Evercare Of Granite City
Inspection history, citations, penalties and survey trends for this long-term care facility in Granite City, Illinois.
- Location
- 3500 Century Drive, Granite City, Illinois 62040
- CMS Provider Number
- 146075
- Inspections on file
- 41
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Evercare Of Granite City during CMS and state inspections, most recent first.
A resident with severe dementia and a history of being combative during care was injured when a CNA, working alone, attempted to reposition her during peri care. Despite care plan instructions to provide care in pairs when the resident was overly stimulated, the CNA proceeded alone, and the resident sustained a left humerus fracture during the episode. Staff interviews confirmed that care should have been paused and assistance sought when the resident became combative.
Multiple incidents of physical and verbal aggression occurred between residents, including one resident striking another in the face, throwing objects, and using racial slurs and threats. Several residents reported feeling unsafe or uncomfortable, and care plans did not consistently address known behavioral risks. Staff witnessed some incidents but interventions were not effective in preventing further abuse.
Two residents with histories of behavioral and cognitive issues were involved in a physical altercation, resulting in one sustaining a nasal fracture. Neither resident had a care plan addressing abuse, despite documented aggression and combative behaviors. The incident was not witnessed by staff and was reported after the fact, with both residents separated and assessed following the event.
A resident with multiple comorbidities and on oxygen therapy reported feeling unwell to a CNA, who placed her on a portable oxygen tank that was empty or low and left her at the nurse's desk without notifying a nurse. The resident was left unattended, became unresponsive, and required CPR and hospitalization for acute hypoxic respiratory failure. Staff interviews and documentation confirmed that required notification procedures were not followed.
Certified Nursing Assistants were found to be administering oxygen therapy to a resident with complex medical needs, despite facility policy requiring only licensed nursing personnel or respiratory therapists to perform this task. Staff interviews revealed confusion and inconsistent practices regarding oxygen administration responsibilities.
The facility failed to properly store and prepare food, risking contamination for all 76 residents. Observations revealed unlabeled and undated food items, improper glove use by staff during food service, and inadequate food temperatures on the steam table, all contrary to facility policies.
A facility failed to prevent resident-to-resident abuse involving two residents. One resident, with a history of dementia and behavioral issues, hit another resident, who has severe cognitive impairment, resulting in a facial abrasion. The care plans for both residents did not address potential abusive behaviors, contributing to the incident. The facility's abuse policy was not effectively implemented, as staff did not intervene before the situation escalated.
A resident with cognitive impairments and multiple diagnoses was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring a two-person assist. The CNA acknowledged the error, and the DON confirmed the expectation for two staff members during such transfers.
Failure to Provide Safe Care During Transfer and Personal Care for a Resident with Dementia
Penalty
Summary
A deficiency occurred when staff failed to provide safe care to a resident with dementia, resulting in the resident sustaining a left humerus fracture. The resident, who was severely cognitively impaired and dependent on staff for activities such as toileting, dressing, and transfers, was known to be occasionally combative and resistive to care due to her dementia. Her care plan included interventions such as approaching her later if she became combative, informing her of care tasks before performing them, and providing care in pairs if she was overly stimulated. On the day of the incident, a CNA transferred the resident from her wheelchair to bed using a full mechanical lift by himself. While providing peri care with the resident on her left side, the resident became combative and began leaning toward the edge of the bed. The CNA attempted to reposition her back to the center of the bed while she was resisting, during which he heard a pop from her arm and the resident cried out in pain. The CNA immediately notified the nurse, who assessed the resident and observed a deformity in her left arm. The resident was subsequently sent to the hospital, where she was diagnosed with an acute spiral fracture of the left proximal humerus. Interviews with staff revealed that the CNA was aware of the resident's combative tendencies but proceeded to provide care alone, contrary to the care plan's recommendation for paired care in such situations. Other staff members, including the LPN and DON, stated that if a resident becomes combative or refuses care, staff should back away and seek assistance rather than continue care. The incident was witnessed by another resident who heard the altercation and the resident's complaint of pain. Documentation and interviews confirmed that the resident's injury occurred during an episode of resistance while care was being provided by a single staff member.
