Elevate Care Des Plaines
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Plaines, Illinois.
- Location
- 1660 Oakton Place, Des Plaines, Illinois 60018
- CMS Provider Number
- 145626
- Inspections on file
- 41
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Elevate Care Des Plaines during CMS and state inspections, most recent first.
A resident with a trach and ventilator dependence was observed using a visibly dirty ventilator circuit and a filter labeled with a change date more than 30 days prior, contrary to the facility’s Respiratory Care Equipment and Supplies policy. The resident and spouse reported that the vent circuit had not been changed monthly, and the RT confirmed the circuit and filters were due for 30-day changes but had delayed replacement until the start of the next month. The DON acknowledged that the vent circuit and filter should be changed per the policy, which requires ventilator circuits and air intake filters to be cleaned and replaced every 30 days.
A facility experienced a complete power loss when its emergency generator failed to activate, leaving all areas without electricity, including ventilators, tube feeding pumps, and other critical equipment. Fourteen ventilator-dependent residents were affected, and emergency (red) outlets remained without power until a portable generator was connected hours later. Maintenance records lacked evidence of required weekly inspections and monthly load-bank testing for the generator in the months before the outage. Nursing and respiratory staff did not initiate manual ventilation (ambu-bagging) as required by the facility’s Emergency Operations Plan, and an RN on duty reported not performing specialized respiratory interventions and focusing on only one ventilated patient. Two nurses on the ventilator unit did not know where backup ventilator batteries were stored, and the RN’s personnel file lacked documented competency in ventilator management and emergency respiratory procedures.
During a facility‑wide power outage when the emergency generator failed, ventilators and other electrical medical devices lost power for several hours, and the facility did not effectively implement its emergency plan requiring manual ventilation and continuous assessment of ventilator‑dependent residents. A resident with chronic respiratory failure and COPD, dependent on full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring during the outage, and there was no evidence that manual ventilation was initiated when emergency outlets were found to be nonfunctional. Staffing consisted of one RT and two nurses for numerous ventilator and tracheostomy patients; one RN working a prolonged double shift reported performing minimal checks, not monitoring other residents due to limited staff, and not documenting care because of lack of computer power. The resident was later admitted to the hospital with an elevated lactic acid level and subsequently expired there with chronic respiratory failure and COPD listed as causes of death.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with necrotizing fasciitis and other comorbidities did not receive prescribed negative pressure wound therapy after independently removing the device and requesting assistance from multiple staff members. Despite repeated requests, staff failed to ensure the wound care nurse was notified or provided care, resulting in the resident waiting several hours without treatment and ultimately calling 911 for hospital transfer. Documentation confirmed no wound care was provided that day, and the resident presented to the hospital with a large, untreated wound.
A resident dependent on tube feeding was hospitalized due to dehydration after the facility failed to implement a registered dietitian's recommendation to increase fluid intake. The recommendation was not communicated effectively due to a transition in the electronic health record system, resulting in the resident receiving insufficient fluids and experiencing severe dehydration and related complications.
The facility failed to maintain cleanliness in the rooms and medical equipment of residents dependent on staff for care, as observed in four cases. Issues included visible dust and substances on oxygen machines, feeding tube monitors, and furniture. The Director of Nursing and Registered Nurse confirmed these observations, highlighting a collaborative effort needed for cleanliness. A staff shortage in housekeeping was noted, impacting daily cleaning routines.
The facility failed to follow physician orders for daily feeding tube site care for four residents dependent on enteral nutrition. Observations revealed undressed sites, outdated dressings, and improper documentation, indicating non-compliance with the facility's policy for daily gastrostomy tube care.
A resident with multiple diagnoses, including dementia and difficulty walking, was improperly transferred by a CNA, resulting in a neck fracture. The resident was wearing slippers instead of non-skid socks, and a gait belt was not used despite the care plan's requirements. The DON confirmed the need for a gait belt and appropriate footwear during transfers.
The facility failed to provide timely and appropriate catheter care for two residents, resulting in one resident's hospitalization for a severe UTI and sepsis. The facility did not obtain urine specimens promptly, failed to document catheter output, and neglected necessary catheter care. These deficiencies were compounded by incomplete documentation and inadequate response to residents' symptoms, such as altered mental status and poor appetite.
