Cisne Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cisne, Illinois.
- Location
- 107 North Watkins Street, Cisne, Illinois 62823
- CMS Provider Number
- 146131
- Inspections on file
- 26
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cisne Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
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.
A resident with extensive traumatic injuries and chronic pain was admitted on scheduled and PRN Percocet and PRN ibuprofen, but only ibuprofen was administered, and it was documented as ineffective. The hospital did not send written narcotic prescriptions, and the DON focused on obtaining those scripts and gave ibuprofen while the resident continued to complain of pain and inability to sleep. Although the pharmacy and facility policy allowed access to Percocet from the electronic stat kit with a provider order and access code, no timely provider order was obtained to use the emergency kit, and no Percocet was given before the resident called 911 and went to the ED for pain management and opioid withdrawal symptoms.
A resident with multiple comorbidities and moderately impaired cognition sustained a right forearm skin tear when his arm became caught between bathroom rails. An RN cleansed the wound with normal saline, applied steri-strips, and notified the NP, who agreed the treatment was appropriate, but no provider order for the dressing or for daily monitoring until healed was entered into the EHR. Review of physician orders and the TAR showed no treatment or monitoring orders and no documentation of ongoing wound care, despite facility policy and the DON’s expectations that new wounds prompt provider orders and documented monitoring.
The facility did not have a licensed administrator in compliance with state law, as the acting administrator's temporary license had expired and there was no documentation of a valid extension or recent exam attempt. The AIT present did not hold a temporary license, and no other active administrator license was identified, affecting all 19 residents.
A resident experienced a fall in the bathroom, resulting in a head scratch. The DON documented that the day shift nurse would notify the POA due to the non-emergent nature of the situation, but the notification was not made. The DON communicated the incident to an RN during the shift report, indicating that she would complete the paperwork and notify the POA. However, the notification was not done, and the facility's policy requiring prompt notification was not followed.
A resident's Hydrocodone medication was mishandled due to inadequate procedures and documentation at the facility. Despite having a prescription, the medication was unaccounted for, and staff were unclear about its administration. The investigation suggested the medication was accidentally discarded, revealing lapses in controlled substance management.
A resident's Hydrocodone was found missing during a narcotic count, but the facility delayed reporting the potential misappropriation. The DON, who was off due to COVID-19, forgot about the issue upon returning to work, leading to a late report to authorities. The facility's policy requires immediate reporting of such incidents, which was not followed in this case.
A facility failed to promptly investigate missing controlled substances for a resident with chronic pain. Despite a nurse discovering a potential diversion during a narcotic count, the investigation was delayed due to the Director of Nursing being out with COVID. The facility's policy mandates immediate investigation of such incidents, which was not followed.
The facility failed to properly account for and document the administration of controlled substances for two residents. One resident, with multiple health issues, had discrepancies in the documentation and administration of Hydrocodone, with staff unaware of the medication's status. Another resident, with a fracture, had missing records for Hydrocodone delivery. The facility's policies on controlled substance management were not followed, leading to a significant deficiency in pharmaceutical services.
A resident received extra doses of Clonazepam due to a transition from paper to electronic medication records, leading to altered administration times. The nurse responsible administered the medication based on memory, not the updated eMAR, resulting in multiple additional doses. Despite the error, the resident showed no adverse effects.
The facility failed to store chemical products properly and did not implement person-centered fall interventions after a fall incident for two dementia care residents. One resident ingested an odor eliminator, resulting in nausea and vomiting, while another resident's care plan was not updated following a fall.
The facility failed to maintain a clean and sanitary ice machine, with black substance and hard water buildup observed. The Dietary Manager and Maintenance staff could not confirm the last cleaning date, and the cleaning procedures were not adequately followed.
The facility failed to maintain a safe, clean, and comfortable environment for its residents, with multiple areas of disrepair and uncleanliness observed. Residents and a family member confirmed their expectations for better maintenance, and the maintenance staff acknowledged the need for repairs but cited a lack of materials, funding, and time as reasons for delays.
