Fargo Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1512 West Fargo, Chicago, Illinois 60626
- CMS Provider Number
- 146169
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Fargo Health Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple behavioral and medical diagnoses was verbally and physically assaulted by another cognitively intact resident on the facility’s smoking patio after an argument over a lighter escalated without staff intervention. Both residents had signed out on independent pass and were smoking with a third resident when derogatory name calling began and one resident punched the other multiple times in the face, causing a comminuted right maxillary sinus fracture and a facial laceration requiring sutures and ED treatment. Surveyors confirmed through interviews and observations that no staff or security were present on the patio during the incident, that residents often smoked without direct supervision, and that monitoring relied on video cameras without audio. Staff, including an LPN, CNAs, the DON, the Administrator, security, and the psychiatric rehabilitation director, acknowledged that residents with behavioral issues can be aggressive, that the smoking area should be supervised, and that the facility is responsible for resident safety on its property. Facility policies on resident rights, abuse prevention, rounds, and smoking safety required prevention of abuse and regular monitoring, but these were not followed, and the facility’s investigation concluded that verbal and physical abuse occurred and caused harm.
The facility failed to properly justify and document involuntary discharges for two residents. One resident with depression, no documented history of aggressive behaviors, and a recent episode of self-harm after a family death was petitioned for involuntary discharge and not allowed to return, while the notice cited danger to others but the record lacked physician documentation or evidence of behaviors endangering other residents. Another resident with paranoid schizophrenia and repeated smoking in non-designated areas, profanity, and aggression was issued an involuntary discharge notice stating that the resident’s needs could not be met, yet the record contained no physician documentation explaining the discharge, what needs could not be met, or what services had been attempted beyond a smoking behavior contract.
A resident with intact cognition and multiple mental health diagnoses, including bipolar disorder and major depressive disorder, had a care plan calling for specialized mental health services such as psychotherapy and supportive counseling. Although several client-centered therapy sessions were documented initially, no further sessions occurred after a certain point, and the Social Service Director confirmed the resident did not participate in any ongoing structured groups or 1:1 psychosocial sessions, despite the availability of outside providers. The resident later reported feeling depressed over a sibling’s death, expressed a desire to go to the hospital, and disclosed self-harm by cutting the wrist, requiring hospital treatment and subsequent psychiatric evaluation, while a suicide/self-harm screening had identified a low to moderate risk and recommended supportive counseling.
Several residents were not provided with admission contract packets at the time of admission, with some waiting over a year to receive them. One resident with intact cognition reported being asked to sign a contract recently, expressing concerns about missing information and lack of time for review. Staff confirmed the facility was years behind in issuing these contracts, and an audit revealed multiple residents without them. The facility's policy did not address timely provision of admission packets.
The facility did not provide bread, Garlic Texas Toast, or appropriate bread substitutes during lunch meals as required by posted menus and dietary policies, affecting all residents receiving food from the kitchen. Multiple residents on regular, mechanical soft, and pureed diets did not receive these items, and staff interviews confirmed that bread had not been served at lunch for about a year without providing a substitute or informing the Registered Dietitian.
Surveyors found that kitchen staff did not consistently wear appropriate hair coverings, and multiple opened food items were not labeled or dated according to facility policy or manufacturer guidelines. Opened pre-thickened liquids and milk were not marked with opened or use-by dates, and some food items were not stored as directed by the manufacturer. These failures had the potential to affect all residents receiving food from the kitchen.
Staff failed to consistently bag soiled linen, transported clean linen in uncovered carts, and did not wear required PPE when providing care to a resident on enhanced barrier precautions for an indwelling catheter. The facility also did not track or report XDROs as required by state regulations, and the resident on EBP was not listed on the facility's EBP list.
Surveyors observed that nurses administered multiple medications to several residents outside the physician-ordered time frames, resulting in a medication error rate of 30%. Medications scheduled for specific times were given late, contrary to facility policy and physician orders, as confirmed by the DON and facility records.
Surveyors found that multi-dose inhalers for two residents were not dated after opening, despite pharmacy instructions to discard after a set period, and that a house stock Tubersol solution requiring refrigeration was stored at room temperature in a medication cart. Staff interviews and policy reviews confirmed that medications were not consistently dated or stored according to professional standards and facility policy.
Two residents were affected when staff failed to serve meals simultaneously to individuals seated at the same table, resulting in one resident waiting and observing another finish eating before receiving his own tray. Additionally, a resident with severe hearing impairment and no speech was not provided with accessible communication aids, and staff lacked training in sign language, relying instead on gestures. These actions did not align with facility policies on resident dignity and communication.
Two residents with limited ROM and physician orders for splint use were repeatedly observed without their prescribed splints in place. Despite care plans and orders specifying daily application, staff did not ensure splints were used as directed, and staff interviews confirmed knowledge of the orders and their purpose.
A resident was found keeping a cigarette accessible on a bedside table, contrary to facility policy requiring secure storage of smoking materials, while another resident with independent pass privileges left the facility without signing out and was not properly monitored or documented by staff. Staff interviews revealed inconsistent understanding and application of procedures for both smoking safety and resident monitoring during community leaves.
A resident with multiple diagnoses and a history of bladder incontinence was not provided with a restorative toileting program as required by facility policy. Staff confirmed that no such program was in place, and the resident reported using pullups and self-initiating restroom use without structured support.
A resident with chronic respiratory conditions was found to have a nebulizer mask and tubing improperly stored in a bedside drawer mixed with personal items and not dated, contrary to facility policy requiring proper storage and dating to prevent contamination. Both an LPN and the DON confirmed the equipment should have been stored in a clean, clear plastic bag and changed regularly.
Multiple incidents occurred in which residents were subjected to physical and verbal abuse by peers, including slapping, pushing, and threatening language. These events were confirmed through interviews and documentation, involving residents with various medical and psychiatric diagnoses. Staff and administrative personnel substantiated the abuse, indicating a failure to protect individuals from harm as required by facility policy and resident rights.
A resident reported being verbally threatened by a former roommate, with the incident documented by security and later substantiated as abuse. Although the security guard informed the administrator and documented the event, the initial report to authorities was delayed, as the administrator did not recognize the urgency or nature of the allegation. Facility policy requires immediate reporting of abuse allegations, but this protocol was not followed, resulting in a deficiency for untimely reporting.