A resident with multiple sclerosis and other conditions was not provided a recliner wheelchair after hospice services ended, despite expressing a desire to get out of bed. The facility's staff, including a CNA and RN, were unaware of the resident's lack of a wheelchair, which was contrary to the facility's policy of meeting residents' needs.
A high-risk resident fell from an unlocked wheelchair in an unsupervised dining room, sustaining facial injuries requiring hospital evaluation. The resident, with a history of dementia and other conditions, was left unsupervised after an activity aide failed to lock both wheelchair wheels. Staff interviews revealed inadequate training on wheelchair use and supervision, contributing to the incident.
A facility failed to follow physician orders for transmission-based precautions for a resident with multiple infections. Despite clear signage, a CNA entered the resident's room without PPE or hand hygiene, misunderstanding the necessity of these precautions. The RN and Infection Prevention Nurse confirmed the requirement for PPE to prevent infection spread, highlighting a deficiency in infection control practices.
The facility failed to protect a resident from abuse, resulting in another resident punching him in the face, causing injuries. The incident occurred when a CNA found the injured resident bleeding and reported it to the nurse. The aggressor admitted to the act, and both residents were transferred to the hospital. The facility's investigation confirmed the abuse, and the aggressor was discharged.
A high-risk resident fell from a wheelchair at the nurse's station due to inadequate supervision, resulting in a laceration that required hospital evaluation and sutures. Despite being identified as a high fall risk, the resident was left unsupervised, leading to the incident.
Failure to Follow 30-Day Ventilator Circuit and Filter Change Policy
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred when the facility did not follow its Respiratory Care Equipment and Supplies policy for changing ventilator circuits and filters. A male resident with intact cognition, admitted with tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder, was observed in bed with a ventilator/tracheostomy setup and cough assistance, using a visibly dirty ventilator circuit and a filter labeled with a change date of 2/20. During observation, the resident and his spouse reported that the facility was not changing the ventilator circuit every month and stated that the last change was on February 20th, which they believed was overdue. The respiratory therapist acknowledged that the resident’s ventilator circuit and filters were due to be changed every 30 days per policy and admitted waiting until the first of the next month instead of following the 30‑day schedule. The DON also confirmed that the ventilator circuit and filter should be changed according to the facility’s policy, which specifies that ventilator circuits and air intake filters must be cleaned and replaced every 30 days, indicating that this schedule was not followed for this resident.
Generator Failure and Inadequate Emergency Response for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency generator functioned during a widespread power outage and to document required weekly and monthly testing of the generator. On the evening of 09/20/25, the primary utility power failed, and the facility’s emergency generator did not engage as designed. The Administrator reported arriving to find the building dark, with the Maintenance Director already on-site attempting to troubleshoot the generator and having contacted the generator contractor. The Administrator stated that the root cause, as relayed by the generator service company, was that condensation in the gasoline tank may have caused water and gas to mix, which then burned out the generator wiring that activates the unit. Review of maintenance records revealed no evidence of weekly generator inspections or monthly load-bank testing for the three months preceding the outage. During the outage, all areas of the facility lost electrical power, including power to mechanical ventilators, tube feeding pumps, air mattresses, mechanical lifts, and other electrically powered equipment. Fourteen ventilator-dependent residents were affected when the emergency generator failed to provide power to life-sustaining devices. The Maintenance Director confirmed that emergency outlets (red plugs) remained without power until a portable generator was obtained and connected at 12:41 AM the following morning. Staff attempted to plug ventilators and other equipment into the red emergency outlets, but nursing staff reported that there was no power to those outlets and that the unit was in total darkness. Nursing and respiratory staff actions during the outage did not follow the facility’s Emergency Operations Plan. The plan states that if a ventilator battery does not continue operating or power is lost, manual ventilation (Ambu-bagging) must be initiated immediately, and that nursing and respiratory staff will ensure medical equipment is energized via red emergency outlets and will continually or continuously assess residents. One RN reported working a double shift and remaining on duty into the early morning hours, stating that he did not initiate manual ventilation or conduct specialized respiratory monitoring for ventilator patients, explaining that he “didn’t do anything to the ventilator patient, it’s not my thing,” and that he focused primarily on one ventilated resident and did not monitor other residents. Another nurse confirmed that manual ventilation was not performed for any of the 14 ventilator-dependent residents during the outage and that she had to call the respiratory therapist when she noticed the ventilators were dark, after which she brought oxygen cylinders to several patients. Staff also demonstrated a lack of knowledge regarding backup ventilator batteries. Two nurses working on the ventilator floor stated they did not know where backup batteries for the ventilators were stored in case of power failure. Personnel file review showed that the RN who was on duty during the outage lacked documented competency evaluation for ventilator management or emergency respiratory procedures such as Ambu-bagging. The combination of the generator’s failure to activate, the absence of documented generator testing, the lack of power to emergency outlets, and the failure of nursing and respiratory staff to implement the facility’s emergency procedures for ventilator-dependent residents led to the cited deficiency and was determined to constitute Immediate Jeopardy to resident health and safety.
