Forest City Rehab & Nrsg Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 321 Arnold Avenue, Rockford, Illinois 61108
- CMS Provider Number
- 145937
- Inspections on file
- 59
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Forest City Rehab & Nrsg Ctr during CMS and state inspections, most recent first.
A resident with an elevated PSA lab result had a documented provider order for a urology referral, but the facility failed to ensure the appointment was scheduled. The NP wrote on the lab report for the resident to see a urologist, and the referral order appeared on the active order summary. The DON stated the referral should have been placed in the medical appointment scheduler’s mailbox, but the scheduler reported no notification of the order and no urology appointment in the schedule book. Review of the electronic medical record confirmed there was no evidence the resident ever saw a urologist.
A resident with schizoaffective disorder died, and afterward an LPN used the resident’s bank information saved on a phone to make 34 charges totaling $4,910.79, including a $1,000 PayPal transfer to herself, and kept the resident’s cell phone at home. The LPN told police the resident had verbally allowed her to use remaining funds after paying for cremation and to keep the phone, but there was no documentation or witnesses to this alleged agreement. Facility policy and the employee handbook prohibited misappropriation of resident property and barred staff from taking residents’ money or belongings.
A resident with multiple chronic conditions, moderate cognitive impairment, and known risk for weight loss experienced a marked decline in oral intake after family-imposed limits on outside food deliveries, but staff failed to consistently document meal intakes, obtain updated weights, or notify the provider and dietitian as required by the care plan and facility policy. CNAs and nurses observed that the resident disliked facility food, frequently refused meals, and appeared to be losing weight, yet intake records were incomplete for several days and no new weight was taken after an earlier documented weight, despite poor or refused intakes. The dietitian’s review was based only on the chart and did not trigger new interventions or a current weight, the resident was not brought to nutritional risk meetings during this period, and the DON later deemed the intake charting unacceptable, while hospital records shortly after transfer documented severe protein-calorie malnutrition and a significantly lower weight.
A resident with multiple comorbidities, moderate cognitive impairment, incontinence, and dependence for hygiene had documented erythema and skin breakdown to the buttocks and peri-area and an order for zinc barrier cream, but nursing staff did not complete or document thorough, ongoing skin assessments. Over approximately one month, records showed only a brief note that the area remained "stable" and a shower sheet indicating buttock redness, without any detailed wound classification, size, tissue description, or drainage. A CNA reported a very red buttock area and use of barrier cream, while an RN acknowledged not inspecting the skin before hospital transfer and not documenting wound assessments beyond treatment administration. The DON and wound care nurse confirmed the absence of required weekly wound assessments despite a facility policy mandating weekly documentation of all skin impairments, and the resident was later found in the ED to have a sacral ulcer.
A staff member with a beard prepared pureed food in the kitchen without wearing a beard covering, in the presence of the Dietary Manager, and continued food preparation without the required restraint. Both the staff member and facility policy confirmed that beard coverings are mandatory during food preparation.
A resident with a suprapubic indwelling urinary catheter was observed multiple times in public areas with their urinary drainage bag uncovered and urine visible, contrary to facility policy requiring privacy bags to promote dignity. The DON confirmed that privacy coverings are expected for catheter bags.
A resident with a history of CVA and bilateral carotid stenosis, whose care plan required built-up utensils for meals, was repeatedly provided only standard or plastic utensils. The resident was observed struggling to eat independently, and staff confirmed the need for adaptive utensils to support his feeding abilities.
Three residents were found to have as-needed orders for psychotropic or anti-psychotic medications, such as haloperidol and lorazepam, without required stop or duration dates. These orders had start dates but did not comply with the facility's policy limiting such medications to 14 days, as confirmed by the DON.
Two residents with urinary catheters did not receive proper catheter care, as their drainage bags were either not positioned below the bladder or were found touching the floor. One resident's catheter bag was repeatedly placed on a wheelchair seat, preventing urine drainage, and the resident developed a UTI. Another resident's catheter bag was observed lying on the floor without a dignity bag. Staff interviews and facility policy confirmed these practices did not meet required standards for catheter care and infection prevention.
Two residents experienced medication administration errors when an LPN failed to prime an insulin pen as required and another LPN administered the wrong allergy medication. These actions led to a medication error rate above the acceptable threshold.
A resident was denied a requested bedtime snack, with staff and dietary personnel confirming that only diabetic residents or those with weight loss are provided snacks in the evening. The resident's care plan and physician orders did not restrict snack access, yet the facility's practice excluded non-diabetic residents from receiving snacks outside scheduled meal times.
Two residents with advanced pressure ulcers did not have their prescribed wound care treatments completed or documented on multiple occasions, particularly on weekends. The wound care nurse confirmed that treatments were not signed off as completed in the Treatment Administration Record, in violation of facility policy requiring documentation after each administration.
A resident with a history of mental illness and prior abuse made an allegation of assault against a CNA after returning from the hospital. The facility did not immediately report the allegation to the administrator or state agency as required, and the accused CNA continued to have contact with the resident. The administrator and LPN did not promptly interview the resident or gather additional details, and the required investigation and reporting were delayed, violating the facility's abuse prevention policy.
A resident with a history of mental illness and prior abuse returned from the hospital and accused a staff member of assault. The allegation was relayed from a CNA to an LPN, who texted the Administrator but did not receive a response. The Administrator was not informed in person until the next day, and the required report to the state agency was not submitted promptly, as confirmed by the DON.
A resident with a history of mental illness and prior abuse returned from the hospital and accused a staff member of assault. The allegation was not immediately investigated, and the staff member continued working until later identified and sent home. Staff did not promptly interview the resident or remove the alleged perpetrator, despite facility protocols requiring immediate action.
A resident's family member reported an allegation of sexual abuse to facility staff after the resident was discharged. The administrator was informed but did not report the allegation to IDPH within the required timeframe, as facility policy mandates immediate reporting of abuse allegations. The report was made two days after the initial notification, resulting in a delay.
The facility failed to serve food at appropriate temperatures, affecting four residents who reported receiving cold meals. Observations showed that food temperatures were below the required 135 degrees Fahrenheit, with residents expressing dissatisfaction and needing to reheat their meals.
The facility failed to maintain proper food temperatures and prevent cross-contamination during meal service on the second floor, affecting all 94 residents. Food items were held below the required 135 degrees Fahrenheit, and residents reported their meals were often cold. Additionally, a dietary aide was observed using the same gloves to handle multiple food items and surfaces without changing gloves or performing hand hygiene, contrary to facility policy.
A resident with multiple medical conditions, including stage 2 pressure ulcers, did not receive timely wound assessments and treatments as prescribed, leading to the deterioration of their condition. The facility failed to conduct an initial wound assessment within 24 hours of admission, and treatment orders were not consistently followed, resulting in the resident's pressure injuries worsening to an unstageable state.
A facility failed to provide a resident with prescribed medications when he left on an overnight pass. The resident's medication strip was not available, and the LPN did not know which medications were needed. The facility's procedures for sending medications with residents were not followed, leading to the deficiency.
A facility failed to report an alleged abuse incident to the administrator. A resident's daughter reported that her mother was pushed by a CNA, but the scheduler did not inform the administrator. The administrator, unaware of the incident, later reviewed video footage and found no contact between the CNA and the resident. The facility's policy mandates immediate reporting of such allegations to the administrator, which was not adhered to.