A resident with dementia was physically abused by her roommate, who had a history of aggressive behavior. Despite signs of verbal and physical aggression, staff failed to prevent the abuse, resulting in the resident sustaining a broken nose. The facility's investigation confirmed the abuse, but staff did not report the warning signs as required by the facility's policy.
A resident in an LTC facility suffered a bruise and skin tear on the left arm due to rough handling by a CNA during incontinence care. The resident, who is cognitively intact, reported the incident, leading to an investigation. The CNA initially denied the incident but later acknowledged seeing the injury. The facility failed to prevent and report the abuse, resulting in the CNA's termination.
The facility did not submit the final investigation report of a resident-to-resident altercation to IDPH within the required timeframe. The incident involved a verbal and physical altercation between two residents, who were separated immediately with no injuries noted. Although the initial report was sent, the final report's submission could not be confirmed by the current administrator.
A facility failed to protect residents from abuse, as evidenced by a CNA hitting a cognitively impaired resident and an unsupervised altercation between two residents over cigarettes. The incidents highlight deficiencies in staff supervision and monitoring, particularly in areas like the smoking area, where residents are vulnerable.
A resident fell from their bed and was injured after a CNA attempted to turn them alone, despite the resident's care plan requiring a two-person assist for bed mobility. The incident caused increased pain and psychosocial harm to the resident, who expressed ongoing fear and anxiety. The facility's policies on fall prevention and personal care services were not followed, leading to the deficiency.
The facility failed to ensure proper food storage, labeling, and dating practices in the kitchen, potentially affecting all 94 residents receiving an oral diet. Undated and expired food items were found in the walk-in cooler and dry storage area, and a staff member's drink was improperly stored in the freezer. The dietary manager acknowledged the importance of these practices to ensure food safety.
The facility failed to ensure that residents' call light devices were within reach, affecting four residents. Observations revealed that call light strings were often hanging from the wall switch and out of reach, despite care plans and facility policies requiring them to be accessible. The Director of Nursing confirmed the importance of having call lights within reach, but this was not consistently practiced.
The facility failed to have a Psychiatric Rehabilitation Services Coordinator (PRSC) to meet the individualized psychosocial and mental health needs of residents. Observations and interviews revealed that several residents with severe mental illness had not received counseling or therapy services, and the Social Services Director was unable to provide adequate support to all residents. The facility had not hired a full-time or part-time PRSC, despite efforts to do so.
The facility failed to provide individualized psychosocial and mental health services to residents with severe mental illness. Five residents were observed with flat affect and low mood, and reported not receiving counseling or therapeutic services. The Social Services Director was overwhelmed and unable to meet the needs of all residents, and additional PRSC positions had not yet been filled.
The facility failed to ensure that the air-conditioner in a resident's room was working, repair a broken wall heat vent cover, and clean and cover the air-conditioner air filter in residents' rooms. These deficiencies affected seven residents and were not reported or addressed by the maintenance staff.
The facility failed to document a resident's code status in the EMR upon admission, despite the resident being cognitively intact and having multiple diagnoses. The code status was only entered after the surveyor's request, highlighting a lapse in protocol.
The facility failed to provide a safe and functional environment for two residents. One resident's privacy curtain was soiled with a stool-like substance and remained uncleaned despite daily inspections. Another resident's room was missing a window screen, allowing flies to enter. Both residents expressed a desire for these issues to be addressed.
The facility failed to assist a resident with shaving facial hair, leading to discomfort. The resident, who has moderate impairment and various medical conditions, was supposed to be shaved but did not receive assistance due to a CNA being off-duty. The resident's care plan requires partial assistance with personal hygiene, and the facility's policy mandates well-groomed hair.
The facility failed to protect a resident from physical abuse by another resident with a history of aggressive behavior. Preventative measures were not in place, and care plans were not updated, leading to multiple injuries for the victim.
The facility failed to maintain an effective pest control program, leading to the presence of cockroaches in the kitchen. A resident reported finding a cockroach in her tray, and traps with cockroaches were found during an inspection. Pest control reports documented the presence of German roaches, but there was no documentation of staff reporting pest problems, and the facility's pest control policy was not effectively implemented.
Failure to Supervise Smoking Patio Resulting in Resident-on-Resident Assault and Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by another resident and to follow its own abuse prevention and supervision policies. On the afternoon of 1/26/2026, two cognitively intact residents with independent community passes were on the facility’s smoking patio after signing out on pass. A verbal altercation began over a cigarette lighter, with both residents engaging in derogatory name calling. One resident (R3), who had a care plan noting potential for inappropriate behavioral problems and a need for supervised community access with restricted independent pass privileges, became agitated and punched the other resident (R2) multiple times in the right facial area. R2 and a witness (R5) both reported that there were no staff or security personnel present on the patio during the verbal escalation or the physical assault, and that no staff came outside to intervene. As a result of the assault, R2 sustained a laceration and a closed fracture of the right anterior maxillary sinus. R2’s hospital records documented an assault with loss of consciousness, a comminuted, mildly impacted fracture of the right anterior maxillary wall, soft tissue swelling, and a facial laceration repaired with sutures. Progress notes from the LPN on duty described R2 returning from the patio with a right facial laceration and minimal bleeding, calling the police, and being transported to the emergency department. Upon return, documentation confirmed the diagnoses of closed fracture of the right maxillary sinus and facial laceration with two sutures below the right eye and a scratch on the right eyebrow. R2’s medical history included schizoaffective disorder, epilepsy, anxiety disorder, insomnia, restlessness and agitation, chronic pain, sleep apnea, nicotine dependence, and other conditions, with an MDS BIMS score of 15 indicating intact cognition. Multiple staff interviews and observations showed that the facility did not provide active supervision of residents on the smoking patio, despite policies requiring resident monitoring and abuse prevention. On two separate observation dates, surveyors saw several residents smoking on the patio without any staff supervision. The security guard stated that supervised smokers should always have a staff member present on the patio, that unsupervised smokers with independent passes were mainly monitored by video cameras without audio, and that it would not be possible to hear verbal abuse or respond quickly enough to prevent a sudden physical assault. CNAs and nursing staff acknowledged that residents with behavioral issues could be aggressive or unpredictable and that someone should be supervising residents at all times to separate them before altercations escalate, but also stated that residents on the patio were not always supervised. The Psychiatric Rehabilitation Services Director, DON, Administrator, and Activity Director all confirmed that no staff witnessed the incident, that there was no supervising staff outside on the patio at the time of the altercation, and that the facility is responsible for residents while on facility property. Facility policies on resident rights, abuse prevention, rounds, and smoking safety required prevention of abuse, hourly monitoring of residents, and maintenance of a safe environment, but these were not followed, resulting in a founded conclusion of verbal and physical abuse of R2 by R3 and physical harm to R2. The facility’s abuse prevention policies defined abuse as the willful infliction of injury with resulting physical harm, including verbal and physical abuse, and required the facility to establish a resident-secure environment, supervise and monitor staff’s ability to meet residents’ needs, and correct inappropriate language or handling at the time situations occur. The Resident’s Rights policy affirmed residents’ right to be free from abuse. The Rounds Policy required daily rounds to ensure residents are monitored every hour or as needed, and the Smoking Safety Policy aimed to provide a safe and healthy living environment recognizing potential harm from careless smoking. Despite these written policies, the facility did not ensure that staff were physically present to supervise residents on the smoking patio, did not ensure that a resident with known behavioral risks and a care plan calling for supervised community access was appropriately supervised, and did not intervene during the verbal escalation that preceded the physical assault. The Administrator and other leaders acknowledged that the smoking patio should be monitored at all times and that staff presence could have de-escalated the situation and prevented the abuse, and the facility’s own final incident investigation concluded that abuse was founded.
