Evercare At Edwardsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Edwardsville, Illinois.
- Location
- 401 St Mary Drive, Edwardsville, Illinois 62025
- CMS Provider Number
- 145555
- Inspections on file
- 38
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 13 (2 serious)
Citation history
Health deficiencies cited at Evercare At Edwardsville during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was alleged by a family member to have not received prescribed medications, with video footage and MARs providing conflicting information. The administrator reviewed the situation but did not report or investigate the allegation as required, and key clinical leaders were not notified, resulting in a failure to follow the facility's abuse prevention policy.
A resident with severe cognitive impairment and multiple diagnoses was prescribed oxycodone, which was reported missing after a nurse failed to administer it as scheduled. The incident was brought to the attention of the facility administrator by a CNA, but the administrator did not report the alleged misappropriation to authorities or follow up with the family, contrary to facility policy.
A resident with severe cognitive impairment and dependency was reported by a family member to have not received prescribed oxycodone. The administrator reviewed video footage and MARs, but did not conduct a formal investigation or notify the DON or VP of Clinical Operations, as required by facility policy. This resulted in a failure to properly investigate an allegation of medication misappropriation.
A resident with cognitive impairment and complex medical needs was transferred to another facility following an altercation, without proper involuntary discharge paperwork or advance written notice. The resident and her family were not informed of their rights, and staff were unaware of the discharge until it was occurring. The ombudsman intervened, and an administrative law judge ordered the resident's return, highlighting the facility's failure to follow required discharge procedures.
A resident with cognitive impairment and significant care needs was discharged without the required medical information being communicated to the receiving provider. The responsible RN was unaware of the discharge until the last minute, resulting in the absence of necessary paperwork and documentation that should have accompanied the resident, in violation of facility policy.
A resident with ESRD was admitted without dialysis services being arranged, resulting in 12 days without treatment and subsequent hospitalization due to critical lab values and symptoms. Additionally, two residents with behavioral issues were involved in repeated altercations, including physical aggression and bruising, despite staff awareness and care plan updates. The facility did not ensure proper care coordination or prevent neglect and abuse as required.
A resident with end-stage renal disease was admitted without dialysis services being arranged, resulting in 12 days without treatment. The resident developed symptoms such as shortness of breath and jaundice, and was found to have critical lab values before being hospitalized. Facility staff did not coordinate or document necessary dialysis care, and there was no interim plan to address the missed treatments.
A resident with end-stage renal disease did not receive dialysis for 12 days due to the facility's failure to notify the physician of missed treatments, resulting in hospitalization for elevated potassium and other complications. The care plan and physician orders lacked documentation of dialysis needs, and the facility did not follow its policy for timely physician notification regarding significant changes in condition.
The facility did not provide enough licensed nursing staff during the evening shift, resulting in multiple residents with complex medical needs receiving their scheduled medications, including pain management, late—sometimes after midnight. Both residents and staff confirmed that the reduction from four to three nurses made it difficult to complete timely medication passes, and Resident Council records documented ongoing complaints about late medications and delayed call light responses.
Surveyors found that multiple residents did not receive their scheduled medications on time, with repeated late administration of pain, cardiac, and sleep medications. Residents and staff reported that the issue was due to insufficient nurse staffing during the evening shift, following a reduction in the number of nurses. Facility records and interviews confirmed that late medication administration was a widespread and ongoing problem, resulting in increased pain and frustration among residents.
A resident with a history of aggression and psychiatric diagnoses struck another resident in the face after the latter attempted to open his door to assist him. The incident resulted in physical injury and fear for the affected resident, despite prior documentation of the aggressor's behavioral risks and interventions such as frequent checks.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, as well as inadequate catheter care and insufficient measures to prevent UTIs.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found that staffing levels and shift leadership did not comply with regulations.
A facility failed to prevent resident-to-resident abuse, involving three incidents where residents with cognitive impairments and behavioral issues engaged in altercations. One resident was hospitalized after being pushed, while another was struck in the face. The facility attributed these incidents to the residents' dementia and confusion, concluding they were not premeditated.
A resident experienced increased pain and discomfort due to the facility's failure to ensure timely availability of prescribed Oxycodone. The resident, who requires monthly prescription renewals for chronic pain management, was left without medication for several days due to ineffective reordering processes and communication issues between staff and the prescribing doctor. The facility's pain management policy was not adequately followed, resulting in incomplete pain assessments and lack of alternative pain relief options.
