Doctors Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Illinois.
- Location
- 1201 Hawthorn Road, Salem, Illinois 62881
- CMS Provider Number
- 145247
- Inspections on file
- 42
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Doctors Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide sufficient night staffing to meet residents’ toileting and incontinence care needs in a timely manner. Two residents who were dependent on staff for toilet hygiene, one with moderate cognitive impairment and one cognitively intact, reported prolonged waits for call light responses and having to sit in urine or feces. CNAs and an LPN described typical call light response times of 15–30 minutes or longer, noted that at least a dozen residents required two-person assistance, and stated that three CNAs on a 12‑hour night shift were not enough. Staffing schedules showed that during part of the night there was only one nurse on duty, who was responsible for meds, treatments, and answering call lights while CNAs performed bed checks, resulting in some residents waiting longer. The DON acknowledged that staffing was adequate for census but not for resident acuity and that when staff were occupied with two-person care or bed checks, call lights could not be answered promptly.
The facility failed to answer call lights in a timely manner for two residents who were dependent on staff for toilet hygiene and incontinence care. One resident with heart failure, physical disability, diabetes, and moderate cognitive deficit, and another resident with heart failure, anemia, CKD, and overactive bladder, both reported or were observed to wait extended periods in urine or feces despite care plans requiring staff assistance to remain dry and clean. Family members described waits of 45 minutes to two hours after call lights were activated before staff provided incontinence care. CNAs and nurses reported that call light response times often ranged from 15–30 minutes or longer, especially at night, citing limited staffing, multiple residents needing two-person assistance, and competing duties such as bed checks, medication passes, and treatments. The facility’s own policy required call lights to be answered as soon as possible, but staff and leadership acknowledged that residents sometimes had to wait when they were busy or when staffing did not match resident acuity.
The facility failed to maintain comfortable hot water temperatures in a shower room used by three dependent residents, including individuals with heart failure, diabetes, hemiplegia, blindness, and severe cognitive impairment. A family member reported that the shower water on the hall was cold, and a CNA stated she had to let the shower run 5–10 minutes before it warmed, despite having recently provided showers there. During the survey, the DON accompanied the surveyor as water temperatures in that shower room were measured at approximately 96–99°F, below the facility’s policy requirement of at least 100°F at resident shower outlets. The Maintenance Director acknowledged this was the first time he was informed of the low temperatures, while facility policy specified a target range of 100–110°F for resident-use hot water.
A deficiency occurred when narcotic medications prescribed for three residents with chronic pain were misappropriated and diverted. During a narcotic count, staff discovered a missing card of controlled medication, which was later found in the wrong section of the med cart with labels switched and the narcotics replaced by other drugs such as metoprolol and potassium. One resident with severe cognitive impairment and chronic pain had ordered oxycodone that was documented as given and effective, but the associated card actually contained metoprolol. Two cognitively intact residents with extensive pain-related diagnoses had hydrocodone orders documented as administered and effective, yet their narcotic cards had been tampered with and the hydrocodone/acetaminophen replaced with potassium, resulting in 120 missing narcotic doses. An RN was suspected of drug diversion after failing to cooperate with the investigation and drug testing, and police were informed of the tampering and suspected offender.
Two residents who were dependent on staff for toilet hygiene and had urinary and/or bowel incontinence reported, and family members corroborated, prolonged waits for incontinence care and call light response, including sitting in urine or remaining soiled with feces for extended periods. Staff interviews described frequent delays of 15–30 minutes or longer in answering call lights, especially on the night shift, due to limited CNA and nurse coverage and the need to prioritize bed checks and residents requiring two‑person assistance. The DON acknowledged staffing was sufficient for census but not for resident acuity, while the facility’s toileting policy required two‑hour checks, incontinence changes, and prompt call light response, which were not consistently carried out.
A resident with urinary incontinence and a history including UTIs had a physician order for a one-time UA and urine culture, but staff were unable to obtain the specimen during initial attempts via straight cath and assisted voiding. After these unsuccessful efforts, there was no documented follow-up for several days, and the urine sample was not collected until four days after the order, despite the facility’s policy that cultures be obtained as soon as practical. A family member reported that the facility still had not obtained the specimen several days after the order and that he ultimately assisted the resident to provide urine for the facility. The DON and an RN acknowledged awareness of the order and the delay, and the UA and culture results later showed abnormal findings, including significant bacterial growth.
A resident with dysphagia, moderate cognitive deficit, and orders for nectar-thick liquids and medications to be crushed did not consistently receive medications in crushed form as ordered. Family members reported that nursing staff, including the DON, attempted to administer whole pills with thin or regular water instead of crushing them in applesauce and using thickened liquids. One incident involved a small pill given whole that remained in the resident’s mouth for about an hour before being spit out. Staff interviews confirmed the resident’s medications were supposed to be crushed in applesauce, and the care plan lacked a problem area for medication administration, while the facility could not provide a policy addressing this practice.
The facility failed to provide sufficient CNA staffing on the 100 hall to meet residents’ needs in a timely manner. A family member and two residents reported that call lights, particularly in the evening and on weekends, were not answered promptly, requiring the family member to walk the halls to locate staff. A CNA described working alone on the 100 hall from early morning, delaying bed checks and allowing her to complete care only for residents needing one-person assistance while residents requiring two-person assistance waited until additional staff arrived. A respiratory therapist confirmed that CNAs perform repositioning every 2 hours, that help is only provided by respiratory therapy as needed, and that having two CNAs on the 100 hall occurs only if they are “lucky,” even though most residents there are dependent on staff. The regional clinical leader stated that staffing assignments are based on public health guidelines and resident needs.
Inadequate Hot Water for Resident Care Areas: Residents on the 200 and 300 halls reported that sinks and shower water were not hot enough for bathing and personal care, with one resident describing freezing cold water during CNA care. Surveyors measured multiple outlets and found water temperatures ranging from 80 to 95 degrees F, below the facility policy requiring at least 100 degrees F at each hot water outlet. The Maintenance Director stated the building was served by 3 water heaters and that routine temperature checks had not been done for quite some time.
Expired meds and supplies, along with unlabeled and improperly dated meds, were found in med storage and med carts. Staff found expired swabs, collection tubes, insulin, nebulizer solutions, a suppository, a syringe, and a needle, plus open eye drops, insulin pens, and insulin bottles without resident ID or open dates. An ADON stated she did not know who one item belonged to, acknowledged expired syringes and needles should be discarded, and said insulin pens and vials should be dated when opened.
The facility failed to complete restraint assessments for two residents who were using hand mitts. Both residents had significant cognitive impairment, were dependent on a respirator, and had physician orders for mitts to prevent pulling at medical devices. Care plans identified physical restraints and called for assessment and documentation of the need for the restraint, but no restraint assessments were found in either record. Staff interviews showed uncertainty about the assessment frequency, and administration could not locate the required restraint documentation.
