Fair Havens Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Illinois.
- Location
- 1790 South Fairview Avenue, Decatur, Illinois 62521
- CMS Provider Number
- 145422
- Inspections on file
- 67
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Fair Havens Senior Living during CMS and state inspections, most recent first.
The facility failed to ensure residents were free from physical abuse when one resident became agitated, accused another of being in their home, and struck that resident on the head multiple times with a house slipper in the presence of an LPN, causing fear for the victim. In a separate incident, a resident with schizophrenia and severe cognitive impairment exhibited aggressive behavior toward a roommate with moderate cognitive impairment and multiple medical conditions, with the roommate reporting being hit and the aggressor later admitting to physical contact. These events occurred despite an existing abuse policy defining abuse as any non-accidental physical or mental injury or sexual assault inflicted upon a resident.
A facility failed to ensure that transportation staff were properly trained and competent in using the manufacturer’s 4‑point wheelchair securement system, and a resident’s report that the wheelchair was moving in the van was not acted upon. A resident with multiple comorbidities, impaired mobility, and wheelchair dependence was transported by a driver who had no formal, supervised training and relied only on a checklist. While the van was moving downhill, the resident felt the wheelchair shift and alerted the driver, who reassured the resident and continued driving until the wheelchair tipped forward and the resident fell to the floor, sustaining leg lacerations and fractures. Subsequent observation showed the driver routinely attached securement hooks to wheelchair armrests with twisted straps, contrary to the manufacturer’s requirement to attach to the solid wheelchair frame at the proper angle, and the maintenance director could not accurately demonstrate use of the installed mechanical retractable system. The facility lacked a transportation policy despite a job description assigning responsibility for resident safety during transport, and training documents referencing manufacturer instructions were not effectively implemented.
Two residents engaged in a physical altercation when one went through the other's belongings and attempted to take a remote, resulting in one resident sustaining bloody fingernail marks and superficial scratches to the forearm. An LPN intervened after hearing a commotion, separated the residents, removed a hanger they were both holding, and noted the injuries. A roommate reported that the aggressive resident frequently hits and screams at staff during ADL care. Despite a facility policy requiring identification and care planning for residents with behaviors and triggers that may lead to conflict, no abuse or behavioral assessments, skin assessment, or care plan updates were completed for the involved residents after the incident.
Three residents experienced deficiencies in catheter care and UTI management, including missed catheter changes, lack of urine output monitoring, improper use of PPE during high-contact care, and delays in obtaining and processing urine samples. These failures led to serious complications for one resident, including hospitalization for urosepsis and acute kidney injury.
Two residents experienced a lack of dignity and respect when one, who was severely cognitively impaired and dependent for ADLs, was found lying in bed with her head partially resting against a wall smeared with dried feces, and her representative was not informed of the incident. Another cognitively intact resident, also requiring extensive ADL assistance, reported that staff sometimes took over an hour to respond to call lights for restroom assistance, leading to urinary incontinence and feelings of disrespect. An LPN acknowledged that such delayed responses were unacceptable, and the DON confirmed the substance on the wall was feces, contrary to facility policy requiring residents be treated with respect and dignity.
A resident with lymphedema, cognitively intact and dependent for transfers, was care planned for a full mechanical lift for bed transfers and a sit-to-stand lift only for toileting in the shower room. Staff instead used a sit-to-stand lift to transfer the resident into bed, positioning the resident too close to the metal bed frame so that the back of the right leg struck the frame, causing a large bruise and pain that required medication. Surveyors later observed CNAs using a sit-to-stand lift for toileting with the resident in a bent posture, knees not fully extended, and the chest strap left loose at the resident’s request, while the resident grimaced and complained of pain. Interviews showed inconsistent staff understanding and use of the correct lift type for bed transfers despite care plan and posted instructions.
The facility did not post State Agency contact information and complaint procedures in a clearly visible and accessible location. During a Resident Council meeting, several residents reported they had not seen any information about the State Agency or how to file a complaint. When questioned, the Administrator directed the surveyor to a posting located beyond alarmed entry doors in a foyer and positioned above normal eye level, making it not clearly visible from inside the facility. This deficiency had the potential to affect all 95 residents in the facility.
The facility did not consistently serve meals at its posted scheduled times, despite a written policy and documented schedule indicating specific hours for breakfast, lunch, and dinner. Surveyors observed breakfast and lunch being served later than scheduled on multiple days, and the Certified Dietary Manager acknowledged that breakfast was delayed because staff had not rolled silverware in time. A resident reported that meals are served late all the time, and this pattern had the potential to affect all 95 residents.
Staff failed to consistently use required PPE, post appropriate signage, and ensure PPE availability for residents on Contact Precautions or Enhanced Barrier Precautions. Several residents with indwelling devices, wounds, or multidrug-resistant infections did not receive care according to infection control protocols, and staff were observed providing care without gowns or gloves, not disinfecting shared equipment, and not following proper hand hygiene or medication administration procedures.
An LPN misappropriated one resident’s insulin by withdrawing Novolog and Lantus from that resident’s vials and administering them to another resident whose blood glucose was low and whose own insulin supply was reportedly depleted, despite facility policy prohibiting use of one resident’s medications for another and the availability of a backup medication system that included insulin. In a separate observation, the same LPN had pre-poured multiple oral medications, including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban, for several residents hours in advance of the scheduled med pass, leaving stacked pill cups on the counter, contrary to facility expectations that medications not be pre-poured.
Two residents experienced multiple medication administration errors when an LPN gave scheduled cardiac and other oral medications significantly outside ordered times, used an insulin vial that was not properly labeled with an opened date, and administered insulin from a vial marked with an expired/discard date. In a separate instance, an LPN reported a blood glucose of 49 for a resident who had eaten breakfast without prior glucose monitoring or morning insulin, then borrowed and administered Novolog and Lantus from another resident’s vials and documented these insulins as given well after the scheduled time. Prescribing information cited for Novolog notes it is rapid-acting and should be given within 5–10 minutes of a meal, with hypoglycemia listed as an adverse reaction.
The facility failed to ensure timely administration of multiple cardiac and diabetic medications, resulting in significant medication errors for several residents. An LPN repeatedly administered Hydralazine, Metoprolol, Isosorbide, Sacubitril-Valsartan, and Furosemide hours outside their scheduled times, with some evening doses not given until early the next morning and some doses given too close together. A resident with diabetes had a critically low blood glucose, and the LPN, who was behind on the medication pass, borrowed Novolog and Lantus from another resident’s insulin vials to administer the dose. Another resident had to request her overdue morning CHF medications near midday. Staff acknowledged that the hall has a heavy med pass and that they often exceed the allowed administration window, while a pharmacist confirmed these medications should be spaced at defined hourly intervals.
Surveyors identified multiple deficiencies in medication storage, labeling, and security, including an unlocked medication cart left unattended by an LPN, insulin vials not kept in original packaging or labeled with opened dates, and insulin pens present without corresponding MAR orders for a resident. In medication rooms and carts, expired TB supplies, insulin from a discharged resident, expired saline flushes, and an opened nutritional product without a dated label were found, along with numerous loose, unidentified pills and pill cups containing pre-popped medications such as pantoprazole, sucralfate, Xarelto, warfarin, and apixaban left on counters. A PRN LPN reported being unfamiliar with facility policies related to these practices.
A resident with atrial fibrillation, hypertension, and heart failure had elevated BP readings obtained by an LPN using an electronic cuff, after which Metoprolol Tartrate was administered. Despite facility policy and the resident’s care plan requiring monitoring of vital signs and reporting abnormalities to the physician, there was no documented manual BP reassessment for several hours and no documentation that the elevated BP was reported. The LPN stated she did not follow up because she considered the reading normal for the resident and saw no distress, while the DON indicated she would have expected a manual recheck and physician notification.
A resident with bilateral leg amputations, moderate cognitive impairment, MASD, and an open coccyx wound was not consistently provided with required pressure-relieving interventions. Policy and wound care orders called for turning every two hours in bed, hourly repositioning in a chair, side-to-side positioning, and use of pillows for offloading, but the resident was repeatedly observed lying on his back without pillows and spending extended time in a wheelchair. CNAs reported attempting to reposition the resident and stated the resident refused side-lying due to pain and removed pillows, yet there was no documentation of refusals or notification to nursing or the physician, despite expectations that such refusals be recorded and monitored.
A resident with a gastrostomy tube had an order for Jevity 1.5 Cal, 300 ml bolus feedings every six hours, but an LPN administered 600 ml using a syringe with a plunger instead of gravity flow, contrary to facility policy and the physician’s order. During the procedure, the LPN intermittently laid the unclamped G-tube on the resident’s lap, causing feeding to leak onto the resident. The LPN later acknowledged the correct ordered volume and that the tube had been left unclamped, and the DON confirmed that enteral feeding volume and method must follow the physician’s order and be given by gravity flow.
The deficiency concerns the facility’s failure to properly offer and document pneumococcal vaccinations for two residents reviewed for immunizations. One resident with moderately impaired cognition did not recall being asked about the pneumonia vaccine, and her POA remembered only influenza and COVID-19 vaccines being offered; the resident’s vaccination authorization form was marked as a refusal but lacked a date. Another resident with intact cognition reported that only influenza and COVID-19 vaccines were offered and stated she would like the pneumonia vaccine. An LPN admissions coordinator reported educating residents and families about vaccines and said one resident had declined the pneumonia vaccine, but acknowledged the refusal form should have been dated. The DON stated that merely asking residents on admission if they want the pneumonia vaccine is not sufficient, despite a facility policy requiring adherence to a pneumococcal vaccine protocol and documentation of education and refusals.