A resident experienced discomfort and withdrawal symptoms due to the facility's failure to ensure timely refills of scheduled opioid medication. Despite the resident's predictable need for monthly prescription renewals, the facility did not manage the reordering process effectively, leading to missed doses. Staff acknowledged the issue but were unable to secure the necessary prescription in a timely manner, highlighting a breakdown in communication and coordination between the facility, pharmacy, and prescribing doctor.
A facility failed to complete PASRR recommendations for a resident with intellectual disabilities and disruptive behaviors. The resident exhibited aggressive behavior, causing fear among other residents and requiring police intervention. Staff reported inadequate training and lack of policies for managing such behaviors, leading to ongoing disruptions and an unsafe environment.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in care plans and treatment. One resident's MDS inaccurately documented pain management, despite reports of significant pain and Oxycodone administration. Another resident's MDS did not reflect behaviors like wandering and potential psychosis, despite observations of such behaviors. The facility lacked a policy on assessment accuracy, contributing to these deficiencies.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed oxycodone due to unavailability. The facility faced issues with the hospice company responsible for medication refills, leading to multiple missed doses. The RN eventually administered the medication from the emergency kit after receiving approval.
Two residents in a LTC facility received inadequate incontinent care, as observed during a survey. A CNA failed to provide timely and thorough care, using incorrect cleansing methods and not adhering to the facility's perineal care policy. One resident reported long wait times for changes and had a recent history of UTI, while the other was left with feces on her skin. The facility's policy required more frequent checks and proper cleansing techniques, which were not followed.
Failure to Report and Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of misappropriation of medication for a resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone every four hours. The resident's family member reported that the resident did not receive any medications during a specific shift, and video footage was reviewed by the administrator, who determined that the nurse had entered the room but did not verify medication administration. The Medication Administration Records (MARs) indicated that medications had been given, but the family member and oncoming nurse reported that the medications were missing and had been documented as administered. Despite the allegation and conflicting accounts, the administrator did not report the incident or initiate an investigation as required by the facility's abuse prevention policy. The Director of Nursing and the Vice President of Clinical Operations were not notified of the allegation, and standard procedures such as checking medication counts and narcotic logs were not followed. The facility's policy mandates prompt and thorough investigation of all reports of misappropriation, but this process was not initiated in this case.
Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication for one resident who was severely cognitively impaired and dependent on staff for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone. According to interviews and record review, a nurse did not enter the resident's room during her shift and informed a family member that the oncoming nurse would administer the medication. The oncoming nurse then reported that the medication was missing, although it had been documented as given. A certified nursing assistant notified the administrator of the situation, but the administrator did not follow up with the family member as promised and did not report the incident to the state health department or law enforcement, as required by the facility's abuse prevention policy.
Failure to Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of medication for one resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone to be administered every four hours. The resident's family member reported that the resident did not receive her medications on a specific date. The administrator reviewed video footage and checked the Medication Administration Records (MARs), which indicated the medications had been given, and concluded the issue was resolved without further investigation. Despite the family member's report that the nurse did not enter the resident's room and that the oncoming nurse stated the medications were missing but documented as given, the administrator did not notify the Director of Nursing or the Vice President of Clinical Operations, nor did she conduct a formal investigation as outlined in the facility's abuse prevention policy. The policy requires prompt and thorough investigation of all reports of misappropriation, including checking medication counts and documentation, and reporting findings to appropriate agencies. The failure to follow these procedures resulted in the deficiency.
Failure to Follow Proper Involuntary Discharge Procedures
Penalty
Summary
The facility failed to follow proper procedures for the transfer and discharge of a resident with cognitive impairment and significant care needs. The resident, who had a diagnosis of malignant neoplasm of the colon and chronic pain, was admitted for long-term care and had a care plan goal to remain in the facility. After an altercation with another resident, the facility sent the resident to the hospital for a psychological evaluation and subsequently transferred her to another facility without her consent. The resident expressed distress about the transfer, and her family was not informed of their rights or provided with appropriate discharge information. Staff interviews revealed that the resident did not want to leave, and the transfer occurred without the knowledge or preparation of her assigned nurse. The facility did not provide the required involuntary discharge (IVD) paperwork to the resident or her representative, nor did they notify them in writing of the reasons for the move as required by policy. The administrator confirmed that no IVD paperwork was filed, and the social services director was unaware of the transfer until after it had occurred. The ombudsman intervened, and an administrative law judge ordered the facility to take the resident back. Documentation and interviews consistently indicated that the facility did not follow established procedures for involuntary discharge, including providing advance notice and ensuring the resident's preferences and needs were considered.