Unnecessary PRN psychotropic medication use. A resident with anxiety disorder and depression had a PRN lorazepam order via GT with no end date, no behaviors documented on the behavior log, and repeated administrations over the prior 3 months. The record did not include documentation supporting extension of the PRN order beyond 14 days, and the RDCS acknowledged PRN meds need an end date.
Failure to provide ordered splinting for limited ROM. A resident with Parkinsonism, a right-hand contracture, and dependence for multiple ADLs was documented as needing a right-hand splint, but the chart lacked a current order and staff were unclear about its use. The resident was repeatedly observed without the splint, staff reported he never wore it or refused it, and the resident said he thought it had been discontinued. Therapy later found the splint in the room, while nursing leadership stated refusals were not documented and staff were not aware of the splint requirement.
Meals were not consistently served at a palatable temperature, with two residents reporting that evening meals were often cold and that they frequently ate them without reheating. Another resident said family often brought food at dinner so he would not have to eat cold food. Resident council discussions reportedly included repeated complaints about cold food, but the minutes and grievance log did not document these concerns, and an Activities staff member confirmed that residents had recently requested reheating because the food was too cold.
An LPN/ADON failed to disinfect a blood glucose machine for the full required minute between uses for three residents who each had orders for blood glucose checks before sliding scale lispro insulin. The machine was wiped for only 20 to 25 seconds after each fingerstick, despite the facility policy requiring durable medical equipment to remain wet for one minute between resident uses. The DON stated it was expected that staff follow the policy for proper disinfection.
The facility failed to maintain adequate nursing and CNA staffing to meet residents’ assessed care needs in a timely manner. Several residents who were cognitively intact or moderately impaired, and who required substantial assistance with ADLs, toileting, and turning/repositioning, reported long waits for call light responses, delays in receiving help with dressing and toileting, and episodes of incontinence while waiting for staff. A ventilator- and trach-dependent resident described having only one CNA on a high-acuity hall at times and waiting over an hour for repositioning. Multiple CNAs and an RN reported working halls alone, being unable to complete all required care such as q2h turning and incontinence care, experiencing frequent uncovered call-ins, and having call light response times of 15 minutes or more. The DON and a physician acknowledged that the facility did not have enough nurses or CNAs, that staff were rushed and sometimes delayed in assessing residents, and that overnight staffing could be as low as one nurse, one respiratory therapist, and two CNAs for the building, contrary to the facility’s own policy to maintain adequate staffing on each shift.
Surveyors found that the facility failed to follow physician and wound clinic orders for antibiotics and wound care for two residents, including one with extensive bilateral lower extremity venous ulcers and a history of MRSA and pseudomonas infections. IV vancomycin orders were altered due to lack of RN coverage, multiple antibiotic orders (including levofloxacin, Cipro, Bumex, and Invanz) were never entered on the MAR or POS or were not administered, and wound care orders requiring Dakins solution, Vashe, exufiber, kerlix, and ACE wraps were frequently not carried out due to supply unavailability. Staff documented worsening redness, purulent and green drainage, severe pain, heavy weeping through dressings, and episodes of dizziness, hypotension, and SOB, while CNAs observed dressings left on for prolonged periods with drainage seeping through. Another resident with CHF did not receive ordered labs and medications, resulting in exacerbation of CHF and respiratory failure. These failures to implement and monitor ordered treatments resulted in worsening infections, sepsis, hospitalization, and death, and were cited at the Immediate Jeopardy level.
A resident with multiple comorbidities and two stage 4 pressure ulcers was on contact/enhanced barrier precautions for MRSA, ESBL, and CRE, with orders for daily and PRN dressing changes to sacral, vulvar, and buttock wounds. Surveyors observed an RN and assisting staff perform wound care wearing only gloves despite isolation signage requiring gown and glove use. The sacral and buttock dressings were soiled with blood and green drainage, one was dated two days earlier, and there was no dressing on the vulvar wound. The RN admitted the dressings had not been changed the prior day due to lack of time rather than resident refusal and also acknowledged using another resident’s Silvadene cream when the ordered cream for this resident could not be found, contrary to facility medication policies.
A resident with multiple chronic conditions and intact cognition reported verbal abuse by a CNA, but the facility's investigation was incomplete. The administrator failed to document all staff interviews, allowed anonymous responses, and did not ensure all relevant staff were questioned, contrary to facility policy requiring full documentation and participation in abuse investigations.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
The facility did not maintain the required temperature in the dietary dry storage area, with the area reaching 90.6°F due to a non-functioning HVAC unit. Staff confirmed the issue had persisted for over a year, and the HVAC company would not provide service until a previous bill was paid. Facility policy requires dry storage areas to remain below 70°F to ensure safe food storage. This deficiency had the potential to affect all 58 residents in the facility.
The facility did not address critical maintenance issues, including non-functioning HVAC and call light systems, due to lack of corporate response and unpaid vendor bills. Despite repeated requests from the administrator and maintenance director, necessary repairs and equipment were not provided, impacting the safety and wellbeing of all residents.
Three residents with significant medical and cognitive needs were left without a functioning call light system in their shared room, relying instead on hand bells that could not be heard over loud industrial fans. Staff and a family member confirmed the call lights had been nonfunctional for extended periods, and the maintenance director reported that repairs were delayed due to unpaid bills with the service company.
The facility failed to implement Enhanced Barrier Precautions (EBP) and Standard Precautions for several residents with indwelling catheters and wounds. Observations revealed missing EBP signage and lack of accessible PPE. Staff performed care without donning gowns, despite acknowledging the need for EBP. This indicates a failure to adhere to infection prevention policies, potentially increasing infection transmission risk.
The facility failed to maintain comfortable temperatures for residents, with heating units not functioning properly, leading to residents using multiple blankets and wearing coats indoors. Additionally, water-damaged ceiling tiles were observed throughout the facility, with no mold testing conducted, raising concerns about potential respiratory risks. The facility's maintenance logs lacked specific temperature documentation, and the administrator was unaware of the extent of the heating issues.
The facility failed to follow menu and diet orders for six residents due to a shortage of breakfast items. The cook did not provide substitutes, and the dietician was unaware of the shortage. The facility's policy requires menu adherence and review of changes with a dietician, which was not followed.
The facility failed to provide adequate hydration to 18 residents, as observed during a survey. Several residents were found without water pitchers or any fluids in their rooms, and some reported only receiving drinks with meal trays. The facility's policy requires routine offering of fluids, but staff interviews revealed inconsistencies in its implementation.
The facility failed to maintain its air conditioning systems, leading to uncomfortable temperatures for all residents. Staff and residents reported that the facility had been very warm, with some rooms cooler than others. The maintenance director confirmed that the air conditioning units were frozen and leaking, and the facility was relying on portable air conditioners and fans. Despite no negative health outcomes, residents expressed discomfort, particularly on days with high outside temperatures. The facility's policies on extreme weather were not effectively implemented, and repairs were delayed due to unavailable Freon.