Failure to Prevent Resident-to-Resident Abuse and Ensure Resident Safety
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving physical and verbal aggression. One cognitively intact resident with a history of delusions, daily behavioral symptoms, and worsening aggression was involved in several altercations. This resident struck another cognitively intact resident in the face with an object and a cup of water, resulting in a visible bruise and discomfort for the victim. The incident was witnessed by an LPN, and the aggressor had recently been removed from 1:1 supervision. The victim reported feeling unsafe and uncomfortable in the facility, and had previously received verbal threats from the aggressor. Additional incidents included verbal and physical altercations between residents, such as one resident yelling, cursing, and threatening another, which escalated to the throwing of a cup of ice and physical intimidation. Another resident reported being subjected to physical aggression, including having cold coffee thrown on him while sleeping, and described ongoing verbal abuse and theft of personal items by his former roommate. This resident expressed feeling unsafe and mistrustful of the aggressor. Other altercations involved racial slurs, threats of violence, and the brandishing of a butter knife, which was retrieved by staff after being observed by a visitor. Care plans for several residents did not document risks for abuse, despite known behavioral histories and previous incidents. The facility's policies state a commitment to protecting residents from abuse by anyone, and staff are responsible for providing a safe environment. However, the repeated incidents of physical and verbal aggression, lack of effective interventions, and failure to update care plans to address abuse risks contributed to the deficiency in protecting residents from abuse and ensuring their safety.
Failure to Prevent Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, resulting in one resident sustaining a minimally displaced fracture to the left nasal bone. One resident, who had a history of hemiplegia, hemiparesis, and unspecified psychosis, was documented as being verbally aggressive toward others but had no care plan addressing abuse. This resident reported being physically attacked by his roommate, who struck him multiple times, prompting him to retaliate with a single blow. Both residents were separated immediately after the incident, and assessments were conducted. The other resident involved had a history of cerebral infarction, major depressive disorder with psychotic features, and significant cognitive impairment, as indicated by a low BIMS score. This resident was known to resist care and had a history of making false statements about being hit by others, but there was no care plan addressing abuse for this individual either. During the altercation, this resident sustained a nasal fracture, as confirmed by a CT scan, and required emergency medical evaluation and treatment. Documentation indicated that this resident was combative with care on a daily basis and had functional limitations on both sides. The facility's records and interviews revealed that neither resident had a care plan specifically addressing abuse, despite documented behavioral concerns and histories of aggression or combative behavior. The incident was not witnessed by staff, but was reported and documented after the fact. The facility's policy stated a commitment to protecting residents from abuse by anyone, including other residents, but the lack of individualized abuse prevention care plans contributed to the failure to prevent this altercation.
Failure to Notify Nurse of Resident's Change in Condition Resulting in Hypoxic Episode
Penalty
Summary
Facility staff failed to notify a nurse of a resident's change in condition, resulting in a lack of timely assessment and intervention. The resident, who had multiple significant diagnoses including COPD, heart disease, and required oxygen therapy, expressed feeling unwell to a CNA after being assisted to her wheelchair. The CNA placed the resident on a portable oxygen tank, which was later found to be empty or low, and left her at the nurse's desk to wait for a nurse, rather than directly notifying nursing staff of the resident's complaints and oxygen needs. The resident remained unattended at the nurse's desk for an extended period, during which time she became unresponsive and hypoxic. Staff interviews revealed that the CNA did not check the oxygen tank to ensure it contained oxygen and did not immediately inform a nurse of the resident's symptoms or the need for oxygen. The nurse assigned to the resident was on lunch break at the time, and coverage procedures were not effectively implemented, as the covering nurse was not made aware of the resident's condition or oxygen needs. When the resident was finally assessed, she was found unresponsive, with no respirations and a faint pulse, requiring CPR and emergency intervention. The resident was subsequently hospitalized with acute hypoxic respiratory failure and other complications. Documentation and interviews confirmed that facility policy required staff to notify a nurse of any resident reporting feeling unwell or experiencing a change in condition, which did not occur in this instance.