Failure to Communicate Required Resident Information at Discharge
Penalty
Summary
The facility failed to communicate required resident information to the receiving provider during the discharge of one resident. The resident, who had diagnoses including malignant neoplasm of the colon and chronic pain, was cognitively impaired and required substantial assistance with transfers. On the day of discharge, the registered nurse responsible was not aware of the discharge until informed by another staff member as the resident was preparing to leave. As a result, the nurse did not have the resident's paperwork ready and was unable to provide a report to the receiving facility. There was no documentation that the necessary paperwork, such as the medication list, progress notes, care plan, and face sheet, was sent with the resident, contrary to the facility's policy and procedures for discharge communication.
Failure to Coordinate Dialysis Care and Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) was free from neglect during the admission process. The resident was transferred from another nursing home and had been receiving dialysis five days per week prior to admission. Upon arrival, no dialysis services were set up or scheduled, and there was no alternate dialysis treatment provided while waiting for a new provider. The resident did not receive dialysis for 12 days, during which time she experienced symptoms including shortness of breath, sweating, weakness, jaundice, and critical laboratory values such as elevated potassium, BUN, and creatinine levels, ultimately requiring hospitalization. Documentation showed that the resident's care plan and physician orders did not include dialysis, and there was no evidence of physician notification or follow-up regarding the missed treatments. Additionally, the facility failed to prevent resident-to-resident altercations involving two residents with behavioral and psychiatric diagnoses. There were multiple documented incidents where one resident was verbally and physically aggressive toward another, including hitting and pulling hair. Staff and other residents witnessed these altercations, and skin assessments confirmed bruising. Despite these repeated behaviors, care plans and interventions did not prevent further incidents, and both residents continued to have conflicts. The deficiencies were identified through interviews, record reviews, and observations, revealing lapses in care coordination, communication, and supervision. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the lack of timely action to secure necessary dialysis treatments and to prevent ongoing resident-to-resident altercations. The events led to significant harm and risk for the residents involved.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on neglect related to coordination of care by not setting up dialysis treatments.
- All department heads on abuse and neglect policy and procedure and no staff was allowed to work until they were in-serviced on abuse and neglect.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis treatment.
Failure to Coordinate Dialysis Care Resulting in Missed Treatments and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, who was dependent on hemodialysis, was admitted to the facility without any dialysis services being set up or scheduled prior to admission. The resident had been receiving dialysis five times per week at the previous facility, but upon transfer, no arrangements were made to continue this essential treatment. The facility did not implement any alternative dialysis treatment while waiting for a new provider, and there was no documentation of dialysis orders or appointments in the resident's records. The care plan and progress notes failed to address the resident's ongoing need for dialysis or any interim measures to manage her condition. During the 12 days following admission, the resident did not receive any dialysis treatments. She began to exhibit symptoms including shortness of breath, sweating, weakness, and jaundiced eyes. Laboratory results revealed critical values, such as elevated potassium, BUN, and creatinine levels. Despite these symptoms and the absence of dialysis, there was no documented follow-up or escalation of care to address the missed treatments. The resident's family ultimately requested that she be sent to the hospital, where she was found to have critical lab values and required a five-day hospitalization. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's dialysis needs. Staff members, including the DON, ADON, and Social Service Director, indicated that it is standard practice to ensure dialysis is arranged before admitting a resident who requires it, but in this case, the process was not followed. The transportation staff attempted to refer the resident to a dialysis center, but the referral did not go through, and there was no effective follow-up. The nephrologist and medical doctor both confirmed that missing dialysis treatments can cause serious harm and that the facility failed to coordinate care to prevent this outcome.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on dialysis care related to coordination of care by not setting up dialysis treatments.
- All department heads on dialysis and procedure and no staff was allowed to work until they were in-serviced on dialysis.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis needs are addressed.
