dehydration, and atrial fibrillation with rapid ventricular response.
A resident with severe cognitive impairment and multiple comorbidities experienced three unwitnessed falls over several months. After the first fall, the only documented intervention was to ensure the call light was within reach, an approach already in place and later deemed inappropriate given the resident’s cognitive status, and no new toileting or environmental interventions were added. Following a second unwitnessed fall, staff again documented only education to use the call light. During a later fall, the resident was found on the floor between the bed and bathroom with a head bump, moaning and appearing in pain, and her wheelchair was across the room despite a care plan requiring assistive devices within reach. A CNA reported that an LPN did not perform a physical or neuro assessment and directed CNAs to get the resident back to bed, while the neuro assessment flow sheet showed the resident as stuporous and unable to follow directions but lacked all required subsequent neuro and vital sign entries and nurse signatures. Family and hospice were not notified until the next day, contrary to hospice protocol and facility policies that require immediate evaluation for injury, completion of neuro checks for possible head injury, and timely notification of the physician and responsible party.
The facility failed to thoroughly investigate two separate resident-to-resident verbal abuse incidents and did not remove an alleged perpetrator from a shared dining room after witnessed verbal abuse. In one case, a resident loudly cursed at another resident in the dining room, causing the victim to leave crying, while other residents were present; the aggressor admitted to yelling harsh words, and a staff member confirmed witnessing the event, yet the investigation did not include interviews with other residents and the aggressor remained in the dining room to finish the meal. In a second case, a resident told another that she hoped he would choke on his water and die, repeating the statement when questioned; although a CNA reported the incident to leadership, the investigation again lacked additional resident or staff interviews. The Administrator/Abuse Prevention Coordinator later acknowledged that both investigations were incomplete and that the aggressor in the dining room incident should not have remained there after the outburst.
A resident with a history of CVA, hemiplegia, aphasia, depression, pain, and unsteadiness, who used a manual w/c for mobility, experienced prolonged delays in transfer to a supportive living facility because the facility repeatedly failed to provide complete and accurate discharge documentation, including SS information, Medicare/Medicaid status, and resident funds records. Physician orders specified that the resident required a properly sized w/c with defined features for mobility, but there was no record that a new w/c was ordered, and the resident was discharged with her own older w/c, which was later observed to be in serious disrepair with cracked and broken side panels, missing plastic, and worn, flat cushioning. The resident and supportive living staff reported that she had requested a new w/c for months, that the facility gave inconsistent information about ordering it, and that the lack of proper documentation and failure to purchase the w/c delayed her admission and left her using the damaged device.
A resident with poor dentition and multiple decayed, broken teeth had a documented plan for monitoring mouth pain and obtaining dental consults as needed, including instructions to hold Eliquis prior to extractions. After a dental clinic determined that multiple extractions were needed, several scheduled appointments were repeatedly rescheduled: once because nursing staff did not hold required medications, once due to an incorrect belief that the resident’s insurance was canceled, and multiple times because the facility could not provide or arrange transportation following a change in van ownership and unresolved coordination with public transit. These combined failures in nursing preparation, insurance verification, and transportation scheduling led to a prolonged delay in completing the resident’s dental extractions.
A resident with multiple serious diagnoses, severe cognitive impairment, and on hospice services experienced a fall with a subsequent change in condition. The assigned LPN did not notify the resident’s family, physician, or hospice at the time of the incident, and the fall report documented no notifications. Family and the POA reported they were not informed until the next day, and hospice confirmed they were contacted the following morning. On assessment the next day, the resident was lethargic, unable to speak, and moaning. The DON later stated that immediate notification of family, provider, and hospice was standard practice, and the LPN acknowledged she had not made the required notifications.
A resident with a history of aggressive behaviors and psychiatric diagnoses verbally abused another resident with depression and psychosis in the dining room, repeatedly yelling profanities and telling the resident to shut up while the dining area was partially occupied. Multiple staff and residents witnessed the outburst, and the targeted resident became upset, cried, and left the dining room. Both residents were cognitively intact per recent MDS BIMS scores, and the aggressor’s care plan already identified a pattern of yelling and inappropriate interactions toward others, with interventions directing staff to intervene and monitor such behaviors. Despite a facility policy prohibiting verbal and mental abuse and requiring review of resident-to-resident altercations as potential abuse, the incident demonstrates that a resident was not kept free from emotional and verbal abuse by another resident.
A resident with hemiplegia, aphasia, and chronic pain, who relied on a manual wheelchair for mobility, repeatedly requested a replacement wheelchair due to severe disrepair of her long‑owned chair, including cracked and missing side panels and a worn, painful cushion. Despite physician orders specifying the need for a wheelchair and cushion at discharge and ongoing involvement from a Medicaid social worker seeking a new chair since 2022, the facility failed to provide required paperwork or arrange for a replacement. The resident was ultimately discharged with the same damaged wheelchair and reported prolonged discomfort and ongoing requests that were not acted upon, while the Administrator later confirmed the facility had not purchased a wheelchair and that the resident had requested one repeatedly over the prior year.
Two residents’ medical records were not accurately maintained. One resident experienced a verbal altercation with another resident in the dining room that led to crying and emotional distress, but the incident and subsequent emotional response were not documented or monitored in the medical record, despite the resident having depression and being cognitively intact. Another cognitively intact resident’s MDS inaccurately indicated no obvious cavities or broken teeth, while the care plan and direct observation showed poor dentition with multiple black, brown, broken, and chipped teeth and a reported plan for full dental extractions and dentures.
A resident with an indwelling catheter and multiple comorbidities developed a penile wound due to staff failing to secure the catheter as ordered, provide timely and complete wound care, and follow infection control protocols. The resident's prescribed zinc cream was not consistently available, wound care was incomplete, and proper documentation and monitoring were lacking, resulting in worsening of the wound and additional pain and treatment needs.
A resident who was cognitively intact reported that staff, including the DON and LPNs, laughed at her concerns about another resident and her own medical condition, which included an abscessed tooth and facial swelling. The resident felt sad and expressed a desire to leave the facility due to these interactions. The administrator acknowledged that staff should be more aware of their conversations when residents are present, in accordance with facility policy on resident rights.
Multiple residents experienced verbal and emotional abuse from both staff and other residents, including an LPN accusing a resident of faking seizures, a CNA mocking and intimidating a resident with cognitive impairment, and repeated verbal altercations between residents involving threats and derogatory language. These incidents were witnessed by staff and acknowledged as abusive under facility policy.
A cognitively intact resident reported that staff were not listening, laughed at her, and expressed a desire to leave AMA. These allegations of mental abuse involving staff were not reported to the State Agency as required, and the Administrator only became aware of the incidents through later record review, contrary to facility policy that mandates immediate reporting of abuse allegations.
A resident with dementia and severe cognitive impairment was able to leave the facility unnoticed through an unlocked and unalarmed exit door and courtyard gate, which were left unsecured to allow independent access for smoking and due to contractor activity. The resident was found outside by a CNA and returned to the facility. The facility's investigation did not identify the root cause or document the unsecured exits involved in the elopement.
A resident with severe cognitive impairment and a history of elopement risk exited the facility through an unlocked, unalarmed door and gate, and was found outside by a CNA. The incident and subsequent investigation were not documented in the resident's medical record, and the facility's investigation failed to identify or record the root cause or the status of the doors and gate involved.
Certified Nurse Assistants did not wear gowns while providing catheter and perineal care to a resident on Enhanced Barrier Precautions for a history of MDRO and an indwelling urinary catheter. Despite clear signage and facility policy requiring gown and glove use for high-contact care, staff provided care and emptied a urinary drainage bag without proper PPE, and the room lacked appropriate disposal bins for contaminated PPE.
A resident who recently returned from the hospital with acute respiratory failure and hypoxia became unresponsive and stopped breathing. During the emergency response, staff attempted to use the AED, but it was found to be nonfunctional due to lack of timely checks and maintenance. Staff proceeded with CPR and used an Ambu bag until EMS arrived, but the resident was later pronounced dead. The facility's policy required daily AED checks, which were not performed.
Several staff members, including the administrator, ADON, and a restorative CNA, consumed alcohol before entering the facility and subsequently performed clinical duties such as skills checks and medication management. Witnesses observed physical signs of intoxication, and the incident had the potential to impact all 54 residents, constituting a failure to maintain professional standards of conduct.