A facility failed to administer physician-ordered anticoagulants to two residents, leading to significant medication errors. One resident, with a history of embolic strokes, missed six doses of Xarelto due to pharmacy issues, resulting in an acute embolic stroke and subsequent hospitalization, where the resident passed away. Another resident went without anticoagulant medication for five days due to delays in delivery. Staff interviews revealed issues with access to the automated medication dispensing system and confusion about medication availability.
The facility failed to prevent the progression of a pressure injury from stage 1 to stage 3 for a resident with severe cognitive impairment, due to inadequate follow-up and documentation. Additionally, another resident with a deep tissue injury did not have the prescribed off-loading boot in place, indicating a lapse in implementing care plan interventions. These deficiencies highlight a failure to adhere to pressure ulcer prevention protocols.
A resident with schizophrenia and major depressive disorder experienced significant weight loss, but the facility failed to conduct regular weight monitoring or provide a dietitian assessment for nine months. Observations showed the resident's meals were often untouched and out of reach, and staff interviews revealed a lack of clarity and responsibility regarding nutritional care. Despite a care plan intervention, no actions were taken in 2024 to address the resident's nutritional needs.
The facility failed to implement enhanced barrier precautions for a resident with a stage III pressure injury, as a CNA provided care without wearing a gown and was unaware of the wound's status. Additionally, another CNA did not follow proper infection control procedures during incontinence care, discarding soiled linen on the floor and not changing gloves after care, contrary to facility policies.
The facility failed to prevent cross-contamination during a lunch service on the first floor. A cook was observed handling hamburger patties with gloved hands that had touched potentially contaminated surfaces without changing gloves, leading to grease transfer onto bread and plates. This action violated the facility's Food Safety and Sanitation policy, which requires changing gloves when they become dirty or before starting a new task. This deficiency potentially affects all residents on the first floor.
A resident with severe cognitive impairment was involuntarily transferred to the hospital without notifying their representative. Despite being listed as the emergency contact, the resident's spouse was not informed of the transfer, as required by the facility's policy. Staff interviews revealed assumptions about notification, but no documentation confirmed it, indicating a communication breakdown.
A facility failed to ensure accurate documentation of a resident's advanced directive. The resident's electronic medical record and physician orders indicated a DNR status, while the POLST form showed a full code, creating a discrepancy. Staff interviews confirmed that the code status should be consistent across all documentation, but this was not the case, indicating a failure in the facility's process.
The facility failed to provide proper wound care management for two residents. One resident's liver drain dressing was not changed since hospital discharge, and there was no documentation of monitoring the site. Another resident's wounds were not assessed or dressed according to orders, and her care plan did not address her wound history. Staff confusion and lack of adherence to facility policies contributed to these deficiencies.
A resident with an indwelling urinary catheter was found without a catheter secure device, leading to the catheter being pulled tightly and coming out twice. CNAs were unaware of the missing secure device, and the resident's care plan did not document the use of such a device. The facility's policy requires catheters to be secured to prevent trauma, which was not followed.
The facility failed to store and date respiratory equipment for two residents, leading to potential contamination. One resident's oxygen tubing and CPAP mask were not dated and improperly stored, while another resident's nebulizer mask and CPAP equipment were also undated and uncovered. The DON confirmed the lack of adherence to the facility's policy requiring weekly changes and dating of equipment.
The facility failed to properly administer medications for two residents. A resident with diabetes missed doses of Trulicity due to pharmacy issues and lack of timely action by the facility. Another resident received insulin without following manufacturer's instructions, risking incomplete dosing. These deficiencies highlight lapses in medication management and adherence to protocols.
The facility failed to date opened insulin pens for two residents, leading to a deficiency in medication storage. An LPN confirmed administering insulin from undated pens, which should have been dated upon opening. The DON acknowledged the requirement for dating insulin pens due to potency degradation after 28 days.
The facility failed to provide safe feeding recommendations and adequate supervision for four residents with dietary restrictions. Residents with dysphagia and other conditions were observed consuming inappropriate diets and eating unsupervised, contrary to their care plans and physician orders. The Director of Nursing acknowledged the need for supervision, but the facility did not adhere to its policies on dietary management.
A resident with a history of aggressive and inappropriate behaviors physically and sexually abused other residents. Despite documented incidents and a criminal background, the facility failed to manage the resident's behaviors, resulting in harm to multiple residents. The facility's abuse prevention policy was not effectively implemented, leading to significant deficiencies.
A resident with a history of aggressive and inappropriate behaviors was inadequately supervised, leading to multiple incidents of physical aggression and sexual misconduct. Despite known risks and escalating behaviors, the facility failed to implement effective supervision and interventions, resulting in harm to other residents.
A resident developed an additional Stage 2 pressure wound and experienced worsening of existing wounds due to the facility's failure to identify, assess, and implement appropriate wound treatment and prevention interventions. The care plan lacked necessary interventions, and wound care treatments were not documented or performed as required.
The facility failed to inform a resident's family/POA of a significant change in condition and hospitalization. Despite the policy requiring notification and documentation, the family/POA was not informed, and there was no documentation in the resident's Progress Notes.
Failure to Schedule Urology Appointment After Abnormal PSA Result
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and resident preferences by not scheduling a urology appointment for one resident after an abnormal lab result. The resident’s prostate specific antigen (PSA) lab result dated 5/14/25 showed a high value, and the nurse practitioner documented on the lab result form that the resident should be referred to urology. An order dated 5/16/25 for a referral to urology related to the high PSA was present on the resident’s active Order Summary Report as of 5/19/25. The DON confirmed that the nurse practitioner had written for the resident to see a urologist and stated that the referral should have been placed in the medical appointment scheduler’s mailbox so the appointment could be made. The medical appointment scheduler reported that no urology appointment had been scheduled for the resident and that there were no entries in the appointment schedule book, stating he believed the appointment was not made because he was never notified of the order or referral. Review of the resident’s electronic medical record by the DON showed no indication that the resident had seen a urologist. This sequence of events demonstrates that despite a documented high PSA result and a corresponding provider order for a urology referral, the internal process for communicating and acting on the referral order failed, resulting in the resident not receiving the ordered urology consultation.
Misappropriation of Deceased Resident’s Funds and Personal Property by LPN
Penalty
Summary
The facility failed to protect a resident’s property from misappropriation by staff. The resident had a diagnosis of schizoaffective disorder and was documented as having expired on a specified date. After the resident’s death, the resident’s sister-in-law reported that multiple charges were made to the resident’s bank account by an LPN, including a $1,000 PayPal transfer to the LPN. Bank statements showed that beginning the day after the resident expired, 34 charges totaling $4,910.79 were made from the resident’s account, including the $1,000 PayPal charge. The sister-in-law also reported that the LPN had the resident’s cell phone at her home. The Administrator stated he first became aware of the situation when police arrived and informed him of the allegations. A police officer reported that the LPN admitted to making purchases using the resident’s bank account after the resident expired, using bank information saved on a phone, and admitted to having the resident’s cell phone at her residence. The LPN claimed the resident had told her she could have the money in his bank account after paying for his cremation and could keep the cell phone, but there was no documentation of this agreement and no witnesses. Facility policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent and stated residents have the right to be free from misappropriation, and the employee handbook stated staff should never borrow or take money or personal belongings from residents.