A facility failed to develop a person-centered comprehensive care plan for a resident with multiple diagnoses, including being underweight. The care plan lacked specific details about the resident's nutritional needs and gastrointestinal tube feedings, which were critical for the resident's care. The MDS/Care Plan Nurse admitted to rushing and not completing the care plan properly.
The facility failed to timely update the care plan for a resident with multiple diagnoses, including Diabetes and Dementia, who had wounds on the left toes and heel. Despite physician's orders for specific treatments, the care plan had not been revised to reflect these wounds and their treatments.
The facility failed to follow its policy for enhanced barrier precautions for three residents requiring infection control measures. One resident with MRSA was not properly isolated, and housekeeping staff did not wear appropriate PPE. Additionally, two residents with wounds were not placed on enhanced barrier precautions as required by the facility's policy.
The facility failed to ensure that quarterly assessments were completed timely for six residents, with delays in completing and transmitting the Minimum Data Set (MDS) assessments. The residents had various medical conditions, including hypertension, Alzheimer's, diabetes, and more, but their assessments were not updated by the required due dates.
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 Follow Stat Kit Policy for Emergency Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for obtaining emergency controlled medications from the electronic first-dose (stat) kit, resulting in a newly admitted resident not receiving ordered narcotic pain medication. The resident was admitted with multiple traumatic injuries, including fractures of the thoracic vertebrae, ribs, pelvis, sacrum, and left humerus, as well as traumatic pneumothorax, bilateral lung contusions, liver and spleen lacerations, and hemoperitoneum. Hospital discharge documentation listed outpatient and after-visit medications that included scheduled Percocet 5-325 mg three times daily and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s admission orders reflected ibuprofen 800 mg every 8 hours PRN and Percocet 5-325 mg every 8 hours PRN for pain, but there was no documentation of Percocet being administered after admission. On the evening and night following admission, the DON documented that the resident complained of pain and was given ibuprofen 800 mg around 11:06 p.m., which was recorded as ineffective in controlling the resident’s pain. The DON also documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication and that the pharmacy reported it had not received those prescriptions. The DON contacted the hospital regarding the missing prescriptions and was awaiting a call back. The DON noted that the resident was informed that the narcotic prescriptions had not been received and that only ibuprofen could be given at that time. The resident remained awake, complained of pain and inability to sleep, and later called 911 requesting transport to the hospital. The facility’s pharmacist later confirmed that the facility contacted the after-hours pharmacy service and was informed that, with a written prescription, Percocet could be sent STAT from a local pharmacy and that the correct dose of Percocet was available in the emergency kit, which also required an order to access. The facility’s Stat Safe Policy and Procedure stated that if a controlled substance is needed, facility staff should contact the pharmacy/after-hours service to retrieve an access code to remove doses from the electronic first-dose kit. The DON stated she was not aware that obtaining a verbal order from a provider to access the emergency kit was an option and acknowledged she did not contact a provider when she first realized the resident had arrived without narcotic prescriptions, citing that there was a lot going on that night. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access the emergency kit or ordered transfer to the ER. During the subsequent ER visit, the resident reported that no pain medication had been administered between arrival at the facility and arrival at the ER, and the ER documentation noted the resident presented for pain management and opioid withdrawal symptoms and was given Percocet 5-325 mg. The sequence of events shows that despite having a policy and an emergency kit process in place for controlled substances, the facility did not obtain the necessary order or access code to retrieve Percocet from the emergency kit for this resident. The DON relied solely on ibuprofen, which was documented as ineffective, and on attempts to obtain written prescriptions from the hospital, without promptly escalating to a provider for a verbal order to access the emergency kit as allowed by policy and pharmacy procedure. The pharmacist later clarified that an emergency verbal order from a provider would have allowed the facility to obtain a code to access the emergency kit for the resident’s pain medication. This failure to follow the Stat Safe Policy and Procedure and to secure timely access to ordered controlled pain medication for the resident with significant traumatic injuries formed the basis of the cited deficiency in pharmaceutical services.