Two residents' privacy was compromised when a video of one resident was posted on social media by agency CNAs, and another resident received wound care with her door open, exposing her bare legs and medical condition to others. An LPN discovered and reported the social media post, and the second resident expressed embarrassment about her lack of privacy during treatment.
A resident with severe cognitive and physical impairments was subjected to mental abuse by two agency CNAs, who repeatedly locked the resident's wheelchair brakes while taunting him to move faster. The incident was recorded and posted on social media, showing the resident visibly distressed and unable to escape the situation. Staff who viewed the video described the actions as antagonizing and abusive, causing significant anxiety and confusion for the resident.
A significant medication error occurred when an agency nurse, on their second day at the facility, administered medications intended for one resident to another with a similar last name. The error happened in the dining room during breakfast, where the nurse gave the resident thin liquids instead of the required thickened liquids. The resident, who had chronic heart failure and impaired decision-making skills, experienced a drop in blood pressure after receiving the wrong medications. The facility's policies on medication administration were not followed.
The facility did not ensure the required Infection Preventionist attended the quarterly QAA meetings, and failed to hold these meetings quarterly. The absence of this key member was confirmed by the DON and Administrator, with meetings occurring before the Infection Control Preventionist's hire date. This oversight potentially affects all 60 residents, as the QAPI Program aims to monitor quality and performance.
The facility failed to maintain an operational Legionella water management plan, potentially affecting all 60 residents. The plan was last reviewed in 2018 and lacked necessary assessments and preventive measures. The Maintenance Director, in the role for four years, had not addressed the plan and was unaware of corporate guidance. The Regional Infection Preventionist confirmed the Maintenance Director's responsibility for the plan.
The facility's Infection Preventionist, temporarily filled by the Regional Infection Preventionist, failed to provide proof of specialized training in infection prevention and control, as required by the facility's Infection Control Manual. This deficiency affects all 60 residents, as the Infection Preventionist could not produce a training certificate and was unavailable to address the issue.
The facility failed to provide required abuse prevention education to staff, affecting all 60 residents. The Administrator confirmed the absence of documentation for staff education on abuse training, as the current management lacks access to previous records. The facility's policy mandates training during orientation, annually, and ongoing sessions, but this was not documented, resulting in the deficiency.
The facility failed to ensure call lights were within reach for four residents, despite care plans indicating high fall risk and the need for accessible call lights. Observations showed call lights on the floor or tied to objects, contrary to the facility's guidelines.
The facility failed to provide timely dining assistance to seven residents who required help with eating. During a dining observation, only one CNA was initially present to assist, leading to delays as residents waited for help. The facility's protocol, which emphasizes timely assistance and personal attention, was not followed, as confirmed by the Director of Nursing and resident reports of ongoing issues with late feeding and insufficient staff.
A resident with hypertension received spironolactone for 23 days despite an order to hold the medication due to symptoms of low blood pressure and dizziness. The facility resumed the medication without authorization, and the resident began refusing doses after experiencing adverse symptoms. The medical provider confirmed no order was given to resume the medication and later discontinued it.
Two residents with cognitive impairments were involved in a physical altercation, resulting in one resident sustaining a laceration. Despite the facility's policy to prevent abuse, the incident occurred, and staff were notified, including the police. The facility's report confirmed the altercation and documented the response to the injury.
The facility failed to conduct a thorough investigation into a resident-to-resident altercation, where one resident was injured. The investigation lacked comprehensive staff and resident interviews, contrary to the facility's abuse prevention policy, resulting in an incomplete understanding of the incident.
A facility failed to request a new Level 1 PASARR for a resident with an intellectual disability within 30 days of admission, as required. The resident's initial PASARR allowed a 30-day stay without further evaluation due to an exempted hospital discharge. The administrator confirmed that the PASARR was expired and a new request had not been made.
A facility failed to identify specific behaviors necessitating anti-psychotic medication for a resident and did not implement a care plan with non-pharmacological interventions. The resident was prescribed Risperidone for Major Depressive Disorder without documented targeted behaviors or psychic distress. Staff confirmed the lack of behavior tracking, and the resident rarely left their room.
The facility failed to administer physician-ordered treatments for two residents with skin conditions. One resident with eczema did not receive Tacrolimus cream and Calamine lotion as ordered, and the care plan was not updated. Another resident with a diabetic ulcer did not receive the newly ordered Medihoney and Calcium Alginate treatment, as the order was not entered into the medical record.
The facility failed to provide proper catheter care for three residents, leading to potential cross-contamination and increased risk of urinary tract infections. CNAs did not follow the facility's catheter care policy, resulting in improper cleaning techniques and unsecured catheter tubing and drainage bags. The care plans for these residents lacked necessary interventions and goals for catheter maintenance.
A facility failed to prevent the unnecessary use of Risperidone for a resident with Major Depressive Disorder and Anxiety Disorder, lacking an approved diagnosis for anti-psychotic use. No psychotropic medication assessment or behavior tracking was documented, and the resident did not exhibit behaviors necessitating the medication. The facility's policy requires such medications only for specific conditions, with assessments upon admission and quarterly, which were not conducted.
A resident with severe cognitive impairment had their food preferences disregarded when served a meal that included vegetables, despite documentation of their dislike for all vegetables. A CNA noted the untouched meal and confirmed the resident's preference, ordering an alternative meal. This incident highlights a failure to adhere to the facility's protocol of honoring food preferences before serving meals.
A resident was not offered the influenza vaccination in 2022 or 2023, despite the facility's policy to offer it to all residents. The resident had a history of receiving the vaccine from 2010 to 2021, but there is no documentation for the subsequent years. A registered nurse confirmed the lack of records for the resident's influenza vaccine.
A resident was not offered a COVID-19 vaccination booster despite expressing interest and not having received a vaccination since April 2021. A registered nurse confirmed that the resident was mistakenly not included in a vaccination clinic held in June 2024.
A resident with diabetes and cognitive impairment developed a diabetic foot ulcer that was not reported to a physician or treated promptly. The ulcer was discovered during a shower, but the facility failed to notify the physician or document the condition until weeks later, leading to a diagnosis of Osteomyelitis and subsequent hospitalization.
A resident with diabetes and chronic conditions developed a black sore on the right great toe, which was documented by a CNA and reported to a Charge Nurse. However, the physician and POA were not notified of this change in condition as required by facility policy. The Wound Weekly Evaluation later documented the wound, but there was a delay in notifying the family.
Significant Medication Errors from Missed Transcription, Unavailable Medications, and Unupdated Orders
Penalty
Summary
The deficiency involves failures to accurately transcribe and administer medications according to physician orders, resulting in significant medication errors for two residents. One resident with a diagnosis of epilepsy was discharged from the hospital with instructions to discontinue a previous phenytoin regimen and start phenytoin 300 mg at bedtime following an admission for elevated phenytoin level, altered mental status, and a urinary tract infection. The new phenytoin order was not entered into the resident’s electronic medical record for the entire stay from admission through discharge, and the physician orders for that period did not include phenytoin. The Assistant DON, who admitted the resident, acknowledged missing the new phenytoin order and failing to enter it, and the DON confirmed that the resident never received any phenytoin while in the facility, despite the resident’s known history of seizures and prior use of Dilantin. The DON also stated she attempted to clarify medication orders with the hospital but did not receive a response and did not follow through. The resident subsequently experienced a seizure in the facility, documented as shaking, foaming at the mouth, and eyes rolled back, lasting three to four minutes, and was transported to the hospital, where emergency documentation noted the resident had not been taking Dilantin and had a low Dilantin level. Another resident with diagnoses including hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II diabetes mellitus did not receive multiple ordered medications due to unavailability and lack of appropriate follow-up. Physician orders included metformin ER 500 mg twice daily, apixaban 5 mg twice daily, and empagliflozin 25 mg once daily. The MAR showed missed doses of apixaban on multiple occasions and missed doses of empagliflozin and metformin on several days, all documented as due to the medications being unavailable. Nursing staff reported that when they could not find these medications in the medication cart, they did not administer them and, in several instances, did not notify the DON, pharmacy, or physician, contrary to the facility’s stated expectations. One nurse reported requesting a refill from the pharmacy for apixaban and notifying the DON, but did not call or speak directly to a pharmacist and did not notify the physician of the missed doses. The same resident also received an incorrect dose of dulaglutide over an extended period due to failures to update physician orders after dose changes were communicated. A physician progress note documented an order change to increase dulaglutide from 1.5 mg subcutaneously weekly to 3 mg, and this change was later re-sent via facsimile, but the order was not updated in the resident’s physician orders. The facility’s electronic medical record showed receipt of the faxed order to increase the dose, yet the physician orders remained unchanged. The facility driver described a process in which orders and progress notes from outside appointments are copied and distributed to key staff, and the ADON stated that the expectation is for the nurse on duty to enter medication change orders when received. Despite this, the MAR from late November through mid-April documented continued administration of dulaglutide 1.5 mg weekly, and the ADON confirmed that during this entire period the resident received the wrong dose. The facility’s medication error policy states that medications shall be administered according to physician orders and defines medication errors as including wrong drug and wrong dose, among other categories.