Removal Plan
- The facility has an emergency policy and procedure system in place on what to do if the facility's electrical system is affected.
- The emergency policy and procedure affecting the facility's electrical system is reviewed upon hire during orientation and educated on annually.
Failure to Provide Respiratory Monitoring and Care During Power Outage
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized respiratory care and continuous clinical monitoring to ventilator‑dependent residents during a total facility power loss. An area‑wide electrical outage occurred, the facility’s emergency generator failed to activate, and all electrical power to the ventilator unit and other medical devices was lost for approximately 3 hours and 15 minutes. During this time, the facility’s Emergency Operations Plan for loss of electrical power, which required initiation of manual ventilation with Ambu‑bags and continuous assessment of residents by nursing and respiratory staff, was not effectively implemented. All ventilator‑dependent residents were ultimately evacuated to the hospital to maintain their health and safety. One resident, identified as having chronic respiratory failure and COPD and requiring full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring in the EHR from the afternoon prior to the outage through shortly after midnight, encompassing the period of the power failure. The respiratory therapist on duty at the start of the outage did not document any respiratory assessments or monitoring for this resident, and the facility could not provide documentation that manual ventilation was initiated once staff realized the red emergency outlets were nonfunctional. Hospital admission records for this resident showed an elevated lactic acid level, which the report notes can be a marker of tissue hypoxia and metabolic stress during respiratory compromise. Staff interviews revealed additional gaps in care and monitoring during the outage. There was one respiratory therapist on site for 14 ventilator‑dependent and 6 tracheostomy residents, and the ventilator unit was staffed with two nurses and two aides. One RN reported working a double shift exceeding 14 hours and stated that he did not perform interventions on ventilator patients beyond checking if a resident was breathing or in distress, did not monitor other residents due to limited staffing, and did not document his actions because the computers had no power. Another nurse reported that the outage began around 9:00–9:30 PM, that ventilator power cords were moved to emergency outlets, and that oxygen cylinders were brought to some patients, but there was no documented evidence that the required manual ventilation and continuous respiratory assessments were carried out for the ventilator‑dependent residents during the generator failure.
Removal Plan
- Updated emergency power outage plan.
- Updated staffing plan for emergencies.
- Updated command list for key personnel outlining responsibilities of responsible individuals.
- Created plan to monitor and track maintenance of life maintaining equipment.
- Created QA tool to monitor compliance.