Failure to Monitor and Respond to Declining Intake Leading to Severe Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to identify, document, and update nutritional interventions for a resident with known risk factors and a history of weight loss, resulting in severe weight loss. The resident had multiple diagnoses including diabetes, atherosclerosis of the aorta, asthma, hypothyroidism, GERD, cataracts, dysphagia, lack of coordination, and gait/mobility abnormalities, and was assessed as having moderate cognitive impairment and requiring supervision to eat. The care plan, initiated months earlier, identified risk for weight gain/loss related to diabetes and hypothyroidism and directed staff to monitor and document meal intake percentages at all three meals and to refer to the physician/dietitian if there was a 5% weight loss over 30 days or 10% over 180 days. The facility’s weight summary showed a weight of 128 pounds in July and 113.6 pounds on 1/6/26, with no subsequent facility weight obtained before the resident’s hospital admission on 1/16/26, when the hospital documented a weight of 80 pounds and severe protein-calorie malnutrition. From 1/6/26 onward, documentation of the resident’s food intake was incomplete and inconsistent despite clear indications of poor intake. The facility’s meal intake records showed the resident consumed 0–25% of breakfast and lunch on 1/6/26 with no entry for the evening meal, no documented intake at all from 1/7/26 through 1/10/26, and refusals to eat on 1/11, 1/13, and 1/15. On 1/12, the resident ate 0–25% at breakfast and lunch, with no entry for the evening meal. A psychiatry note dated 1/15/26 recorded staff reports that the resident had not been eating and that after the family placed a spending limit on the resident’s food delivery app card, she reportedly stopped eating. A dietary progress note on 1/15/26, based only on chart review and not an in-person assessment, stated that the resident’s intakes had been poor, that she required 1:1 supervision with meals, and that she was on appetite stimulants and multiple nutritional interventions, but it did not prompt a new weight or updated interventions in response to the recent decline in intake. Multiple staff interviews confirmed that the resident’s intake had declined significantly when her ability to order outside food was reduced, and that this change was not followed by timely weights, consistent intake documentation, or notification to the provider or dietitian. CNAs reported that the resident disliked facility food, often refused substitutes, and had markedly decreased intake after her food delivery spending was limited; they stated they reported this to nurses, but intake documentation remained sparse or missing for several days. Nursing staff, including an LPN and an RN, acknowledged that when a resident stops eating, a weight should be obtained and the provider and dietitian notified, and that in this case no weight was entered after 1/6/26 despite visible weight loss and very low or refused intakes. The dietary manager and dietitian both stated they were not made aware of the extent of the poor or undocumented intakes, and the resident was not discussed in nutritional risk meetings during the period in question. The DON reviewed the intake records and characterized the charting as completely unacceptable, noting that CNAs are expected to document every meal and that such documentation is essential to monitor whether residents are meeting nutritional needs. The facility’s own weight policy called for a systematic interdisciplinary effort to identify and track residents with significant changes in appetite and decreased oral intake in the last seven days, but this process was not effectively implemented for this resident between 1/6/26 and 1/16/26.
Failure to Perform and Document Ongoing Skin Assessments for At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough initial and ongoing skin assessments for a resident at risk for skin breakdown who had documented redness to the buttocks and peri-area. The resident had multiple diagnoses including diabetes, atherosclerosis of the aorta, asthma, hypothyroidism, GERD, cataracts, dysphagia, lack of coordination, and gait/mobility abnormalities. A facility assessment showed moderate cognitive impairment, dependence on staff for toilet hygiene, substantial to maximal assistance needs for personal hygiene, and supervision for bed mobility. An order dated 12/16/25 directed application of zinc barrier cream to the buttocks twice daily and as needed for incontinence, and a care plan initiated the same day identified impaired skin integrity related to incontinence with erythema, excoriation, and skin breakdown to the peri-area and buttocks. Despite these identified risks and care needs, the electronic medical record contained no documented nursing skin assessment of the buttocks from 12/16/25 until the resident’s transfer on 1/16/26. A progress note on 12/25/25 stated that zinc barrier cream to the buttocks and perineal area continued and that the area remained stable, but did not include wound classification, size, tissue description, or drainage. A shower sheet dated 1/6/26 documented redness to the buttocks, yet there was still no corresponding nursing skin assessment with detailed wound characteristics. When the resident was sent to the hospital on 1/16/26 for abnormal labs, the emergency department record documented a sacral ulcer. Staff interviews confirmed the lack of thorough and ongoing skin assessments. A CNA reported the resident had a “real red area” on her buttocks and that barrier cream was applied, and stated CNAs report skin issues to nurses. The RN who sent the resident to the hospital acknowledged she did not inspect the resident’s skin before transfer, had last seen the resident’s bottom 3–4 days earlier, noted redness and irritation, and admitted she did not document skin assessments, only the barrier cream on the treatment record without size or description. The DON confirmed there were no skin/wound assessments since 12/16/25 except for a brief 12/25/25 note and stated she would expect location, appearance, and size to be charted. The wound care nurse described documenting only what she saw visually and monitoring without consistent, detailed assessments, and acknowledged the resident had persistent redness to the peri-area and buttocks and that it was possible the wound opened. The facility’s wound policy required weekly assessment and documentation of any skin impairments by the wound nurse or designee, which was not followed for this resident.
Failure to Ensure Beard Coverings Worn During Food Preparation
Penalty
Summary
A staff member with a beard was observed preparing pureed bread and vegetables in the kitchen without wearing a beard covering, as required by facility policy. The Dietary Manager was present in the kitchen during this time but did not ensure the staff member wore the appropriate beard restraint. The staff member continued to prepare and puree food for the noon meal without donning a beard cover, despite acknowledging that facility policy mandates beard coverings when preparing food. The facility's Food Safety and Sanitation policy, dated 9/17/23, specifies that beard restraints should be worn at all times during food preparation.
Failure to Maintain Resident Dignity with Uncovered Urinary Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a suprapubic indwelling urinary catheter was repeatedly observed in public areas, including the dining room and from the hallway while in bed, with their urinary drainage bag visible and not covered by a privacy bag. The urine in the collection bag was visible to others on multiple occasions. The facility's Director of Nursing confirmed that privacy bags should be used to maintain resident dignity, and the facility's dignity policy specifies the use of privacy coverings for urinary catheter bags as an example of promoting dignity and respect.
Failure to Provide Adaptive Utensils for Resident with CVA
Penalty
Summary
The facility failed to provide adaptive utensils to a resident who required them for independent feeding due to a history of cerebrovascular accident (CVA) and bilateral carotid stenosis. The resident's care plan specified the need for built-up silverware at meals, and meal tickets confirmed this requirement. However, during observations on two consecutive mornings, the resident was given only standard or plastic utensils and was seen attempting to eat with these, resulting in difficulty managing his food. Staff interviews confirmed the resident's need for weighted utensils to assist with eating and to promote strength in his affected hand. The facility's policy also indicated that adaptive eating equipment should be provided to residents who need them to promote feeding independence.