Insufficient Night Staffing Leading to Delayed Call Light and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to respond to call lights and incontinence care needs in a timely manner. The facility census was 50 residents, with documentation that multiple residents required assistance with toileting and incontinence care, including two residents who were dependent on staff for toilet hygiene. One resident with heart failure, age-related physical disability, diabetes, and a moderate cognitive deficit (BIMS score 11) was care planned as incontinent of bowel and bladder and requiring staff assistance to remain dry and clean, including the use of briefs and pads. A family member reported that in the evenings it took longer for staff to respond to call lights and that this resident had to sit in feces and urine for up to two hours. Another resident with heart failure, anemia, chronic kidney disease, and overactive bladder, who was cognitively intact (BIMS score 15) and dependent on staff for toilet hygiene, was care planned as occasionally incontinent of urine and at risk for bladder and bowel incontinence, requiring assistance to remain dry and clean and to maintain briefs and incontinence supplies. This resident reported that it sometimes took an hour or more for staff to answer call lights and that she had to sit in urine when responses were delayed. Multiple CNAs stated that call light response times could range from 15 to 30 minutes, and one CNA reported that three CNAs on the 12‑hour night shift were not enough to meet residents’ needs timely, especially given that at least 12 residents required the assistance of two staff for incontinence care. Staff interviews and schedule reviews showed that night staffing patterns contributed to delayed responses. CNAs reported that when they were performing bed checks, call lights had to wait. An LPN stated that on the 12‑hour night shift there were three CNAs and two nurses, but from 3 AM to 5 AM she was the only nurse, responsible for passing medications, doing treatments, and answering call lights when able, while CNAs conducted bed checks and prioritized which call lights to answer. She acknowledged that some residents might have to wait longer, particularly if they had used their call light frequently and staff believed they had already been cared for. An RN stated she had concerns about timely call light response at night because staffing was not adequate. The DON stated they had enough staff for the census but not for resident acuity, acknowledged that residents requiring two‑person assistance caused others to wait, and confirmed that when staff were busy with bed checks they could not answer call lights. The administrator stated they followed state staffing guidelines and confirmed that from 3 AM to 6 AM there were three CNAs and one nurse on duty.
Failure to Answer Call Lights Timely Resulting in Prolonged Incontinence
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignity and timely response to call lights, resulting in prolonged periods in soiled briefs for two residents who were dependent on staff for toileting and incontinence care. Resident 1 (R1), admitted with heart failure, age-related physical disability, and diabetes, had a care plan indicating urinary and bowel incontinence and the need for staff assistance to remain dry and clean. R1’s MDS documented a moderate cognitive deficit and dependence on staff for toilet hygiene. Family members reported that in the evenings it took longer for staff to respond to call lights and that R1 had to sit in feces and urine for up to two hours. One family member stated she arrived on an occasion to find R1’s call light on and R1 with feces on him, and that she waited 45 minutes before locating staff to provide care; she also described another occasion when they waited an hour for assistance after a bowel movement before she again had to find staff. Resident 2 (R2), admitted with heart failure, anemia, chronic kidney disease, and overactive bladder, had an MDS showing intact cognition but dependence on staff for toilet hygiene. R2’s care plan documented occasional urinary incontinence, continence of bowel, and a need for assistance to remain dry and clean while using briefs. R2 reported that it sometimes took an hour or more for staff to answer call lights and that she was incontinent and had to sit in urine when responses were delayed. These resident and family reports directly conflicted with the facility’s stated purpose in its “Answering the Call Light” policy, which requires that residents’ calls be answered as soon as possible. Staff interviews further described systemic delays in answering call lights, particularly on the night shift. CNAs reported that it usually took 15–30 minutes to answer call lights and that three CNAs were not enough to meet residents’ needs timely, especially when multiple residents required two-person assistance for incontinence care. A CNA stated that when call lights were going off during bed checks, the call lights had to wait. An LPN reported that from 3 a.m. to 5 a.m. there were three CNAs and only one nurse, who was simultaneously responsible for medications, treatments, and answering call lights, and that staff had to prioritize which call lights to answer, acknowledging that some residents might wait longer, particularly if staff believed they had already been cared for. A nurse and the DON both stated that staffing was adequate for census but not for resident acuity, and that when staff were busy with other tasks such as bed checks or assisting residents requiring two staff, call lights could not be answered promptly, leading to residents waiting longer for needed incontinence care.
Failure to Maintain Comfortable Hot Water Temperatures in Shower Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure comfortable and appropriate hot water temperatures in a resident shower room used by multiple residents. One resident, who had heart failure, age-related physical disability, diabetes, a moderate cognitive deficit, and was dependent on staff for bathing, had a family member report that the water in the shower on that resident’s hall was cold during the resident’s stay. Another resident with heart failure, anemia, chronic kidney disease, and overactive bladder, who was cognitively intact and dependent on staff for bathing, reported showering twice weekly and generally using the shower on the same hall, though this resident stated she had not personally experienced water temperature issues. A third resident with aphasia, hemiplegia, hemiparesis, history of falling, blindness, anorexia, severe cognitive impairment, and substantial/maximal assistance needs for bathing was also assigned to shower in this same hall according to the facility’s shower schedule and care plan. On the survey date, the surveyor, accompanied by the DON, verified the accuracy of the surveyor’s thermometer in ice water and then measured the water temperature in the shower room serving these residents. The initial shower water temperature was 98.4°F, and after allowing the water to run for several more minutes, the temperature decreased to 96.8°F. The DON stated that this shower room was rarely used and was unsure whether staff used it at all. A CNA working on that hall reported that she had given showers earlier in the week, including to the first resident, using that hall’s shower. She stated that residents did not complain about the water temperature but that she had to let the water run for about 10 minutes before it heated up. The Maintenance Director reported that an unidentified housekeeper had checked the water temperature in the same shower room and found it to be 98.6°F. He stated that this was the first time he had been made aware that the water temperature in that shower room was too low and that his goal temperature range was 100–115°F. The facility’s policy requires that hot water distribution systems provide at least 100°F at each hot water outlet at all times and that hot water available to residents at shower, bathing, and handwashing facilities not exceed 110°F. The observed temperatures in the shower room used for the three residents did not meet the facility’s stated requirement of at least 100°F, resulting in a failure to ensure a comfortable water temperature for residents dependent on staff for bathing.