A significant German cockroach infestation was observed in food service areas, including the staff lounge, kitchen, and steam table line, with live and dead insects found in drawers, cabinets, and a refrigerator with a broken seal. Staff confirmed the ongoing issue and that utensils from infested areas were used to plate meals. Pest control efforts and sanitation practices were inadequate, failing to meet facility policies and potentially affecting all residents.
A CNA, who was also an LPN student but not yet licensed, assisted an LPN by handing out medications to several residents in the hallway. The CNA did not prepare the medications but distributed them as directed by the LPN, despite facility policy and job descriptions restricting medication administration to licensed personnel or qualified medication aides.
The facility did not maintain an effective pest control program, resulting in the presence of cockroaches in the kitchen, serving areas, and resident rooms. Staff and a resident confirmed sightings of live and dead cockroaches, and surveyors observed evidence of infestation in multiple areas. Pest control efforts were inconsistently documented, and the issue persisted over several months.
A dependent resident with severe cognitive impairment did not receive scheduled showers, and there was no documentation of showers, refusals, or alternative hygiene care. Staff interviews and family reports confirmed the lack of hygiene care, and the DON acknowledged missing documentation, resulting in the resident not receiving appropriate personal hygiene.
A resident with multiple psychiatric diagnoses experienced a lapse in receiving a prescribed controlled substance (Lunesta) due to the facility's inability to obtain a timely signed prescription from the psychiatric provider. Nursing staff made repeated attempts to secure the prescription, and an alternative medication was administered in the interim. The resident was aware of the missed doses and reported that the substitute medication was less effective.
A resident with multiple medical conditions, including a femur fracture and chronic leg ulcers, was administered Hydromorphone for pain at intervals shorter than the physician-ordered six hours on several occasions. This was confirmed by the DON and corporate clinical staff through review of controlled drug records.
A resident with multiple chronic conditions received PRN Hydromorphone as ordered, with administration documented on the controlled drug record. However, nursing staff failed to record these administrations on the Medication Administration Record, as required by facility policy and physician orders.
A resident with chronic ulcers and a femur fracture did not receive wound dressing changes as ordered, resulting in saturated dressings and soiled bedding. Nursing staff documented the treatment as completed when it had not been done, and the facility's policy for prompt and accurate documentation was not followed.
Two residents with known fall risks were left unsupervised during activities requiring staff oversight—one during a shower and another while smoking outside—resulting in falls. Both residents had documented needs for supervision due to physical or cognitive impairments, but staff failed to remain present as required, leading to unwitnessed accidents.
A resident with an indwelling urinary catheter for obstructive and reflux uropathy experienced pain and frequent urine leakage due to the catheter not being secured with a leg strap or adhesive tape, as required by facility policy. The resident's bed linens were found wet, and the resident reported ongoing discomfort and requests for proper catheter securing that were not addressed. Staff confirmed the absence of a leg strap and the need to notify nursing about the resident's pain.
A resident with severe cognitive impairment and high assistance needs was found to have accumulated urine-soaked clothing on the floor of her room, resulting in strong odors. Staff acknowledged lapses in timely laundry removal and assistance with toileting, and a family member reported multiple bags of soiled clothes and a saturated recliner. Facility policy requiring a clean and odor-free environment was not followed.
A resident dependent on staff for hygiene due to paraplegia and weakness was left in soiled conditions for an extended period after requesting incontinence care. Multiple staff, including CNAs and an RN, were aware of the resident's request but did not provide timely assistance, instead prioritizing other tasks. Facility policy requiring prompt response to resident needs was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Two residents experienced a lack of dignity due to staff actions: one was removed from the facility during a meal without explanation and had personal belongings handled disrespectfully, while another was left with a washcloth in an incontinence brief after rushed care for dialysis, resulting in humiliation when the odor was noticed by others. Both incidents involved failures in communication and respect for resident dignity.
A resident with a history of alcohol abuse and multiple medical conditions was verbally abused and threatened with bodily harm by a roommate after being moved into a shared room. The incident, which was witnessed by a housekeeper, occurred despite facility policies requiring identification and care planning for residents at risk of abuse.
Multiple residents reported receiving cold and unappetizing meals due to delays in meal tray delivery and lack of temperature maintenance, as confirmed by direct observations and resident council meeting minutes. Residents with varying cognitive abilities expressed dissatisfaction, and some avoided eating meals or requested reheating due to the persistent issue.
The facility did not maintain an adequate supply of linens, with only a portion of laundry equipment functioning and limited towels and washcloths available. Staff reported frequent linen shortages and difficulty keeping up with laundry due to understaffing. Multiple residents stated they had not received scheduled showers, citing a lack of linens and laundry staff as the reason.
Multiple residents did not receive showers as required, with observations showing poor hygiene such as food-stained clothing and oily hair. Residents reported not receiving showers for over a week, and staff interviews revealed ongoing shortages of linens and housekeeping staff, leading to missed ADL care. Facility policy requires showers twice weekly, but documentation and resident statements confirmed this was not met.
The facility did not consistently perform or document shift-to-shift controlled medication counts as required, with missing or incomplete count sheets and lack of dual nurse signatures. Several residents received controlled medications that were not properly documented on the MAR, and in some cases, medications were administered without verifying active orders in the electronic record. Staff confirmed these discrepancies and the DON acknowledged that required documentation was missing or incomplete.
Multiple residents experienced significant medication errors due to the facility's failure to administer medications as ordered, delays in reordering controlled substances, and lack of timely physician notification when medications were missed or delayed. LPNs and the DON confirmed issues with medication supply, late administration, and insufficient documentation, affecting pain management, blood pressure control, and diabetes care.
The facility did not ensure proper storage and timely destruction of controlled medications for two residents. In one case, Morphine was found outside the locked controlled compartment, and in another, discontinued Norco tablets remained in the medication cart. Staff interviews and record reviews confirmed these lapses, and required shift change documentation was incomplete.
A LTC facility experienced a 13.51% medication error rate due to failures in administering medications as per physician orders. Errors included unavailability of medications, incorrect dosages, and failure to follow administration instructions. These issues affected five residents and were contrary to the facility's Medication Administration Policy.
A resident with paraplegia felt intimidated and verbally abused by an RN who misheard a conversation and aggressively confronted the resident. Despite reporting the incident to the Administrator-In-Training, the resident's concerns were dismissed, and the RN continued to work, exacerbating the resident's fear and anxiety.
A resident reported feeling threatened and verbally abused by an RN, but the facility failed to investigate the allegation or protect residents. The RN continued to work without suspension, and no evidence of an investigation was found in the facility's records, violating the facility's Abuse Prevention Program policy.
A resident reported feeling threatened and verbally abused by an RN to the Administrator-In-Training, who failed to report the allegation to the state agency as required by the facility's policy. The policy mandates immediate reporting of abuse allegations to the Illinois Department of Public Health, but the facility's records showed no evidence of such reporting.
The facility failed to maintain functional and homelike shower rooms, affecting all 102 residents. The 200 and 300 hall shower rooms were in disarray with construction debris and equipment, and had been shut down for safety reasons. The Maintenance Director stated repairs had been ongoing for six months without completion. Residents expressed dissatisfaction with the condition of the shower rooms, noting mold, insects, and construction debris, and reported having to use other halls' shower rooms, which were also in poor condition.
The facility's dishwasher failed to reach the required 180 F for sanitizing dishware, with observed temperatures ranging from 156 F to 178 F. The Dietary Manager acknowledged the issue, and the Maintenance Director had contacted a service company for repairs. The Administrator was unaware of the problem until the survey and noted the need for improved communication among staff. The facility's contract with a specific service company delayed immediate repairs.
The facility, with a 154-bed capacity, failed to employ a qualified Social Worker, impacting 102 residents. The Administrator confirmed the absence of a degreed Social Worker, and the former Social Services Director, now Business Office Manager, lacked the necessary qualifications. The staff roster shows the Social Services position is vacant.
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches and sewer flies in the kitchen area. The dishwasher area was saturated with water due to leaks, and a two-compartment sink was leaking sewage water onto the floor. The Dietary Manager was aware of the issue, and a maintenance work order had been submitted. Resident complaints about fruit flies were documented in the Resident Council Meeting Minutes.
The facility's door alarms and monitoring systems were not functioning properly, affecting all 102 residents. The Maintenance Director admitted the system failed to emit sounds when doors were opened, and screens at nurse stations were not displaying the facility map. Some doors lacked functional alarms and could be opened easily. The Administrator acknowledged the issue and the lack of communication and action to fix it. Staff were not always present in areas where residents could exit unsupervised, and they did not respond to door ajar announcements due to non-functional screens.
The facility failed to accurately assess and document the smoking status of three residents, leading to discrepancies in their MDS and care plans. The smoking schedule listed them as smokers, but their MDS inaccurately documented them as non-smokers. One resident's care plan lacked a focus area for smoking, and another's smoking assessment was incomplete. The Infection Preventionist/Wound Nurse confirmed these discrepancies.
The facility failed to timely assess residents for pressure ulcer risk and complete treatments as ordered, affecting three residents. Documentation was missing for pressure ulcer treatments on the sacrum, buttocks, and right heel, as well as daily skin checks. The facility's policy requires Braden Assessments upon admission, weekly for a month, then quarterly, but these were not updated. Additionally, treatment documentation was not completed as required.