Lack of Stop Dates for PRN Psychotropic and Anti-Psychotic Medications
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic and anti-psychotic medications had appropriate stop or duration dates for three residents reviewed for pharmacy services. Specifically, one resident had an order for haloperidol as needed every 8 hours, and two residents had orders for lorazepam as needed at varying intervals. All of these orders had documented start dates but lacked required stop or duration dates. According to the facility's own policy, as-needed psychotropic and anti-psychotic medications are limited to 14 days, but this was not reflected in the orders reviewed. The Director of Nursing confirmed that PRN psychotropic and anti-psychotic medications require a stop date.
Failure to Maintain Proper Catheter Bag Positioning and Infection Control
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents with urinary catheters, as observed through multiple instances where catheter drainage bags were not properly positioned. For one resident with a history of prostate cancer and obstructive and reflux uropathy, the catheter bag was repeatedly found resting on the seat of a wheelchair next to the bed, which was lower than the seat, resulting in the bag being below the level of the bladder. This improper positioning prevented urine from draining into the bag. The resident subsequently developed blood in the urine, was diagnosed with a urinary tract infection, and was started on antibiotics. Staff interviews confirmed that catheter bags should be positioned below the bladder to ensure proper drainage and prevent complications. Another resident with diagnoses including type 2 diabetes mellitus, obstructive and reflux uropathy, and benign prostatic hyperplasia was observed on several occasions with the urinary catheter bag not placed in a dignity bag and the lower half of the collection bag lying on the floor. Staff interviews and facility policy confirmed that catheter bags and tubing should not touch the floor to prevent infection. The facility's own catheter care policies were not followed in both cases, as the drainage bags were not maintained in appropriate positions to ensure proper urine flow and infection control.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 7.14% based on 28 observed opportunities with 2 errors. In one instance, a resident with type two diabetes mellitus and diabetic neuropathic arthropathy was ordered to receive 15 units of Humalog insulin via pen three times daily. The LPN administering the insulin did not prime the insulin pen and needle by wasting two units prior to injection, contrary to facility policy and standard practice. The LPN stated that she only primes the pen when opening a new one, not with each administration. The facility's policy requires priming the pen with two units before every use to ensure the correct dose is delivered. In another case, a resident with an order for cetirizine 10 mg daily for allergies was instead given loratadine 10 mg by an LPN. The DON confirmed that cetirizine and loratadine are different allergy medications. The facility's medication administration policy requires verification of the right medication, dose, route, time, and resident identity before administration. These failures resulted in the facility exceeding the acceptable medication error rate threshold.
Failure to Provide Snacks to Non-Diabetic Resident Upon Request
Penalty
Summary
A deficiency occurred when a resident was not provided a snack outside of scheduled meal service times, despite expressing a desire for a bedtime snack. The resident reported not receiving snacks and stated that when a request was made, the Dietary Manager responded that only diabetic residents receive snacks. Interviews with facility staff, including an LPN, the Dietary Manager, and the Dietitian, confirmed that snacks are only provided to diabetic residents or those with weight loss, and that no snacks are offered to other residents in the evening. Review of the resident's diet order and care plan showed no restrictions or physician orders prohibiting snacks outside of scheduled meal times.
Failure to Complete and Document Pressure Injury Treatments
Penalty
Summary
The facility failed to ensure that pressure injury treatments were completed and properly documented for two out of three residents reviewed for pressure injuries. For one resident with a stage 4 pressure ulcer on the left lower back and multiple comorbidities including diabetes, COPD, and peripheral vascular disease, the Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as completed on several weekend dates. The wound care nurse confirmed that treatments should be documented after completion and that if not documented, it is considered not done. The resident's care plan required wound management per treatment orders, and facility policy mandated that staff initial the TAR after each administration. Similarly, another resident with a stage 3 pressure ulcer on the right ankle, along with diagnoses such as right-sided hemiplegia, obesity, and traumatic brain injury, had wound care treatments that were not signed off as completed on multiple weekend dates. The wound care nurse again confirmed the lack of documentation and reiterated the importance of following treatment orders. The care plan for this resident also required wound care per treatment orders, and the facility's policy specified that physician-ordered treatments must be documented on the TAR after each administration.
Failure to Timely Report, Investigate, and Protect Resident Following Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention policy in the case of one resident with a history of mental illness and prior abuse. After the resident returned from the hospital and made an allegation of assault against a staff member, the required immediate reporting to the administrator and to the Department of Public Health was not completed within the policy's specified timeframe. The administrator was notified via text message by the LPN, but did not respond, and the nurse did not follow up with a phone call as required. The administrator did not initiate the investigation or report the allegation to the state agency until the following day, missing the two-hour reporting window outlined in the facility's policy. Additionally, the staff member accused of abuse continued to have contact with the resident after the allegation was made, contrary to the policy that requires immediate removal of the accused from resident contact pending investigation. The administrator did not interview the resident about the incident, and the LPN did not gather further details from the resident. The initial and final abuse investigation reports were not sent to the state agency until days after the incident, further demonstrating a failure to follow established procedures for timely reporting, investigation, and protection of the resident during the investigation process.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident with a history of mental illness and prior abuse. The resident, identified as being at risk for abuse and/or neglect, returned from the hospital and made a statement accusing a staff member of assault. This statement was heard by a CNA, who relayed it to an LPN shortly after the resident's return. The LPN then texted the Administrator/Abuse Coordinator about the allegation, but did not receive a response. The Administrator was not informed in person until the following day and acknowledged that the report to the state survey agency was delayed. The Director of Nursing later confirmed that there was no record of a timely report being sent to the state agency regarding the abuse allegation, and the initial report was only sent several days after the incident. The facility's policy required immediate reporting of all abuse allegations, but this protocol was not followed in this instance.
Failure to Immediately Investigate and Suspend Staff After Abuse Allegation
Penalty
Summary
The facility failed to immediately investigate an allegation of abuse and did not immediately suspend the alleged perpetrator while the investigation was ongoing for one resident. The resident, who had a history of mental illness and prior abuse, returned from the hospital and made a statement identifying a staff member as the person who assaulted her. This statement was relayed to a nurse, who then informed the administrator via text message, but the administrator did not respond at that time. The nurse did not interview the resident for further details, and the administrator did not speak to the resident about the allegation upon being notified the next day. The alleged perpetrator continued to work until later in the day when they were identified and sent home. Documentation shows that the staff member involved wrote a statement about the incident, and the resident's care plan indicated a risk for abuse, instructing staff to follow facility policy for all suspected or reported instances. Despite these protocols, the facility did not act immediately to investigate the allegation or remove the alleged perpetrator from duty, as confirmed by interviews with staff and review of time cards. The initial and final abuse allegation investigations were sent to the state agency several days after the incident.