Misappropriation and Diversion of Resident Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their medications, specifically controlled narcotics, for three residents reviewed for abuse. On 3/27/26, nursing staff identified that a card of narcotics previously delivered for one resident was missing during a pre-count of controlled substances. The LPN and RN on duty reported that nine cards of narcotics had been delivered the prior shift, but only eight cards and papers were present, and the missing card was associated with one resident’s oxycodone prescription. Subsequent investigation located the missing card in the wrong section of the medication cart and revealed that labels on narcotic cards for three residents had been switched and the narcotic medications replaced with other drugs. Further review showed that one resident, who had severe cognitive impairment and chronic pain related to cerebral infarct, hemiplegia, and dependence on a respirator, had an order for oxycodone 5/325 mg every six hours as needed. The Medication Administration Record (MAR) documented that oxycodone was administered as ordered and was effective in relieving pain, with pain scores ranging from 0–4. However, the facility discovered that this resident’s narcotic card had been tampered with and that the medication in the card was metoprolol (Lopressor) instead of oxycodone, indicating that the resident’s ordered narcotic medication had been misappropriated and replaced with a non-equivalent drug. Two additional residents with chronic pain conditions were also affected. One cognitively intact resident with diagnoses including rheumatoid arthritis, spinal stenosis, chronic back and right shoulder pain, radiculopathy, arthropathic psoriasis, kyphosis, calciphylaxis, and chronic pain had an order for hydrocodone 10/325 mg to be given four times a day as needed. The MAR showed the hydrocodone was documented as administered and effective, with pain scores ranging from 0–8, and the resident later commented that pain medication seemed to run out faster than expected but voiced no formal concern. Another cognitively intact resident with chronic pain related to diabetic neuropathy, polyosteoarthritis, migraine history, peripheral vascular disease, and osteoarthritis of the right knee had an order for hydrocodone 10/325 mg every four hours as needed, with MAR entries indicating the medication was effective or somewhat effective and pain scores ranging from 0–8. The investigation determined that two additional narcotic cards for these residents had been tampered with and that hydrocodone/acetaminophen had been replaced with potassium 10 mEq, resulting in a total of 120 missing narcotic doses across the three residents. During the investigation, the DON and staff identified that the narcotic cards had been altered by switching labels and substituting non-narcotic medications for the ordered controlled substances. A specific RN was suspected of involvement in the drug diversion after failing to respond to calls for interview and drug testing and later informing the DON by text that she would not return to the facility or participate in the investigation. Law enforcement was notified and noted that the medication cards had been tampered with and that this RN was believed to be the offender. The facility’s own Abuse Prevention Program defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the events described met this definition through the wrongful use and diversion of residents’ prescribed narcotic medications.
Failure to Provide Timely Incontinence Care and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and respond promptly to call lights for residents dependent on staff for toileting and hygiene. One resident with heart failure, age-related physical disability, diabetes, moderate cognitive deficit, and documented dependence on staff for toilet hygiene with occasional urinary and bowel incontinence had a care plan stating they required assistance to remain dry and clean and used briefs and pads. A family member reported that this resident had to wait up to two hours for care after a bowel movement, and on separate occasions the family member found the resident with feces on his body while the call light was on, waiting 45 minutes and about an hour respectively before staff were located to provide incontinence care. Another resident with heart failure, anemia, chronic kidney disease, overactive bladder, and frequent urinary and bowel incontinence, who was cognitively intact and dependent on staff for toilet hygiene, reported that it sometimes took an hour or more for staff to answer call lights, resulting in the resident sitting in urine when responses were delayed. Staff interviews further described delays in answering call lights and providing incontinence care, particularly on the 12‑hour night shift. A CNA stated it could take 15–30 minutes to answer call lights and that three CNAs were not enough to meet residents’ needs timely, noting that call lights might have to wait during bed checks. An LPN reported that during certain early morning hours she was the only nurse on duty, responsible for medications and treatments while CNAs performed bed checks, and that call lights were prioritized so some residents, especially those perceived to have been recently cared for, might wait longer. An RN stated she had concerns about timely call light response and incontinence care at night due to inadequate staffing, and the DON acknowledged that while staffing met census, it did not meet resident acuity, especially for residents requiring two‑person assistance, causing others to wait. The facility’s toileting policy required residents to be checked every two hours and changed if incontinent, and call lights to be answered as soon as possible, but the reported delays and resident/family accounts showed this was not consistently followed, while the Administrator denied having concerns or complaints about timely incontinence care.
Delay in Obtaining Ordered Urinalysis for Incontinent Resident
Penalty
Summary
The facility failed to obtain a timely urinalysis for a resident with a diagnosis that included urinary tract infections and documented urinary incontinence. The resident’s care plan identified bowel and bladder incontinence and the need for assistance to remain dry and clean, including the use of briefs and pads. A physician’s order was entered for a one-time urinalysis and urine culture at 5:30 AM on 3/27/26. Nursing documentation shows that in the early morning of 3/27/26, an RN attempted twice to obtain the urinalysis via straight catheter and then by having the resident stand at the bedside to void into a urinal, but these attempts were unsuccessful. There was no further documentation of additional attempts or follow-up related to obtaining the ordered urinalysis until 4/1/26. The urinalysis was ultimately collected on 3/31/26 and sent to the lab on 4/1/26, four days after the original order, with results later showing abnormal findings and a urine culture growing more than 100,000 CFU/mL of pseudomonas aeruginosa. A family member reported that several days after the order, the facility still had not obtained the specimen, and that he had the resident drink water, assisted him to stand, and was able to obtain the urine sample himself for the facility. The RN who initially attempted collection stated she reported the unsuccessful attempts to the next shift but was unsure what occurred afterward and acknowledged it should not have taken four days to obtain the sample. The DON confirmed awareness of the order, acknowledged the difficulty due to the resident’s incontinence, and stated the family had provided a urinal with urine that could not be used. The facility’s Clinical Cultures policy states that cultures are to be obtained as soon as practical when ordered, which was not followed in this case.
Improper Administration of Crushed Medications for Resident With Dysphagia
Penalty
Summary
Failure to provide appropriate pharmaceutical services occurred when a resident with dysphagia and an order for medications to be crushed did not consistently receive medications in crushed form. The resident, who had diagnoses including dysphagia (oropharyngeal phase), heart failure, age-related physical disability, and diabetes, had a physician’s order allowing medications to be crushed, excluding enteric or time-released medications, and a diet order for regular solids with nectar-thick liquids and household shakes. The resident’s MDS documented a moderate cognitive deficit and dependence on staff for bathing. Despite these orders and conditions, the resident’s care plan did not include a problem area related to medication administration. Family members reported that nursing staff attempted to administer the resident’s medications whole and with thin or regular water instead of crushed in applesauce with thickened liquids. One family member stated a nurse brought medications whole with thin liquids when they were supposed to be crushed in applesauce and given with thickened liquids. Another family member reported that the DON gave a small pill whole, stating the resident could take one pill whole, and later the resident spit out the intact pill after keeping it in his mouth for about an hour. A grievance/complaint documented that the DON gave a pill whole with regular water, despite the family stating the resident took medications in applesauce and was on thickened liquids. Nursing staff interviews confirmed that the resident’s medications were to be crushed in applesauce. The facility was unable to provide a policy related to this specific deficient practice.