Failure to Follow Physician Orders for Daily Leg Wrap Treatments
Penalty
Summary
Failure to provide care by qualified persons according to a resident’s written plan of care occurred when nursing staff did not consistently implement a physician’s order for daily bilateral leg wraps. A cognitively intact resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II diabetes mellitus had a physician order directing nursing to wrap both legs with elastic compression bandages from the dorsum of the feet to below the knee every morning and remove them at bedtime. Review of the Treatment Administration Record for April 2026 showed seven missed treatments for the ordered leg wraps between 4/1/26 and 4/23/26. The Director of Nurses confirmed that nurses are required to document treatments on the TAR, to notify the physician if residents refuse treatments, to document refusals in the medical record, and that this resident’s legs were to be wrapped daily per the physician’s order. These findings demonstrate that the ordered leg wrap treatments were not provided and/or not documented as required, and that there was no documented physician notification or refusal documentation corresponding to the missed treatments, resulting in a failure to follow the resident’s plan of care and physician orders.
Failure to Respond to Significant Change in Condition for Resident With Covid and Atrial Fibrillation
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond to a significant change in condition for one resident with a known history of paroxysmal atrial fibrillation and a recent Covid-19 diagnosis. The resident’s care plan required staff to notify the physician of any abnormal readings. On a documented date, an RN obtained vital signs and recorded a new-onset irregular heart rate of 111 beats per minute. Despite this abnormal finding and the resident’s cardiac history, the irregular pulse was not reported to the physician or PA, and the resident was not sent out for evaluation at that time. The facility’s Change in Condition Procedure required a full nursing assessment, including full vital signs and evaluation of level of consciousness, respiratory status, abdomen, functional status, and pain, followed by notification of the medical provider, but this process was not followed. Multiple CNAs reported that during the period when the resident was ill with Covid, the resident experienced a rapid decline, including extreme weakness, shortness of breath, inability to feed or care for himself, lethargy, appearing dazed, and repeatedly stating he did not feel well. CNAs V6, V8, and V9 stated they repeatedly reported these concerns and the resident’s change in condition to an LPN and an RN, but the LPN repeatedly stated she was too busy with a medication pass to assess the resident and did not act on their concerns. The RN recalled CNAs reporting a significant change in the resident’s condition and that they had reported it to the LPN, who did not respond. The DON later assessed the resident and sent him to the hospital, where he was diagnosed with Covid-19, acute renal failure, elevated troponin, hyperkalemia, dehydration, and atrial fibrillation with rapid ventricular response. The PA stated that an irregular pulse of 111 in this resident should have been reported or resulted in an emergency room evaluation and that the resident’s clinical picture warranted further diagnostic testing.
Failure to Implement Targeted Fall Interventions and Complete Post-Fall Neurological Assessments
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions, ensure needed mobility devices were within reach, and complete required post-fall assessments and notifications for a resident with severe cognitive impairment. The resident had multiple significant diagnoses, including senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic kidney disease stage IV, unsteadiness on feet, and lack of coordination. An MDS documented a Brief Interview of Mental Status score of 5/15, indicating severe cognitive impairment, and that the resident required supervision and contact assistance with toileting and used a wheelchair for mobility. On one date, the resident experienced an unwitnessed fall while attempting to get up to go to the bathroom and fell over a recliner chair footrest, striking her face on the floor. The fall investigation documented that the resident’s POA requested hospital transfer, and the resident returned with a small head laceration and no new orders. The facility’s fall log listed the intervention as ensuring the call light was within reach and functioning, an intervention that had already been in place and which the DON later confirmed was not appropriate for a resident with severe cognitive impairment. No new targeted interventions addressing toileting needs or the recliner footrest were documented after this fall. Later in the same month, the resident had another unwitnessed fall, was found on the floor, and could not state what happened. The only intervention documented was to educate the resident to use the call light and wait for assistance, which the DON again confirmed was not appropriate given the resident’s cognitive status. On a subsequent date, the resident had another unwitnessed fall while moving from one bed to another and was found on the floor between the bed and bathroom. The fall report documented a small bump to the head near the right eye, that vital signs were taken, the resident was helped back to bed, and again instructed to use the call light for help. The CNA who found the resident stated the wheelchair was across the room, out of the resident’s reach, despite a care plan intervention that assistive devices be kept within reach. The CNA reported the resident was mumbling, groaning, appeared in pain, had a large bump above the right eyebrow that swelled immediately, and was without oxygen. The CNA stated the LPN did not assess the resident, directed staff to get her up, and left the room, with another CNA later obtaining vital signs. The neurological assessment flow sheet initiated after this fall showed the resident as stuporous and unable to follow directions at the initial time, but all other required neurological and vital sign fields were left blank at that time and at all subsequent required intervals, with no nurse signature. The DON confirmed that neurological assessments were not completed, that there was no thorough investigation to determine root cause, and that appropriate notifications to family, physician, and hospice were not made. The MAR showed that ordered PRN lorazepam and morphine were not administered on the date of the fall, while family and hospice staff later reported the resident was lethargic, moaning, swollen and bruised, and appeared to have suffered a serious head injury and untreated pain. The facility’s own fall reduction and neurological assessment policies required evaluation for injury, neurological assessment for possible head injury, and timely notification of physician, responsible party, and hospice, which were not carried out in this case. Family members stated they were not notified of the fall when it occurred and only learned of it later, expressing that they would have come in immediately had they been informed. They also reported being told by a CNA that the nurse instructed CNAs to get the resident off the floor and back to bed without the nurse completing an assessment, and that the nurse said she would give morphine but was later observed at the desk on her phone and reading. Another LPN reported that when she came on duty the next day, there was no documentation that the prior LPN had completed neurological assessments or contacted the physician, hospice, or family, and that she herself then attempted to reach family and hospice, who came in right away. The hospice RN confirmed hospice was not notified until the following morning, despite hospice protocol requiring immediate notification of falls so hospice staff can assess the resident. The hospice RN described the resident as having been alert and conversational the day before the fall and as lethargic and unable to converse when seen the next morning, and stated that, based on her experience, the resident had likely sustained a concussion and brain bleed and needed earlier evaluation. The DON, after reviewing the fall investigations, care plans, assessments, neurological assessments, vital-sign documentation, interventions, and fall reports, confirmed that standard practice to thoroughly assess a resident post-fall was not followed. The DON verified that the interventions of reminding the resident to use the call light were not appropriate for a resident with severe cognitive impairment, that toileting should have been addressed after the first fall when the resident was attempting to go to the bathroom independently, that neurological assessments were not completed after the last fall, and that appropriate notifications to family, physician, and hospice were not made. The facility’s written policies on fall reduction and neurological assessment, which require evaluation for injury, use of neurological assessment guidelines for possible head injuries, and timely notification of physician, responsible party, and on-call nurse, were not adhered to in the resident’s case.