Failure to Properly Justify and Document Involuntary Discharges
Penalty
Summary
The deficiency involves the facility’s failure to ensure that involuntary transfers and discharges were not based solely on residents’ conditions at the time of transfer to acute care and to obtain and maintain required physician documentation supporting the reasons for involuntary discharge. For one resident (R1), who had a diagnosis of depression and no documented history of physical, verbal, or other behavioral symptoms on the most recent MDS, the facility initiated an involuntary transfer and discharge after the resident expressed depression over a sister’s recent death, stated a desire to go to the hospital, and cut her own wrist with scissors. Progress notes show the resident was sent to the hospital via 911, returned the same day with stitches, and was placed on 1:1 observation before being petitioned for involuntary discharge to another hospital for psychiatric evaluation and not allowed to return. The administrator and DON both stated that the resident was not a danger to other residents and that the self-harm incident was more like a cry for help, yet the facility issued a Notice of Involuntary Transfer or Discharge citing endangerment to the safety of individuals in the facility. The notice for R1, addressed to the resident and the legal guardian and signed by the former social services director, documented the regulatory reason as endangerment to the safety of individuals in the facility under 483.15(c)(1)(i)(C). However, the electronic health record contained no physician documentation explaining how the resident endangered the safety of individuals in the facility or supporting the stated regulatory basis for the involuntary discharge. The record also lacked documentation of behaviors that endangered other residents, and the DON and administrator both acknowledged that the resident was not aggressive and did not pose a threat to others. The legal guardian reported being informed by the facility that the resident could not return because she needed 24-hour care and might again use scissors to harm herself, and also reported being satisfied with the resident’s care and wishing the resident could have returned. For another resident (R4), who had paranoid schizophrenia and a history of smoking in non-designated areas, profanity, and aggressive behaviors toward staff and peers, the facility initiated an involuntary transfer and discharge after staff observed the resident smoking in a non-designated area, becoming verbally aggressive, and refusing redirection. Progress notes described the resident as a threat and harmful to self and others and noted that nursing staff contacted the physician, who recommended further evaluation, after which the resident was petitioned and sent to the hospital. The social services director completed and signed a Notice of Involuntary Transfer or Discharge citing that the resident’s welfare and needs could not be met by the facility under 483.15(c)(1)(i)(A), stating that the facility could not accommodate the resident’s smoking schedule and supervision needs and that the resident had violated the smoking policy multiple times. However, the electronic health record lacked physician documentation of the reason for the proposed discharge, did not specify what services the facility was unable to provide to meet the resident’s needs, and did not document what the facility attempted beyond a smoking behavior contract, resulting in a failure to support the regulatory basis for the involuntary discharge in the clinical record.
Failure to Provide Ongoing Behavioral Health Services and Implement Psychosocial Care Plan
Penalty
Summary
The facility failed to implement a care plan for psychosocial and mental well-being and to provide necessary behavioral health services for a resident with multiple mental health diagnoses, including bipolar disorder (current episode depressed), major depressive disorder, restlessness and agitation, and a history of seizures and chronic pain. The resident’s MDS showed intact cognition, and the care plan identified a need for specialized rehabilitation, support, counseling, and/or psychotherapeutic services, including mental health services such as psychotherapy, life skills training, and substance abuse services. Interventions in the care plan included obtaining consent, assisting the resident in locating an appropriate treatment provider, making initial appointments, and arranging transportation as necessary. The record showed that client-centered therapy sessions occurred on several documented dates, with the last session indicating the therapist would continue individualized biweekly therapy for six months, but no further therapy sessions were documented after that date. The Social Service Director reported that the facility had outside providers who came twice weekly for support groups and 1:1 sessions, and another provider offering intensive outpatient group therapy off-site, but she was not aware that the resident participated in any of these services and could not provide documentation of the resident’s participation in structured group or individualized mental health sessions. She also stated that the facility’s Social Services Department did not conduct any therapy groups or individualized sessions to address residents’ mental health needs. Progress notes later documented that the resident stated being depressed due to a sister’s death, expressed a desire to go to the hospital, and reported self-harm by cutting the right wrist with scissors, with bleeding observed. The resident was sent to the hospital via 911, returned the same day with stitches and was placed on 1:1, then was petitioned for involuntary discharge for psychiatric evaluation and was issued an involuntary discharge, not being allowed to return. A suicide/self-harm screening documented the resident as presenting a low to moderate risk for self-harmful behavior and recommended integration with structure, direction, and supportive counseling. The facility’s Social Services policy stated that it is the policy to provide a competent variety of psychological programming and therapeutic recreation opportunities to meet each resident’s mental and psychosocial well-being needs.