The facility failed to employ a full-time DON, affecting all 109 residents. The Administrator confirmed the absence of a full-time DON for six months, and during the survey, no DON was present. The CMS-802 Matrix form documents 109 residents in the facility.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents. In one incident, an abuse investigation dated 3/15/2026 at 8:45 PM documented that one resident (R3) became agitated with another resident (R10), accusing R10 of being in R3's house, and then began hitting R10 on the head with a shoe. A Licensed Practical Nurse (V10) witnessed R3 hitting R10 on the head with the shoe. During an interview on 3/24/2026 at 12:46 PM, R10 recalled being hit a few times with a house slipper by R3, stated that R3 was accusing R10 of being in R3's home, and reported that this interaction was frightening. The Administrator (V1) later confirmed that, based on interviews with R10 and V10, it was determined that R3 did hit R10 multiple times in the head with a shoe and that the allegation of abuse was substantiated. In another incident, the facility’s abuse investigation dated 2/9/2026 at 8:45 PM documented that resident R7 had aggressive behaviors toward resident R6, with R6 reporting that R7 hit R6 with a closed fist. R6’s care plan shows an admission date of 10/25/2024 and diagnoses including poisoning by hydantoin derivatives, essential hypertension, and cerebral infarction, with a Minimum Data Set (MDS) indicating moderate cognitive impairment. R7’s MDS documents severe cognitive impairment, and R7’s care plan lists diagnoses including schizophrenia, dysphagia (oropharyngeal phase), constipation, hyperlipidemia, and benign prostatic hyperplasia. On 3/23/2026 at 10:55 AM, R6 stated having been hit by a roommate in the past but could not recall the specific date, while R7 was deemed non-interviewable due to severe cognitive decline and dysphasia. On 3/23/2026 at 3:15 PM, an LPN (V7) reported that R7 admitted to hitting R6 on the arm when questioned on 2/9/2026. The facility’s abuse policy dated 10-2022 defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.
Failure to Train Van Staff on Wheelchair Securement Leads to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure transportation staff were properly trained according to the wheelchair securement system manufacturer’s instructions and to respond appropriately when a resident reported wheelchair movement in the transport van. One resident, R3, had a care plan documenting multiple diagnoses including acute on chronic diastolic congestive heart failure, morbid obesity, hypertension, localized edema, depression, anxiety disorder, heart disease, and chronic kidney disease. R3 had weakness, bilateral lower extremity edema, impaired mobility, used a manual wheelchair for locomotion, and required staff assistance for activities of daily living and transfers. On the day of the incident, R3 was being transported in the facility’s van when the wheelchair moved and tipped forward while the van was in motion. According to the facility’s investigation and staff interviews, the van driver (V13) transported R3 to the van in a wheelchair, applied wheelchair restraints and a lap belt, and began driving down a hill away from the facility. Shortly after the van began moving, R3 felt the wheelchair move and alerted the driver that the wheelchair was moving; the driver reportedly told R3 that she would be okay and continued driving. The driver then heard R3 scream, looked in the rearview mirror, and saw the wheelchair tipped forward with R3 leaning forward and attempting to brace herself. The driver parked, assessed the situation, then drove the van back around the parking lot to the main entrance to obtain help. When the DON (V2) and an LPN (V11) entered the van, they observed the wheelchair tipped forward, R3 on the floor with the left leg under her, blood present, and the restraint straps still attached and pulled taut, making it difficult to free R3 from the wheelchair and seatbelt. Emergency department and orthopedic records document that R3 fell out of the wheelchair in the transport van, sustained multiple lacerations to the lower extremities, and suffered fractures of the left tibia and fibula, including a proximal tibia fracture, fibular head fracture, distal fibula fracture with extension to the ankle syndesmosis, and an anterior inferior tibiofibular avulsion fracture. Interviews and record review showed that the van driver stated she was not formally trained on driving the van or securing residents, had only received a safety checklist, and had no supervised training or daily safety checklist for the van. The maintenance director (V5) claimed to have trained the driver and had signed training checklists, but the forms were photocopied, lacked the trainee’s signature, and the driver denied receiving the post-incident training documented. Observation of the driver securing another resident (R8) in the van showed the J-hooks of the mechanical retractable system attached to the wheelchair armrests at an improper angle with twisted straps, and another resident (R12) reported the driver had repeatedly used armrests as anchoring points. The manufacturer’s manual and the facility’s own training checklist required attachment of tie-down hooks to a solid wheelchair frame at an approximate 45-degree angle, with no twisting of straps, and specified that the system should only be operated by individuals who fully understand its use, requirements that were not met in this case. Additional interviews and document review revealed that the facility did not have a transportation policy at the time of the incident, despite the transportation aide job description stating that the purpose of the role was to provide safe and timely transportation in compliance with federal, state, local, and corporate requirements and to assume responsibility for residents’ safety while transporting. The driver’s training forms referenced following the manufacturer’s guide for specific instructions on how to secure the wheelchair and client and included a detailed checklist for proper wheelchair securement and patient restraint, including inspection of straps, correct floor anchor positioning, attachment to appropriate anchor points on the wheelchair frame, and avoidance of strap twisting. However, the observed practices of the driver and the maintenance director’s inability to accurately demonstrate use of the specific mechanical retractable system in the van showed that these procedures were not effectively taught or followed. These combined failures in training, policy, and response to the resident’s report of wheelchair movement led to R3 sliding forward in the wheelchair, the wheelchair tipping forward, and R3 falling onto the van floor, resulting in significant injury.
Removal Plan
- Conducted in-service education on proper securing of resident wheelchairs in the transportation van, including the facility policy, for the approved transportation drivers and the maintenance director
- Utilized a video training about the securement straps and seat belts in the transportation van for the approved transportation drivers and the maintenance director
- Conducted return demonstrations for the approved transportation drivers and the maintenance director
- Developed a facility policy for securement of wheelchairs in the transportation van
- Reviewed the job description for the transportation drivers
- Developed a list of approved transportation drivers
- Conducted a Quality Assurance Meeting to discuss the Immediate Jeopardy citation, needed training, proficiency checklist, list of approved drivers, review of transportation aide job description, development and corporate approval of facility policy, and abatement plan
- Conducted audits for residents utilizing the facility van to be transported to appointments
- Confirmed the transportation drivers completed proper demonstration for securement technique of an occupied wheelchair into the facility transportation van
Failure to Prevent and Assess Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, as required by its Abuse Prevention and Reporting policy. The policy states that residents have the right to be free from abuse, including physical abuse such as hitting, slapping, pinching, and controlling behavior through corporal punishment, and that staff must identify residents with increased vulnerability, triggers, and behaviors that might lead to conflict through admission assessments, comprehensive care plans, and MDS assessments. Staff are required to use the care planning process to identify problems, goals, and approaches to reduce the chances of abuse and to monitor and update these on a regular basis. In this case, the facility did not complete abuse or behavioral assessments after a resident-to-resident altercation, and there was no skin assessment or care plan update or revision for the injured resident following the incident. On the date of the incident, an LPN heard a commotion in a shared room and observed both roommates physically touching each other, with one resident in a wheelchair and the other on the bed. One resident complained that the other was on her side of the room and bothering her belongings, while the other responded confrontationally. The LPN removed a hanger both residents were holding, separated them into the hallway, and then observed that one resident’s forearm was bloody, with apparent nail marks and superficial scratches that were cleansed and treated with triple antibiotic ointment. Interviews indicated that one resident had a history of aggressive behaviors and that the altercation occurred when one resident was going through the other’s personal belongings and wanted the remote, leading to the scratching. Another roommate reported that the aggressive resident hits and screams at staff during ADL assistance. The DON confirmed that the injured resident received fingernail scratches to the right forearm and that no behavioral services, behavioral assessments, or abuse assessments were completed for the aggressive resident after the interaction.
Failure to Provide Appropriate Catheter Care and Timely UTI Management
Penalty
Summary
The facility failed to provide appropriate and hygienic catheter care, monitor urinary catheter output, and timely treat symptoms of urinary tract infection (UTI) for three residents. For one resident with a history of multidrug-resistant infections and moderate cognitive impairment, staff did not consistently change the urinary catheter as ordered, with a gap of several months between documented changes. There was also a lack of routine monitoring and documentation of urinary output. Staff did not follow Enhanced Barrier Precautions (EBP), as they failed to wear gowns during high-contact care activities, including catheter care and transfers, despite posted signage and available PPE. Catheter care was not performed according to protocol, with incomplete cleaning of the catheter tubing. These failures led to the resident developing urinary retention, UTI, urosepsis, acute kidney injury, and hydronephrosis, requiring hospitalization and urinary stent placement. Another resident was observed with urinary catheter tubing dragging on the floor during transfer, and the collection bag was held above the level of the bladder, causing urine to drain back toward the bladder. The clip intended to keep the tubing off the floor was not used. Staff again did not wear gowns during high-contact care, despite EBP signage. The resident's urine was noted to be cloudy with sediment, and subsequent urine cultures revealed significant bacterial growth, including ESBL E. coli and vancomycin-resistant Enterococcus faecalis. A third resident experienced frequent UTIs, and there were delays in obtaining and processing urine samples after symptoms were reported. Documentation showed a lag of several days between the onset of symptoms and the collection and processing of urine samples, with no evidence that the initial sample was sent to the laboratory. Orders for antibiotics were not received until nine days after symptom onset, and there was a lack of documentation regarding the handling of urine specimens. These actions and inactions contributed to the deficiencies identified in the care of residents with urinary catheters and UTIs.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to protect the dignity and psychosocial well-being of two residents by not ensuring they were treated with respect and assisted promptly with personal needs. One resident, who was severely cognitively impaired, required maximum assistance with activities of daily living and had a diagnosis of dementia. This resident was observed lying in bed on the left side with the right side of the head positioned partially on a pillow and partially against a wall. The wall next to the bed had noticeable dried brown hand wipes on the white surface, which the Director of Nursing identified as feces, and stated that the resident's head was lying in the feces. The resident’s power of attorney later reported that no one from the facility had contacted them about the incident and stated that the resident would not have appreciated having her head lying in feces. Another resident, who was cognitively intact and required maximum assistance with activities of daily living, reported that when needing to use the restroom, the call light system was activated but at times it took over an hour for staff to respond. The resident stated that this delay resulted in urinary incontinence and made the resident feel disrespected. A Licensed Practical Nurse confirmed that all call lights should be answered as quickly as possible, that a response time of over an hour was not acceptable, and that this resident was alert and would know when restroom assistance was needed. The facility’s policy stated that every effort would be made to assist each resident in exercising their rights to ensure they are always treated with respect, kindness, and dignity.