Failure to Thoroughly Investigate Resident-to-Resident Verbal Abuse and Remove Alleged Perpetrator from Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into two separate resident-to-resident verbal abuse allegations and to remove an alleged perpetrator from a shared dining room after witnessed verbal abuse. In the first incident, a state report dated 01/16/26 documents that an allegation of verbal abuse occurred between residents identified as R16 and R17 in the dining room. The facility’s investigation included staff witness statements but did not include interviews with other residents who were present in the dining room. Subsequent interviews revealed that another resident (R7) overheard R16 yelling “pretty bad words” at R17, causing R17 to leave crying, and another resident (R14), who dined at the same table as R16, recalled R16 “cussing up a blue streak” at R17 and described the behavior as uncalled for. R16 later admitted to yelling harsh curse words at R17 because he believed R17 was laughing at him, and R18, who was present, confirmed that R16 was agitated, yelled curse words, and that R17 left the dining room upset and crying. Despite this, R16 and R18 remained in the dining room to finish their meal, and a dietary assistant (V33) stated she witnessed the verbal abuse while other unidentified residents were present. In the second incident, a state report dated 12/12/25 documents an allegation of verbal abuse between residents R3 and R4 in a hallway near the nursing desk. A CNA (V50) reported that while charting at the nursing desk, she heard R3 cursing at R4 and telling him she hoped he would choke on his water and die; when R4 questioned what was said, R3 repeated the statement. V50 told R3 the behavior was not acceptable and removed her from the hall, then reported the incident to the Assistant DON (V51) and the Administrator/Abuse Prevention Coordinator (V1). R3 later did not recall the incident, and R4 stated he did not recall the exact words but knew R3 was not nice and cussed at him. The investigation documentation for this incident did not include additional resident or staff interviews beyond these statements. During review of the hard-copy investigations, the Administrator/Abuse Prevention Coordinator (V1) acknowledged that both investigations lacked witness statements from other residents, which are part of a thorough investigation, and also acknowledged she had misunderstood R16’s post-incident location and that R16 should not have remained in the dining room after shouting profanities at R17.
Failure to Provide Required Discharge Documentation and Appropriate Wheelchair for Resident Transfer
Penalty
Summary
The deficiency involves the facility’s repeated failure to provide complete and accurate documentation and personal records needed for a resident’s discharge and admission to a supportive living facility, as well as failure to obtain an appropriate wheelchair as ordered. The resident had a history of cerebral infarction with hemiplegia and hemiparesis affecting the right dominant side, foot drop, aphasia, expressive language disorder, major depressive disorder, pain, and unsteadiness on feet, and used a manual wheelchair for mobility. Physician orders documented that the resident was to be discharged to an assisted living facility and required a specific-sized wheelchair with defined features due to her cerebrovascular conditions, but there was no documentation in the medical record confirming that a new wheelchair had been ordered. On the day of discharge, the discharge summary noted that discharge education was performed, medications were sent with the resident, and that the resident took her own wheelchair and hemi-walker because they belonged to her. Subsequent observation at the supportive living facility showed the resident using a wheelchair in visible disrepair, including a cracked and broken plastic side panel near her hip, missing plastic on the armrest, and both armrests wrapped in thin elastic bandage tape. The resident reported that she had repeatedly requested a new wheelchair for months, including after becoming eligible for Medicare, and stated that the facility had told her at various times that a wheelchair was being ordered and later that it was not. She described the cushion as worn, tattered, and flat, and stated that the broken plastic poked and hurt her hip, requiring her to be extra careful. Interviews with the executive director and other staff at the supportive living facility revealed that they experienced numerous delays in obtaining the resident’s necessary documents from the skilled facility, including Social Security information, Medicare/Medicaid status, and accurate resident funds records. They reported that the skilled facility could not initially determine whether the resident was Medicaid or private pay, did not have an active Social Security card or award letter, and sent a commingled resident funds ledger with other residents’ information blacked out instead of a separate statement for this resident. These documentation issues, along with unresolved questions about the wheelchair order, caused months of delay in the resident’s admission to the supportive living facility despite her eligibility. The administrator of the skilled facility later confirmed that the delay in discharge was due to paperwork, identification records, and resident funds records not being submitted by the prior business office manager, and also confirmed that the facility did not purchase the resident’s wheelchair despite her repeated requests over the past year, resulting in her discharge with the broken wheelchair.
Failure to Provide Timely Dental Extractions Due to Missed Preparation and Transportation
Penalty
Summary
The deficiency involves the facility’s repeated failure to ensure transportation and appropriate nursing preparation for a resident’s needed dental extractions, resulting in prolonged delay of care. The resident had an MDS showing intact cognition and a care plan documenting poor dentition with obvious tooth decay, broken teeth, and goals to remain free from mouth pain, with instructions to observe for mouth pain and obtain dental consults as needed. A county health department dental consultation documented that the resident was to have multiple tooth extractions and that Eliquis was to be held for 24 hours before the procedure. Despite this, a scheduled dental appointment was rescheduled because nursing staff did not hold the resident’s medications as ordered, and the Regional Director later confirmed that this appointment should have been kept and that nurses should have been aware of the medication hold requirement. Further delays occurred due to administrative and transportation issues. Another dental appointment was rescheduled because the resident’s insurance was incorrectly believed to be canceled, although the Regional Business Office Manager later stated this was a mistake and that the resident had active Medicaid coverage at the time. Additional appointments were rescheduled when the facility could not provide transportation after a change in facility ownership and while the new operator was researching insurance and title for the facility van, and because the van driver/scheduler was unable to secure local public transportation. The van driver/scheduler reported that all appointments had been pushed out by weeks and that the resident’s dental work had been on hold for a couple of months. As a result, the resident, who had multiple black and brown broken teeth with only three upper and three lower chipped teeth remaining, experienced a delay of approximately ten months from the initial visit when extractions were determined to be needed.
Failure to Notify Family, Physician, and Hospice After Resident Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s family, physician, and hospice following a fall and change in condition. The resident had multiple serious diagnoses, including carcinoma of the left bronchus, senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, stage IV chronic kidney disease, muscle disorder, unsteadiness on feet, and lack of coordination, and was admitted to hospice with a prognosis of six months or less. The resident’s MDS showed a Brief Interview for Mental Status score of 5/15, indicating severe cognitive impairment. A fall incident report documented that the resident fell at 7:30 p.m. on 12/06/25, with the assigned LPN identified, and specifically noted “No notifications found.” The facility’s Fall Reduction Policy required evaluation for injury and notification of the physician, responsible party, and on-call nurse after a change in condition, and the hospice contract required facility staff to contact hospice’s Administrator on Call for services related to the terminal illness. Interviews and record review confirmed that no notifications were made the night of the fall. Family members and the resident’s Power of Attorney reported they were not notified of the 12/06/25 fall until the following day, 12/07/25. An LPN coming on duty the next morning stated she learned of the fall during shift report and found no documentation that the physician, hospice, or family had been notified; she then attempted to reach family and hospice. At that time, the resident was described as lethargic, unable to speak, and moaning. The hospice RN confirmed hospice was not notified until the morning after the fall and stated that, based on her experience, the resident had a concussion and likely a brain bleed and was comatose post-fall with changes in swallowing and breathing and no emotional response. The DON stated that the resident’s family, provider, and hospice should have been called immediately, and the LPN who was on duty at the time of the fall acknowledged it had been a hectic night and she had not notified the family, physician, or hospice.
Failure to Protect a Resident From Verbal Abuse by Another Resident in the Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident verbal and emotional abuse in the dining room. One resident (R16), who had documented behavioral issues including aggression and inappropriate yelling or arguing with others, verbally targeted another resident (R17) during a meal. R16 had diagnoses of undifferentiated schizophrenia and bipolar disorder and was receiving risperidone; his MDS BIMS score was 15/15, indicating no cognitive impairment. R17 had diagnoses of unspecified depression and unspecified psychosis and was receiving sertraline and aripiprazole; his BIMS score was 14/15, also indicating no cognitive impairment. On the date of the incident, multiple witness statements described a verbal exchange in the dining room. Dietary staff reported that R17 was in the dining room joking and laughing with staff when R16 suddenly yelled, “Shut the (F-expletive) up,” and repeatedly used the F-word while looking at R17. One dietary assistant stated she initially assumed the yelling was directed at R17 and told R16 that the dining room was everyone’s home. Another dietary assistant and the cook both confirmed that R16’s profanity was directed at R17, that the dining room was about half full at the time, and that R17 became upset and left the dining room crying shortly afterward. Other residents (R7 and R14) also reported overhearing R16 yelling “pretty bad words” and “cussing up a blue streak” at R17 in the dining room, which they felt was uncalled for. R17 later stated that he cried and returned to his room when R16 would not stop cussing at him, explaining that he had depression and that being yelled at with profanities was overwhelming. During a subsequent interview, R17 became tearful while recounting the event. In a later interview, R16 admitted that he “put (R17) in his place,” acknowledged yelling harsh words because he thought R17 was laughing at him, and confirmed that R17 later came to him crying and asking if they were still friends. The facility’s own policy on Resident Right to Freedom from Abuse, Neglect and Exploitation defines verbal and mentally abusive behaviors, requires associates not to use verbal or mental abuse, and directs the facility to review resident-to-resident altercations as potential abuse situations. Despite this, the incident as described shows that R17 was subjected to witnessed resident-to-resident verbal and emotional abuse in the dining room. The facility’s care plan for R16 documented a known pattern of aggressive behaviors toward other residents, including yelling or arguing inappropriately and sometimes following others while continuing to be rude or inappropriate. Interventions in the care plan required staff to intervene when R16 exhibited behaviors toward other residents, ensure everyone’s safety, and monitor all inappropriate behaviors, including type, time, provocation, staff present, and resolution. Nonetheless, on the day of the incident, R16’s verbally aggressive behavior toward R17 occurred in a public dining setting, was witnessed by staff and residents, and resulted in R17 becoming emotionally distressed and leaving the dining room in tears. This sequence of events demonstrates that the facility did not ensure that R17 was free from resident-to-resident emotional and verbal abuse as required by its own policy and resident rights. Additionally, the Administrator/Abuse Prevention designee acknowledged during interview that the investigation of the allegation that R16 verbally abused R17 in the dining room had not yet been fully processed or scanned, even though the incident had occurred earlier. The facility’s policy states that when abuse is identified, the facility will take appropriate steps to remediate noncompliance and protect residents from additional abuse, including reviewing resident-to-resident altercations as potential abuse. The documented witness accounts, resident interviews, and R16’s own admission collectively establish that a resident-to-resident verbal abuse incident occurred and that the facility failed to ensure R17’s right to be free from such abuse.