Failure to Timely Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required timeframe to the Illinois Department of Public Health (IDPH). After a resident was discharged home, her daughter reported to facility staff that the resident had alleged being sexually assaulted during her stay. The daughter initially contacted the facility regarding a missing cell phone and, during the conversation, mentioned the allegation of sexual abuse. This information was relayed to the facility administrator by the admissions staff. Despite being informed of the allegation, the administrator did not immediately report the incident to IDPH, believing that reporting was unnecessary since the resident was no longer at the facility. The facility's own policy requires that allegations of abuse be reported to IDPH immediately, but not later than two hours after the allegation is made if it involves abuse or serious bodily injury. The report to IDPH was ultimately made two days after the initial allegation was received, exceeding the required reporting timeframe.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a temperature that met resident satisfaction, affecting four residents who were reviewed for food temperatures. Observations and interviews revealed that residents consistently received food that was cold by the time it was served. One resident reported that the Dietary Manager informed him that the food temperature met state requirements, but it was still cold when served. Another resident mentioned frequently needing to reheat his food in the microwave, while a third resident expressed a preference for warmer food but chose to eat it cold. A fourth resident noted that the food was usually cold upon receipt, and using the microwave to reheat it would result in long wait times due to the number of residents needing to do the same. During an observation on the second floor, it was noted that the dietary aide had forgotten the thermometer initially but later checked the food temperatures. The recorded temperatures for various food items, including regular and pureed textures, were below the facility's policy requirement of maintaining a minimum temperature of 135 degrees Fahrenheit on the steam table before serving. The temperatures ranged from 104 to 129 degrees Fahrenheit, indicating a failure to adhere to the facility's food safety and sanitation policy, which contributed to the residents' dissatisfaction with the food temperature.
Food Temperature and Cross-Contamination Deficiencies
Penalty
Summary
The facility failed to maintain proper food temperatures and prevent cross-contamination during meal service on the second floor, affecting all 94 residents residing there. Observations revealed that various food items, including shredded chicken, rice, and corn, were held at temperatures below the required 135 degrees Fahrenheit on the steam table. Residents reported that their food was often cold by the time it was served, with some resorting to reheating their meals in a microwave. The Dietary Manager was unaware of the required holding temperatures and confirmed that there was no temperature log for the second floor steam table. Additionally, cross-contamination risks were identified when a dietary aide was observed using the same gloves to handle multiple food items and surfaces without changing gloves or performing hand hygiene. The aide touched containers, the steam table, and various food items, including cheese and lunch meat, without using tongs or changing gloves. The facility's policy requires proper handwashing techniques and glove changes to prevent the spread of infection and cross-contamination, which were not followed in this instance.
Failure to Timely Assess and Treat Pressure Injuries
Penalty
Summary
The facility failed to assess and treat a resident's pressure injuries in a timely manner, leading to the deterioration of the resident's condition. The resident, who was admitted with multiple medical conditions including sepsis, diabetes, and stage 2 pressure ulcers on both buttocks, did not receive the prescribed wound treatments consistently. The resident's treatment orders, which required wound care twice daily, were not followed, resulting in missed treatments over a ten-day period. There was no documentation of the resident refusing treatment, and the initial wound assessment was delayed by a week. The wound care nurse, V3, confirmed that the resident's wounds were not assessed upon admission, and the admitting nurse failed to identify the existing pressure injuries. The Director of Nursing, V2, acknowledged that the wound treatment orders were entered but not initiated as required. The Licensed Practical Nurse, V4, who was covering the wound care position, did not perform the necessary assessments due to the resident's admission occurring after her shift. The facility's policy mandates that wound assessments should be conducted within 24 hours of admission, but this was not adhered to in this case. The lack of timely wound assessment and treatment contributed to the resident's pressure injuries worsening from stage 2 to an unstageable condition. The facility's wound policy emphasizes the importance of systematic wound care to promote healing and prevent deterioration, but the failure to implement these practices resulted in the resident's condition deteriorating. Interviews with staff, including the Nurse Practitioner, V5, highlighted the necessity of following treatment orders and documenting any refusals, which was not done in this instance.
Failure to Provide Medications for Resident on Overnight Pass
Penalty
Summary
The facility failed to ensure that a resident had his prescribed medications when leaving the facility on an overnight pass. The resident, identified as R1, did not have his medication strip available when he left the facility with his power of attorney (POA). The nurse's notes did not document that R1 left the building, and a handwritten note given to R1's POA indicated that the medication strip was not available. The medications that R1 was supposed to receive during his time away included several psychotropic and other medications for conditions such as schizophrenia, hypertension, and anxiety. The Director of Nursing (DON) explained the procedure for sending medications with residents who leave the facility, which involves using small envelopes to label and send the medications. However, the LPN involved, V4, stated that the medication strip was not in the medication cart and did not know which specific medications were supposed to be given to R1. V4 also mentioned that she did not have access to the medication machine and did not check if the medications were available there. The facility's guidebook and policy on administering medications emphasize the importance of ensuring medications are sent with residents when they leave for extended periods.
Failure to Report Alleged Abuse to Administrator
Penalty
Summary
The facility failed to report an allegation of abuse to the administrator for one of the residents reviewed for abuse. The incident involved a resident who allegedly reported to her daughter that she was pushed by a Certified Nursing Assistant (CNA) after receiving a ham sandwich. The daughter's report was communicated to the facility's scheduler, who did not inform the administrator. The administrator was unaware of the incident until an interview conducted by surveyors. Upon reviewing video footage, the administrator found no contact between the CNA and the resident. The facility's Abuse Prevention policy requires employees to report any incident or suspicion of abuse to the administrator immediately, which was not followed in this case.
Failure to Administer Anticoagulants Leads to Resident's Stroke
Penalty
Summary
The facility failed to ensure that a resident with a history of embolic strokes received physician-ordered anticoagulants, leading to significant medication errors. Resident R167, who had a history of strokes due to embolism, was readmitted to the facility with a physician's order for Xarelto, an anticoagulant. However, the medication was not administered as prescribed due to issues with obtaining it from the pharmacy, resulting in the resident missing six doses. This failure contributed to R167 experiencing an acute embolic stroke, requiring emergency transport to the hospital, where the resident later passed away. The deficiency also involved another resident, R116, who was prescribed Rivaroxaban for atrial flutter. The facility failed to administer the anticoagulant for five days due to delays in receiving the medication from the pharmacy. This lapse in medication administration was documented in the resident's electronic Medication Administration Record (eMAR), which showed that the medication was on order but not delivered. The facility's policies and procedures for administering medications were not followed, leading to these significant medication errors. Interviews with facility staff, including the Director of Nursing and Licensed Practical Nurses, revealed a lack of access to the automated medication dispensing system and confusion about the availability of medications. The Director of Nursing admitted to not being aware of the medication's availability and the issues with the automated system. The facility's failure to ensure timely administration of anticoagulants as ordered by physicians resulted in Immediate Jeopardy, highlighting a breakdown in the medication management process.
Removal Plan
- All licensed nursing staff have been re-educated to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available. Education includes an emphasis on the importance of securing medications, such as blood thinners/anticoagulants.
- The Administrator re-educated licensed clinical management nursing staff on the process to follow-up with pharmacy when authorization is required.
- A system is in place to ensure commonly available medications are available through pharmacy, back up pharmacy and the backup medication dispensing system.
- Re-education is completed by Administrator/DON/MDS/clinical management directors. All licensed nursing staff have been contacted via phone by the Administrator/DON/MDS/or clinical management directors and prior to the beginning of the next shift worked and will sign education sheets ensuring the licensed nursing staff was re-educated.