Improper Use of Sit-to-Stand Lift Causes Resident Leg Bruising
Penalty
Summary
A deficiency occurred when staff failed to follow the resident’s assessed transfer status and the facility’s Safe Lifting and Movements of Residents policy, resulting in improper use of a sit-to-stand lift and injury. The cognitively intact resident, who had lymphedema in both legs and was dependent on staff for chair, bed, and toilet transfers, was care planned to use a full mechanical lift for transfers to and from bed and a sit-to-stand lift only for toileting in the shower room. Despite this, CNAs used a sit-to-stand lift to transfer the resident into bed, positioning the resident too close to the metal bed frame, which led to the back of the resident’s right leg striking the frame. The resident subsequently developed a baseball-sized blue/purple bruise and hardening on the back of the right calf/knee area and reported new right leg pain that required pain medication. During surveyor observation, CNAs were again seen using a sit-to-stand lift for toileting, with the resident bearing weight in a bent posture, knees not fully extended, and the chest strap left loose because the resident reportedly did not like it tightened. The resident grimaced, moaned, and complained of pain during these transfers and pointed out the bruise, stating that staff had banged her leg on the bed and that it hurt. Interviews and record review confirmed that some staff used a full mechanical lift and others used a sit-to-stand lift for bed transfers, and that at least one CNA had recently started working on the hallway and had been told the resident used a sit-to-stand lift, contrary to the care plan and posted instructions in the room. These actions and inconsistencies in following the documented transfer requirements led to the resident’s bruising and pain.
State Agency Complaint Information Not Posted in an Accessible Location
Penalty
Summary
The facility failed to post the name, address, and telephone number of the State Agency, including information on how to file a complaint, in an accessible location within the facility as required by F575. The facility’s Long-Term Care Facility Application for Medicare and Medicaid dated 12/07/2025 documented a census of 95 residents. During a Resident Council meeting, multiple residents reported they had not seen any information posted in the facility related to the State Agency or how to file a complaint, and several other residents present agreed they were not aware that such information was posted. When the surveyor asked the Administrator about the posting, the Administrator directed the surveyor to the front entrance, past alarmed entry doors, into a foyer area where the State Agency complaint contact information was displayed at a height above the surveyor’s eye level while standing, and the information was not clearly visible from inside the facility. This failure had the potential to affect all 95 residents residing in the facility, as the required State Agency contact information and complaint procedure details were not posted in a clearly visible and accessible location within resident areas.
Failure to Serve Meals at Posted Scheduled Times
Penalty
Summary
The facility failed to serve meals at the posted and scheduled times as outlined in its dietary policy and application for Medicare and Medicaid, which state that three well-planned meals will be served at regularly scheduled hours of 7:30 a.m. for breakfast, 11:30 a.m. for lunch, and 5:00 p.m. for dinner. Record review confirmed these scheduled times, and the Certified Dietary Manager verified them during interview. However, surveyor observations showed breakfast service began at 8:10 a.m. and lunch at 12:15 p.m. on one day, and breakfast began at 8:17 a.m. on another day, all later than the posted times. During interview, the Certified Dietary Manager stated that breakfast was late being served because no staff had rolled silverware, which was needed before serving the meal. A resident reported that meals are served late all the time. This failure to adhere to scheduled meal times had the potential to affect all 95 residents in the facility. The deficiency centers on the inconsistency between the facility’s documented dietary policy and actual practice, as evidenced by delayed meal service on multiple observed days, staff acknowledgment of operational issues (lack of rolled silverware) causing delays, and resident report of chronic lateness of meals.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for residents requiring Contact Precautions and Enhanced Barrier Precautions (EBP). Multiple instances were observed where staff did not wear required personal protective equipment (PPE), such as gowns and gloves, when providing care to residents with indwelling devices, wounds, or infections with multidrug-resistant organisms. In several cases, signage indicating the need for isolation or EBP was missing or not updated, and PPE supplies were not readily available outside resident rooms. Staff members were observed entering rooms and providing care without donning appropriate PPE, and some staff expressed uncertainty about which residents required precautions or the correct use of PPE. Specific residents with documented infections or indwelling devices, such as urinary catheters or wounds, were not consistently placed on the appropriate precautions. For example, one resident with a positive urine culture for ESBL E. coli and Providencia stuartii remained in a shared room without consistent use of Contact Isolation by staff, despite ongoing physician orders. Other residents with indwelling catheters or wounds did not have EBP signage posted, and staff did not use gowns and gloves during high-contact care activities, including catheter care and transfers. In some cases, staff were observed using shared equipment, such as vital signs machines, without disinfecting them between residents, and wearing gowns outside resident rooms contrary to protocol. Medication administration practices also failed to meet infection control standards. An LPN was observed preparing and administering insulin without disinfecting vial stoppers, performing hand hygiene, or wearing gloves. The LPN also placed an uncapped syringe in her pocket before administering insulin. Facility policies required hand hygiene before and after medication administration, disinfecting vial tops with alcohol, and proper disposal of needles, but these procedures were not followed. These failures were confirmed by interviews with nursing leadership and staff, who acknowledged the lapses in infection prevention and control practices.
Misappropriation and Improper Handling of Resident Medications
Penalty
Summary
The deficiency involves the misappropriation and improper use of resident medications and failure to follow medication administration policies. A facility policy stated that drugs ordered for one resident must not be used for another, and the abuse prevention program defined misappropriation of resident property as wrongful use of a resident’s belongings without consent. Despite this, an LPN reported that after obtaining a blood glucose of 49 for one resident, she determined that the resident was out of insulin and decided to “borrow” insulin from another resident, acknowledging she had been taught not to do so. She withdrew 2 units of Novolog and 10 units of Lantus from one resident’s insulin vials and administered them to another resident, even though the facility had a backup medication system that included insulin. Prescribing information for Novolog specified that insulin vials should not be shared between different patients, even with different needles. The deficiency also includes improper medication handling and preparation practices. During observation of medication storage on one hall, four pre-poured medications in pill cups were found stacked on the counter, intended for a later medication pass. The LPN on duty stated she was PRN and not aware of the facility’s policies or procedures and confirmed that the pre-poured medications were for multiple residents, including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban scheduled for administration several hours later. The DON later confirmed with the LPN that she had pre-poured these medications and stated that medications should not be pre-poured, indicating that the observed practice was inconsistent with facility expectations and contributed to the identified deficiency.
Medication Administration Errors and Improper Insulin Practices
Penalty
Summary
The deficiency involves failure to administer medications as ordered and to maintain an acceptable medication error rate, resulting in 8 errors out of 25 opportunities (32%) for two residents. For one resident, an LPN prepared and administered multiple morning oral medications, including Hydralazine, Potassium Chloride, Torsemide, and Oxybutynin, significantly later than the scheduled 9:00 AM time, with actual administration occurring between 11:38 AM and 11:41 AM. The same resident’s lispro insulin vial was not in its original box, was not properly labeled with a dispensed or opened date, and bore a handwritten date next to the expiration/discard date; the LPN administered 2 units of lispro insulin from this vial. The resident’s blood pressure readings taken shortly thereafter were elevated, and the LPN administered Metoprolol Tartrate at 12:00 PM. The pharmacist later stated that Hydralazine should be spaced approximately 6–8 hours apart and Metoprolol Tartrate 10–12 hours apart, and that administering these medications too close to the next scheduled dose could increase medication effects, while late doses could result in elevated heart rate and blood pressure as the medication’s effects diminish. For another resident, the LPN stated that the resident’s blood glucose was 49 and that the resident was out of insulin. The LPN withdrew 2 units of Novolog and 10 units of Lantus from another resident’s insulin vials and administered them to this resident, despite acknowledging she had been taught not to borrow medications. The LPN also stated she was behind on 8:00 AM medications, including this resident’s insulin, and that the resident had eaten breakfast around 7:00 AM without having blood glucose checked or morning insulin administered beforehand. The medication administration record showed that Lantus 10 units subcutaneously daily at 8:00 AM was actually given at 10:52 AM, and Novolog per sliding scale scheduled for 8:00 AM was given at 10:48 AM. The Novolog prescribing information indicates it is a rapid-acting insulin that should be administered within 5–10 minutes of a meal, and adverse reactions include hypoglycemia.