Failure to Obtain Replacement Wheelchair Resulting in Prolonged Use of Damaged Equipment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and arrange for a replacement wheelchair for a dependent resident, resulting in prolonged use of a wheelchair in disrepair. The resident had multiple neurologic and functional diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, right foot drop, aphasia, expressive language disorder, major depressive disorder, recurrent pain, and unsteadiness on feet. The resident’s MDS documented use of a manual wheelchair for mobility, and the MAR showed ongoing use of extended-release Tylenol for pain management up to the date of discharge. Physician orders documented that the resident required a wheelchair and cushion for discharge, specifying wheelchair dimensions, cushion thickness, and bilateral swing-away footrests. Surveyor observation at the supportive living facility after discharge found the resident using a wheelchair with the left arm in visible disrepair: the plastic side panel holding the armrest was cracked into several pieces, with a two-inch section of broken plastic bent inward and wrapped in thin elastic bandage tape, abutting the resident’s left hip. A five-inch section of plastic was missing from the same armrest, and the right armrest was wrapped in disposable elastic bandage material. The resident reported that the cushion was worn, tattered, flat, and caused discomfort to her buttocks, and that the broken plastic side panel poked and hurt her hip, requiring her to be extra careful to avoid being jabbed. The discharge summary documented that the resident left with her several-years-old wheelchair and hemi-walker, which belonged to her, and did not indicate that a new wheelchair had been provided. The resident stated she had asked and begged for a new wheelchair for months while at the facility, including after becoming eligible for Medicare, and that facility staff, including the Administrator, repeatedly told her they would check into it but did not follow through. She reported that the facility at one point said they were purchasing a wheelchair and later said they were not, and that she remained uncomfortable in her old wheelchair, which she had used for years since her stroke. The Meridian Medicaid social worker reported attempting to obtain a new wheelchair for the resident since 9/12/22, repeatedly requesting necessary paperwork from the facility and being told the paperwork was lost under both old and new ownership. The social worker stated that the resident’s wheelchair was in bad shape and cutting into her side, and that Medicaid would have provided a new wheelchair if the facility had supplied the required documentation. The Administrator confirmed that the facility did not purchase the resident’s wheelchair and that the resident had repeatedly requested a new one over the past year.
Failure to Maintain Complete and Accurate Medical Records for Emotional Distress and Dental Status
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a BIMS score indicating no cognitive impairment, an incident of resident-to-resident verbal abuse in the dining room was reported to the state but not documented in the resident’s medical record. The incident involved another resident yelling profanities, including the F-word and telling the resident to “shut up,” causing the resident to cry and return to their room. The resident, who has depression, reported feeling overwhelmed and was observed tearing up when recounting the event. There was no documentation in the medical record of the altercation, the resident’s crying episodes, or any monitoring of the resident’s emotional response such as anxiety, fear, or increased depression. For another resident, the facility’s MDS documented no obvious or likely cavities or broken natural teeth, despite other records and observations indicating significant dental problems. The resident’s care plan documented poor dentition with obvious tooth decay, and on interview the resident reported dental issues and a plan to have all teeth extracted and replaced with dentures. Direct observation showed multiple black and brown broken teeth worn down to the gum level, with only six remaining chipped, darkly discolored teeth. The administrator confirmed that the MDS coding for this resident’s dental status was incorrect and inconsistent with the resident’s other medical records and current oral health condition.
Failure to Provide Timely and Complete Catheter and Wound Care, Leading to Penile Injury
Penalty
Summary
A resident with multiple complex medical conditions, including chronic kidney disease, urinary retention, and an indwelling urethral catheter, was admitted to the facility without any penile wounds. The resident required significant assistance with personal care and was dependent on staff for toileting. The care plan instructed staff to anchor the catheter tubing high on the resident's thigh to prevent pulling and reduce the risk of injury, and to monitor and report any redness or skin issues. Despite these instructions, the catheter was repeatedly found unsecured, and the resident developed redness, excoriation, and eventually an open, bleeding wound on the penis. Staff failed to provide timely and complete catheter and wound care as ordered. The resident's physician ordered zinc cream to be applied twice daily to the penile wound, but documentation shows that the cream was not available on multiple occasions, and the treatment was not consistently administered. Additionally, staff did not fully retract the resident's foreskin during perineal and wound care, resulting in incomplete cleansing and assessment of the wound. There was also a lack of proper wound documentation, including measurements and drainage assessment, and the facility was unable to provide records of ongoing wound monitoring. Infection control practices were not followed during wound care. A CNA and an RN both failed to change gloves or perform hand hygiene between cleansing the wound and applying the prescribed zinc cream, and the RN applied the cream with contaminated gloves. The catheter remained unsecured during care, and staff acknowledged not following proper procedures. The DON confirmed that the penile wound was caused by constant pulling of the catheter and that the facility should not have run out of zinc oxide. The resident's wound worsened during the stay, and the facility could not provide adequate documentation of wound assessment or monitoring.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
A cognitively intact resident (R8) reported that staff failed to treat her with dignity and respect. According to the Minimum Data Set and nurse progress notes, the resident was observed crying and stated that staff were not listening to her, laughed at her, and made her feel sad. The resident also expressed a desire to leave the facility Against Medical Advice (AMA) due to these interactions. The resident recounted an incident where she was concerned about another resident who was screaming, and when she went into the hallway, the Director of Nursing (DON) was reportedly yelling and laughing at her. Additionally, the resident described having an abscessed tooth with significant facial swelling and stated that when she informed staff, including the DON and two LPNs, they yelled and laughed at her concerns. The facility's administrator acknowledged that staff should always treat residents with dignity and respect and recognized the need for staff to be more aware of their conversations when residents are present. The facility's policy, approved in December 2024, affirms each resident's right to a dignified existence, self-determination, and communication without interference or reprisal. The events described indicate that the facility failed to uphold these rights for the resident involved.
Failure to Protect Residents from Verbal and Emotional Abuse
Penalty
Summary
The facility failed to protect residents from verbal and emotional abuse by both staff and other residents, as evidenced by multiple incidents involving seven residents. One resident with epilepsy and a seizure disorder was repeatedly accused by an LPN of faking seizures, both privately and in front of others, causing the resident to feel upset, embarrassed, and mistrusted. This was corroborated by a CNA who witnessed the LPN making disparaging remarks about the resident's condition in the resident's presence. Another incident involved two residents with cognitive impairments and behavioral concerns who engaged in a verbal altercation, with one threatening physical harm and the other responding with derogatory language. Staff confirmed that the altercation required intervention and separation. Additional cases included a resident with panic disorder and cognitive impairment who was prevented from leaving the dining room by a CNA, who also mocked and intimidated the resident, causing visible distress. This behavior was witnessed and described as mentally abusive by other staff members. Further deficiencies were noted when a CNA provided discourteous and physically rough care to a resident with dementia and mobility issues, including shoving the resident and making callous remarks about the risk of falling. There were also repeated instances of one resident with severe cognitive impairment verbally abusing another resident, using profane and derogatory language in common areas. Staff and the administrator acknowledged these behaviors and confirmed that such actions are considered abuse under facility policy.