Failure to Provide Timely Admission Contracts to Residents
Penalty
Summary
The facility failed to provide admission contract/agreement packets in a timely manner to five residents, as evidenced by observations, interviews, and record reviews. One resident, who had been living in the facility for over two years and had an intact cognitive status, reported only recently being asked to sign a contract for services. The resident expressed dissatisfaction with the process, noting that the contract contained blank areas, missing pages, and insufficient time was given for review. The resident also described being called to a meeting by the administrator, who accused him of discouraging others from signing the contract, which the resident denied. The resident was concerned that the contract could alter his living arrangements and expressed reluctance to sign it. Staff interviews confirmed that the facility was three years behind in providing admission contracts to residents already in the facility, prompting the hiring of a consultant to address the issue. The Director of Social Services acknowledged that the admission contract, which outlines policies, regulations, resident rights, and payment terms, should be provided at the time of admission. An audit conducted by the administrator revealed that several residents had not been offered admission contracts, with most affected residents lacking these documents for over a year after admission. The facility's admission policy, dated January 2025, did not include procedures for providing the admission packet or contract during or at the time of admission.
Failure to Serve Menu-Required Bread Items During Meals
Penalty
Summary
The facility failed to follow its posted menus, spreadsheets, and standardized recipes, resulting in residents not receiving all required food items during meal service. Observations on multiple occasions showed that residents on various diets, including regular, mechanical soft, and pureed, did not receive bread, Garlic Texas Toast, or appropriate bread substitutes as listed on the menu and required by the facility's dietary policies. Residents expressed dissatisfaction, noting that they would have liked to receive the missing bread items and that meal portions felt insufficient. Interviews with dietary staff revealed that the cook did not serve bread or bread substitutes at lunch, despite these items being listed on the menu and spreadsheets. The dietary manager confirmed that bread was not being served at lunch for about a year, based on instructions from a previous administrator, and that no menu substitute was provided. The Registered Dietitian was unaware that bread was being omitted and stated that all menu items should be served as planned to ensure nutritional adequacy. The facility's own policies and menu documents required bread or bread equivalents to be served at specific meals, and recipes for these items were available in the kitchen. Record review confirmed that all residents had dietary orders specifying their required diets, and the menu spreadsheets detailed the bread or bread substitute to be served for each diet type. The failure to provide these items was not discussed with the Resident Council, and the Registered Dietitian was not informed of the change. The deficiency affected all 93 residents receiving food from the facility's kitchen, including those on specialized diets such as pureed or thickened liquids.
Failure to Follow Food Safety and Sanitation Standards in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food safety and sanitation practices. A dietary aide was seen in the food preparation area without a beard or mustache covering, despite having facial hair. The dietary manager confirmed that all facial hair should be covered and that beard protectors were available, but the aide had not used one upon entering the kitchen. Later, the same aide was observed wearing a beard protector that did not fully cover his mustache while preparing lunch trays. During a tour of the walk-in refrigerator, several opened containers of pre-thickened liquids and milk were found without any opened or use-by dates labeled by staff. Although the manufacturer’s printed best-by dates were visible, the containers also included instructions to use the product within seven days of opening, which was not being followed due to the lack of labeling. The dietary manager acknowledged that without an opened date, it was impossible to determine how long the items had been stored, and that the facility was not adhering to the manufacturer’s guidelines for use after opening. Additionally, an expired bottle of ground cloves was found, and a container of soy sauce that required refrigeration after opening was being stored at room temperature, contrary to manufacturer instructions. Interviews with the dietary manager and registered dietitian confirmed that the facility’s policy requires all food items to be labeled with the date received, the date opened, and the discard or use-by date, and that manufacturer guidelines for storage and use should be followed. The failures to properly label, date, and store food items, as well as to ensure appropriate use of hair restraints, had the potential to affect all residents receiving food from the kitchen. No residents were reported as NPO at the time of the survey.
Failure to Implement Infection Control Measures and Track XDROs
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures in several key areas. During a survey, it was observed that staff did not consistently bag or secure soiled linen and resident clothing before sending them down the laundry chute, resulting in loose items falling into collection bins. Additionally, clean linen and resident clothing were transported in uncovered carts, contrary to facility policy. Interviews with the laundry attendant and infection preventionist confirmed that these practices were not always followed, and staff acknowledged that linen should be bagged or covered during transport to prevent contamination. The facility also failed to track and report cases of extensively drug-resistant organisms (XDROs) as required by state regulations. The infection preventionist and director of nursing both stated that they had not been tracking or reporting XDROs to the appropriate registry, despite regulatory requirements and facility policy. This lack of tracking and reporting was confirmed through interviews and review of facility documentation. Furthermore, staff did not adhere to enhanced barrier precautions (EBP) for a resident with an indwelling suprapubic catheter. Two certified nursing assistants were observed transferring the resident without wearing the required gown and gloves, despite clear signage and physician orders indicating the need for EBP. The infection preventionist and LPN confirmed that staff should have worn appropriate PPE during high-contact care activities for residents on EBP. The resident's care plan and physician orders documented the need for these precautions, but the facility's EBP list did not include the resident, indicating a lapse in communication and documentation.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 30% error rate during observed medication administration for four residents. Surveyors observed registered nurses and licensed practical nurses administering medications outside the physician-ordered time frames. Specifically, medications scheduled for 8:00 AM were administered between 9:31 AM and 10:03 AM, exceeding the facility's policy of administering medications within one hour before or after the scheduled time. The errors involved multiple medications, including Levetiracetam, Valproic acid, Lamotrigine, Gabapentin, Eliquis, Diltiazem, Metformin, Namenda, and Depakote, all given later than ordered. The Director of Nursing confirmed that the facility's protocol requires medications to be administered within one hour of the scheduled time and acknowledged that administration outside this window is considered a medication error. The facility's medication administration policy, dated January 2024, also specifies this timing requirement. The survey findings were based on direct observation, interviews, and review of physician orders and medication administration records, all of which confirmed that the medications were not given according to the prescribed times.