Failure to Notify Physician of Missed Dialysis Leading to Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a resident who did not receive dialysis for 12 days, resulting in the resident's hospitalization. The resident had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, but the Physician Order Sheet did not include an order for dialysis, only for monitoring the dialysis catheter. The care plan also did not document that the resident was receiving or awaiting approval for dialysis treatments. Progress notes indicated that the resident complained of symptoms such as shortness of breath, weakness, and sweating, and reported missing a dialysis session. Although the physician was notified of a missed dialysis day and low glucose, there was no documentation that the physician was informed about the ongoing lack of dialysis treatments or that the resident went 12 days without dialysis. The medical director confirmed that he was not made aware that the resident had not received dialysis as recommended and stated that, had he known, he would have sent the resident to the hospital for treatment. Hospital records confirmed that the resident had not received dialysis for about two weeks since transfer to the facility, resulting in elevated potassium, BUN, and creatinine levels. The hospital provided dialysis, and the resident was hospitalized for five days before being discharged back to the facility. The facility's policy requires timely notification of the physician and family when there is a significant change in a resident's condition or a need to alter treatment. In this case, the lack of communication and documentation regarding the resident's dialysis needs and missed treatments led to a significant lapse in care and a failure to follow established protocols for physician notification.
Failure to Provide Sufficient Licensed Nursing Staff Results in Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to meet the needs of all residents, as evidenced by interviews and record reviews for four residents with complex medical conditions. These residents reported that their scheduled evening medications, including pain management and other critical treatments, were frequently administered late. Residents described being woken up to receive medications well past the scheduled times, sometimes after midnight, resulting in increased pain and dissatisfaction. The issue was corroborated by the residents' cognitive status, as documented in their Minimum Data Set (MDS) assessments, and by their direct statements regarding the impact of late medication administration. Multiple staff members, including LPNs and the wound care nurse, confirmed that the reduction in evening nursing staff from four to three nurses between 6 PM and 10 PM made it difficult to complete medication passes on time. Staff reported that the change was made by facility ownership to save money, and that three nurses were insufficient to manage the medication needs of the resident population during the evening shift. The facility's own policy requires staffing levels to be based on resident census and needs, and the daily census showed 100 residents at the time of the survey. Resident Council meeting memoranda further documented ongoing concerns, with residents expressing frustration about waiting until after 11 PM for medications and call lights not being answered promptly. The Director of Nursing acknowledged awareness of the issue and the difficulty nurses faced in completing all required tasks with the reduced staffing. The administrator also confirmed that medication administration times were being documented as late, consistent with resident and staff reports.
Failure to Administer Medications at Scheduled Times Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to administer medications at the scheduled times for four residents reviewed for medication administration. Documentation showed repeated late administration of critical medications, including acetaminophen, carvedilol, oxycodone, trazodone, and hydromorphone. Medication Administration Records (MARs) indicated that evening medications were often given hours after the scheduled time, with some doses administered after midnight. Residents reported experiencing increased pain and disrupted sleep due to these delays, and several stated that nurses had to wake them up late at night to take their medications. Interviews with residents and staff revealed that the late administration of medications was a persistent issue, particularly during the evening shift. Residents, including the President of the Resident Council, expressed frustration and discomfort, noting that the problem had become more pronounced in recent months. Staff members, including LPNs and the wound care nurse, consistently attributed the delays to insufficient nurse staffing during the 6 PM to 10 PM shift. They reported that the facility had recently reduced the number of nurses from four to three during this critical period, making it difficult to complete medication passes on time. Facility leadership, including the Administrator and DON, acknowledged awareness of the issue, as documented in Resident Council meeting memoranda and interviews. The facility's own medication administration policy requires medications to be given within one hour of the scheduled time, but records and staff statements confirmed that this standard was not being met. The deficiency affected all residents in the facility, as the late administration of medications was not limited to the sampled residents but was reported as a widespread concern.