Failure to Timely Report Allegations of Mental Abuse
Penalty
Summary
The facility failed to report allegations of mental abuse involving a cognitively intact resident on two separate occasions. According to the resident's medical record, the resident was observed crying and reported that staff were not listening to her, were laughing at her, and that she wanted to leave against medical advice. Despite these documented concerns, the allegations of mental abuse involving staff members were not reported to the State Agency as required. The Administrator stated that she was not made aware of the resident's allegations on the dates they occurred and only discovered the issue through her own review of the resident's records at a later date. Facility policy requires that all allegations of abuse be reported immediately to the Administrator, who is responsible for overseeing investigations. In this case, the required reporting process was not followed, and the allegations were not communicated to the appropriate authorities in a timely manner.
Failure to Supervise Exit Doors and Investigate Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment by leaving an exit door and a courtyard gate both unlocked and unalarmed, which allowed a resident with severe cognitive impairment and a diagnosis of dementia to elope from the building unnoticed. The resident, who was independently mobile and had a recent mental status change, was found walking outside along the building perimeter by a Certified Nursing Assistant (CNA) who observed the resident through a window while providing care to another individual. The resident stated they were trying to go home and appeared disoriented, but was able to return to the facility with staff assistance. At the time of the incident, the courtyard gate was left open and unlocked due to a mowing contractor's access, and the hallway exit door was routinely kept unlocked and unalarmed to allow residents who smoke to access the courtyard without staff supervision. The facility's elopement investigation did not identify or document the root cause of the incident, nor did it note that the exit door and courtyard gate were unsupervised, unlocked, and unalarmed at the time of the elopement. The facility's policy requires adequate supervision and a root cause analysis following an elopement, but the investigation failed to address these requirements. The resident's care plan indicated minimal staff assistance was needed for ambulation, but assessments documented severe cognitive impairment and elopement risk factors.
Failure to Document Resident Elopement and Investigation
Penalty
Summary
The facility failed to document an elopement incident and subsequent investigation in the medical record of a resident with dementia, weakness, muscle wasting, and severe cognitive impairment. The resident, who was independently mobile and assessed as at risk for elopement, was found outside the facility by a CNA after exiting through an unlocked and unalarmed door leading to a courtyard, and then through an unlocked gate to the sidewalk. The incident was observed by staff, and the resident was returned to the facility without any door alarms sounding. The unlocked gate was attributed to a mowing contractor's access, and the exit door was routinely left unlocked and unalarmed to allow residents to access a smoking area. Despite the occurrence of the elopement, there was no documentation of the incident in the resident's nursing progress notes or electronic medical record, except for a note in a risk section not typically accessible to medical or nursing staff. The facility's elopement investigation did not identify or document the root cause of the incident, nor did it note the status of the doors and gate at the time. The Director of Nursing was unsure if the elopement was documented in the resident's medical record, confirming the lack of proper documentation.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to wear the required gowns while providing direct care, including indwelling urinary catheter care and perineal care, to a resident on Enhanced Barrier Precautions (EBP) due to a history of Multi Drug Resistant Organism (MDRO) and the presence of an indwelling urinary catheter. During the observed care, the CNAs did not don gowns as required by facility policy, despite signage indicating EBP precautions outside the resident's room. Additionally, one CNA emptied the resident's urinary drainage bag without wearing a gown. The room lacked appropriate disposal bins for contaminated Personal Protective Equipment (PPE), and no disposed PPE was found in the room's garbage cans. Both CNAs acknowledged after the incident that gowns should have been worn during these care activities. The Assistant Director of Nursing/Infection Preventionist confirmed that staff are expected to use appropriate PPE, including gowns and gloves, when providing high-contact care to residents on EBP, particularly those with a history of MDRO and indwelling devices. Facility policy specifies that gown and glove use is required during high-contact activities such as hygiene care and care involving indwelling medical devices.
Failure to Maintain AED Results in Nonfunctional Equipment During Cardiac Emergency
Penalty
Summary
The facility failed to ensure timely checks and maintenance of its medical equipment, specifically the Automated External Defibrillator (AED). According to interviews and record reviews, the AED was not checked daily as required, and the last documented check occurred at the end of June. On the day of the incident, when a resident returned from the hospital with a diagnosis of acute respiratory failure with hypoxia, the resident experienced an episode of not breathing and became unresponsive. Staff followed protocol by moving the resident to his room, placing him on the bed with a cardiac board, and retrieving the code cart and equipment. During the emergency response, the RN attempted to use the AED on the resident, but the device would not function. The RN was unsure if the battery was dead or if there was another issue. As a result, staff proceeded with chest compressions and used an Ambu bag while waiting for EMS to arrive. EMS took over upon arrival, but the resident was pronounced dead after 20 minutes of resuscitation efforts. The facility's policy required daily checks and maintenance of the AED, but this was not followed, leading to the equipment being nonfunctional during a critical event.
Staff Performed Clinical Duties After Consuming Alcohol
Penalty
Summary
Facility staff, including the previous administrator, assistant director of nursing (ADON), and a restorative certified nursing assistant (CNA), admitted to consuming alcoholic beverages a few hours before entering the facility. On the evening in question, these staff members attended a local bar/restaurant, where more than one drink was consumed by some of them. Later that night, they entered the facility and performed work-related duties, including conducting skills checks with staff and assisting with medication management. Multiple witness statements and employee corrective action forms confirm that these staff members were present in the facility after drinking alcohol. Observations included glassy eyes, rosy faces, and hyperactive behavior from the restorative CNA, as well as similar physical signs in the ADON. The staff members interacted with other employees, observed resident care, and participated in clinical activities while under the influence of alcohol. No direct harm to residents was reported, but the conduct was noted as a violation of professional standards and facility policy. The incident had the potential to affect all 54 residents residing in the facility, as documented in the facility's resident matrix. The facility's assessment outlines the necessary resources and staff roles required to provide competent care, which were compromised by the actions of the involved staff members. The deficiency centers on the failure to maintain a professional standard of conduct by allowing staff to work under the influence of alcohol while performing duties within the facility.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to protect the privacy and confidentiality of two residents' personal and medical information. In the first instance, a video of a resident with severe cognitive impairment, Alzheimer's disease, and Parkinson's disease was posted on social media by two agency CNAs. The video was discovered by an LPN, who saw it on a social media story while at work. The video depicted the resident in the facility and was shared without authorization, violating the facility's HIPAA protocol and resident privacy policies. The facility's own protocol explicitly prohibits the unauthorized disclosure of resident information on internet sites and emphasizes the importance of maintaining privacy. In the second instance, a resident with no cognitive impairment, diagnosed with bilateral lower leg cellulitis and lymphedema, was observed receiving wound care in her room with the door wide open. The resident's bare legs and feet, which were affected by severe dryness, scaling, and pitting edema, were in clear view of multiple unidentified residents, staff, and visitors passing by. The wound care process resulted in visible skin debris falling to the floor, further exposing the resident's condition. The resident expressed embarrassment about her condition being visible to others and stated a preference for privacy during treatments. Both incidents demonstrate a failure to ensure privacy during care and to protect confidential resident information, as required by facility policy and residents' rights. The actions and inactions of staff in both cases directly led to the exposure of residents' private information and personal dignity.
Mental Abuse of Resident by Agency CNAs via Social Media Video
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, cognitive communication deficit, Parkinson's disease, and generalized anxiety disorder, who was severely cognitively impaired and dependent on staff for mobility, was subjected to mental abuse by two agency CNAs. The incident involved the CNAs repeatedly locking the resident's wheelchair brakes while taunting him to move faster, despite his inability to do so. The CNAs took turns locking and unlocking the wheelchair, causing visible distress, anxiety, and confusion in the resident, who was unable to understand or respond appropriately due to his cognitive and physical limitations. The abuse was recorded on video and posted to social media by one of the CNAs, with the other CNA re-posting it. The video showed the resident in a corner, facing a blank wall, being taunted and prevented from moving. Observers of the video, including an LPN and another CNA, described the resident as appearing very upset, anxious, and in distress throughout the duration of the video, which lasted less than a minute. The actions of the CNAs were described as antagonizing and intended to cause mental harm, with the resident unable to escape or defend himself due to his condition and the physical restraint imposed by the staff. The facility's abuse prevention policy explicitly prohibits all forms of abuse, including mental abuse facilitated by technology such as unauthorized video recordings and social media posts. The policy defines mental abuse to include humiliation, harassment, and the use of recordings in a manner that demeans or humiliates residents. The actions of the CNAs, as documented in the video and described by staff, were in direct violation of this policy, resulting in the resident being subjected to mental anguish and humiliation.
Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to correctly identify a resident before administering medications, resulting in a significant medication error. An agency nurse, on their second day at the facility, mistakenly administered medications intended for one resident to another resident with a similar last name. This error occurred in the dining room during breakfast, where the nurse gave the resident thin liquids instead of the required thickened liquids, despite a CNA's intervention. The resident who received the wrong medications had a primary diagnosis of chronic heart failure and was severely impaired in decision-making skills. The medications administered included a range of drugs such as antiarrhythmics, anticoagulants, antihypertensives, and others, which were not prescribed for the resident. This led to a drop in the resident's blood pressure, as confirmed by the facility's medical staff and the medical director. The facility's policies require adherence to the five rights of medication administration, which were not followed in this instance. The facility had a binder with policies and procedures for new and agency staff, but the nurse did not adhere to these guidelines. The incident was documented, and the facility acknowledged the significant medication error.
Failure to Include Infection Preventionist in QAA Meetings
Penalty
Summary
The facility failed to ensure that the required personnel attended the quarterly Quality Assessment and Assurance (QAA) committee meetings and did not hold these meetings quarterly as mandated. Specifically, the facility's QA Meeting Members list lacked the required Infection Preventionist, and the attendance sheets for the meetings did not include the signature of an Infection Control Preventionist. The absence of this key member was confirmed by the Director of Nursing and the Administrator, who acknowledged that the meetings occurred before the Infection Control Preventionist was hired on August 1, 2024. Additionally, there was no documentation of a first quarterly QA Meeting for 2024, and the second quarter meeting held in June 2024 also lacked the presence of an Infection Control Preventionist. This oversight has the potential to affect all 60 residents residing in the facility, as the QAPI Program is designed to monitor quality and performance, find opportunities for improvement, and meet regulatory requirements. The facility's failure to include an Infection Control Preventionist in these critical meetings indicates a lapse in adhering to the QAPI Program's comprehensive approach to maintaining and improving safety and quality.
Failure to Maintain Legionella Water Management Plan
Penalty
Summary
The facility failed to maintain an operational Legionella water management plan, which could potentially affect all 60 residents. The Legionella Management Procedure was last reviewed in 2018 and lacked an assessment to identify areas where Legionella and other pathogens could grow and spread, as well as measures to prevent and monitor the growth of waterborne pathogens. The Maintenance Director, who has been in the position for about four years, admitted to not having done anything with the Legionella water management plan since starting and stated that corporate had never discussed it with him. He also acknowledged not having assessed the building for potential growth areas of Legionella or other pathogens and did not have a routine to flush unused water lines. The Regional Infection Preventionist confirmed that the Maintenance Director was responsible for implementing and following the facility's Legionella water management plan.
Infection Preventionist Lacks Required Training Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control, as required by their Infection Control Manual dated 2019. This deficiency potentially affects all 60 residents in the facility. During an interview, the Director of Nursing stated that the Regional Infection Preventionist was acting as the facility's Infection Preventionist until a facility nurse could be trained for the role. However, the Regional Infection Preventionist was unable to provide a copy of her training certificate. Despite attempts to locate the certificate, it was not found, and the Infection Preventionist was not present at the facility as expected to resolve the issue.
Lack of Staff Training on Abuse Prevention
Penalty
Summary
The facility failed to provide the required abuse prevention education to its staff, which has the potential to affect all 60 residents. During a survey, the Administrator and Abuse Prevention Coordinator confirmed that there was no facility-wide documentation of staff education on abuse training available. The current management company does not have access to the previous owner's education documents. The facility's policy on abuse prevention and prohibition, revised in January 2024, outlines that staff should be trained on the Abuse Prohibition Program during orientation, annually, and ongoing educational sessions, as per state regulations. However, this training was not documented, leading to the deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as observed during a survey. The Certified Nursing Assistant's Guidebook from 2021 mandates that call lights should be within reach before leaving a resident's room. However, during observations, it was noted that the call lights for four residents were not accessible. For instance, one resident's call light was found on the floor at the foot of the bed, while another's was tied to a stuffed animal on a bedside table, out of reach. These observations were made despite care plans indicating that these residents were at high risk for falls and required their call lights to be within reach as an intervention. The care plans for the residents involved documented specific interventions to ensure call lights were accessible, highlighting the importance of this measure due to their high fall risk. Despite this, the facility did not adhere to these interventions, as evidenced by the call lights being placed on the floor or tied to objects, making them inaccessible. The Assistant Director of Nursing confirmed that all residents' call lights should be within reach at all times, indicating a lapse in following established protocols and care plans designed to prevent falls and ensure resident safety.
Failure to Provide Timely Dining Assistance
Penalty
Summary
The facility failed to provide timely dining assistance to seven residents who required physical staff assistance with eating. During a dining observation, it was noted that these residents were seated at a designated table for those needing assistance, with their meals served and uncovered, but only one CNA was present to assist them initially. This resulted in a delay, as the CNA began feeding one resident while the others waited. A second CNA joined 21 minutes later to assist another resident, leaving five residents still waiting for help. The Director of Nursing later confirmed the lack of adequate staff to assist the residents and acknowledged that residents should not have to wait 40 minutes for assistance. The facility's protocol for communal dining emphasizes the importance of timely assistance and personal attention to residents during meals. However, the observation and resident council meeting minutes indicated that the facility did not adhere to these guidelines, as residents reported ongoing issues with late feeding and insufficient staff. The facility's protocol also specifies that no more than two residents should be assisted by one CNA at a time, a guideline that was not followed during the observed dining period.
Failure to Hold Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to adhere to a medical provider's order to hold the administration of a resident's blood pressure medication, spironolactone, resulting in the resident receiving the medication for an additional 23 days without authorization. The resident, who was diagnosed with hypertension, was initially ordered spironolactone along with other blood pressure medications. On August 6, 2024, the resident's medical provider documented symptoms of nosebleed, dizziness, and low blood pressure, leading to an order to hold the spironolactone indefinitely. Despite this order, the facility's Medication Administration Records show that the medication was only held from August 7 to August 9, 2024, and then resumed from August 10 to September 1, 2024. The resident began refusing further doses on September 2, 2024, after experiencing symptoms of low blood pressure and dizziness. The medical provider confirmed that there was no order to resume the medication, and subsequently discontinued the spironolactone on September 5, 2024.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents, R44 and R58. On the date of the incident, R58, who has schizophrenia and dementia with psychosis, grabbed R44's arm, leading to a physical altercation. R44, who has moderate cognitive impairment, responded by swinging an empty coffee cup at R58, although no contact was made. R44 sustained a small laceration on his right forearm during the incident. The incident was documented in R58's Resident to Resident Physical Aggression Initiated form, which noted R58's history of wandering and cognitive impairment. R58's Minimum Data Set (MDS) indicated moderate cognitive impairment and behaviors of wandering and delusions. R44's MDS also indicated moderate cognitive impairment and behaviors of verbal aggression. The altercation was confirmed by the facility's Administrator/Abuse Prevention Coordinator, who substantiated the allegation of physical abuse. The facility's policy on abuse prevention and prohibition emphasizes the right of residents to be free from abuse by anyone, including other residents. Despite this policy, the incident occurred, and staff were notified, including the local police, the Administrator, and the Director of Nursing. The facility's final report confirmed the physical altercation and documented the staff's response in assessing and treating R44's injury. However, the report highlights a failure to prevent the incident and protect the residents involved.
Incomplete Investigation of Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into a physical abuse incident involving two residents, R44 and R58. The incident occurred when R58, unprovoked, approached R44, who was in a wheelchair near the nurse's station, and grabbed R44's right arm, causing a laceration. The altercation escalated when R44 attempted to defend himself by swinging a cup at R58. Despite the presence of staff, the investigation was incomplete, lacking interviews with all staff and residents involved or present during the incident. The facility's final report included only two witness statements from CNAs, without any resident interviews or additional staff input. The facility's policy on abuse prevention and investigation mandates a comprehensive investigation, including interviews with all staff on duty during the incident and any residents who might have witnessed or been affected by the event. However, this protocol was not followed, as confirmed by the facility's Administrator and Regional Administrator. The investigation did not include interviews with all staff members present during the shift, nor did it involve interviews with the residents involved or other potential witnesses. This oversight resulted in an incomplete understanding of the incident and whether the alleged abuse was substantiated.