Insufficient CNA Staffing on 100 Hall Delays Call Light Response and Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the 100 hall to meet residents’ needs in a timely manner and to ensure adequate assistance with care. A family member reported that during evening hours and on weekends it is very hard to get assistance from staff when call lights are activated, and that she has to walk the halls to find staff to assist a resident. During a resident council meeting, two cognitively intact residents stated that in the evening it is difficult to get someone to answer call lights, and one of these residents lives on the 100 hall. The daily census report shows there were 10 residents residing on the 100 hall. A CNA reported that residents need to be turned and repositioned every two hours or as needed, but stated she performs bed checks “as often as I can by myself,” explaining that the next CNA does not arrive until 10:00 a.m. and that residents requiring two-person assistance may not be attended to until that time if she cannot find help. On the morning in question, the CNA stated she had been working alone on the 100 hall since 6:00 a.m. due to a call-in and was only able to begin bed checks at 8:54 a.m., completing care only for residents requiring one-person assistance while no other CNA was present or scheduled on the hall. A respiratory therapist stated that CNAs are responsible for repositioning during two-hourly rounds, that respiratory therapy will help with bed checks if needed, and that there are two CNAs assigned to the 100 hall only “if they are lucky,” despite residents there being mainly dependent on staff. The regional director of clinical services stated that staffing is based on public health guidelines and resident needs when assigning staff.
Inadequate Hot Water for Resident Care Areas
Penalty
Summary
The facility failed to ensure there was hot water for showers and personal care for the 21 residents residing on the 200 and 300 halls. During the survey, a resident who was alert and oriented stated that the facility did not have hot water and reported that when CNAs cleaned her up, the water was freezing cold, describing it as awful to be wiped with a cold washcloth. Another alert and oriented resident stated that he never had hot water in the sink in his room for washing up at night and in the morning, and that the shower room water temperature was better but not always hot. Surveyors measured water temperatures in multiple locations on the 200 and 300 halls and found temperatures below the facility’s policy requirement of at least 100 degrees Fahrenheit at each hot water outlet. The sink in one room measured 80 degrees Fahrenheit, another measured 82.8 degrees Fahrenheit, the 300 hall shower room hand sink measured 84 degrees Fahrenheit and the shower head measured 80 degrees Fahrenheit, another room sink measured 87.6 degrees Fahrenheit, and another measured 95 degrees Fahrenheit. The 200 hall shower room shower head measured 95 degrees Fahrenheit. The Maintenance Director stated there were three water heaters controlling the entire building and that he had been checking water temperatures daily when there were problems, but had not been doing so for quite some time. He also stated he was working on turning up the water heaters from 102 to 105 in an attempt to get the water to heat up.
Expired and Unlabeled Medications Found in Storage and Medication Carts
Penalty
Summary
Drugs, biologicals, and medical supplies were found stored with expired dates, missing resident identification, and missing opening dates in the facility’s medication storage areas and medication carts. In the medication refrigerator, staff found five bags containing swabs and lab collection tubes with expiration dates of 10/2024, an unopened vial of Daptomycin with no resident name and an expiration date of 1/12/25, an unopened vial of Humulin R insulin with an expiration date of 11/21/25, two boxes of Arformoterol nebulizer solution labeled for R26 with one box expired on 1/19/26 and another on 12/1/24, two boxes of Formoterol nebulizer solution labeled for R26 with expiration dates of 7/2025, and a Bisacodyl suppository with an expiration date of 1/2026 and no resident name. In the North Hall medication cart, staff found an open bottle of Systane eye drops with no resident name, a sodium chloride pre-filled syringe expired 1/31/26, and a 20 gauge needle expired 4/10/24. In the Southwest Hall medication cart, staff found an ampule of Albuterol nebulizer solution with only R12’s first name written on it and no directions for use, an opened Insulin Glargine pen labeled with R44’s name but no order label and no date documenting when it was opened, and an opened bottle of Lantus insulin with no resident identification and no documented open date. The assistant director of nursing stated she did not know who the Systane eye drops belonged to and discarded them, acknowledged that expired syringes and needles should be thrown away but said there was not a sharps container large enough for all of them, and stated insulin pens and vials should be dated when opened. The report also notes that R44 had an order for insulin glargine, R12 had an order for ipratropium-albuterol nebulization, R5 had a discontinued order for formoterol nebulizer solution, and R26 had an order for arformoterol with no current order for formoterol nebulizer solution.
Missing restraint assessments for residents using hand mitts
Penalty
Summary
The facility failed to provide restraint assessments for 2 residents, R3 and R7, who were both using hand mitt restraints. R3 was admitted with diagnoses including cerebral infarction, dependence on respirator, chronic respiratory failure with hypercapnia, and acute pulmonary disease. R3’s MDS documented significant cognitive impairment, and the care plan identified a focus area for physical restraints with an intervention to assess and document the need for the restraint. Physician orders directed use of a right-hand mitt as needed to prevent pulling or removal of tubes, with release every 2 hours for 15 minutes with supervision as needed. R3 was observed in bed with the right-hand mitt in place, and a progress note documented the mitt continued, but no restraint assessments were found in the record. R7 was admitted with diagnoses including cerebral palsy, dependence on a respirator, contracture of muscle at multiple sites, cerebral infarction, and pulmonary fibrosis. R7’s MDS also documented significant cognitive impairment and use of a limb restraint less than daily. The care plan identified physical restraints and included an intervention to assess and document the need for the restraint. Physician orders directed use of a left-hand mitt as needed related to pulling at medical devices, with release every 2 hours for 15 minutes with supervision as needed. R7 was observed in bed with the left-hand mitt applied, and a progress note documented the mitt continued, but no restraint assessments were found in the record. Staff interviews confirmed that nursing staff were responsible for restraint assessments, but the DON could not state how often they were required, and administration stated the required assessments for R3 and R7 could not be found.
Unnecessary PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary medication use. The resident’s face sheet listed diagnoses of anxiety disorder and depression, and the current physician order sheet included lorazepam 0.5 mg once daily via gastric tube as needed for anxiety, with a start date of 1/09/2026 and no end date. The resident’s behavior tracking for the last 3 months did not list any behaviors. The resident’s medication administration record for the last three months showed lorazepam was administered on multiple dates, including 1/15/26-1/20/26, 2/2/25, 2/3/26, 2/5/26, 2/9/26-2/12/26, 2/15/26-2/18/26, and 2/24/26-2/26/26. There was no documentation in the resident’s record to show a reason for extending the lorazepam PRN order beyond 14 days. The Regional Director of Clinical Services stated that she was aware PRN medications need an end date and that she would continue working with physicians to ensure the paperwork is completed accordingly if they do not want to reduce the medication.
Failure to Provide Ordered Splinting for Limited ROM
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. The resident had diagnoses including Parkinsonism, symptomatic epilepsy, partial seizures, hypotension, anemia, asthma, contracture of the right hand, and chronic pain. The most recent quarterly MDS documented cognitive intactness with a BIMS of 15, an impairment on one side for upper extremity range of motion, dependence for several ADLs, and partial to moderate assistance for multiple mobility tasks. The MDS also documented restorative services for transfers and walking during the look-back period. The resident’s care plan addressed ADL functional status and rehabilitation needs related to contracture of the right hand and low physical activity, with interventions including assistance with ADLs, restorative programs as indicated and ordered, and therapy as ordered. A progress note documented that the resident had not used the splint for some time and was referred to therapy for re-evaluation of splinting needs and comfort. However, the physician order report did not document an order for a splint, while an occupational therapy in-service training sign-off sheet stated the resident should wear the right-hand splint for 4 hours daily and put it on when he got up in the morning. During observations on multiple days, the resident was seen without the splint on the right hand. The CNA stated the resident never wears the splint and will refuse it, while the resident stated staff no longer put it on and he thought it had been discontinued. Therapy staff stated the splint should be on the resident’s right hand and later found it in the room on the dresser, noting therapy would re-evaluate the resident and work on stretching his hand. Nursing leadership and staff stated they were not aware of an order for the splint, were unsure how often it was worn, and acknowledged there was no documentation of refusals in the chart. The facility policy stated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.