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving one resident who was struck in the face by another resident. The incident occurred when one resident, who has a history of inappropriate contact, physical aggression, and paranoia, reacted aggressively after another resident attempted to open his door to assist him. The aggressor, who is cognitively intact but has multiple psychiatric diagnoses including Alzheimer's Disease, psychosis, and obsessive-compulsive disorder, became agitated and hit the other resident, resulting in redness to the face and arm, as well as bleeding from the head. The affected resident, who is also cognitively intact and has diagnoses including cerebral infarction and Alzheimer's Disease, reported feeling fearful of the aggressor and stated he does not feel safe around him, although he generally feels safe in the facility when staff are present. Prior to the incident, the aggressor's care plan documented a history of physical aggression, poor impulse control, and a dislike of having his personal space invaded. The care plan also noted previous encounters with other residents and interventions such as 15-minute checks. Despite these documented risks and behaviors, the incident occurred when the other resident, unaware of the behavioral symptoms, attempted to help by opening the door, which triggered the aggressive response. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents, and defines resident-to-resident abuse as willful, deliberate actions.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three residents, resulting in one resident being sent to the hospital. The incidents involved residents with varying degrees of cognitive impairment and behavioral issues. In one case, a resident with severe cognitive impairment and a history of wandering struck another resident in the face, leading to redness and the need for medical evaluation. The facility's investigation concluded that the incident was isolated and not premeditated, attributing it to the resident's dementia and confusion. In another incident, two residents with dementia and behavioral issues were involved in an altercation. One resident attempted to take items from a table, leading to a confrontation where the other resident swung a cup, causing a minor injury. Both residents were separated and placed under one-on-one monitoring. The facility's report indicated that neither resident had a history of aggressive behavior, and the incident was not considered premeditated or targeted. A third incident involved a resident with a personality disorder and Alzheimer's disease pushing another resident, causing a fall and subsequent hospital visit. The facility did not view this as abuse, citing the resident's peculiar behavior and lack of malicious intent. Despite the incidents, the facility's staff and administration did not perceive these behaviors as aggressive or intentional, and they continued to monitor the residents involved.
Failure to Ensure Timely Pain Medication Availability
Penalty
Summary
The facility failed to ensure that pain medications were readily available for a resident, leading to increased pain and discomfort. The resident, who is cognitively intact, relies on Oxycodone for chronic pain management due to hip deterioration. Despite the predictable need for monthly prescription renewals, the facility did not manage the reordering process effectively, resulting in the resident being without medication for several days. The resident reported severe pain and withdrawal symptoms during these periods without medication. Interviews with staff revealed a lack of clarity and responsibility in the medication ordering process. A staff member mentioned that the medication card indicates when to reorder, but there was confusion about whether the pharmacy or the doctor was at fault for the delay. The Nurse Practitioner, who was in charge, could not write prescriptions for controlled substances, and the facility's attempts to contact the doctor were not timely or effective, leading to gaps in medication availability. The facility's pain management policy requires regular pain assessments and timely interventions, but these were not adequately followed. The resident's pain assessment was incomplete, and there was no PRN Tylenol order to manage pain in the absence of Oxycodone. The Director of Nursing acknowledged the oversight in pain assessment and the need for a referral to pain management. Despite the facility's policy, the resident experienced significant pain and distress due to the unavailability of prescribed pain medication.
Failure to Ensure Timely Opioid Medication Refill
Penalty
Summary
The facility failed to ensure the availability of scheduled opioid medication for a resident, resulting in the resident missing several doses of pain medication and experiencing discomfort and withdrawal symptoms. The resident, who is cognitively intact, relies on Oxycodone for chronic pain management due to hip deterioration. Despite the predictable need for a monthly prescription renewal, the facility did not manage the reordering process effectively, leading to the resident being without medication for several days. Interviews with staff and the resident revealed a lack of communication and coordination between the facility, the pharmacy, and the prescribing doctor. The resident expressed frustration over the recurring issue of running out of medication and the lack of proactive measures to prevent it. Staff members, including the Director of Nursing and the Assistant Director of Nursing, acknowledged the problem but indicated that they were unable to compel the doctor to provide the necessary prescription in a timely manner. The facility's Controlled Substance Prescription Policy outlines the process for obtaining and renewing prescriptions, but it appears that these procedures were not followed effectively. The policy requires the pharmacy to notify the facility if a prescription is not obtained before the medication runs out, but this did not prevent the resident from experiencing a gap in medication availability. The nurse practitioner involved was unable to write the prescription due to not having a DEA number, further complicating the situation.