Failure to Request New PASARR for Resident with IDD
Penalty
Summary
The facility failed to request a new Level 1 PASARR (Preadmission Screening and Resident Review) within 30 days of admission for a resident identified as R32, who was reviewed for PASARR compliance. R32's initial Level 1 PASARR indicated evidence of a serious mental or intellectual disability and noted that further PASARR was not required due to an exempted hospital discharge, allowing a stay of up to 30 days in a Medicaid-certified nursing facility without further evaluation. However, the facility did not submit a new Level 1 screen to Maximus by the 30th day after R32's admission, as required. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that the current PASARR for R32 was expired and that a new request had not been made.
Failure to Identify Behaviors and Implement Care Plan for Anti-Psychotic Use
Penalty
Summary
The facility failed to identify specific behaviors in a resident that necessitated the use of anti-psychotic medication and did not develop or implement a care plan with non-pharmacological interventions before administering the medication. This deficiency affected one resident, who was prescribed Risperidone for Major Depressive Disorder. The resident's care plan lacked documentation of targeted behaviors or expressions of psychic distress, and no non-pharmacological interventions were noted. A quarterly assessment indicated the resident did not exhibit indicators of psychosis or behaviors. Interviews with facility staff confirmed the absence of behavior tracking for the resident, who seldom left their room.
Failure to Administer Physician-Ordered Treatments for Skin Conditions
Penalty
Summary
The facility failed to apply treatments as ordered by the physician and care plan interventions for two residents reviewed for skin conditions. One resident, who has a history of eczema, was observed with multiple scabbed areas and red flaky patches on the skin, with blood under the fingernails, indicating self-inflicted scratches due to excessive itching. The resident's physician had ordered Tacrolimus cream and Calamine lotion for treatment, but these were not documented in the Medication and Treatment Administration Records after a certain date, and the care plan was not updated with these interventions. The wound nurse confirmed that the Tacrolimus cream was effective and should have been a current order, and the assistant director of nursing acknowledged that the absence of documentation likely meant the cream was not used. Another resident had a diabetic ulcer on the left foot, with the dressing observed to be saturated with yellow and red drainage, and the presence of slough and eschar in the wound beds. The wound nurse stated that the treatment order had changed to Medihoney and Calcium Alginate due to the wound's condition, but this new order was not entered into the medical record. The registered nurse applied betadine instead of the newly ordered treatment, indicating a failure to administer the correct treatment as per the updated physician's order.
Improper Catheter Care and Maintenance
Penalty
Summary
The facility failed to provide proper catheter care for three residents, leading to potential cross-contamination and increased risk of urinary tract infections. For one resident, a CNA used a no-rinse wipe improperly by not changing the area of the wipe when cleaning different parts of the resident's body, including the penis and buttocks. Additionally, the CNA did not anchor the catheter tubing at the meatus, causing unnecessary pulling on the catheter. The facility's policy requires changing the position of the cloth with each cleansing stroke and securing the catheter, which was not followed in this instance. Another resident was observed with their urinary catheter drainage bag laying flat on the floor, uncovered, and the catheter tubing was not secured to the leg. The resident's care plan did not include interventions or goals for catheter care and maintenance. Similarly, a third resident's catheter drainage bag was also found laying on the floor. The facility's catheter care policy, which aims to prevent catheter-associated urinary tract infections, mandates that catheter tubing and drainage bags be kept off the floor and secured, which was not adhered to in these cases.
Failure to Prevent Unnecessary Use of Anti-Psychotic Medication
Penalty
Summary
The facility failed to prevent the unnecessary use of the anti-psychotic medication Risperidone for a resident identified as R20. The resident's Order Summary Report listed diagnoses of Major Depressive Disorder and Anxiety Disorder, but did not include any approved diagnosis for the use of anti-psychotic medication. Despite the prescription of Risperidone for Major Depressive Disorder, there was no documentation of a psychotropic medication assessment or any specific targeted behaviors or indicators of persistent psychiatric distress that would necessitate the use of such medication. Interviews with the Assistant Director of Nursing and Registered Nurses revealed that there was no behavior tracking conducted for R20, and the resident did not exhibit indicators of persistent psychiatric distress or behaviors endangering themselves or others. The facility's policy on psychotropic medication use stipulates that such medications should only be administered when necessary for specific conditions, and a Psychoactive Medication Review assessment should be completed upon admission and quarterly. However, these procedures were not followed for R20, leading to the inappropriate continuation of anti-psychotic medication without a valid diagnosis or documented need.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as R34, who was reviewed for food preferences among a sample of 39 residents. R34 has a severe cognitive impairment, as indicated by a Brief Interview of Mental Status score of three out of 15. The resident's diet order specifies a regular diet with mechanical soft texture and honey/moderately thick consistency liquids. R34's lunch meal ticket, which was undated, documented a dislike for all vegetables. However, during an observation on September 5, 2024, a Certified Nursing Assistant (CNA) identified as V7 was feeding several residents and noted that R34's plate, which included mechanical soft meat, mashed potatoes, and whole cooked cauliflower, was untouched. V7 confirmed that R34 did not like the served meal and had ordered a grilled cheese instead. The CNA also confirmed that R34's diet card indicated a dislike for vegetables, yet the plate included cauliflower, contrary to the facility's protocol to honor residents' food preferences before serving meals.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to offer influenza vaccinations to a resident, identified as R6, as part of their immunization protocol. According to the facility's Infection Prevention and Control Manual dated September 2022, it is the policy to offer influenza vaccinations to all residents. However, a review of R6's immunization report revealed that while the resident routinely received the influenza vaccine from 2010 to 2021, there is no documentation of the vaccine being offered or administered in 2022 or 2023. Furthermore, R6's medical record lacks any indication that the influenza vaccination was offered during these years. During an interview on September 6, 2024, a registered nurse (V8) confirmed the absence of records for R6's influenza vaccine for the years in question.
Failure to Offer COVID-19 Booster to Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccination booster to a resident, identified as R36, who was part of a sample list of 39 residents reviewed for immunizations. On September 3, 2024, R36 reported not being offered any vaccinations since being admitted to the facility and expressed a desire to receive the COVID-19 booster. The resident's immunization record indicated that the last COVID-19 vaccination was administered on April 1, 2021. On September 6, 2024, a registered nurse, identified as V8, confirmed that a COVID-19 vaccination clinic was held in June 2024 by an outside organization, but R36 was not included on the list for the clinic, resulting in the resident not being offered the vaccine.
Failure to Notify Physician and Obtain Treatment for Diabetic Ulcer
Penalty
Summary
The facility failed to notify the physician of a new diabetic foot ulcer, obtain a treatment order, and complete wound assessments for a resident with a history of Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Chronic Diastolic Heart Failure. The resident, who was moderately cognitively impaired and required assistance for all activities of daily living, was found to have a black sore on the right great toe during a shower on 5/21/24. This information was reported to the Charge Nurse, and a bandage was applied, but there was no documentation that the physician was notified of the change in the resident's skin condition. The lack of documentation and notification continued until 6/11/24, when the Wound Nurse completed a Weekly Skin Check and noted the new area on the resident's right great toe. The resident was subsequently diagnosed with Osteomyelitis and started on antibiotics. The resident's condition worsened, leading to hospitalization for IV antibiotics and a scheduled toe amputation. The facility's policy required weekly skin checks and immediate notification of the provider and resident representative upon identifying new skin conditions, which was not followed in this case.
Failure to Notify Physician and POA of Resident's Diabetic Ulcer
Penalty
Summary
The facility failed to notify the physician and the Power of Attorney (POA) of a resident's change in condition, specifically regarding diabetic ulcers on the resident's right great toe. The resident, who has Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure, was found to have a black sore on the right great toe during a shower on 5/21/24. This was documented by a CNA and reported to the Charge Nurse, who applied ointment and a bandage. However, there were no progress notes indicating that the physician or POA were informed of this change in the resident's skin condition on that date. Further investigation revealed that the Director of Nurses and the Wound Nurse were unaware of the shower sheet or progress note about the resident's toe. The Wound Weekly Evaluation form documented the wound on 6/10/24, with clinician notification on the same day and family notification on 6/12/24, indicating a delay in communication. The facility's policy requires monthly skin checks and immediate notification of medical practitioners and resident representatives for any newly identified issues, which was not adhered to in this case.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