Failure to Obtain and Document Provider Orders for Skin Tear Treatment and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a provider’s order for treatment and ongoing monitoring of a skin tear. A male resident with diagnoses including end stage renal disease, type II diabetes, and epilepsy, and a BIMS score of 11 indicating moderately impaired cognition, was admitted with a care plan identifying risk for impaired skin integrity. A skin issue risk assessment documented that the resident sustained a skin tear to the right forearm when his arm became caught between two bathroom rails near the toilet. The RN cleansed the wound with normal saline and applied three steri-strips, and documented that the NP was notified, but there was no documentation of any provider order for the treatment or for monitoring the wound until healed. Review of the resident’s discontinued and current physician orders and the TAR for the relevant month showed no orders for treatment or daily monitoring of the right forearm skin tear and no documentation that treatments or monitoring were performed. On interview, the resident did not recall how the injury occurred, and the wound appeared to be healing without signs of infection. The RN stated she notified the POA, NP, and administration, and that the NP indicated the treatment she provided was appropriate, but she did not document any order or obtain an order for ongoing monitoring, believing it was a one-time, common-sense dressing. The NP confirmed she had been contacted and agreed the initial treatment was appropriate, but stated the treatment and daily monitoring should have been entered as provider orders in the electronic health record. The DON stated her expectation that such orders be documented and placed on the TAR for daily reminders, and the facility’s skin policy required notifying the healthcare provider for further treatment orders when a new wound is identified.
Failure to Maintain Licensed Administrator in Accordance with State Law
Penalty
Summary
The facility failed to ensure that a licensed administrator, in accordance with state law, was present and operating the facility. Review of records and interviews revealed that the individual serving as administrator held only a temporary license, which had expired. The administrator was unavailable for interview due to hospitalization, and there was no documentation provided to confirm recent attempts to take the licensing exam or to show that an extension for the temporary license had been filed or approved. The Administrator in Training (AIT) had only been at the facility for a few weeks and did not possess a temporary administrator license. The Regional Director of Operations confirmed that the administrator had applied for a licensure extension, but no documentation was available to verify this or to show that the extension was granted. At the time of the survey, there was no evidence of any other active administrator license connected to the facility. The facility's resident matrix indicated that 19 residents were residing in the facility during this period.
Failure to Notify Resident's Representative of Fall Incident
Penalty
Summary
The facility failed to promptly notify the resident's representative of a fall incident involving a resident. The resident, who was admitted with multiple diagnoses including osteomyelitis, dementia, and heart failure, experienced a fall in the bathroom, resulting in a head scratch that bled. The incident occurred early in the morning, and the Director of Nursing (V2) documented that the day shift nurse would notify the Power of Attorney (POA) due to the non-emergent nature of the situation. However, the notification was not made, and the responsible party was not informed of the fall. The Director of Nursing (V2) communicated the incident to the Registered Nurse (V3) during the shift report, indicating that V2 would complete the necessary paperwork and notify the POA. V2 later texted V3, apologizing for not making the notification. V3 assumed V2 would handle the notification, but it was not done. V2 later informed the facility administrator (V1) about the oversight, and V2 claimed to have informed the family during a visit, although this was not documented. The facility's policy requires the charge nurse to notify the attending physician and responsible parties promptly, which was not adhered to in this case.