- Reviewed and updated staffing plan.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Provide Timely Wound Care Following Physician Orders
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders for wound care for a resident with necrotizing fasciitis, sepsis, type II diabetes, polyneuropathy, and anxiety disorder. The resident was cognitively intact and had a physician order for negative pressure wound therapy (NPWT) to be applied to the right foot on specific days and as needed. On the day of the incident, the resident independently removed the NPWT device after showering and wrapped her foot in a towel due to a strong odor. She repeatedly requested assistance from various staff members, including a CNA, nurse, social service director, and front desk staff, to have the wound care nurse attend to her wound, but her requests were not acted upon or communicated effectively to the wound care nurse. Multiple staff members, including the CNA, nurse, social service director, and front desk staff, either assumed the wound care nurse would see the resident during rounds or did not follow up after initial attempts to contact the wound care nurse. The wound care nurse reported not receiving any requests or reports about the resident needing wound care after her initial morning encounter. The facility's protocol required staff to call the wound care nurse directly if a resident requested wound care, but this was not done. Documentation for the day showed no record of wound care being provided, and the only progress note indicated the resident was non-compliant with prescribed wound care, had removed her wound vac, and was upset, eventually insisting on hospital transfer. The resident waited approximately five hours without receiving wound care, ultimately calling 911 herself and being transported to the hospital. Upon EMS arrival, the resident and her husband reported that she had been requesting wound care and pain management for several hours without response. EMS documented a large, deep, weeping wound on the right foot, and hospital records confirmed the resident presented with pain, erythema, and exposed tendon, with no wound care provided that day. The facility's grievance and policy documents further confirmed the lack of adherence to physician orders and wound care protocols.
Failure to Ensure Adequate Hydration for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on tube feeding for nutrition, received the recommended amount of fluids. This deficiency was identified for a resident who was hospitalized with dehydration, high blood sodium, and hypotension. The resident, a male with a complex medical history including brain damage, epilepsy, and acute kidney failure, was admitted to the facility and was receiving enteral nutrition via a feeding tube. The care plan for the resident included interventions for potential impaired nutrition and required the registered dietitian to assess fluid needs and report any signs of dehydration. The registered dietitian recommended an increase in the resident's enteral flush from 30ml to 200ml every four hours to provide adequate hydration. However, the facility continued to administer only 30ml flushes as per the existing physician order, which was not updated to reflect the dietitian's recommendation. The resident's progress notes did not document any communication with the physician regarding the recommended increase in fluids, and the resident was subsequently hospitalized with severe dehydration and related complications. The Director of Nursing reported that the registered dietitian's recommendation was not communicated effectively due to a transition in the electronic health record system. The recommendation was entered into an inactive system and was not transferred to the active system, resulting in the facility being unaware of the need to increase the resident's fluid intake. The failure to communicate and implement the dietitian's recommendation led to the resident not receiving the necessary amount of fluids, contributing to his hospitalization.
Facility Fails to Maintain Cleanliness in Resident Rooms and Equipment
Penalty
Summary
The facility failed to adhere to its housekeeping policy and procedure, resulting in unclean and unsanitary conditions in the rooms and medical equipment of residents who are entirely dependent on staff for care. This deficiency was observed in four residents, each with significant medical needs, including brain damage, epilepsy, pressure ulcers, and feeding tube use. The observations revealed multiple instances of visible dust, particles, and substances on medical equipment such as oxygen machines and feeding tube monitors, as well as on furniture and other surfaces within the residents' rooms. For one resident, the oxygen machine and respiratory equipment were found with visible dust, and a brown substance was observed on the feeding tube monitor and pole. Uncovered syringes were also noted on the dresser, and the refrigerator had visible dust and residue. Another resident's room had similar issues, with dust on the oxygen machine and respiratory equipment, stained mats, and uncovered syringes. The resident's care plan indicated complete dependence on enteral feeding due to conditions like dementia and renal disease. The facility's Director of Nursing and Registered Nurse confirmed the observations and acknowledged the responsibility of nursing and respiratory staff in maintaining the cleanliness of medical equipment. The Housekeeping Supervisor noted that housekeeping staff are responsible for cleaning the rooms daily, but a staff shortage due to illness had impacted this routine. Despite the collaborative effort required to maintain cleanliness, the deficiency persisted, affecting the residents' environment and potentially their care.