Failure to Properly Label and Store Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications and biologicals in accordance with professional standards. Specifically, opened multi-dose inhalers for two residents were not dated, despite pharmacy labels indicating a required discard date after opening. Multiple inhalers were found opened without dates, and staff interviews confirmed that inhalers should be dated upon opening to ensure proper tracking of expiration. Additionally, a vial of Tubersol solution, labeled as house stock and requiring refrigeration, was found stored in a medication cart at room temperature rather than in a refrigerator. Staff were unsure of the delivery date and acknowledged that the solution should be refrigerated to maintain potency. Record review showed that the affected residents had physician orders for the medications in question, and facility policies required dating of opened medications and proper storage according to manufacturer and pharmacy guidelines. The facility's own policies specified that medications with shortened expiration dates after opening must be dated, and that certain biologicals, such as Tubersol, must be refrigerated whether opened or unopened. These deficiencies were identified during inspection of medication carts and rooms, and were confirmed through staff interviews and review of facility policies.
Failure to Ensure Resident Dignity and Effective Communication
Penalty
Summary
The facility failed to ensure that residents' rights to dignity, self-determination, and effective communication were upheld, as evidenced by two separate incidents involving two residents. In the first incident, a resident with multiple medical diagnoses, including schizophrenia, COPD, and malnutrition, was observed sitting at a dining table with another resident. While the other resident received his meal promptly, this resident waited for approximately nine minutes without being served, despite inquiring about his meal. Staff continued to serve other residents before eventually providing the meal, resulting in the resident watching his tablemate finish eating before he received his own tray. Facility policy and the Director of Nursing both confirmed that residents seated at the same table should be served at the same time to maintain dignity and a homelike environment. In the second incident, a resident with highly impaired hearing and absence of speech was not provided with effective and accessible means of communication. The resident's care plan indicated the need for communication aids such as cue cards and a communication board, but these were not available or accessible in the resident's room. Staff interviews revealed that none of the staff had received training in sign language, and most relied on gestures or facial expressions to communicate. The communication board was found attached to the wall and could not be detached for use, and cue cards were not present. The resident confirmed that he did not use the communication board or cue cards. Facility policies required that meals be served in a manner that respects residents' dignity and that communication aids be made available for residents with communication needs. Despite these policies and recent in-service training for staff on meal service and seating arrangements, the facility did not ensure that these standards were met for the affected residents, resulting in a failure to honor their rights to dignity and effective communication.
Failure to Apply Splints as Ordered for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that splints were applied as ordered by the physician for two residents with limited range of motion. One resident with a history of a right distal radius fracture and diagnoses including paroxysmal atrial fibrillation, osteoporosis, and osteoarthritis, was observed multiple times without the prescribed right wrist splint in place. The resident reported that staff had previously applied the splint but could not recall the last time it was used. The physician order and care plan specified that the splint should be applied daily, with removal only for bathing, sleeping, writing, or physical therapy, yet observations confirmed the splint was not in use during the review period. Another resident with left-sided hemiplegia following cerebrovascular disease and a left hand contracture was also observed multiple times without the ordered left arm/hand splint. The care plan and physician order required daily application of the splint, with removal at bedtime and for skin checks. Staff interviews confirmed awareness of the orders and the importance of splint use to prevent contractures, but the splints were not applied as directed. The facility's contracture prevention policy required contracture prevention appliances to be applied as ordered, but this was not followed for these residents.
Failure to Safely Store Smoking Materials and Monitor Residents on Independent Pass
Penalty
Summary
The facility failed to ensure that smoking materials were safely stored and not accessible to other residents, as observed with one resident who kept a cigarette on top of the bedside table in a shared room. The resident, who had a history of smoking and multiple medical diagnoses including chronic obstructive pulmonary disease and schizophrenia, stated he kept his lighter and cigarette with him, although he had lost his lighter. Staff interviews confirmed that smoking materials are not supposed to be kept by residents and should be stored securely to prevent access by others, especially those not assessed as safe to smoke or who wander. Additionally, the facility did not adequately monitor or document the whereabouts of a resident who had independent community pass privileges. The resident left the facility without signing out, and there was no documentation of when the resident left or returned. Staff were unable to provide information on the resident's departure, and there was no evidence that required procedures, such as notifying supervisors or filing a missing person report, were followed when the resident did not return as expected. The facility's policies did not clearly outline staff responsibilities for residents on short community leaves without medications, nor did they specify actions to take when residents failed to sign out or return on time. The lack of proper supervision and adherence to facility policies regarding both smoking materials and independent community passes resulted in unsafe conditions and inadequate monitoring of residents. Staff interviews revealed gaps in knowledge and inconsistent practices related to the facility's procedures for resident safety in these areas.
Failure to Provide Restorative Toileting Program for Bladder Continence
Penalty
Summary
The facility failed to provide a restorative toileting program to maintain bladder functioning for one resident who was reviewed for bowel and bladder continence. The resident had diagnoses including major depressive disorder, bipolar disorder, asthma, and seizure, and was documented as frequently incontinent on the Minimum Data Set (MDS), though another MDS assessment indicated bladder continence. During interviews, the resident reported using pullups, getting up to use the restroom as needed, and not receiving any bladder toileting restorative program. Facility staff confirmed that there was no bladder toileting restorative program in place, and that certified nursing assistants were expected to encourage the resident to use the bathroom and offer help if needed. The facility's policy required comprehensive assessment and placement into an incontinence toileting program for residents demonstrating incontinence, but this was not implemented for the resident in question.