Failure to Safeguard Controlled Substances
Penalty
Summary
The facility failed to protect and safeguard controlled substances for a resident, identified as R1, who was cognitively intact and had a prescription for Hydrocodone to manage chronic pain. The Controlled Drug Administration Record indicated that 24 Hydrocodone tablets were received, but discrepancies arose when the facility could not produce records for subsequent deliveries. Additionally, the Medication Administration Record showed no doses were given on certain dates, despite the presence of the medication. During a narcotic count, it was discovered that R1's Hydrocodone was missing, and no documentation of its destruction or discontinuation was found. Staff interviews revealed confusion and lack of clarity regarding the presence and administration of the medication. Several nurses stated they had not administered the medication to R1, who reportedly did not complain of pain. The Director of Nursing, who was absent due to illness, later found the narcotic sheet misplaced, indicating a lack of proper documentation and oversight. The investigation revealed that the facility's procedures for handling controlled substances were inadequate, leading to the misplacement and potential misappropriation of R1's medication. The facility's incident report concluded that the medication was likely accidentally discarded due to disorganization and lack of attention, highlighting significant lapses in the management and documentation of controlled substances.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property within the required time frames for one resident. The resident, who had a history of osteomyelitis, orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension, had an order for Hydrocodone for chronic pain. A registered nurse discovered that the slot for the resident's Hydrocodone was empty during a narcotic count, despite the medication not being discontinued or destroyed. The nurse notified the administrator and the Director of Nursing (DON) about the potential diversion. The DON was off work due to COVID-19 and did not immediately act on the information about the missing narcotic sheet, which was found folded under supplies in the medication cart. Upon returning to work, the DON forgot about the potential diversion due to other pressing issues. The administrator and DON began investigating the issue only after both returned to work, which led to a delay in reporting the incident to the appropriate authorities. The facility's policy requires immediate reporting of any suspected misappropriation of resident property to the administrator and other officials within 24 hours. However, the report to the Illinois Department of Public Health, police, physician, and Power of Attorney was not made until several days after the initial discovery of the missing medication. This delay in reporting constitutes a failure to adhere to the facility's abuse prevention program and state regulations.
Delayed Investigation of Missing Controlled Substances
Penalty
Summary
The facility failed to timely initiate an investigation into an allegation of missing controlled substances for a resident. The resident, who was cognitively intact, had an order for Hydrocodone for chronic pain. The Controlled Drug Administration Record indicated that 24 Hydrocodone tablets were received, but discrepancies were noted in the Medication Administration Record, which showed no doses given on specific dates despite records indicating otherwise. A Registered Nurse discovered the potential diversion during a narcotic count and reported it to the Administrator, but the investigation was delayed. The Director of Nursing was notified of a narcotic sheet found in the medication cart but did not begin investigating until several days later due to being out with COVID. The Administrator was informed of the potential drug diversion and, along with the Director of Nursing, began investigating the issue days after the initial report. The facility's policy requires immediate investigation upon learning of potential misappropriation of resident property, which was not adhered to in this case.
Deficiency in Controlled Substance Management
Penalty
Summary
The facility failed to properly account for, maintain records of, and document the administration of controlled substances for two residents, R1 and R3. R1 was admitted with multiple diagnoses including osteomyelitis, dementia, and chronic pain, and had an order for Hydrocodone as needed. However, there were discrepancies in the documentation and administration of this medication. The Controlled Drug Administration Record showed that 24 Hydrocodone tablets were received, but there was no documentation of administration on certain dates, and the narcotic count was inconsistent. Staff interviews revealed confusion and lack of clarity regarding the presence and administration of the medication, with some staff unaware of the medication's status or location. R3, who was admitted with a fracture and other health issues, also had an order for Hydrocodone. Although R3 reported a decrease in the need for pain medication, the facility failed to maintain accurate records of the controlled substances. A delivery slip indicated that 30 Hydrocodone tablets were delivered, but the corresponding controlled drug count sheet was missing. The facility's policies require a physical inventory of controlled substances at each shift change and proper documentation, which was not adhered to in this case. The Director of Nursing acknowledged the expectation for staff to accurately count and document narcotics, but the facility was unable to produce the necessary records for both residents. The lack of proper documentation and accountability for controlled substances indicates a significant deficiency in the facility's pharmaceutical services, as they failed to ensure the safe and accurate administration of medications to meet the needs of the residents.