- A house audit was completed which consisted of the Director of Nursing ensuring that all residents prescribed blood thinners are receiving the prescribed medications, per physician orders.
- New licensed nursing staff hired are educated to ensure residents admitted to the facility have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available.
- On the spot education for licensed nursing staff is being conducted to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available.
- A weekly audit of 5 residents will continue for four months to ensure residents have all medications are available, including blood thinners and all medications are received in a timely manner, per physician orders.
- The DON or designee perform QAPI audits of 5 residents a week for 4 months to ensure medications are administered as prescribed.
- An analysis of the audits are presented through QAPI quarterly. QAPI Audits are completed using direct observation, resident interview and medical record review.
- A root cause analysis was completed to determine process breakdown, barriers and process improvement. The root cause analysis was completed by the IDT which included the Administrator, clinical management licensed staff, pharmacy representation, corporate clinical staff and the medical director.
- All QAPI audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if further audits will continue after the completion of 4 months.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to appropriately follow up on a report of a stage 1 pressure injury for a resident, leading to the progression of the injury to a stage 3 pressure ulcer. The resident, who was admitted with severe cognitive impairment and was dependent on staff for personal hygiene and mobility, was at risk of developing pressure ulcers. Despite a reddened area being noted by a CNA during a bed bath, no nursing progress notes or skin assessments were found until the injury had progressed to a stage 3. The facility's policy required thorough weekly examinations by a licensed nurse, but the initial assessment and documentation were not completed in a timely manner. Another resident, who returned from the hospital with a deep tissue injury to the right heel, did not have the prescribed off-loading boot in place during a care and dressing change. The resident's care plan required maintaining off-loading heel boots and repositioning every 1-2 hours, but these interventions were not consistently implemented. The facility's policy on pressure ulcer and skin condition assessment did not adequately address pressure ulcer prevention, contributing to the oversight in care. The facility's failure to implement timely interventions and follow established protocols for pressure ulcer prevention and care resulted in the progression of pressure injuries for two residents. The lack of documentation and communication among staff members further exacerbated the situation, as necessary notifications and assessments were not completed as required by the facility's policies.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional care for a resident, identified as R103, who experienced significant weight loss. R103, a male resident with schizophrenia, major depressive disorder, and anxiety disorder, was not weighed or assessed by a dietitian for nine months following a notable weight loss. Observations revealed that R103 was pale, cachectic, and his meals were often untouched and out of reach, indicating a lack of proper nutritional monitoring and intervention. Interviews with facility staff, including an LPN, ADON, and Restorative Nurse, highlighted a lack of clarity and responsibility regarding nutritional monitoring and interventions for R103. The LPN admitted to not checking if residents received the correct diet, while the Restorative Nurse mentioned inconsistent weight monitoring and documentation. The Dietary Manager confirmed that no nutritional assessment had been conducted since January 2024, and there were no documented interventions to address R103's weight loss. The Dietitian, who had been at the facility for 2 to 3 months, was unaware of R103's weight concerns and emphasized the importance of regular weight monitoring and re-approaching residents who refuse to be weighed. Despite a care plan intervention to weigh the resident monthly and refer to a dietitian if significant weight loss occurred, no actions were taken in 2024 to address R103's nutritional needs. The facility's policy required regular weight monitoring and dietitian review, but these were not followed, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with a pressure injury. A Certified Nursing Assistant (CNA) was observed providing care to a resident with a stage III pressure injury on the coccyx without wearing a gown, despite the requirement for enhanced barrier precautions, which include wearing a gown and gloves during high-contact care activities. The CNA was unaware of the wound's status, and there was no enhanced barrier precaution sign on the resident's door or an isolation cart in the hallway. The Director of Nursing confirmed that enhanced barrier precautions should be in place for residents with wounds to prevent contamination and spread of infection. Additionally, the facility failed to follow proper infection control procedures during incontinence care for another resident. A CNA was observed discarding soiled linen on the floor and not changing gloves after providing care, which is against the facility's policy. The CNA carried soiled linen through the hallway without bagging it and did not change gloves before assisting the resident into a wheelchair. The Director of Nursing stated that soiled linen should be bagged and gloves changed after care to prevent contamination, as per the facility's policies on linen handling and perineal care.
Failure to Prevent Cross-Contamination During Meal Service
Penalty
Summary
The facility failed to handle food in a manner that prevents cross-contamination, as observed during a lunch service on the first floor. The Dietary Manager, V32, stated that the noon meal included an open face turkey sandwich and alternatives such as hamburgers and grilled cheese sandwiches. During the lunch service, the cook, V33, was observed handling hamburger patties with gloved hands that had previously touched potentially contaminated surfaces, including handles, bags, and food containers. V33 did not change gloves between tasks, resulting in a layer of grease on the gloves, which then transferred to slices of bread and the tops of plates, leaving grease streaks. The facility's Food Safety and Sanitation policy, revised in September 2023, requires that single-use gloves be changed as soon as they become dirty or torn and before beginning a different task. V32 acknowledged that V33 should have used tongs or changed gloves to prevent cross-contamination. This failure to adhere to the facility's policy on glove use has the potential to affect all residents residing on the first floor, as noted in the facility's resident census, which showed 81 out of 164 residents live on that floor.
Failure to Notify Resident's Representative of Involuntary Transfer
Penalty
Summary
The facility failed to notify a resident's representative of an involuntary transfer to the hospital for a resident with severe cognitive impairment. The resident, identified as having multiple diagnoses including stroke, nicotine dependence, and chronic obstructive pulmonary disease, was admitted to the facility from the hospital. Shortly after admission, the resident expressed a desire to leave Against Medical Advice (AMA) but was deemed unsafe to do so due to disorientation and confusion. The decision was made to involuntarily transfer the resident back to the hospital for evaluation and treatment. The facility's records, including the social service note and progress notes, did not indicate that the resident's spouse, who was listed as the emergency contact and surrogate decision maker, was notified of the transfer. Interviews with facility staff, including the Social Services Assistant Director and the Director of Nursing, revealed that there was an assumption that the notification had been made, but no documentation was found to confirm this. The staff involved in the transfer process did not communicate effectively to ensure the resident's representative was informed. The facility's policy on changes in resident condition requires notifying the resident's responsible party of significant changes, including involuntary transfers. However, in this case, the policy was not followed, as evidenced by the lack of documentation and confirmation of notification to the resident's spouse. This oversight highlights a breakdown in communication and adherence to established procedures for notifying family members or representatives during critical events.