Improper Storage of Nebulizer Equipment
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask and tubing were found improperly stored inside a bedside nightstand drawer, mixed with personal items, and not dated. The resident, who had been living in the facility for over a year, was alert and oriented, and reported periodic use of nebulization treatments. Observation confirmed that the nebulizer equipment was not stored according to infection control protocols. The LPN acknowledged that the storage was improper upon inspection. Further review revealed that the facility's policy required nebulizer masks and tubing to be changed at least every three days, dated when changed, and stored in a clean, clear plastic bag to prevent contamination. The DON confirmed these requirements during an interview. The resident's medical history included chronic respiratory conditions such as malignant neoplasm of the lung and COPD, and physician orders documented regular and as-needed nebulizer treatments. Medication administration records showed the treatments were being given as ordered, but the storage and dating of the equipment did not comply with facility policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by other residents, as evidenced by three separate incidents involving multiple individuals. In the first incident, one resident with hypertension, hemiplegia, and a history of cerebral infarction was slapped in the face by another resident diagnosed with hypertension, anxiety disorder, schizophrenia, and bipolar disorder. The altercation began after a dispute over a TV remote, with the aggressor becoming agitated and physically striking the other resident. Staff and administrative interviews confirmed the physical abuse, and documentation indicated that the incident was substantiated. In a second event, a resident with extrapyramidal and movement disorder and schizophrenia was pushed and scratched by another resident with schizoaffective disorder and chronic pain. The altercation occurred in a common area after a verbal exchange escalated, resulting in one resident being pushed, falling, and sustaining a minor injury. Both residents were found to be cognitively intact, and the incident was confirmed as physical abuse through staff interviews and medical record review. The third incident involved verbal abuse, where a resident verbally threatened another following a disagreement about bathroom use. The aggressor confronted the other resident on the porch, using explicit language and making a direct threat of physical harm. Both parties acknowledged the incident, and the administrator confirmed that verbal abuse had occurred. Facility policies and residents' rights documents were referenced, outlining the definitions and expectations regarding abuse prevention, but the incidents demonstrated a failure to uphold these standards.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported to the appropriate authorities within the mandated timeframe. A resident (R5), who was cognitively intact and had diagnoses including diabetes, hypertension, restlessness, and agitation, reported that her former roommate (R6), also cognitively intact with diagnoses of bipolar disorder and schizophrenia, verbally threatened her in a confrontational manner. The incident involved R6 approaching R5 on the porch and stating, 'I'll beat your mother f*****g a**,' which R5 perceived as a vicious and unprovoked verbal assault. Following the incident, R5 reported the threat to the facility's security guard (V6), who documented the event in the Security Report and stated he informed the administrator (V1) and a nurse on the first floor. However, both the LPN (V7) and CNA (V8) working that shift denied being informed of any unusual events or allegations of verbal abuse. The administrator (V1) acknowledged receiving a call from security but did not recognize the urgency or nature of the report as verbal abuse at that time. The initial report to the state agency was not made until several days later, after V1 received the information in real time, rather than immediately as required by facility policy and regulation. Documentation confirmed that the incident was later substantiated as abuse, with both internal and external reports indicating that the verbal threat constituted verbal abuse. Facility policy requires immediate reporting of any abuse allegations to the Department of Public Health within 24 hours, but this protocol was not followed in this case, resulting in a delay in the mandated reporting process.
Failure to Protect Resident from Roommate Abuse
Penalty
Summary
The facility failed to protect a resident, R2, from abuse by her roommate, R3, resulting in R2 sustaining a broken nose. R2, an elderly resident with dementia and other health issues, was struck by R3, who has a history of aggressive behavior and mental health diagnoses. The incident was reported by a CNA who found R2 with facial injuries during breakfast. R2 indicated that she was hit by 'the little lady,' referring to R3. Another resident, R7, who shared the room with R2 and R3, reported hearing R2 scream and witnessing R3's intimidating behavior towards R2. Despite these signs, the staff failed to prevent the abuse. Interviews with staff and residents revealed that R3 had a pattern of verbal and physical aggression towards R2, which was known to some staff members. R7 reported that R3 would often yell at R2 and had expressed a wish for R2's death. The facility's Director of Nursing was unaware of R3's behavior towards R2, and the staff did not report the signs of abuse as required by the facility's abuse policy. The facility's investigation confirmed the abuse, but the failure to act on the warning signs and protect R2 from R3's aggression led to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R3, from physical abuse, resulting in a bruise and skin tear on R3's left arm. The incident occurred when a CNA, identified as V11, allegedly handled R3 roughly during incontinence care, causing the injury. R3, who is cognitively intact with a BIMS score of 15, reported that V11 dug her fingers into R3's arm and flipped R3 over, leading to the skin tear and bruising. R3 expressed fear and stated that V11 had been mean to R3 for some time. The incident was first noticed by another CNA, V14, who observed the injury and reported it to the LPN, V3. V3 assessed the injury and informed the DON, V2, who then conducted an investigation. During the investigation, V11 initially denied causing the injury but later acknowledged seeing the skin tear after being confronted with statements from other staff. V11 failed to report the injury to the nurse on duty, which was a violation of the facility's abuse prevention policy. The facility's administrator, V1, and the DON, V2, suspended and subsequently terminated V11 following the investigation. The incident was reported to the local police, and R3's physician was notified, who confirmed that R3 has fragile skin due to chemotherapy. The physician emphasized that staff should not use their nails to reposition residents, as it can cause injury. The facility's failure to prevent and properly report the abuse led to the deficiency being cited.
Failure to Submit Final Investigation Report to IDPH
Penalty
Summary
The facility failed to submit the final investigation of an alleged abuse incident to the Illinois Department of Public Health (IDPH) within the required five-day timeframe. This deficiency affected two residents involved in a resident-to-resident altercation. On the day of the incident, one resident reported a verbal and physical altercation with another resident, which resulted in both residents being separated immediately, and no injuries were noted. Although the initial incident was reported to IDPH on the same day, the final investigation report was not confirmed as submitted. The current administrator, who was not employed at the time of the incident, could not find any confirmation that the final report was sent, despite locating a final incident investigation report. The facility's abuse policy mandates that a complete written report of the investigation's conclusion be sent to the Department of Public Health within five working days after the occurrence.