Medication Administration Error Due to eMAR Transition
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically involving a resident with a history of dementia, hypertension, and anxiety disorders. The resident was prescribed Clonazepam to be administered twice daily, but due to a transition from paper to electronic medication administration records (eMAR), the administration times were altered. This led to the resident receiving additional doses of Clonazepam on multiple occasions, as the nurse administering the medication did not adhere to the updated eMAR schedule. The error was discovered when a registered nurse noticed discrepancies in the medication administration and reported it to the Director of Nursing and the Administrator. The nurse responsible for the error admitted to administering the medication based on memory rather than consulting the eMAR, resulting in the resident receiving extra doses. Despite the error, the resident did not exhibit any adverse effects from the additional medication. The Director of Nursing initiated an investigation into the medication error and attempted to notify the resident's power of attorney and the nurse practitioner. The investigation confirmed that the error was due to the nurse's failure to follow the updated eMAR, which had changed the administration times for Clonazepam. The facility's medication administration policy requires medications to be administered safely and documented as required, which was not adhered to in this case.
Failure to Store Chemicals Properly and Update Care Plans
Penalty
Summary
The facility failed to ensure chemical products were stored according to current standards of practice and did not implement person-centered fall interventions after a fall incident for two dementia care residents. One resident, a female with early-onset Alzheimer's Dementia, ingested an odor eliminator that was improperly stored in her room. This resulted in the resident experiencing nausea and vomiting. The Director of Nursing confirmed that the product should not have been accessible to the resident and that all resident rooms were subsequently checked for hazardous liquids. The product is no longer used by the facility. Another resident, an elderly individual with multiple diagnoses including dementia, experienced a fall in the bathroom. The care plan for this resident did not include updated, person-centered fall interventions following the incident. The Minimum Data Set/Care Plan Nurse admitted to rushing and forgetting to update the care plan. The facility's policy requires comprehensive assessment and periodic reassessment to develop a person-centered comprehensive plan of care, which was not followed in this case. Both incidents highlight the facility's failure to adhere to safety protocols and ensure proper documentation and implementation of care plans. The lack of proper storage of hazardous materials and the failure to update care plans after significant events contributed to the deficiencies observed by the surveyors.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary ice machine, which has the potential to affect all 20 residents residing in the facility. During an initial tour of the kitchen, surveyors observed a black substance on the inside flap of the ice machine and a white hard water buildup along the hinges and edges of the lid. The Dietary Manager stated that the maintenance man cleans the ice machine once a month but could not confirm the last cleaning date due to the absence of a 2024 monthly cleaning log. The Maintenance staff confirmed that he had cleaned the machine in April but acknowledged difficulties in thoroughly cleaning certain parts of the machine and mentioned the need for pressure washing. The facility's Ice Machine Cleaning and Sanitizing Procedures policy requires thorough cleaning and sanitizing of all interior surfaces, which was not adequately followed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. Observations revealed multiple areas of disrepair and uncleanliness, including peeling carpet, chipped paint, and discolored floor tiles in various parts of the facility such as hallways, communal bathrooms, the nurses' station, and the dining room. Specific issues included missing baseboards exposing a black/brown substance, bowing wall tiles, and missing blind slats in a resident's room. Interviews with residents and a family member confirmed their expectations for a well-maintained facility, and the maintenance staff acknowledged the need for repairs but cited a lack of materials, funding, and time as reasons for the delays in addressing these issues. The Director of Nursing confirmed that multiple residents could potentially use the communal bathroom that was found to be in disrepair, except for one resident who only receives bed baths. The facility's policy emphasizes the importance of maintaining a safe, clean, and organized environment to provide the best care and comfort for residents. Despite this policy, the facility's physical environment was found to be lacking, affecting the quality of life and care for the residents. The facility's application for Medicare and Medicaid documented that 20 residents reside in the facility.