Significant Medication Timing Errors and Improper Insulin Borrowing
Penalty
Summary
The deficiency involves the facility’s failure to administer cardiac and related medications within required timeframes, resulting in significant medication errors for multiple residents. One resident received Hydralazine, ordered three times daily at 9:00 AM, 1:00 PM, and 9:00 PM, at 11:38 AM and 2:08 PM on one day, and at 11:10 AM and 2:30 PM on another day, outside the one-hour before/after window stated by the nurse. The same resident’s Metoprolol Tartrate, ordered at 9:00 AM and 8:00 PM, was administered at 12:02 PM for the morning dose, and the evening doses on two consecutive days were not given until early the following mornings (12:35 AM and 4:17 AM). During observation, the LPN administered the resident’s morning oral medications, including Hydralazine, then obtained elevated blood pressure readings and administered Metoprolol at noon, confirming that medications are supposed to be given within one hour of the scheduled time. Another resident with diabetes had a blood glucose of 49, and the LPN stated the resident was out of insulin and proceeded to borrow Novolog and Lantus from another resident’s vials before administering them, while also being behind on 8:00 AM medications for several residents as indicated by overdue (red) medication alerts. This resident’s Isosorbide, Metoprolol Tartrate, and Hydralazine were repeatedly administered late or too close together, including an evening Hydralazine dose given less than five hours before the next morning dose and other doses given many hours after the scheduled times. A third resident reported around midday that she had not yet received her morning medications; record review showed her Sacubitril-Valsartan and Furosemide, both ordered for CHF, were administered several hours late on multiple days, with some evening doses given in the early morning hours. Staff, including the LPNs and pharmacist, confirmed that the unit has a heavy medication pass, that the nurse often runs past the allowed medication window, and that these medications should be spaced at specific hourly intervals to avoid excessive or diminished effects.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
The deficiency involves multiple failures in medication storage, labeling, and security. An LPN left the 200-unit medication cart unlocked and unattended, contrary to the facility’s policy requiring carts to be locked when not in use. During a medication pass, a resident’s lispro insulin vial was observed not in its original box and without an opened date, bearing only a handwritten expiration/discard date. The same cart contained two Tresiba insulin pens labeled for another resident with dispensed dates but no corresponding medication order on that resident’s MAR. The resident receiving lispro insulin had an order for sliding scale insulin three times daily, and the manufacturer’s instructions require opened vials to be discarded after 28 days of use. Additional deficiencies were identified in the 300 Hall medication room and carts. In the medication refrigerator, opened house stock TB supplies and insulin from a discharged resident were found past their expiration dates, along with expired prefilled normal saline flush syringes. An opened container of 2 Cal Vanilla Medication Pass on top of the refrigerator lacked an expiration date. The 300 Hall medication cart contained approximately 50 loose pills scattered in a drawer. In the 200 Hall medication storage area, unidentified loose pills were found in a pill cup inside a cabinet, and multiple pill cups containing pre-popped, resident-specific medications (including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban) were observed lying on the counter. A PRN LPN working on the unit stated she was not aware of the facility’s policies or procedures regarding these practices.
Failure to Reassess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to reassess and report an elevated blood pressure for a resident with significant cardiac diagnoses. The facility’s Acute Changes in Condition Clinical Protocol requires nurses to monitor and report changes in condition, including vital signs, to the physician and to make pertinent observations and collect appropriate information before contacting the physician. The resident’s active care plan, which includes diagnoses of atrial fibrillation, hypertension, and heart failure, directs staff to monitor vital signs and report abnormalities to the physician. On the specified date and time, an LPN obtained blood pressure readings of 162/121 in the left arm and 170/100 in the right arm using an electronic blood pressure cuff and then administered Metoprolol Tartrate 50 mg. The resident’s blood pressure log for the month shows readings ranging from 130/72 to 170/100, with a 170/100 reading documented shortly after the elevated readings were obtained. However, there is no documentation that the resident’s blood pressure was reassessed after the initial elevated readings until several hours later, nor is there documentation that the elevated blood pressure was reported to the physician. In an interview, the LPN stated she did not perform any follow-up on the blood pressure because she considered it normal for the resident and observed no signs of distress, and she acknowledged that she did not reassess the blood pressure manually. The DON stated she would have expected the nurse to recheck the blood pressure manually and, if it remained elevated, to notify the physician.
Failure to Implement Repositioning and Offloading for Resident With MASD and Coccyx Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions and repositioning for a resident with moisture-associated skin damage (MASD) and an open coccyx wound. The facility’s pressure ulcer prevention policy requires residents to be repositioned at least every two hours in bed and every hour when in a chair. Despite this, the resident was repeatedly observed lying on his back in bed on an air mattress without pillows for offloading or side positioning, and there was no documentation of repositioning refusals. The resident, who has bilateral leg amputations, moderate cognitive impairment, and is dependent on staff for bed mobility and transfers, reported that he has sores on his buttocks that began in the hospital and that staff do not reposition him often enough or place him on his side. Clinical documentation on the Wound Evaluation & Management Summary identified partial-thickness MASD wounds and an open area on the coccyx, with recommended interventions including offloading the wound, side-to-side positioning, and repositioning per facility protocol. CNA task charting also prompted turning and repositioning every two hours and the use of pillows for offloading. However, observations showed the resident remained on his back for extended periods in both bed and wheelchair, and CNAs acknowledged that the resident was on his back and reported he refused side-lying due to pain and removed pillows. The wound nurse stated the resident should be turned every two hours with limited sitting time, that CNAs should notify the nurse and physician and document refusals, and that behavior monitoring should be implemented, but she was unable to find any documentation of refusals of care in the medical record.
Improper Bolus G-Tube Feeding Administration and Failure to Follow Physician Order
Penalty
Summary
The facility failed to administer a gastrostomy tube feeding according to the physician’s order and facility policy for one resident receiving bolus tube feedings. The facility’s policy for gastric tube feeding via syringe (bolus) required verification of the physician’s order for product and volume, review of the resident’s care plan, and administration of the prescribed amount of feeding and water by gravity flow using a syringe without a plunger, followed by clamping the tube before detaching the syringe. The resident had a physician’s order for Jevity 1.5 Cal, 300 ml bolus feedings every six hours. During observation, an LPN stated the resident received 600 ml of feeding and proceeded to use a syringe with a plunger to push 600 ml of Jevity 1.5 Cal into the resident’s gastrostomy tube, rather than allowing it to flow by gravity. Between drawing up each syringe of feeding, the LPN attempted to hold the gastrostomy tube with one hand, then laid the unclamped tube on the resident’s lap, causing feeding to leak out onto the resident. The LPN later confirmed that the physician’s order was for 300 ml, not 600 ml, and acknowledged that the tubing had been left unclamped during administration, resulting in leakage. The DON confirmed that physician orders should be followed for enteral feeding volume and that bolus feedings should be administered by gravity flow.
Failure to Properly Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to properly offer and administer pneumococcal vaccinations to two residents reviewed for immunizations. One resident had a Minimum Data Set (MDS) indicating moderately impaired thought processes and stated she did not remember being asked about the pneumonia vaccine at admission, but expressed that she would like to receive it if offered. Her family member and POA, who was present at admission, recalled the facility offering influenza and COVID-19 vaccines but not the pneumonia vaccine, and also stated it would be beneficial for her to receive the pneumonia vaccine. The resident’s Authorization and Release for Vaccinations form was marked as a refusal to sign but was undated. Another resident, whose MDS documented intact thought processes, reported not recalling that the pneumonia vaccine was offered at admission. She stated that the facility had offered influenza and COVID-19 vaccines during the current year but not the pneumonia vaccine, and that she would like to receive the pneumonia vaccine if available. The LPN Admissions Coordinator stated that she educates residents and families about the vaccine program at admission and reported that the first resident declined the pneumonia vaccine on a specific date, acknowledging that the refusal form should have been dated. The DON stated that simply asking residents on admission whether they want the pneumonia vaccine is not sufficient. The facility’s written Pneumococcal Vaccine Program policy requires staff to follow a protocol to determine eligibility upon admission, discuss recommendations with the physician when needed, and document education and refusals in the medical record, including when immunization is refused.
Widespread Cockroach Infestation in Food Service Areas
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in its food service areas, resulting in a significant German cockroach infestation. Observations revealed copious amounts of living and dead cockroaches in the staff lounge, which shares a wall with the kitchen and steam table food service line. The infestation extended to the refrigerator in the staff lounge, where cockroaches were found crawling through broken seals and present on shelves and drawers. The steam table food service line itself had numerous cockroaches in drawers and cabinets containing serving utensils, with live insects observed crawling onto the salad bar serving counter. Staff interviews confirmed that the cockroach problem had been ongoing and that pest control measures had not been effective. Dietary staff were observed using utensils stored in infested drawers to plate resident meals, and the Director of Nursing confirmed the presence of cockroaches in these areas during active meal service. Pest control invoices documented a high severity level of German cockroaches in the kitchen and recommended improved sanitation practices, which had not been adequately implemented. Facility policies required all food storage, preparation, and distribution areas to be kept clean and free of infection sources, and for an effective pest control program to be maintained, but these standards were not met. The deficiency had the potential to affect all 95 residents residing in the facility.