Meals Served at Cold Temperature
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature for 3 of 3 residents reviewed for palatability, including R1, R5, and R23. During a resident council meeting, R1 and R5 stated that evening meals are cold and that they often eat the food cold rather than regularly asking for it to be reheated. R1 was the resident council president and was alert to person, place, and time, and R5 stated he attends resident council meetings regularly and was also alert to person, place, and time. R23, who was alert to person, place, and time, stated that his family often brings him food at dinner so he does not have to eat cold food. R5 later stated that the issue of cold evening food had been brought up regularly in resident council meetings. Review of the resident council minutes for the last 6 months showed no concerns documented regarding dietary issues or cold food, and the grievance log for the last 6 months showed no grievances related to cold food by residents or family. An Activities staff member stated that cold food had been mentioned in resident council meetings in the past and could not explain why those complaints were not documented in the minutes; the staff member also stated that the prior week, R1 and R5 requested their meals be reheated because they complained the food was too cold.
Inadequate Disinfection of Blood Glucose Machine
Penalty
Summary
The facility failed to follow its infection control policy for cleaning durable medical equipment when a blood glucose machine was used for three residents. The policy titled "Cleaning of Durable Medical Equipment" states that all durable medical equipment, including blood glucose monitoring machines, must be disinfected with the appropriate disinfectant between resident uses and that the surface must remain wet for one minute at room temperature. During observation, V3, the LPN/ADON, gathered a blood glucose machine, lancet, alcohol wipe, and Micro-Kill wipe, sanitized hands, donned gloves, and entered each resident’s room to perform blood glucose testing before sliding scale lispro insulin administration. After each fingerstick, V3 discarded the lancet and wiped the blood glucose machine with a Micro-Kill wipe for 20 seconds with the first two residents and 25 seconds with the third resident, then placed the machine on a Kleenex or new Kleenex before discarding the wipe and removing gloves.
Failure to Maintain Adequate Nursing Staff to Meet Resident Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a daily basis to meet residents’ needs in a timely manner and to ensure adequate licensed nurse coverage on each shift. Multiple residents with significant ADL, toileting, and repositioning needs reported prolonged waits for assistance despite care plans specifying frequent turning, toileting assistance, and incontinence care. The facility’s own staffing policy states that adequate staffing will be maintained on each shift to meet resident needs and regulatory requirements, yet interviews and record review showed that staffing levels were often inadequate for the 47 residents in-house. One resident with polyosteoarthritis, morbid obesity, COPD, a sacral pressure ulcer, and dependence for toileting and turning/repositioning reported that she is supposed to be repositioned at least every two hours but sometimes goes longer than that. She stated that when she activates her call light or yells out, it can take staff a very long time to respond, and that there are times when it takes a long time for a nurse to come to her room or bring pain medication. Another resident with moderately impaired cognition, muscle weakness, and a history of repeated falls, who requires substantial/maximal assistance with toileting and transfers, reported that he feels the facility is very short-staffed. He described waiting up to 20 minutes or longer for call lights to be answered and recounted a recent fall that occurred after he put on his call light, became impatient while waiting for staff, and attempted to move on his own. Additional residents described similar delays and unmet care needs. One cognitively intact resident who is dependent for toileting and needs assistance with transfers stated that it takes staff "forever" to help him get dressed in the morning and that he has experienced incontinence episodes while waiting for staff to answer his call light. Another resident requiring substantial/maximal assistance with toileting and transfers reported waiting over 30 minutes at times for call lights to be answered and having incontinence episodes while waiting, then needing assistance with cleanup. A ventilator- and tracheostomy-dependent resident with muscular dystrophy, contractures, and dependence for toileting and turning/repositioning stated that there are times when only one CNA is assigned to her hallway, which includes multiple residents with vents and trachs, and that she has waited over an hour for assistance with repositioning and for call lights to be answered. Staff interviews corroborated that staffing was frequently insufficient to meet resident needs. Multiple CNAs reported working entire halls alone for extended periods, including a CNA who worked a 12-hour shift alone on one hall and was unable to complete all resident care, such as turning/repositioning, incontinence care, and showers. CNAs stated that when short-staffed, call light response times could be 15 minutes or longer, and residents who required turning every two hours were not consistently turned on schedule, with intervals stretching to 2.5–3 hours while staff tried to balance feeding and other care tasks. CNAs also reported that call-ins were sometimes not covered, that they had to borrow staff from other halls to complete transfers and repositioning, and that some resident care likely went unfinished on short-staffed days. The Director of Nursing acknowledged that the facility did not have enough nurses or CNAs and stated that they were losing staff "left and right." She reported that staffing patterns left, after 3 a.m., only one nurse, one respiratory therapist, and two CNAs to cover a specialized trach/vent unit and other high-acuity halls, and that she did not feel this was a safe number of staff to provide proper care. She stated that nurses and CNAs were in a hurry to get as much done as possible and might be missing things or delaying assessments and care. A physician also indicated that there had been discussions about resident care in relation to current staffing and that decisions about staffing were up to the facility company. These statements, combined with resident reports and care plan requirements, demonstrate that the facility failed to maintain adequate staffing on each shift to meet residents’ assessed needs in a timely manner.