Inconsistent Advanced Directive Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's advanced directive, specifically for one resident reviewed for advanced directives. The resident's electronic medical record indicated a Do Not Resuscitate (DNR) status, which was consistent with the physician's orders dated April 17, 2024. However, the POLST (Practitioner Order For Life-Sustaining Treatment) form dated September 13, 2024, indicated the resident was a full code, creating a discrepancy between the documented code status and the POLST form. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the code status should be consistent across all documentation, including the electronic medical record, physician orders, and POLST form. The facility's policy requires that any changes in code status be communicated to nursing by social services, and that the POLST form should match the physician's orders. The inconsistency in the resident's code status documentation was identified during a review of the resident's records, highlighting a failure in the facility's process to ensure accurate and consistent documentation of advanced directives.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to ensure proper treatment orders and care for two residents with wound care needs. For the first resident, there was no evidence of a care plan addressing the management of an accordion drain for a liver abscess. The resident's dressing, placed at the hospital, had not been changed since admission to the facility. The facility's records lacked documentation of monitoring or changing the dressing for the liver drain, and there was a noted shortage of PICC line dressing change kits. Staff interviews revealed confusion about the necessity of dressing changes for the drain site, and the facility's policy on post-operative drains was not followed. The second resident had wounds on her left second toe and right dorsal foot, which were not properly assessed or dressed according to orders. The wound care nurse observed that the resident's wounds were not covered with the prescribed dressings, and an initial wound assessment was not conducted for the right dorsal foot wound. The resident's care plan did not address her history of these wounds, and the facility's wound policy, which requires documentation of wound assessments, was not adhered to. Both cases highlight a lack of adherence to treatment orders and facility policies, resulting in inadequate wound care management. The facility's failure to conduct initial wound assessments and ensure proper dressing changes for the residents' wounds contributed to the deficiencies identified during the survey.
Failure to Secure Catheter for Resident
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had a catheter secure device in place, as observed during a survey. The resident, identified as R49, was found lying in bed without a catheter secure device, and the catheter tubing was pulled tightly to the left with the drainage bag secured to the lower part of the bed frame. Certified Nursing Assistants (CNAs) V28 and V29, who were providing a bed bath to the resident, were unaware of the absence of the secure device. The resident communicated through nodding that his catheter had come out twice, indicating a lack of securement. The Director of Nursing (DON), identified as V2, confirmed that the facility uses catheter secure devices to prevent trauma and tension on the catheter tubing and that these should be offered to all residents with catheters. The resident's care plan, dated prior to the observation, indicated a risk for complications related to catheter use but did not document the use of a catheter secure device or any refusal of such a device. The facility's catheter care policy, dated 2018, mandates that indwelling catheters be secured to prevent trauma, which was not adhered to in this instance.
Failure to Properly Store and Date Respiratory Equipment
Penalty
Summary
The facility failed to properly store and date respiratory equipment for two residents, leading to potential contamination. For the first resident, a male with chronic obstructive pulmonary disease and other health issues, the oxygen tubing and CPAP mask were not marked with the date they were initiated, and the equipment was improperly stored. The oxygen tubing was found in contact with the floor, and the CPAP mask was hanging from a drawer knob, both uncovered. The Director of Nursing acknowledged that respiratory equipment should be stored in a baggie when not in use to prevent contamination and should be dated according to the facility's policy. For the second resident, a male with chronic obstructive pulmonary disease and obstructive sleep apnea, the nebulizer mask and tubing also lacked date markings. The CPAP facemask and tubing were found uncovered on the bedside table. The Director of Nursing confirmed that there were no orders to change the tubing, resulting in a lack of documentation. The facility's policy requires that oxygen equipment be changed and dated weekly and as needed, but this was not adhered to for these residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications properly for two residents, leading to deficiencies in pharmaceutical services. Resident R62, who has a history of anxiety disorder, Type 2 Diabetes, emphysema, bipolar disorder, and hypertension, did not receive her prescribed diabetic medication, Trulicity, as scheduled in September 2024. The medication was not sent by the pharmacy, and the facility did not take timely action to resolve the issue, resulting in missed doses on two occasions. The Director of Nursing was unaware of the missed doses until later, indicating a lapse in communication and medication management. Resident R153, a Type 2 diabetic, did not receive his fast-acting insulin according to the manufacturer's instructions. An LPN administered the insulin without wiping the pen tip with alcohol, priming the pen, or holding the plunger button for the recommended duration, which could result in an incomplete dose. The Director of Nursing confirmed these steps were not followed, which are necessary to ensure the full dose of insulin is delivered. These actions demonstrate a failure to adhere to proper medication administration protocols, potentially compromising resident care.
Failure to Date Opened Insulin Pens
Penalty
Summary
The facility failed to properly date opened insulin pens for two residents, R153 and R166, which is a requirement for medication storage. During an inspection of the 200-hall medication cart, it was observed that R153's fast-acting insulin pen had a yellow sticker with sections for Date Open, Date Expire, and Initials, all of which were left blank. The pen showed signs of being opened, as indicated by a damaged red tamper seal and some insulin being dispensed. The LPN, V9, confirmed administering insulin from this pen earlier in her shift and acknowledged that the pen should have been dated upon opening. R153's Order Summary Report confirmed an active order for fast-acting insulin to be administered four times daily. Similarly, R166's long-acting and fast-acting insulin pens were found with blank yellow stickers for Date Open, Date Expire, and Initials, and no other dates were documented on the pens. The seals on these pens were also damaged, indicating they had been opened. V9 admitted to administering insulin from these undated pens and confirmed that they should have been dated when opened. R166's Order Summary Report showed active orders for both fast-acting and long-acting insulin. The Director of Nursing, V2, stated that insulin pens are supposed to be dated upon opening, as their potency degrades after 28 days, and mentioned that staff had been recently in-serviced on this procedure.
Inadequate Supervision and Dietary Management for Residents
Penalty
Summary
The facility failed to provide safe feeding recommendations for four residents, leading to potential safety hazards. Resident R2, diagnosed with dysphagia, bipolar disorder, and dementia, was observed being given potato chips by the Assistant Director of Nursing, despite being on a mechanical soft diet. The speech therapist confirmed that R2 should not have been given potato chips and required supervision due to swallowing difficulties. Similarly, Resident R3, with diagnoses including hemiplegia and dysphagia, was observed eating potato chips and a regular diet unsupervised, contrary to his care plan that required a pureed diet and 1:1 assistance during meals. Resident R6, diagnosed with dysphagia following cerebral infarction, was observed feeding himself a pureed diet rapidly without supervision, contrary to his physician's orders that required 1:1 supervision and cueing for swallowing safety. The speech therapist confirmed that R6 needed supervision to ensure safe eating practices. Resident R9, with chronic bronchitis and COPD, was observed feeding himself a whole sandwich in bed without assistance, despite his care plan indicating a need for a pureed diet and 1:1 hand feeding. The speech therapist noted that R9 should have been receiving the diet specified in his orders. The Director of Nursing acknowledged that all residents on altered diets require some level of supervision, and those needing 1:1 supervision should not be served food until staff are ready to sit with them. The facility's policies on pureed and mechanical soft diets emphasize the need for individualized dietary modifications based on residents' swallowing and chewing abilities. However, the facility failed to adhere to these policies, resulting in residents receiving inappropriate diets and inadequate supervision during meals.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical and sexual abuse by a resident (R1) with a history of aggressive and inappropriate behaviors. R1, who had a criminal background and diagnoses including dementia and cognitive communication deficit, exhibited escalating aggressive behaviors towards staff and other residents. Incidents included R1 punching another resident (R2) in the face, flipping a resident (R3) out of a chair, and exposing himself to a resident (R4). Despite R1's documented history of aggression and inappropriate behavior, the facility did not adequately assess or manage the risks posed by R1, leading to multiple instances of abuse and harm to other residents. R1's aggressive behaviors were documented in various notes and reports, including instances of physical aggression towards staff and residents, and sexually inappropriate behavior. R1's criminal history background check revealed felony convictions and a history of violent behavior. Despite these red flags, R1 was admitted to the facility and his aggressive behaviors were not effectively managed. Staff reported multiple incidents where R1 was physically and verbally aggressive, including trapping a CNA in his room while masturbating, placing a choke hold on staff, and throwing a can of pop at a CNA. These behaviors escalated to physical assaults on residents, including punching R2 and flipping R3 out of a chair. The facility's failure to adequately assess and manage R1's behaviors resulted in significant harm to other residents. R1's care plan and risk assessments did not accurately reflect the severity of his behaviors, and interventions were insufficient to prevent further incidents. The facility's abuse prevention policy was not effectively implemented, leading to multiple instances of abuse and harm to residents. The Immediate Jeopardy was identified and later removed when R1 was placed on 1:1 supervision and subsequently discharged from the facility with police involvement.