Unlicensed Staff Administered Medications
Penalty
Summary
A Certified Nursing Assistant (CNA), who was also a student in a Licensed Practical Nurse (LPN) program but not yet licensed, administered medications to several residents. The CNA stated that on one occasion, an LPN asked for assistance in handing out medications to residents who were waiting in the hallway. The CNA did not prepare the medications but distributed them to four or five residents as directed by the LPN, following instructions on whether to give the medications whole or in applesauce. The CNA could not recall the specific residents involved or the exact date of the incident, which occurred several months prior to the interview. Record review confirmed that the CNA was only eligible to work in that capacity and that the facility's job description for CNAs did not include medication administration. The facility's policy specified that only the Director of Nursing, licensed nursing personnel, and qualified medication aides are responsible for administering medications. The Director of Nursing confirmed that CNAs are not permitted to administer medications and was unaware that this incident had occurred. The facility had 95 residents at the time of the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy and procedure, resulting in the presence of cockroaches in the kitchen, adjacent meal serving/steamtable area, and resident rooms. Observations included remnants and carcasses of cockroaches on glue boards and counters in the kitchen and serving areas. Staff interviews confirmed ongoing awareness of cockroach activity in these areas, with both maintenance and dietary staff acknowledging the presence of live and dead cockroaches. Invoices from the pest control company documented recurring cockroach issues in the kitchen and public areas over several months. A resident reported a direct encounter with a cockroach in their room, describing an incident where a cockroach was found crawling on their leg and subsequently retreated under the heating/AC unit. The Maintenance Director stated that pest control companies had sprayed affected areas, and that additional spraying was performed by facility staff, but no records were kept regarding the dates, times, or chemicals used. Surveyors also personally observed live cockroaches in common areas adjacent to the kitchen and serving areas. The facility's CMS Matrix 802 form documented that 95 residents resided in the facility at the time of the survey.
Failure to Provide and Document Showers for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, as documented by a Brief Interview of Mental Status score of 9/15, did not receive scheduled showers as required by facility policy. The resident required substantial to maximal assistance for personal hygiene and was scheduled to receive showers twice weekly. Review of the resident's shower documentation for the month revealed no entries indicating that showers were provided, nor any documentation of refusals or alternative hygiene measures such as bed baths. Interviews with staff confirmed that the resident had not received showers for an extended period, and that required documentation was missing. The resident herself could not recall her last shower and expressed a desire to be clean, while a family member reported persistent odors and raised concerns to staff without resolution. The Director of Nursing acknowledged the lack of documentation and stated that without completed records, there was no way to know if showers were missed or refused. The facility's policy, revised in August 2002, requires showers to promote cleanliness and observe skin condition, but this was not followed for the resident in question. The absence of documentation and follow-up resulted in the resident not receiving appropriate hygiene care, as confirmed by staff, the resident, and her family member.
Failure to Maintain Timely Supply of Controlled Substance Medication
Penalty
Summary
A deficiency occurred when the facility failed to maintain a timely supply of a Schedule IV controlled substance, Lunesta (eszopiclone), for a resident diagnosed with schizoaffective disorder, major depressive disorder with psychotic symptoms, generalized anxiety disorder, auditory hallucinations, and insomnia. The resident had a physician's order for Lunesta 2 mg to be administered at bedtime, but documentation showed that the medication supply was depleted and not replenished in a timely manner. The facility's records indicated that after the last dose was sent with the resident on a home visit, there were no further deliveries of Lunesta until a new prescription for an increased dose was received and filled several days later. During the period when Lunesta was unavailable, administration and nursing notes documented that staff were waiting on a signed prescription from the psychiatric provider, which is required for controlled substances. Multiple attempts were made by nursing staff to contact the psychiatric provider for the necessary prescription, but there was a delay in response. The medical director was notified of the situation, and an alternative medication, melatonin, was ordered to be given as needed for insomnia until the Lunesta prescription could be filled. The resident was aware of the missed doses and expressed concern about the interruption in receiving the prescribed medication, stating that the alternative medication did not work as well as Lunesta. Staff interviews confirmed that the delay was due to the psychiatric provider's failure to provide a signed prescription, despite repeated requests from the facility. The documentation shows that the resident went several days without the prescribed controlled substance due to this delay.
Failure to Administer PRN Pain Medication at Ordered Intervals
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident who was admitted with diagnoses including a right femur fracture, chronic ulcers on both lower legs, and gait abnormalities. The resident had a physician's order for Hydromorphone HCl 4 mg to be given orally every six hours as needed for pain. Record review revealed that the medication was administered at intervals shorter than the prescribed six hours on multiple occasions, with some doses given as little as 30 minutes apart. This deviation from the physician's order was confirmed by both the Director of Nursing and the Corporate Clinical Education staff upon review of the controlled drug records.
Failure to Document PRN Controlled Medication Administration on MAR
Penalty
Summary
The facility failed to document the administration of medication on the Medication Administration Record (MAR) for one resident reviewed for medication administration. According to the facility's policy, each medication or treatment administered must be promptly documented in the medication record after administration to validate that residents are receiving drugs and biologicals as ordered by the physician. In this case, a resident with diagnoses including a right femur fracture, chronic ulcers on both lower legs, and gait abnormalities was admitted and had a physician's order for Hydromorphone HCl Oral Tablet 4 MG to be given every six hours as needed for pain. Record review showed that the Controlled Drug Receipt/Record/Disposition form documented multiple administrations of Hydromorphone to the resident on various dates and times. Nursing staff confirmed that signing the controlled drug form indicated the medication was administered and that it should also be documented on the MAR. However, review of the MAR for the relevant month revealed that these administrations were not recorded as required, despite confirmation from nursing staff and facility leadership that the medication had been given according to the controlled drug records.
Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to complete a physician-ordered wound treatment for one resident with chronic ulcers and a history of a right femur fracture. The resident's care plan required wound dressing changes to both knees twice daily, as ordered by the physician. On the day of the survey, the resident reported that the dressing changes had not been completed as scheduled, and the dressings present were dated from the previous day. Observation confirmed that both knee dressings were overly saturated with serosanguinous drainage, which had soaked through to the pillowcases and towels placed under the knees, as well as onto the bed. The resident stated that this was a common occurrence and that the dressing changes were not consistently performed twice daily as ordered. Record review showed that the Treatment Administration Record was signed off as if the wound dressing change had been completed that morning, despite the treatment not having been performed at that time. The physician's order specified the application of Gentamicin Sulfate Cream to the left knee twice daily at specific times. Nursing staff confirmed that the dressings were overdue and that the documentation did not accurately reflect the care provided. The facility's policy required prompt documentation of treatments after administration to validate that residents receive care as ordered, which was not followed in this instance.
Failure to Provide Supervision Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents with known fall risks. One resident, who had diagnoses including muscle weakness, lack of coordination, and repeated falls, experienced an unwitnessed fall in the shower after being left unattended by a CNA. The resident reported slipping while trying to get dressed after the shower, and the Assistant Director of Nursing confirmed that the CNA should not have left the resident alone. This resident had a history of falls, including incidents related to not locking walker brakes and a seizure, but the specific deficiency cited was the lack of supervision during the shower, which resulted in a fall. Another resident, with diagnoses of unspecified dementia, psychotic and mood disturbances, and a consistently high fall risk, required supervision while smoking according to assessments and care plans. Despite this, the resident was left unsupervised on the smoking patio, where she fell after her walker became caught on uneven pavement. The fall was witnessed by another resident, who reported that no staff were present at the time. The Assistant Director of Nursing confirmed that this resident was not independent with smoking and required staff supervision, which was not provided at the time of the fall.
Failure to Secure Indwelling Catheter and Prevent Leakage
Penalty
Summary
A deficiency occurred when staff failed to maintain a urinary indwelling catheter in a secure manner for a resident with a diagnosis of obstructive and reflux uropathy. The resident's care plan indicated the presence of an indwelling catheter and a risk for urinary tract infection, with a goal to remain free from catheter-related trauma. During observation, it was noted that the resident did not have a security leg strap or any adhesive tape to secure the catheter, as required by facility policy. The catheter tubing and drainage bag were also not dated, and the resident's linen and bed were found to be wet due to urine leakage from the catheter. The resident reported ongoing pain at the catheter insertion site, describing sensations of the catheter pulling and requests for the catheter to be secured, which had not been addressed. The resident also stated that the catheter had not been changed monthly as ordered, and that frequent leakage resulted in daily pad changes by CNAs. The CNA confirmed the absence of a leg strap and the need to notify the nurse about the resident's pain. Facility policy required the use of adhesive tape or a leg band to secure the catheter, but this was not implemented, leading to the resident's discomfort and repeated episodes of urine leakage.
Failure to Maintain Odor-Free Resident Room Due to Accumulated Soiled Laundry
Penalty
Summary
The facility failed to maintain a resident room free of odors from urine-soaked clothing, affecting one resident with severe cognitive impairment and substantial assistance needs for toileting hygiene. Observations and interviews revealed that soiled clothing was left to accumulate on the resident's floor, resulting in a strong odor. Staff acknowledged that laundry is supposed to be picked up at least every shift and returned the same day, but admitted that this was not always achieved. A CNA confirmed that the resident often removes her own clothes and leaves them on the floor, and that staff are responsible for picking up soiled laundry and assisting with toileting, but in this case, a large amount of urine-soaked clothing had accumulated over several days. A family member reported finding several large garbage bags of urine-soaked clothes in the resident's room and noted that the resident's recliner was also saturated due to lack of protective pads. The facility's policy requires maintaining a clean, odor-free, and comfortable environment, but this was not upheld in the resident's room. The deficiency was identified through observation, staff and family interviews, and review of facility policy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident who was dependent on staff for hygiene due to paraplegia, lack of coordination, and weakness. The resident was cognitively intact and required assistance with personal care, including toileting and bed mobility. On the early morning in question, the resident requested assistance from a CNA to be cleaned after an episode of incontinence. The CNA stated they would return but did not, and the resident reported waiting approximately 45 minutes while hearing the CNA in another room. The resident alerted multiple staff members, including another CNA and a registered nurse, but was not cleaned until the day shift arrived. Interviews with staff confirmed that the resident's call light was answered, but the aides prioritized getting other residents up for the day instead of providing the requested incontinence care. The CNAs and RN acknowledged the resident's request but did not provide care at that time, with the RN stating they were in the middle of a medication pass and would find someone to help. Documentation did not show any incontinence care provided to the resident on the date in question. The facility's policy requires prompt response to call lights and resident needs, which was not followed in this instance.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency are not provided in the report.