Failure to Follow Feeding Tube Care Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedures for feeding tube care by not following physician orders for daily cleansing and dressing of feeding tube sites for residents dependent on enteral nutrition. This deficiency was observed in four residents, each with significant medical histories requiring enteral feeding. The facility's policy mandates daily gastrostomy tube care, which was not consistently performed, as evidenced by missing documentation and observations of improper site care. One resident, a male with a history of brain damage, epilepsy, and other severe conditions, was found with a feeding tube site that lacked a dressing and had a noticeable scab. The registered nurse acknowledged that the site should have been cleaned and dressed nightly, as per the physician's orders. Another resident, a female with partial paralysis and dysphagia, had a feeding tube site with an outdated dressing and visible staining, indicating that the site had not been properly cleaned and redressed as required. Additional observations included a female resident with Alzheimer's disease and dysphagia, whose feeding tube site was found without a dressing and with old drainage. The licensed practical nurse confirmed that the site should have been dressed nightly. Similarly, another female resident with a history of stroke and dysphagia had a feeding tube site with an undated dressing and signs of crust and dry drainage. The Director of Nursing confirmed that the night shift was responsible for changing the dressings, and missing entries in the Treatment Administration Record suggested that the required care was not administered.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to properly transfer a resident, resulting in the resident being hospitalized with a neck fracture. The resident, an elderly female with multiple diagnoses including dementia and difficulty walking, was being transferred from a wheelchair to a shower chair by a Certified Nursing Assistant (CNA). During the transfer, the resident began to slide and was lowered to the floor. The resident was wearing slippers at the time, which were not appropriate for transfers, and a gait belt was not used despite the care plan indicating its necessity. The CNA involved in the transfer stated that the resident could transfer independently and did not require a gait belt, contrary to the care plan and Minimum Data Set (MDS) which indicated the need for maximum assistance and a gait belt during transfers. The Director of Nursing confirmed that the resident should have been wearing non-skid socks and a gait belt should have been used. The incident led to the resident sustaining an acute C7 spinous process fracture, as confirmed by hospital records.
Deficient Catheter Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with indwelling catheters, leading to severe health consequences. For one resident, the facility did not obtain a urine specimen from the catheter in a timely manner, failed to document catheter output, and did not provide necessary catheter care. This resident, who had a history of UTIs and other significant health issues, showed signs of increased confusion and distress, which were not adequately addressed by the staff. Despite orders for a urinalysis, the specimen was not collected promptly, and the resident was eventually hospitalized with a severe UTI and sepsis. The facility's documentation was incomplete and inconsistent, with missing entries for urine output and catheter care in the Medication Administration Record (MAR). The resident's care plan included monitoring for signs of UTI and providing catheter care, but these interventions were not effectively implemented. The staff failed to recognize and respond to the resident's symptoms, such as altered mental status and poor appetite, which were indicative of a UTI. The lack of timely intervention and communication with healthcare providers contributed to the resident's deterioration and subsequent hospitalization. Another resident also experienced issues with catheter care, as evidenced by the presence of sediment in the catheter tubing and missing documentation of urine output and catheter care. This resident had a history of frequent UTIs and was on antibiotic therapy for a positive urine culture. The facility's failure to adhere to its own policies and procedures for catheter care and monitoring contributed to the deficiencies observed by the surveyors.
Failure to Provide Recliner Wheelchair for Resident
Penalty
Summary
The facility failed to provide a recliner wheelchair to a resident, identified as R12, who expressed a desire to get out of bed and interact with the environment. R12, who is [AGE] years old, was admitted to the facility with diagnoses including multiple sclerosis, a sacral ulcer, chronic anemia, and protein energy undernutrition. The Minimum Data Set (MDS) indicated that R12 uses a wheelchair for mobility. However, during facility rounds, R12 was observed in bed and stated a desire to get out but was unable to do so due to the lack of a wheelchair. The resident mentioned not remembering the last time they got up and had asked nursing assistants for assistance but was told there was no chair available. The deficiency was further highlighted when a Certified Nursing Assistant (CNA) confirmed that R12 had been using a recliner wheelchair provided by hospice services, which was removed after hospice care was discontinued. The CNA admitted to not having gotten R12 out of bed since the hospice service ended. A Registered Nurse and the Assistant Director of Nursing were unaware of the lack of a recliner wheelchair for R12, despite the facility's policy stating that residents should have reasonable arrangements to meet their needs. The Director of Nursing expected all residents to have a wheelchair upon admission or as needed, but no wheelchair was available for R12 during the surveyor's checks.