Deficiencies in Resident Protection and Supervision
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving a Certified Nurse Assistant (CNA) identified as V9, who was reported to have hit a resident, R5, on the head. R5, who is cognitively impaired with a BIMS score of 0, was unable to provide a statement. However, another resident, R6, witnessed the incident and reported it. The facility's investigation substantiated the claim, leading to the termination of V9. R5's medical history includes conditions such as hemiplegia, schizophrenia, and dementia, which contribute to his vulnerability. In another incident, two residents, R2 and R3, engaged in a verbal and physical altercation in the patio/smoking area, resulting in injuries. R2, who has a BIMS score of 15, and R3, with a BIMS score of 13, both have cognitive impairments. The altercation began over a disagreement about cigarettes, leading to R3 striking R2 and R2 scratching R3. The facility's investigation confirmed the occurrence of the altercation, and it was noted that no staff were present during the incident, which occurred outside of the usual smoking time. The facility's abuse prevention program, dated 10/2022, outlines the commitment to protecting residents from abuse and establishing a resident-sensitive environment. However, the incidents involving R5, R2, and R3 highlight failures in staff supervision and monitoring, particularly in areas where residents are known to congregate, such as the smoking area. The lack of staff presence during the altercation between R2 and R3, and the failure to prevent the physical abuse of R5 by V9, demonstrate deficiencies in the facility's ability to ensure a safe environment for its residents.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident's fall from the bed to the floor, despite the resident being assessed as requiring a two-person assist for bed mobility. The incident occurred when a Certified Nursing Assistant (CNA) attempted to turn the resident alone, resulting in the resident falling face-first onto the floor. The resident, who has a history of idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and other significant health issues, experienced increased pain and psychosocial harm from the fall. The resident expressed feelings of fear and anxiety following the incident, which were discussed with the facility's psychiatrist and Director of Nursing (DON). The resident's care plan indicated a high fall risk and required substantial/maximal assistance for bed mobility, specifically noting the need for two-person assistance. However, on the night of the incident, the CNA did not follow this protocol and attempted to turn the resident alone. The CNA admitted to not ensuring the resident was in the middle of the bed and not seeking assistance from another staff member. The bed was also not positioned against the wall, which was different from the resident's previous room setup, contributing to the fall. The facility's policies on fall prevention and personal care services were not adhered to in this case. The CNA's failure to follow the care plan and the facility's safety protocols directly led to the resident's fall and subsequent injury. The incident highlights a lapse in staff training and adherence to established safety precautions, resulting in harm to the resident and a failure to provide adequate supervision to prevent accidents.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and dating practices in the kitchen, which could potentially affect all 94 residents receiving an oral diet. During a tour of the kitchen, the surveyor observed undated bowls of apple sauce, deli meat cheese sandwiches, and a block of cheese in the walk-in cooler. Additionally, seven packages of premium sliced ham were found to be expired. The dietary manager acknowledged the importance of labeling, dating, and discarding expired foods to ensure food safety and prevent illness. In the freezer, a water bottle containing a dark liquid, identified as belonging to staff, was found, which the dietary manager admitted could contaminate food products. In the dry storage area, a container of navy beans was found to be expired. The facility's policies on food storage and labeling were not followed, as evidenced by the undated and expired food items. The dietary manager's job responsibilities include inspecting food storage areas to ensure they are maintained in a clean, safe, and sanitary manner, which was not upheld in this instance.
Failure to Ensure Call Light Devices Were Within Residents' Reach
Penalty
Summary
The facility failed to ensure that residents' call light devices were within reach, affecting four residents. On multiple occasions, residents were observed with their call light strings hanging from the wall switch and out of reach. For instance, one resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and schizophrenia, was unable to locate or reach the call light string. Another resident, who was cognitively intact but had diagnoses such as schizophrenia and dementia, also had their call light string out of reach and confirmed they could not access it when needed. Additionally, a resident with severe cognitive impairment and a history of falls was observed with their call light string hanging towards the floor and out of reach. This resident's care plan specifically mentioned the need for the call light to be within easy reach to prevent falls. Another resident, who was cognitively intact and had multiple diagnoses including pulmonary embolism and acute respiratory failure, also had their call light string positioned out of reach, despite their care plan indicating the need for assistance. The Director of Nursing confirmed that call light strings should be positioned within residents' reach, typically attached to the pillow, to ensure they can call for help when needed. The facility's policy and job descriptions also mandate that call lights must be within easy reach of residents. However, observations and interviews revealed that this was not consistently practiced, leading to the deficiency noted in the report.
Failure to Provide Psychiatric Rehabilitation Services Coordinator
Penalty
Summary
The facility failed to have a Psychiatric Rehabilitation Services Coordinator (PRSC) to meet the individualized psychosocial and mental health needs of residents. This deficiency was identified through observations, interviews, and record reviews. The facility census was reported as 96 residents, with 68 residents diagnosed with severe mental illness (SMI). Several residents were observed with flat affect and low mood, and multiple residents reported not having seen a counselor or therapist recently. The Social Services Director, who recently started working at the facility, was responsible for providing psychosocial services to all 96 residents, including those with SMI. However, the Director admitted that a therapist only comes twice a week to conduct group sessions, and no PRSC was observed interacting with residents during the survey period. The facility's policy and job description for the PRSC indicate that the role is essential for planning, developing, organizing, implementing, evaluating, and directing social service programs to meet the emotional and social needs of residents. Despite this, the facility had not hired a full-time or part-time PRSC, as confirmed by the Administrator, who stated that efforts were being made to fill these positions. The lack of a PRSC has the potential to affect all residents requiring psychosocial support, particularly those with severe mental illness, as the current staffing levels are insufficient to meet their needs.