Failure to Follow Antibiotic and Wound Care Orders Leading to Sepsis and Death
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and adequately monitor and treat worsening bilateral lower extremity venous wounds and infections for a resident with multiple comorbidities, including lymphedema, cellulitis of both lower limbs, MRSA infection, pseudomonas, severe sepsis with septic shock, diabetes with neuropathy, and chronic edema. The resident had intact cognition per a BIMS score of 15 and an active diagnosis of wound infection and venous/arterial ulcers on the MDS. The care plan documented sepsis and a history of bilateral lower extremity wounds, with approaches specifying treatment and antibiotics per order and to report ineffective treatment or adverse effects to the physician. Despite this, multiple antibiotic and wound care orders from a consulting wound clinic and from a hospital were not entered into the electronic record, not available on the POS or MAR, or not administered as ordered. The consulting wound clinic ordered IV vancomycin 1 g BID for 14 days, but facility staff documented they could not administer IV medications every 12 hours due to lack of RNs on night shift. The order was changed to vancomycin 1 g daily and later to 1.5 g daily, yet the MAR showed multiple days where vancomycin was not administered, marked as the resident being unavailable or the medication being on hold. Additional clinic orders for Bumex, Levaquin, and Cipro were not found on the MAR or POS. Later, the clinic ordered levofloxacin 750 mg daily for 10 days and a Medrol dose pack; staff documented awareness of the resident’s allergy to levofloxacin, faxed the clinic for clarification, and noted that the antibiotic order was not clarified, but the levofloxacin order never appeared on the MAR or POS. Another clinic order for Invanz 1 g daily for 14 days for ESBL UTI was documented in progress notes, but Invanz was not present on the MAR or POS, and multiple nurses stated they did not remember the resident ever receiving Invanz. Staff notes show repeated attempts to contact the clinic and pharmacy about missing Invanz orders, but also show that follow-up was not consistently completed or clearly handed off. Wound care orders were also not consistently implemented as written. The clinic and hospital ordered specific wound care regimens, including Dakins 0.25% solution wet-to-dry dressings, Vashe wound solution, exufiber dressings, ABD pads, kerlix, and ACE wraps. The MAR documented numerous instances where ordered treatments were not administered due to drug or item unavailability, with nurses substituting wound cleanser and available dressings instead of Dakins, Vashe, exufiber, or kerlix. Staff interviews confirmed that Dakins solution, Vashe, exufiber, and kerlix were often unavailable, that dressing changes were sometimes not done when scheduled, and that some nurses still checked off treatments as completed per order despite not having the correct supplies. CNAs reported dressings with old dates, unraveling, and drainage seeping through, and nurses documented worsening bilateral lower extremity redness, bleeding, purulent and greenish drainage, increased pain, and extensive weeping through dressings. The resident experienced episodes of dizziness, hypotension, and shortness of breath, was repeatedly sent to the hospital, and was ultimately diagnosed with septic shock secondary to bilateral leg wound infection and cellulitis due to pseudomonas and MRSA, with hospital records and the death certificate listing septic shock and skin and soft tissue infections as causes of death. A second resident with congestive heart failure was also cited in the deficiency for failure to complete ordered lab work and administer medications as ordered, resulting in worsening CHF, respiratory failure, hospitalization, and subsequent death, but the detailed narrative in the report focuses on the first resident’s course. The surveyors determined that the facility failed to follow physician orders for antibiotics and wound care, failed to ensure availability and administration of ordered medications and supplies, and failed to adequately monitor and respond to the resident’s declining condition. These failures led to worsening infection of bilateral lower extremity venous wounds, development of sepsis, and the resident’s death, and contributed to an Immediate Jeopardy determination for failure to provide treatment and care according to orders, resident preferences, and goals for two of three residents reviewed for death.
Failure to Follow Wound Care Orders and Isolation Protocols for Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and adhere to infection control protocols for a resident with multiple complex medical conditions and stage 4 pressure ulcers. The resident was admitted with diagnoses including muscular dystrophy, muscle wasting and atrophy, muscle weakness, osteomyelitis of the sacral and sacrococcygeal vertebrae, paresthesia of the skin, underweight status, and multiple sclerosis. The MDS documented intact cognition and the presence of two stage 4 pressure ulcers. The care plan identified the resident as requiring contact isolation for MRSA, ESBL, and CRE involving the nares, sacrum, and vagina, and also documented risk factors for skin breakdown, including decreased mobility, contractures, history of ulcers, chronic osteomyelitis, and underweight status. Surveyors observed a wound dressing change during which staff did not follow the facility’s enhanced barrier precautions policy. An enhanced barrier precaution sign was posted on the resident’s door, but the RN performing the dressing change and assisting staff only wore gloves and did not don gowns. The RN removed a sacral dressing that was dated two days earlier and appeared dirty and soiled through with blood and green drainage, and a right buttock dressing that was also soiled with blood and green drainage and lacked a date. There was no dressing present on the vulvar wound at the time of observation. The RN then cleansed each wound with normal saline and applied calcium alginate and Silvadene cream mixed with collagen powder. Interviews and record review showed that physician orders required daily and as-needed dressing changes to the sacrum, vulva, and right buttock, and that the resident was on contact isolation for infected wounds. The RN acknowledged that the wound dressings had not been changed the previous day, not due to resident refusal but because she did not have time, despite the daily order. The RN also stated she could not locate the resident’s Silvadene cream and instead used another resident’s prescribed wound medication, contrary to facility policy that medications supplied for one resident are never administered to another. Additional staff confirmed they forgot to wear gowns during the wound care, despite the isolation signage and policies requiring gown and glove use for high-contact care under enhanced barrier or contact isolation precautions. The administrator confirmed expectations that staff follow physician orders, use resident-specific prescription creams, and wear required PPE for residents on isolation or enhanced barrier precautions.
Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving a resident who was cognitively intact and had multiple chronic medical conditions, including chronic atrial fibrillation, congestive heart failure, and chronic kidney disease. The resident reported that a certified nurse assistant (CNA) was verbally abusive on more than one occasion, describing incidents where the CNA spoke to her in a loud and mean tone. The resident was unable to recall the CNA's name but provided a physical description. The facility's records show that the administrator initiated an investigation, notified the police and physician, and submitted a report to the state health department. However, the investigation was incomplete and lacked critical documentation. The administrator collected 18 staff questionnaires, but only 12 were identified by name, while the remaining 6 were anonymous with no way to determine who provided the information. The administrator admitted to not keeping a list of interviewed staff and could not confirm whether all relevant staff, including those scheduled during the alleged incidents, were interviewed. Several CNAs who worked during the relevant period stated they were not made aware of the allegation, were not interviewed, and did not complete any questionnaires regarding the incident. The facility's abuse prevention policy requires that all interviews be documented with names and contact information, and that all staff participate in investigations. The administrator stated that some staff refused to sign their names and that she could not force them to cooperate. The regional operations director clarified that participation is mandatory and that refusal could result in termination. The investigation file did not meet the facility's policy requirements, as it lacked a complete list of interviewed staff and failed to ensure all relevant staff were questioned and identified.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Maintain Safe Temperature in Dietary Dry Storage Area
Penalty
Summary
The facility failed to maintain the required temperature of less than 70 degrees Fahrenheit in the dietary dry storage area, as observed during a survey. The ambient air temperature in the dry storage area was measured at 90.6 degrees Fahrenheit using a calibrated thermometer. The Dietary Manager confirmed that the HVAC unit in the dry storage area had not been functioning and that the area had been very hot since the start of summer. The Maintenance Director reported that the HVAC company would not service the unit until an outstanding bill from previous work was paid. The Former Administrator stated that requests to corporate for HVAC repairs had been ongoing for over a year. Facility policy requires dry storage areas to be kept at temperatures not exceeding 70 degrees Fahrenheit to ensure food is stored safely and sanitarily. At the time of the survey, 58 residents were residing in the facility.
Failure to Address Facility Maintenance and Safety Needs Due to Corporate Inaction
Penalty
Summary
The facility failed to ensure effective and efficient use of its resources to maintain the safety and wellbeing of all 58 residents. The former administrator reported repeatedly contacting corporate regarding non-functioning HVAC and PTAC systems, as well as the need for dining room floor repairs, but received no response or authorization to address these issues. The maintenance director stated that the HVAC repair company and the call light repair company refused to provide services due to unpaid bills, resulting in unresolved HVAC problems and at least one resident room without a functioning call light system. Despite requests for 33 PTAC units for resident rooms, only 4 were provided. The regional director of operations indicated that corporate was unaware of these ongoing issues.