Failure to Lock Wheelchair and Supervise Resident Leads to Fall
Penalty
Summary
The facility failed to ensure the wheelchair locking mechanism was engaged and failed to supervise a high-risk resident, resulting in the resident falling out of an unlocked wheelchair in an unsupervised dining room. The resident sustained bruising to the left side of the face and a cut above the left eye, requiring hospital evaluation and four sutures. The incident occurred when the activity aide transported the resident to the dining room and did not lock both sides of the wheelchair. The resident was left unsupervised, and the fall occurred shortly after. The resident involved in the incident had a history of dementia with other behavioral disturbances, anemia, anxiety disorder, major depressive disorder, essential hypertension, heart failure, glaucoma, osteoarthritis, and vertigo. The resident was assessed as high risk for falls, with a care plan indicating the need for the wheelchair to be locked at all times and for the resident to be placed in supervised areas when out of bed. Despite these precautions, the resident was left unsupervised in the dining room, leading to the fall. Interviews with staff revealed that the activity aide was not adequately trained on the use of wheelchairs and the importance of locking both wheels. The aide admitted to locking only one side of the wheelchair and was unaware of the need for supervision in the dining room. The facility's policies on fall prevention and wheelchair safety were not effectively communicated or enforced, contributing to the incident.
Failure to Follow Isolation Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to physician orders for transmission-based precautions for a resident diagnosed with multiple infections, including Klebsiella in the urine and MRSA in the nares. The resident was placed on contact and droplet isolation precautions due to their neutropenic status, as documented in their care plan. Despite clear signage indicating the need for PPE and isolation precautions, a CNA entered the resident's room without performing hand hygiene or donning any PPE, collected a meal tray, and continued to other rooms without following proper infection control protocols. The CNA admitted to not wearing PPE because they believed it was unnecessary if they did not touch the resident. This misunderstanding was corrected by the RN and the Infection Prevention Nurse, who both confirmed that PPE must be worn by anyone entering the room to prevent the spread of infection. The facility's infection control policy, revised in May 2024, outlines the necessity of PPE and hand hygiene to prevent the transmission of infectious agents, but these protocols were not followed in this instance, leading to a deficiency in infection control practices.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident (R4) from abuse, resulting in R3 punching R4 in the face, causing discoloration to the right eye and bleeding from the nose and mouth. The incident occurred on 12/12/2023 when a Certified Nursing Assistant (CNA) found R4 bleeding and reported the situation to the nurse. R3 admitted to punching R4 because R4 was coughing and allegedly did so on purpose after R3 asked him to stop. R4's care plan indicated a risk for abuse due to dementia and behavioral disturbances, while R3's care plan noted a risk of abuse due to schizophrenia and a history of provoking others. Both residents were transferred to the hospital for further evaluation, and the police were notified, but no criminal charges were pursued due to the mental diagnoses of both residents. The facility's investigation confirmed that R3 hit R4, and R3 was subsequently discharged from the facility. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, and exploitation. The deficiency was corrected on 12/15/2023.
Inadequate Supervision of High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise a high-risk resident (R2) for falls, resulting in R2 falling out of his wheelchair and sustaining injuries. R2, who has a history of falls and multiple medical conditions including Orthostatic Hypotension, Major Depressive Disorder, and Mild Cognitive Disorder, was left unsupervised at the nurse's station. Despite being identified as a high fall risk, R2 was allowed to fall asleep in his wheelchair and subsequently fell forward onto the floor, causing a laceration on the bridge of his nose that required hospital evaluation and sutures. Interviews with staff revealed that R2 was being moved around by a CNA (V9) to prevent him from falling out of bed. However, R2 was left at the nurse's station while the CNA attended to another resident. The LPN (V10) at the nurse's station was not closely monitoring R2 at the time of the fall, as she was engaged in other tasks and conversations. Multiple staff members, including V8 and V17, confirmed that they did not witness the fall but heard a loud noise and found R2 on the floor. The Director of Nursing (V2) acknowledged that R2 had a history of falls and that the facility was aware of his high fall risk. Despite this, the facility did not have a specific policy on monitoring high fall risk residents, relying instead on general supervision practices. Observations by the surveyor also noted a lack of supervision in the dining room, where residents were left unattended, further highlighting the facility's inadequate supervision practices.
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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