CNAs Administered Oxygen Therapy Contrary to Facility Policy
Penalty
Summary
Certified Nursing Assistants (CNAs) were observed administering oxygen to a resident with multiple complex medical conditions, including COPD, heart disease, and a history of coronary artery bypass graft. The resident was dependent on staff for most activities of daily living and required continuous oxygen therapy as ordered by a physician. The resident reported that after being transferred to a wheelchair by a CNA, the CNA placed the nasal cannula and informed the resident that the oxygen tank was empty, instructing the resident to wait for a nurse to refill it. The resident also stated that both CNAs and nurses would put the oxygen on her, and that she was kept on oxygen at all times. Interviews with multiple CNAs and licensed nursing staff revealed inconsistent understanding and practices regarding who is authorized to administer or adjust oxygen therapy. Some CNAs reported routinely placing residents on portable oxygen tanks, while others were unsure if this was within their scope of practice. Licensed staff and the Director of Nursing provided conflicting statements about whether CNAs were permitted to perform this task, despite facility policies specifying that only licensed nursing personnel or respiratory therapists are responsible for administering oxygen and medications. The facility's policies clearly state that medication administration, including oxygen therapy, is restricted to licensed personnel, yet CNAs were observed and reported to be performing these duties.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and preparation, leading to potential contamination risks for all 76 residents. During a kitchen tour, it was observed that several food items, including drinks, rice, Panko breadcrumbs, beans, and cornmeal, were stored in containers without proper labeling or dating. The Dietary Manager acknowledged that these items should have been labeled and dated to prevent any guessing about their freshness or safety. Additionally, during breakfast service, a staff member was observed handling food with gloves that had been contaminated. The staff member did not change gloves or wash hands after cleaning a dirty bowl before continuing to serve food. Furthermore, the temperatures of scrambled and boiled eggs on the steam table were found to be below the required 135 degrees Fahrenheit, which could allow bacteria to grow and potentially cause foodborne illness. The facility's policies require food to be stored and served at safe temperatures, with proper labeling and dating to ensure food safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, R29 and R42. R42, who has a history of dementia with behavioral disturbances, bipolar disorder, and other mental health conditions, was involved in an incident where she hit R29 in the face. R42's care plan did not address potential abusive behaviors, despite her history of verbal outbursts and inappropriate behaviors. On the evening of the incident, R29 reported to a CNA that R42 had slapped her while she was in bed. As R42 walked past, she reacted to R29's accusation by hitting her in the face, resulting in a 0.5 cm abrasion on R29's left cheek. R29, who has severe cognitive impairment and uses a wheelchair, was also not protected from abuse as her care plan did not address potential abuse despite her history of becoming angry and confrontational when confused. After the incident, R29 was assessed for injuries, and it was noted that she had a small abrasion on her cheek. The facility's response included separating the residents and notifying the necessary medical and administrative personnel, but the lack of preventive measures in the care plans contributed to the occurrence of the incident. The facility's abuse policy, which aims to protect residents from abuse by anyone, was not effectively implemented in this case. The Director of Nursing acknowledged that resident-to-resident altercations should be avoided and that staff should intervene before situations escalate. However, the incident highlights a failure in the facility's systems to prevent such abuse, as evidenced by the lack of specific interventions in the residents' care plans to address their behavioral issues and protect them from harm.
Failure to Ensure Safe Resident Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident diagnosed with Down's syndrome, hypothyroidism, major depressive disorder, dysphagia, and cognitive impairments. The resident, who was nonverbal and dependent on staff for most activities, was observed being transferred using a mechanical lift by a single Certified Nursing Assistant (CNA), despite the requirement for a two-person assist. The CNA admitted to not having a valid reason for performing the transfer alone, acknowledging that two other aides were available at the time. The Director of Nursing confirmed the expectation that at least two staff members should be present during transfers involving a mechanical lift, with no exceptions for single-person transfers. The resident's care plan and transfer documentation clearly indicated the need for a two-person assist, aligning with the facility's policy for using the mechanical lift. This incident highlights a breach in protocol, as the CNA did not adhere to the established guidelines for safe resident transfers.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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