Failure to Ensure Resident Dignity During Care and Discharge
Penalty
Summary
The facility failed to ensure the dignity of two residents as evidenced by staff actions and omissions. In the first instance, a cognitively intact resident with multiple medical diagnoses, including heart failure and diabetes, was reportedly treated roughly by the facility administrator, who took silverware from the resident's hand while eating and removed the resident from the dining area. The resident's personal belongings were packed without explanation, and the resident was transported away from the facility without being informed of the reason, causing confusion and distress. Staff reported that the resident's belongings were left on the ground outside, and the resident repeatedly asked why she was being removed, indicating a lack of communication and respect for her dignity. In the second instance, another resident who required assistance to prepare for dialysis activated the call light early in the morning but did not receive timely help. Two CNAs arrived shortly before the resident's scheduled transportation and hurriedly prepared him, resulting in a washcloth being left inside his incontinence brief. The resident became aware of an odor after dialysis, which was confirmed by both the dialysis nurse and the transportation driver, leading to feelings of humiliation. Upon return to the facility, staff discovered the washcloth during care, and the resident was visibly upset and requested to be left alone. These events demonstrate failures in providing dignified and attentive care to the residents involved.
Failure to Prevent Verbal Abuse Between Roommates
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents sharing a room. One resident, who had a history of alcohol abuse, cognitive impairment, and multiple medical diagnoses, was moved into a room with another resident who had moderate cognitive impairment and required significant assistance with activities of daily living. Shortly after the room change, both residents engaged in a verbal altercation, during which one resident threatened the other with bodily harm. This exchange was witnessed by a housekeeper, who confirmed hearing the threat and the yelling from the nurse's station. The facility's Abuse Prevention Program policy requires staff to identify residents with increased vulnerability to abuse and to implement care planning strategies to reduce the risk of abuse, neglect, or mistreatment. Despite these requirements, the care planning and monitoring processes did not prevent the verbal abuse incident. The resident who was threatened reported that his belongings were moved without his knowledge and that he was subjected to yelling and threats of bodily injury by his roommate. Staff intervention occurred only after the altercation, when the threatened resident was moved to another room.
Failure to Serve Hot and Palatable Food to Residents
Penalty
Summary
The facility failed to ensure that hot food was served to three residents out of three reviewed for dietary services. Observations conducted over several days revealed that meal trays were delivered to the hallway by kitchen staff, but nursing staff delayed passing the trays to residents for periods ranging from 11 to 18 minutes. The trays contained both hot and cold food items, but there was no hot plate under the ceramic plates to maintain food temperature. Multiple residents reported that their food was consistently cold, and some stated they had informed staff about this issue previously. One resident mentioned requesting staff to reheat food in a microwave, while another reported not eating meals due to the food being cold and unappetizing. Resident Council meeting minutes from two separate months documented ongoing complaints from residents about cold food. The residents involved had varying cognitive statuses, with two being cognitively intact and one having moderate cognitive impairment. The deficiency was identified through interviews, record reviews, and direct observations, all of which consistently indicated that the facility did not maintain food at a safe and appetizing temperature during meal service.
Failure to Provide Sufficient Linens for Resident Care
Penalty
Summary
The facility failed to provide sufficient linens to ensure a safe and sanitary environment for all 98 residents. On the day of the survey, only one out of three washing machines was operational, and two out of four dryers were working. Observations revealed that only about three dozen each of hand towels and washcloths were available in storage areas. Staff interviews confirmed ongoing shortages, with housekeeping and laundry aides reporting frequent linen shortages, especially on weekends, and difficulty keeping up with laundry demands due to understaffing. The Director of Nursing also acknowledged shortages of both linens and housekeeping staff, sometimes requiring staff to be pulled from other duties to complete laundry tasks. Resident interviews during a council meeting revealed that multiple residents had not received showers in the past week, with staff attributing this to a lack of linens and laundry staffing. Residents reported that grievances about this issue had been filed after every monthly council meeting, and that scheduled showers were not being provided as required. Facility policy requires specific linens for bathing, but the lack of available linens prevented adherence to this policy.
Failure to Provide Required Showers and ADL Assistance Due to Linen and Staffing Shortages
Penalty
Summary
The facility failed to provide showers and adequate assistance with activities of daily living (ADLs) for five residents who were unable to perform these tasks independently. During a Resident Council meeting, multiple residents reported not having received showers in the past week, despite facility policy requiring showers twice weekly. Observations confirmed that these residents had visible signs of poor hygiene, including food on their clothing, oily hair, and dirt under their nails. Medical records corroborated that the last documented showers for these residents were well beyond the required frequency, with some not having received a shower for up to two weeks. Interviews with staff revealed that a shortage of linens and housekeeping staff contributed to the failure to provide showers. Certified Nursing Assistants (CNAs) reported running out of linens, particularly on weekends, and the Director of Nursing confirmed that staff shortages led to CNAs being unable to locate necessary supplies. Additionally, it was noted that towels and linens were sometimes stored in residents' drawers, further complicating access. Despite grievances being filed by residents after each monthly council meeting, there was no reported improvement in the provision of showers or ADL assistance.
Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to accurately account for controlled medications and document shift-to-shift controlled medication counts for all seven residents reviewed for controlled medications. Facility policy requires that controlled medications be counted at the end of each shift by both the outgoing and incoming nurse, with documentation and reporting of discrepancies to the Director of Nursing (DON). However, observations revealed that controlled medication binders for multiple medication carts were missing required Controlled Substance Shift Change Count Sheets, and where forms were present, they often lacked two nurse signatures or had missing entries for specific dates. The DON confirmed that not all required forms could be located for the relevant months and that the process was not being followed as outlined in facility policy. Further review of medication administration records (MARs) and controlled drug receipt/record/disposition forms showed discrepancies in medication administration documentation. For example, one resident received Lorazepam without an active order in the electronic medical record, and doses were administered and signed out on controlled drug records but not on the MAR. Staff interviews revealed that medications were sometimes given based on verbal reports or hospice instructions without verifying active orders in the electronic record, and doses were not always documented on the MAR as required. In another case, a resident's Norco administration was not recorded on the MAR, despite being signed out on the controlled drug form, with staff citing power outages as a reason for not completing documentation. These findings demonstrate that the facility did not consistently follow its own policies for controlled medication management, including shift-to-shift counts, dual nurse verification, and accurate documentation of medication administration. The discrepancies between controlled drug records and MARs, as well as missing or incomplete count sheets, were confirmed by staff and the DON during the survey.
Failure to Administer and Reorder Medications Timely, Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered timely and as ordered, and did not consistently reorder medications to prevent running out, resulting in significant medication errors for four residents. For one resident, a change in Tramadol order from PRN to scheduled dosing was not properly managed, leading to missed doses due to delays in obtaining a signed prescription and confusion over whether the medication should be administered as needed or on a schedule. Documentation showed that the resident was without Tramadol for multiple scheduled doses, and staff and pharmacy communications revealed delays in reordering and confusion about medication supply responsibilities. Another resident experienced a lapse in receiving Norco due to the facility running out of the medication and delays in sending a signed prescription to the pharmacy. This resident also had multiple instances where other medications, including insulin and antihypertensives, were administered significantly later than scheduled, with no documentation of physician notification regarding these delays. Nursing notes confirmed the lack of timely communication with the physician and delays in medication administration. A third resident did not receive scheduled doses of Amlodipine and Metoprolol on several occasions, with the nurse withholding the medications based on blood pressure readings despite the absence of physician-ordered parameters for withholding. There was no documentation of physician notification for these withheld doses. Additionally, another resident reported repeated delays in receiving evening medications, with audit reports confirming multiple instances of late administration. Staff interviews attributed these delays to workload and staffing issues, and the DON confirmed the expectation for timely administration and documentation, which was not met in these cases.
Failure to Properly Store and Destroy Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly stored and destroyed according to policy for two residents. In one instance, a resident's Morphine Sulfate was found stored in the bottom drawer of a medication cart, which is not a locked compartment designated for controlled substances. The medication was supposed to be kept in a locked controlled medication compartment, but was instead located among inhalers. The controlled drug record indicated that only one dose had been signed out, and staff interviews confirmed that the medication was misplaced and not secured as required. Additionally, the facility's controlled substance shift change count sheets were incomplete, with missing entries for the relevant period, and the Director of Nursing confirmed that the required documentation was not fully available. In another case, a resident's Norco prescription had been discontinued, but the medication card with 19 tablets remained in the locked compartment of the medication cart. The order for Norco had been discontinued several days prior, yet the medication was not removed or destroyed as per facility policy. The Director of Nursing verified that the medication should have been pulled and destroyed after discontinuation, but this was not done, resulting in the continued presence of discontinued controlled medication in the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer recommendations for five residents, resulting in a medication error rate of 13.51 percent. For one resident, Flonase was not administered because it was not available in the medication cart, despite being a stock drug. Another resident did not receive their Hydrocodone-Acetaminophen due to the pharmacy's delayed delivery, which had occurred previously. Additionally, a resident was not instructed to rinse their mouth after using Trolley Lepta, as required by the physician's order. Further errors included administering the incorrect dosage of Tylenol to a resident, where 500 mg was given instead of the prescribed 325 mg. Another resident did not receive their Budesonide Formoterol Fumarate as ordered, even though the medication was available on the cart. These incidents highlight a failure to adhere to the facility's Medication Administration Policy, which mandates that drugs be administered in accordance with licensed medical practitioners' orders.