Failure to Maintain Functioning Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system for three residents who required assistance, as observed during the survey. All three residents had significant medical conditions, including hemiplegia following cerebral infarction, vascular dementia, chronic respiratory failure, and other motor neuron disease, with varying levels of cognitive impairment. The call lights in their shared room were not operational, and instead, the residents were given hand bells to use for summoning assistance. Interviews with the residents revealed that the call lights had been nonfunctional for periods ranging from about a week to several months. The Maintenance Director confirmed awareness of the issue and stated that the company responsible for repairing the call lights refused service due to unpaid bills. The deficiency was further compounded by the presence of large, loud industrial fans in the hallway, which made it difficult or impossible for staff to hear the hand bells when residents attempted to call for help. Staff interviews confirmed that the noise from the fans significantly interfered with their ability to hear the bells, especially when they were not in the immediate vicinity. A family member also observed the use of hand bells and was informed by staff that the call light was not working. The facility's policy required prompt reporting of defective call lights to the nursing supervisor, but the issue persisted without resolution, and the administrator was unaware of the payment issue with the repair company until the time of the survey.
Failure to Implement Enhanced Barrier Precautions and Standard Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Standard Precautions for five residents reviewed for infection control. The facility's policy requires the use of EBP for residents with certain conditions, such as indwelling catheters or chronic wounds, to prevent the spread of infections. However, observations revealed that EBP signage was missing, and personal protective equipment (PPE) was not readily available outside the rooms of residents who required these precautions. For instance, a resident with an indwelling urinary catheter did not have EBP signage on their door, and PPE was not accessible. A registered nurse performed catheter care without donning a gown, despite acknowledging that EBP should be used for such care. Similarly, another resident with multiple wounds and an indwelling catheter did not have EBP signage, and the Director of Nurses did not wear a gown while performing wound care, although proper hand hygiene and glove use were observed. Additionally, a resident with a history of cellulitis and actively weeping wounds did not have EBP or PPE in place. The infection control nurse confirmed that EBP should be implemented for residents with tracheostomies, indwelling catheters, wounds, or open areas. These observations indicate a failure to adhere to the facility's infection prevention and control policy, potentially increasing the risk of infection transmission among residents and staff.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain comfortable temperatures for nine residents, with heating units in their rooms either not functioning or blowing cold air. Observations revealed residents using multiple blankets and wearing coats indoors to keep warm. The facility's maintenance logs did not document specific temperatures, and the heating units were reported as non-operational by both staff and residents. The facility's policy on extreme weather was not effectively implemented, as the heating systems were not adequately maintained, leading to discomfort among residents. Additionally, the facility had issues with water-damaged ceiling tiles, which were observed in multiple areas, including near the nurse's station and various halls. The water damage was attributed to condensation from piping between the ceiling and ceiling tiles, as explained by the facility administrator. Staff confirmed that during the summer, the heating units leaked water, requiring makeshift solutions like trash cans and bath blankets to manage the leaks. Despite replacing numerous ceiling tiles, the facility had not conducted any mold or mildew testing, raising concerns about potential respiratory risks for residents. The facility's maintenance director acknowledged the ongoing issues with the heating units and the need for new systems, but cited cost as a barrier. The administrator was unaware of the extent of the heating problems and had not initiated any environmental policy regarding the water-damaged ceiling tiles. The lack of specific temperature documentation and the absence of mold testing further highlighted the facility's inadequate response to maintaining a safe and comfortable environment for its residents.
Failure to Follow Menu and Diet Orders
Penalty
Summary
The facility failed to follow the menu and diet orders for six residents, as observed during a survey. On the morning of October 3, 2024, a resident reported not receiving eggs or double meat with breakfast, contrary to their dietary preferences. On October 8, 2024, during a breakfast meal observation, the cook stated that the kitchen had run out of meats and eggs, and the delivery truck was expected later that day. The cook admitted that no substitutes were provided for the missing items, as the kitchen was also out of yogurt and peanut butter, and no discussion with the dietician occurred regarding substitutions. The dietician confirmed that substitutions should have been made with items of equivalent nutritional value, such as yogurt or peanut butter, but was unaware of the shortage. The administrator also stated that substitutions should be made when items are unavailable. The dietary supervisor noted that one resident's dietary card did not list the required items, which were added after the issue was discovered. The facility's policy requires that menus be followed and any changes due to stock shortages be reviewed with a registered licensed dietician, which was not adhered to in this instance.
Inadequate Hydration for Residents
Penalty
Summary
The facility failed to provide adequate hydration to 18 out of 47 residents, as observed during a survey. Multiple residents were found without water pitchers or any other fluids available in their rooms. For instance, one resident was observed without a water pitcher and stated that they usually only receive drinks with their meal trays. Another resident had a water pitcher that was warm to the touch and had not been refilled with fresh ice water until later in the day. These observations indicate a lack of consistent access to fluids for the residents. The facility's policy on hydration, dated December 2016, requires staff to offer fluids routinely, in addition to those provided on meal trays. However, interviews with the facility's nursing staff revealed inconsistencies in the implementation of this policy. The Assistant Director of Nursing stated that staff are expected to refresh residents' water every four hours, yet observations showed this was not consistently done. The Director of Nursing acknowledged the expectation for water pitchers to be filled before a certain time but was unaware of why this was not adhered to on the day of the survey.
Facility Fails to Maintain Air Conditioning, Causing Resident Discomfort
Penalty
Summary
The facility failed to maintain air conditioning equipment, resulting in uncomfortable temperatures for all 47 residents reviewed. Observations on June 26, 2024, revealed that the dining room was notably warm, with two PTAC units and a portable air conditioner running, yet the temperature remained high. Staff members, including a registered nurse and certified nurse assistants, reported that the facility had been very warm recently, with some rooms cooler than others. The maintenance director confirmed that the air conditioning units on the roof were frozen and leaking, and the facility was relying on portable air conditioners and fans to manage the heat. Interviews with residents indicated discomfort due to the heat, although no negative health outcomes were reported. Residents expressed that their rooms were warmer than usual, particularly on June 25, 2024, when outside temperatures were extremely high. The maintenance director admitted that temperature checks were only logged as completed without recording actual temperatures, and no checks were conducted over the weekends. The administrator was aware of the air conditioning issues and had contacted a repair service, but repairs were delayed due to the unavailability of necessary Freon. The facility's policies on extreme weather and heat index were not effectively implemented, as evidenced by the lack of timely maintenance and monitoring of air conditioning systems. The director of nursing was not informed of the issues over the weekend, and the assistant director of nursing noted that requests for air conditioner repairs had not been approved by corporate. The facility's failure to maintain a comfortable environment for residents, as required by regulations, was evident in the observations and interviews conducted during the survey.
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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