Failure to Provide Individualized Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized psychosocial and mental health services to meet the needs of residents diagnosed with mental disorders or psychosocial adjustment difficulties. This deficiency affected five residents who were observed with flat affect and low mood, and who reported not receiving any counseling or therapeutic services. Despite being cognitively intact, these residents had not interacted with a counselor or Psychiatric Rehabilitation Services Coordinator (PRSC) recently, as required by their care plans. The facility's social services staff, specifically the Social Services Director/PRSD, was responsible for providing psychosocial services to all 96 residents, including 68 with severe mental illness (SMI). However, the PRSD admitted to being overwhelmed and unable to meet the individualized needs of all residents. The facility had advertised for additional PRSC positions but had not yet filled them. Observations and interviews with nursing staff confirmed the lack of PRSC presence and interaction with residents on the nursing units. The care plans for the affected residents detailed specific psychosocial and mental health interventions that were not being implemented. For example, one resident with schizophrenia was supposed to receive encouragement to verbalize thoughts and feelings and learn stress management techniques. Another resident with major depressive disorder and anxiety was to be encouraged to verbalize feelings. The facility's policies and job descriptions outlined the responsibilities of the PRSC, which included providing assessments, group interventions, and one-on-one support, but these services were not being adequately provided.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure that the air-conditioner in a resident's room was working, failed to repair a broken wall heat vent cover, and failed to clean and cover the air-conditioner air filter in residents' rooms. These deficiencies were observed on the third floor and had the potential to affect seven residents. Specifically, in one room, the wall heat vent cover was hanging and almost falling off, and the window shades were torn and worn out. In another room, a resident complained about the heat, and the air-conditioner was observed blowing warm air with a non-functional on/off button. Additionally, in four other rooms, the air-conditioner air filters were found without vent covers and had a thick layer of accumulated dust. The maintenance staff was notified of these issues, but the maintenance log did not show that staff had reported the problems or that maintenance staff was in the process of repairing them. The facility's job description for the Director of Maintenance outlines the responsibility to ensure that the facility is maintained in a safe and comfortable manner, which was not followed in this instance. The deficiencies were identified through observation, interview, and record review, highlighting a failure to maintain a safe and comfortable environment for the residents.
Failure to Document Resident's Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was documented under the physician's order in the electronic medical record (EMR). This deficiency affected one resident (R11) who had multiple diagnoses including paranoid schizophrenia, epilepsy, essential hypertension, asthma, type 2 diabetes, and chronic obstructive pulmonary disease. Despite being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14, R11's code status was not entered into the physician's order sheet upon admission. The code status was only documented after the surveyor requested the resident's advance directives orders, indicating a lapse in the facility's protocol for documenting code status upon admission. Interviews with the Social Service Director (V16) and the Director of Nursing (V2) revealed that the admitting nurse is responsible for entering the resident's code status order upon admission. Both V16 and V2 acknowledged the importance of having a code status order to ensure the resident's wishes are honored and to provide appropriate care. The facility's policy dated 01/01/17 also mandates that all residents be provided with information on advance directives upon admission and be treated as full code if no advance directive is provided. However, in this case, the policy was not followed, resulting in the deficiency noted by the surveyor.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe and functional environment for two residents who were cognitively intact and had various medical diagnoses, including schizophrenia, essential hypertension, and major depression. One resident's privacy curtain was observed to be soiled with a brown stool-like substance, and the resident expressed a desire for it to be cleaned. Despite the housekeeping supervisor's statement that privacy curtains should be inspected and cleaned daily, the curtain remained soiled upon re-inspection the following day. The housekeeping supervisor acknowledged the importance of clean privacy curtains to prevent smells, germs, and to maintain a clean environment. Another resident's room was observed to be missing a window screen, which allowed flies to enter the room. The resident confirmed that the window had never had a screen and expressed a desire for one. The maintenance director, responsible for checking and maintaining window screens, was unaware of how long the screen had been missing and stated that window screens are important to prevent flies and mosquitoes from entering the facility. Despite this, the window remained without a screen upon re-inspection the following day.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to ensure that residents receive assistance with shaving facial hair, affecting one resident (R12) who was reviewed for personal hygiene and care. R12, who has diagnoses including inflammatory polyneuropathy, age-related osteoporosis, essential hypertension, and hyperlipidemia, was observed with facial hair and reported that she was supposed to be shaved the previous day but did not receive assistance. R12 expressed discomfort due to the facial hair and indicated that she could shave herself if provided with a razor, although the facility typically performed the shaving for her. A CNA confirmed that she usually shaves R12 on weekends but was off during the past weekend, leading to the missed shaving. The CNA acknowledged that R12 could likely shave herself with minimal assistance. The Director of Nursing stated that facial hair on residents should be cut as it could be irritating and undesirable. R12's care plan indicated that she requires partial/moderate assistance with personal hygiene, including shaving, and should be provided with training to promote her highest level of independent performance. The facility's policy on personal care services mandates that each resident's hair should be kept clean, neat, and well-groomed.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident (R1) from physical abuse by another resident (R2). R2, who had a history of physical, verbal, and sexually inappropriate behavior, physically assaulted R1, causing multiple injuries. The facility did not have preventative measures in place for R2, nor did they update R1's care plan to address potential abuse before and after the incident. This lack of action led to R2 physically assaulting R1, resulting in multiple bruises and scratches on R1's body. R2 had a documented history of aggressive behavior, including incidents of physical, verbal, and sexually inappropriate actions towards both staff and residents. Despite this, R2's care plan did not address these behaviors, and there were no psychiatric or medical notes documenting any interventions. R2's progress notes detailed multiple incidents of aggression and inappropriate behavior, yet the facility failed to implement measures to ensure the safety of other residents. The facility's abuse prevention policy required staff to identify residents with increased vulnerability to abuse and to incorporate security measures into the care plans of identified offenders. However, the facility did not follow these procedures for R2. Additionally, the Social Service Director admitted to being unaware of the need to care plan for abuse incidents and the guidelines for protecting victims from perpetrators. This lack of knowledge and failure to follow established protocols contributed to the deficiency in protecting residents from abuse.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to have an effective pest control program and did not monitor and log pest issues related to the presence of cockroaches in the kitchen. This deficiency was identified through observations, interviews, and review of records. A resident reported finding a cockroach in her tray, and during an inspection of the kitchen, two traps containing cockroaches were found under the three-sink compartment and the deep freezer. Pest control reports from March and April 2024 documented the presence of German roaches in the main kitchen area, including equipment, stoves, and preparation tables. Despite these reports, the Maintenance Director (V3) stated that there were no complaints of pests since February 2024 and admitted that there was no documentation of staff reporting pest problems in the kitchen. The facility's policy for pest control, which was not dated, requires routine checks and monitoring by maintenance and housekeeping staff, with a log maintained of pest issues. However, this policy was not effectively implemented, as evidenced by the ongoing presence of cockroaches and the lack of documentation. The Maintenance Director acknowledged the need to call pest control again due to the persistent problem but was unable to provide pest monitoring logs. This failure to maintain an effective pest control program has the potential to affect all 98 residents' food preparation and consumption due to the presence of cockroaches in the kitchen.
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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