Removal Plan
- R1 no longer resides in the facility.
- R2 is at baseline and continues to reside safely in the facility.
- R3 is at baseline and continues to reside safely in the facility.
- R4 is at baseline and continues to reside safely in the facility.
- All staff are in the process of being re-educated on the abuse policy to ensure residents are free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
- The Administrator/DON/MDS/management directors will complete the education. All staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets on keeping from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
- A list of identified offenders was reviewed by Social Service staff to ensure a safety plan is in place, per the plan of care.
- New hires will be educated on ensuring residents are kept free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place during orientation.
- On the spot education on abuse training knowledge is completed to ensure compliance System: Education to be completed by the start of next scheduled shift.
- A weekly audit of 10 residents will continue to ensure residents free of physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
- Audits will be completed by Social Services Director or designee and an analysis presented through QAPI.
- Audits are completed using direct observation, resident interview and medical record review.
- A root cause analysis was conducted to identify barriers and further education needed.
- All audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if the audits will continue at that time.
Failure to Supervise Resident with Escalating Aggressive and Sexual Behaviors
Penalty
Summary
The facility failed to adequately supervise a resident with known escalating behaviors of physical and sexual aggression. This resident, who had a history of aggressive and inappropriate behaviors, was not properly monitored despite multiple incidents of aggression towards staff and other residents. The resident's behavior included physical aggression such as punching another resident in the face and flipping another resident out of a chair, as well as sexually inappropriate behavior, including exposing himself to a female resident. Despite these incidents, the resident was only placed on 15-minute checks, which were inconsistently documented and not effectively implemented, leading to further incidents of aggression and sexual misconduct. The resident's medical history included diagnoses of dementia, cognitive communication deficit, and a history of criminal behavior, including felony convictions and substance abuse. The facility's records show that the resident exhibited aggressive behaviors shortly after admission, including physical aggression towards staff and other residents, and sexually inappropriate behavior towards a staff member. Despite these behaviors, the facility's response was inadequate, with inconsistent supervision and failure to implement effective interventions to manage the resident's behavior. Interviews with staff revealed that the supervision checks were not consistently performed or documented, and there was confusion among staff about who was responsible for monitoring the resident. The facility's policy on safety and supervision of residents was not effectively followed, leading to multiple incidents of aggression and sexual misconduct by the resident. The failure to provide adequate supervision and implement effective interventions resulted in the resident being able to continue exhibiting aggressive and inappropriate behaviors, ultimately leading to the resident being discharged with police involvement after sexually assaulting another resident.
Removal Plan
- R1 no longer resides in the facility.
- R2 is at baseline and continues to reside safely in the facility.
- R3 is at baseline and continues to reside safely in the facility.
- R4 is at baseline and continues to reside safely in the facility.
- All staff are in the process of being re-educated on the abuse policy to ensure residents are free from physical and sexual abuse and behavior management for residents with a safety plan in place.
- Education includes supervising residents with escalating behaviors, monitoring and placing interventions in place.
- A system is in place to ensure supervision checks are completed as identified by the facility.
- The form is reviewed daily by clinical management to ensure it is completed and accurate.
- The Administrator/DON/MDS/management directors will complete the education.
- All staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets on ensuring residents are free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
- A list of identified offenders was reviewed by Social Service staff to ensure a safety plan is in place, per the plan of care.
- New hires will be educated on ensuring residents are kept free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place during orientation.
- On the spot education on abuse training, identifying escalating behaviors, monitoring and placing interventions in place.
- A knowledge check is completed to ensure compliance.
- A system is in place to ensure supervision checks are completed.
- Education to be completed by the start of next scheduled shift.
- A weekly audit of 10 residents will continue to ensure residents free of physical and sexual abuse, staff identifying escalating behaviors, monitoring and placing interventions in place and a system is in place to ensure supervision checks are completed.
- Audits will be completed by Social Services Director or designee and an analysis presented through QAPI.
- Audits are completed using direct observation, resident interview and medical record review.
- A root cause analysis was conducted to identify barriers and further education needed.
- All audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator.
- QAPI will determine if the audits will continue at that time.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to identify, assess, and implement pressure wound treatment and prevention interventions for a resident, leading to the development of an additional Stage 2 pressure wound and the worsening of existing wounds. The resident was admitted with a Stage 3 pressure wound on the left heel and a wound on the sacrum, but the care plan did not include any treatment or prevention interventions. The resident did not receive any wound care treatments from the time of admission until several weeks later, and there was no documentation of a complete wound assessment during this period. The Wound Care Physician's evaluations indicated that the resident's wounds worsened over time, and a new Stage 2 pressure wound developed. The facility's Wound Care Nurse and Director of Nursing confirmed that wound care treatments were not documented and therefore likely not performed. The resident did not refuse wound care, and the lack of treatment was attributed to failures in the facility's processes and documentation. The facility's policy required weekly wound assessments and documentation, but these were not completed as required. The care plan was inadequate, lacking necessary interventions such as a turning/repositioning schedule and special mattress. The facility's staff acknowledged the deficiencies in wound care and documentation, which contributed to the resident's deteriorating condition.
Failure to Notify Family/POA of Resident's Change in Condition and Hospitalization
Penalty
Summary
The facility failed to inform a resident's family/Power of Attorney (POA) of a significant change in the resident's condition and subsequent hospitalization. On 1/3/24, a resident (R1) was found to be lethargic, with an altered mental status, elevated heart rate, and low oxygen levels. Emergency Medical Services (EMS) were called, and R1 was transported to the hospital. However, the facility did not notify R1's POA, who later learned of the hospitalization from the hospital staff. Interviews with the facility's Licensed Practical Nurses (LPNs) and Registered Nurse (RN) confirmed that the standard procedure is to notify the family/POA and document this communication in the Nurse's Notes, but this was not done in R1's case. The facility's Change in Resident's Condition Policy, reviewed on 2/1/22, mandates that nursing or social service staff alert the family of a resident's change in condition and document the communication in the resident's medical record. Despite this policy, there was no documentation in R1's Progress Notes indicating that the family/POA was informed of the change in condition or the hospitalization. The lack of communication and documentation represents a failure to adhere to the facility's policy and ensure the family/POA was promptly informed of the resident's critical condition and transfer to the hospital.
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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