Failure to Address Behavioral Health Needs and Ensure Accurate Assessments
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screen Resident Review (PASRR) recommendations were completed for a resident with a qualifying diagnosis and disruptive behaviors. The resident, identified as R4, had a diagnosis of mild intellectual disabilities, schizoaffective disorder, and bipolar disorder. Despite the PASRR indicating that a resident review should be completed when the short-term approval was ending, this was not done. Additionally, the resident's Minimum Data Set (MDS) inaccurately documented that R4 did not have potential indicators of psychosis, such as hallucinations or delusions, and did not reject evaluation or care, nor wander, which contradicted observations and reports from staff and other residents. Multiple interviews with residents and staff revealed that R4 exhibited disruptive and aggressive behaviors, including using foul language, making other residents feel unsafe, and requiring police intervention on several occasions. Staff and residents reported feeling intimidated and scared by R4's behavior, which included cursing, making inappropriate comments, and unpredictable actions. Despite attempts to redirect R4 and provide one-on-one care, the interventions were unsuccessful, and the behavior continued to affect the well-being of other residents. The facility lacked adequate staff training and policies related to behavioral health services, as noted by the Director of Nursing and other staff members. The facility's administrator was unaware of R4's PASRR requirements, and there was no policy in place for managing residents with behavioral health issues. The facility's failure to address R4's behavioral health needs and ensure accurate assessments and interventions contributed to the ongoing disruptive behavior and the negative impact on the facility's environment.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their care plans and treatment. For one resident, the Minimum Data Set (MDS) inaccurately documented that the resident had not received scheduled or PRN pain medications, despite the resident's reports of significant pain and the administration of Oxycodone as per physician's orders. The resident's care plan noted potential for pain and required monitoring of pain interventions, yet the quarterly pain assessment was incomplete, and the resident's diagnoses related to pain were not updated in the facility's records. The Director of Nursing acknowledged the inaccuracies in the MDS and the need for a referral to pain management. Another resident's MDS failed to reflect behaviors such as wandering and potential indicators of psychosis, despite observations and reports of the resident walking anxiously and talking to imaginary people. The care plan documented the resident's behavior of walking throughout the facility and cursing, which was not successfully managed by the interventions attempted. The facility had a behavioral health counselor available, but the resident refused to see her. The facility did not provide a policy related to the accuracy of assessments, contributing to the deficiencies noted.
Failure to Administer Prescribed Medications Due to Unavailability
Penalty
Summary
The facility failed to administer prescribed medications to a resident, identified as R2, who was part of a sample reviewed for pharmacy services. R2, who was admitted with diagnoses including metabolic encephalopathy, Alzheimer's, and interstitial cystitis, was severely cognitively impaired and dependent on staff for daily activities. The care plan for R2 included monitoring for pain and ensuring medication compliance. However, the Medication Administration Record (MAR) indicated that R2's prescribed oxycodone was not administered multiple times over several days due to the drug being unavailable. Interviews and record reviews revealed that the facility experienced issues with the hospice company responsible for R2's medication, leading to a lack of timely refills. The Assistant Director of Nursing acknowledged the problem with the hospice company, and the Director of Nursing was unaware of the situation due to a lack of documentation by the RN who had been contacting hospice. The RN confirmed the absence of oxycodone in the medication drawer and the need for a prescription to access the emergency kit. Eventually, the RN received approval to administer oxycodone from the emergency kit, but this was after several missed doses.
Inadequate Incontinent Care for Two Residents
Penalty
Summary
The facility failed to provide timely and thorough incontinent care for two residents, R1 and R5, as observed during a survey. R1 reported that it sometimes takes up to two hours to be changed when incontinent and that she had not been changed since the previous night. During an observation, a CNA, V9, provided inadequate care by not checking R1's incontinence status earlier, using a soap that required rinsing without rinsing or drying the areas, and failing to clean R1's inner vaginal folds. R1's adult diaper and gown were saturated with urine, and she had redness in her groin and buttocks areas. R1 had a recent history of hospitalization for sepsis and a urinary tract infection, and her care plan did not address her urinary incontinence or UTI. R5 also experienced inadequate care, as she reported not being checked or changed since early morning. When V9 provided care, he used a no-rinse peri-wash incorrectly, did not clean R5's inner vaginal folds, and left feces on her left buttock before putting on a new adult diaper. V9 also failed to dry any areas after cleansing. R5's care plan indicated she was at risk for irritant contact dermatitis due to incontinence and required care after each incontinent episode. The facility's policy on perineal care was not followed, as it required separating the labia, washing, rinsing, and drying the area from front to back. The Assistant Director of Nurses stated that incontinent residents should be checked and changed at least every two hours and that staff should thoroughly cleanse all areas affected by urine or feces. The facility's failure to adhere to these standards resulted in inadequate care for R1 and R5.
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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