Resident Intimidated by RN's Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Registered Nurse (RN), which resulted in the resident experiencing mental anguish, fear, and anxiety. The incident involved a resident who is cognitively intact and has paraplegia. The resident reported that the RN entered his room aggressively after mishearing a conversation about a 'stink' in the hallway as a threat to call the 'state.' The RN reportedly yelled at the resident, causing him to feel intimidated and scared, especially given his inability to physically defend himself due to his condition. The resident immediately reported the incident to the Administrator-In-Training, expressing feelings of being threatened and abused. However, the administrator dismissed the resident's concerns, attributing them to the resident's history of being 'ridiculous.' A Certified Nursing Assistant (CNA) who witnessed the incident corroborated the resident's account, describing the RN's behavior as aggressive and threatening. Despite the resident's expressed fear and discomfort, the RN continued to work that night and later returned to the resident's room to offer an apology, which the resident rejected. The facility's inaction in addressing the resident's concerns and the RN's behavior contributed to the resident's ongoing distress and lack of safety in his environment.
Failure to Investigate Abuse Allegation and Protect Residents
Penalty
Summary
The facility failed to implement its Abuse Policy to thoroughly investigate an allegation of abuse and protect residents from the alleged perpetrator. A resident reported feeling threatened and verbally abused by a registered nurse (RN) and immediately informed the Administrator-In-Training. Despite the report, the RN continued to work that night and was not suspended. The Administrator-In-Training only spoke to the resident and the RN, without conducting a full investigation or removing the RN from duty. The RN continued to care for all residents in the 300-hallway, including the resident who made the allegation, without any suspension or further inquiry. The facility's records, including the Abuse Investigations and the resident's Electronic Medical Record, did not show any evidence of an investigation into the abuse allegations. The facility's Abuse Prevention Program policy requires immediate protection of residents and prompt investigation of all reports of abuse, which was not followed in this case.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Policy by not immediately reporting an allegation of abuse to the State Agency. A resident reported feeling threatened and verbally abused by a registered nurse to the Administrator-In-Training. Despite receiving this report, the Administrator-In-Training did not report the allegation to the state agency as required by the facility's Abuse Prevention Program policy. The policy mandates that any allegation of abuse be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation. The facility's records did not include evidence of the abuse allegation being reported to the State Agency, indicating a failure to adhere to the established policy.
Facility Fails to Maintain Functional and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain the shower rooms in a homelike and functional condition, affecting all 102 residents. On multiple occasions, surveyors observed the shower rooms on the 200 and 300 halls in a state of disarray, with construction debris, tools, and equipment scattered throughout. The 200 hall shower room had hardened cement tile mastic, a steel mixing blade, and a pile of tiles from demolition. The 300 hall shower room was being used as a storage area, with various items such as recliners, mechanical lifts, and housekeeping carts cluttering the space. Both shower rooms had been shut down for safety reasons, and the facility had not completed the necessary repairs. The Maintenance Director, V12, stated that the repair work had been ongoing for six months, but the individual responsible for the work had not returned to finish the job. The Administrator, V1, confirmed that the shower rooms on the 200 and 300 halls had been non-functional for approximately two months due to water damage and loose tiles. Despite attempts to obtain estimates for repairs, no progress had been made, and the facility's maintenance staff was unable to complete the work due to other responsibilities. Residents expressed dissatisfaction with the condition of the shower rooms, noting the presence of mold, insects, and construction debris. Several residents reported having to use shower rooms on other halls, which were also in poor condition. The 100 and 400 hall shower rooms had issues such as blackened areas resembling mold, non-functional valve handles, and doors that did not close properly. Residents expressed frustration with the ongoing construction and the lack of progress in completing the repairs.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dishwasher water temperatures at the required level to sanitize dishware, potentially affecting all 102 residents. During observations, the dishwasher's final rinse temperatures were recorded at 156 F, 161 F, and 163 F, which are below the required 180 F for proper sanitation. The Dietary Manager, V22, confirmed the required temperatures and acknowledged the issue, suggesting the use of disposable plates and utensils as a temporary measure. The Maintenance Director, V12, had contacted a service company for repairs, but they were unavailable until the following day. The Administrator, V1, was unaware of the issue until informed during the survey and recognized the need for better communication among staff to address such problems promptly. Despite the availability of a 3-compartment sink for manual dishwashing, the dietary staff were reluctant to use it due to the time it required. The facility's contract with a specific service company further complicated the repair process, as another technician could not service the dishwasher without breaching the contract.
Facility Lacks Qualified Social Worker for 154-Bed Capacity
Penalty
Summary
The facility failed to provide the services of a qualified Social Worker for their facility with a bed capacity of 154, affecting all 102 residents residing in the facility. The Administrator, identified as V1, confirmed that the facility does not have a Social Worker with a degree and has not had one for an undetermined period. The former Social Services Director, V31, who does not possess a bachelor's degree in Social Work or a Human Services Field, was moved to the position of Business Office Manager. V31 had minimal supervision in the role of Social Services Director, receiving only two hours of consultation on one occasion. The facility's staff roster does not list anyone in the Social Services position, confirming the vacancy.
Pest Control Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain an effective pest control program, which was evident through the presence of pests in the kitchen area. During an observation, the Maintenance Director noticed a live cockroach on a trash can next to the dishwasher and numerous small flying insects, commonly referred to as sewer flies or fruit flies, around the floor drains and dishwasher area. The floor in the dishwasher area was saturated with water due to the dishwasher spraying out water when the cycle started, and a significant amount of water was observed coming out from under the dishwasher door. Additionally, a two-compartment stainless steel sink adjacent to the food preparation counters was leaking sewage water onto the floor. The Dietary Manager acknowledged awareness of the flies, particularly around the floor drains and dishwasher drain, and mentioned that the kitchen staff attempted to keep the floor dry and used chemicals to eliminate the flies. A maintenance work order had been submitted for the leaking sink drains. Resident complaints about fruit flies were documented in the facility's Resident Council Meeting Minutes from February 2024, indicating an ongoing issue.
Non-Functional Door Alarms and Monitoring Systems
Penalty
Summary
The facility failed to maintain its door alarms and computer-based door monitoring systems in functional condition, which could potentially affect all 102 residents. The Maintenance Director, V12, acknowledged that the system was not functioning to emit a sound when a door was opened, and the monitor screens at various nurse stations were either black or not displaying the facility floor map. This required staff to visually monitor the screens to know if a door was opened, which was not feasible given the system's current state. Additionally, several doors, including those leading to courtyards and a loading dock, did not have functional audible alarms, and some could be opened with a simple push. The electronic bracelet monitoring alarms were functional, but not all residents used them. The Administrator, V1, expressed concern over the non-functional door alarms and acknowledged that the Maintenance Director and Assistant were supposed to check the alarms daily. However, there was a lack of communication and action to address the issues promptly. During the survey, it was observed that staff were not always present in areas where residents could potentially exit the facility unsupervised, such as the activity room and during scheduled smoking times. The staff also did not respond to audible announcements of doors being ajar, as they were unaware of which doors were open due to the non-functional screens.
Inaccurate Smoking Status Assessment and Documentation
Penalty
Summary
The facility failed to accurately assess and document the smoking status of three residents, leading to discrepancies in their Minimum Data Sets (MDS) and care plans. Specifically, the smoking schedule listed five residents as current smokers, but the MDS for three of these residents inaccurately documented them as non-smokers. Resident 11's MDS did not reflect her current tobacco use, and her care plan lacked a focus area for smoking, despite her smoking assessment indicating she requires assistance to light cigarettes. Resident 12's MDS also inaccurately documented no tobacco use, and his smoking assessment was incomplete, though it noted he does not light his own cigarette safely. Resident 13's MDS incorrectly documented her as a non-smoker, although she had resumed smoking after admission. The Infection Preventionist/Wound Nurse confirmed these discrepancies and acknowledged that Resident 13 should have been reassessed when she resumed smoking.
Failure to Timely Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to timely assess residents for the risk of developing pressure ulcers and to complete pressure ulcer treatments according to physician orders. This deficiency affected three residents who were reviewed for wound care. For one resident, the Braden Scale assessment was not updated, and multiple instances of missed documentation for pressure ulcer treatments on the sacrum, buttocks, and right heel were noted in both November and October. Another resident's treatment administration record showed missed documentation for pressure ulcer treatments on the sacrum and daily skin checks in October and September. Similarly, the third resident's treatment records indicated missed documentation for pressure ulcer treatments on the left outer ankle and sacrum in October and November. The facility's policy requires Braden Assessments to be conducted upon admission, weekly for the first month, then quarterly, and with any significant change in condition. However, the most recent Braden Scale assessments for the residents were not updated as per the policy. Additionally, the facility's policy on medication and treatment administration requires prompt documentation of each treatment administered, which was not adhered to, as evidenced by the missing documentation in the treatment administration records for the residents involved.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which is a requirement for the operation of the facility. This deficiency affects all 109 residents residing in the facility. The Administrator confirmed that the facility has not had a full-time DON for six months. During the survey conducted from November 19 to November 22, 2024, there was no DON working in the facility. The CMS-802 Matrix form dated November 19, 2024, documents that 109 residents reside in the facility.
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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