Failure to Develop Person-Centered Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident (R18) who was admitted with multiple diagnoses including Odynophagia, Diabetes Mellitus Type II, Chronic Pancreatitis, Superior Mesenteric Artery Syndrome, Distal Esophageal ulceration with possible Barrett's, and microcytic anemia. The resident's care plan did not specify the reason for the nutritional problem focus area, which was due to the resident being underweight. Additionally, the care plan lacked information regarding the resident's gastrointestinal tube and the feedings ordered as needed according to meal intake. The care plan also did not document the most recent information indicating that the resident was no longer using enteral feedings as of 04/11/24. This oversight was acknowledged by the MDS/Care Plan Nurse, who admitted to rushing and forgetting to complete the care plan properly. The resident's nutritional status was critical, with a BMI of 16.7 indicating underweight, and the Registered Dietitian had recommended additional nutritional interventions. However, these recommendations were not reflected in the care plan. The facility's Comprehensive Care Planning policy mandates a thorough assessment and periodic reassessment to develop a person-centered care plan, but this was not adhered to in the case of R18. The care plan was incomplete and did not address the resident's specific needs, leading to a deficiency in providing appropriate care.
Failure to Update Care Plan for Resident with Wounds
Penalty
Summary
The facility failed to add identified problem areas and to revise care plans timely for one resident reviewed for care plan timing and revision. The resident, who was admitted with multiple diagnoses including Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia, was observed to have a betadine treatment applied to the left toes and a pressure wound to the left heel. Despite these observations and the physician's orders for specific treatments, the resident's care plan had not been updated to reflect these wounds and their treatments. The care plan, which was initiated on 06/02/2022, had not been revised to include the wounds to the left great toe and left heel, nor did it document the current treatment orders or any person-centered interventions for pressure ulcer care. The MDS/Care Plan Nurse admitted to rushing and forgetting to complete the care plans. The facility's Comprehensive Care Planning policy mandates that care plans be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychosocial needs, but this was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its policy and procedure for enhanced barrier precautions for three residents (R2, R12, and R18) who required infection control measures. During an initial tour, no isolation rooms were observed, and the Resident Matrix did not indicate any residents on transmission-based precautions. R18, who had MRSA in his gastrointestinal tube site, was not properly isolated, and housekeeping staff did not wear appropriate PPE while in his room. The Director of Nursing acknowledged that enhanced barrier precautions had not been implemented and that R18 should have been on precautions earlier. Additionally, R2, who had a venous wound, and R12, who had wounds on her left foot and toe, were not placed on enhanced barrier precautions as required by the facility's policy. The Enhanced Barrier Precautions policy, dated 7/13/23, mandates the use of gown and gloves during high-contact resident care activities for residents with open wounds, indwelling medical devices, or MDRO infections. Despite this, the facility did not implement these precautions for R2, R12, and R18. The Director of Nursing admitted that the facility had only discussed enhanced barrier precautions but had not yet put them into practice. This lack of adherence to infection control protocols led to the observed deficiencies in the care of these residents.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly assessments were completed timely for six residents. Specifically, the quarterly Minimum Data Set (MDS) assessments for residents R5, R10, R12, R13, R14, and R15 were not completed and transmitted by their respective target due dates. For instance, R5's quarterly MDS, which had a target due date of 2/18/24, was not completed and transmitted until 4/24/24. Similarly, R15's quarterly MDS, due on 3/20/24, was not completed and transmitted until 4/28/24. These delays were confirmed by V6, the Care Plan Coordinator/MDS, and documented in MDS validation reports provided on 5/2/24. The report details the specific medical conditions of each resident, such as hypertension, Alzheimer's, diabetes, renal insufficiency, hyperlipidemia, coronary artery disease, peripheral vascular disease, osteopathic conditions, alcohol abuse, seizures, adjustment disorder, and mild cognitive impairment. Despite these conditions, the facility did not adhere to the required timelines for updating the residents' assessments, leading to a deficiency in maintaining timely and accurate records. This lapse in timely assessment could potentially impact the quality of care provided to these residents.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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