Goldwater Care Gibson City
Inspection history, citations, penalties and survey trends for this long-term care facility in Gibson City, Illinois.
- Location
- 620 East First Street, Gibson City, Illinois 60936
- CMS Provider Number
- 145911
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Goldwater Care Gibson City during CMS and state inspections, most recent first.
The facility failed to protect a resident from physical abuse by another resident on two separate occasions, despite having an abuse prevention policy and a care plan identifying the aggressor’s risk factors. In one hallway incident, a housekeeper observed one resident push another in the chest, and the victim verbally expressed pain. In a later hallway incident, a CNA saw the same resident strike the same peer on the forearm when the victim attempted to help move the aggressor’s wheelchair after it became caught on equipment. One resident was cognitively intact, while the other had moderate cognitive impairment with mood disturbances related to dementia and a care plan directing staff to monitor for behaviors that could place others at risk.
A resident with severe Parkinson’s disease, prior stroke with left arm paralysis, and on anticoagulant therapy was care-planned as non–weight bearing, totally dependent for ADLs, and at high risk for falls, with an intervention for the bed to be kept in a low position and the resident positioned in the middle of the mattress. On one night, the assigned CNA left the resident after observing him asleep and went to the nurse’s station; when she later resumed rounds, she found the resident on the floor next to a waist-high bed with side rails up. The resident reported he had been calling for help and had chest pain, and staff used a mechanical lift to return him to bed. Hospital evaluation the same day documented multiple acute right rib fractures, and the resident stated his bed was usually kept at about waist height. The DON confirmed the care plan required a low bed and that the bed should not have been in a high position while the resident was in it, indicating the fall-prevention intervention was not implemented as planned.
Multiple incidents occurred in which residents with cognitive impairments physically abused other residents, despite care plans and interventions intended to prevent such events. In each case, staff witnessed the altercations and attempted to intervene, but were unable to prevent physical contact, resulting in minor injuries or distress. The facility's policies prohibiting abuse were not effectively implemented, leading to repeated resident-to-resident abuse.
The facility did not update care plans or implement new interventions after a resident with dementia exhibited aggressive behaviors, including physically striking other residents in the dining room. Staff were not consistently aware of or following seating arrangements meant to prevent further incidents, and there was no documentation of psychiatric evaluation after the altercations.
The facility did not document multiple resident-to-resident altercations involving individuals with dementia/Alzheimer's disease, nor did it record notifications to families and physicians as required. These incidents, witnessed by CNAs and a family member, were not reflected in the residents' medical records, despite facility policy mandating such documentation.
Two residents did not receive timely toileting assistance and incontinence care, as required by facility policy. One resident was left in soiled conditions for extended periods, with family members reporting that staff did not return to provide care, resulting in discomfort and skin irritation. Another resident experienced long delays in call light response, leading to episodes of incontinence and distress. Staff acknowledged that insufficient staffing contributed to these delays, especially during busy times.
Two residents with complex medical conditions received as-needed opioid medication that was signed out by an LPN on the controlled drug record, but the administration was not documented on the MAR as required by facility policy. Staff and administrator interviews confirmed the missing documentation, which did not follow established medication administration guidelines.
Two residents with severe cognitive impairment were involved in an incident where one resident, known for aggressive behaviors, physically struck and verbally abused another resident. Staff and resident interviews confirmed a pattern of aggression, and the abused resident experienced psychosocial harm, as evidenced by crying after the event.
A CNA repeatedly engaged in unprofessional and disrespectful behavior, including rough handling, failure to assist with toileting, and inappropriate language toward residents, some of whom were cognitively intact or had significant care needs. Despite multiple disciplinary actions and staff reports, the CNA continued to provide care, resulting in a failure to uphold resident dignity and rights.
The facility did not follow its Abuse Prevention and Reporting Policy after an incident where one resident hit and yelled at another. Although a CNA reported the event to the Administrator, there was no notification to the State Agency or to the residents' representatives, and no documentation of the incident was found in the medical records.
Two residents with severe cognitive impairment were involved in a physical and verbal altercation, witnessed by a CNA, where one resident hit and yelled at another. Although staff notified the administrator, the incident was not investigated, documented in the medical record, or reported to the state survey agency, contrary to facility policy.
Two residents were involved in a physical and verbal altercation, with one resident hitting and threatening another. Although staff intervened and an LPN assessed the affected resident for injury, the facility failed to provide a complete and chronological investigation record. Required details such as the timing of the incident, notifications, interviews, and follow-up assessments were missing from the documentation, contrary to facility policy.
The facility failed to respond to call lights in a timely manner for several residents, resulting in delays of up to 45 minutes or more for assistance. Residents, including those with cognitive impairments and requiring substantial help, reported ongoing issues with call light response times during resident council meetings. Despite staff education efforts, the problem persisted, as acknowledged by the facility administrator.
The facility failed to provide scheduled showers and nail care for two residents. One resident, with moderate cognitive impairment, reported receiving only one shower since admission, despite being scheduled for twice-weekly showers. Another resident, cognitively intact, reported not receiving the scheduled two showers per week. Facility records confirmed these deficiencies, and the DON acknowledged the failure to provide the required care.
A resident with severe cognitive impairment and multiple medical conditions, including Parkinson's Disease and right-sided hemiplegia, was left unsupervised in her room with a meal tray, contrary to her care plan. This lack of supervision led to the resident falling while attempting to reach for a call light or to turn on the light, resulting in a head laceration requiring sutures. Staff interviews confirmed the resident required total care and should not have been left alone during meals.
A resident with Alzheimer's and other conditions was improperly transferred by a CNA using a mechanical lift without assistance, contrary to facility policy. This resulted in the resident sustaining a shoulder hematoma and a distal femoral fracture. The CNA admitted to the solo transfer, and the facility's investigation confirmed the lack of assistance during the incident.
A resident in a LTC facility received an incorrect Warfarin dosage for 24 days due to the facility's failure to follow physician orders and monitor PT/INR levels. The resident, with a complex medical history, experienced Warfarin toxicity, leading to internal bleeding and death. Facility staff confirmed the failure to adhere to medication orders and monitoring protocols.
A resident was prescribed Plavix but was given Warfarin, leading to critical PT/INR levels and eventual death due to Warfarin toxicity. The facility's quality improvement program failed to address medication errors, and key personnel were unaware of the issue until after the incident.
The facility failed to respond to call lights promptly for several residents, as identified through interviews and record reviews. Resident Council Meetings documented concerns about long wait times across all shifts, with reports of nearly hour-long waits during the second shift. Multiple residents expressed frustration over delays, attributing them to staff shortages and busy schedules. The Resident Council President confirmed that long wait times were frequently discussed in meetings.
The facility failed to serve meals at an appropriate temperature, affecting several residents. Meal trays were delivered uncovered, and residents were left without assistance, leading to meals cooling down before consumption. Staff and residents reported issues with meal service timing and staffing shortages, resulting in cold food complaints. The Dietary Manager acknowledged these issues, indicating a recurring problem with meal temperature and service timeliness.
A resident, dependent on staff for bathing, did not receive scheduled showers due to staff being too busy or understaffed. The resident's showers were supposed to occur twice weekly, but documentation showed gaps in June and no showers in July. The facility's policy requires showers to be offered twice weekly and documented, which was not followed.
Two residents experienced mental and physical abuse by agency CNAs, V13 and V14, who were rude and dismissive of their care needs. One resident was handled roughly, exacerbating her leg pain, while the other was forced to attempt tasks beyond her physical capability, causing fear and distress. The facility's administrator confirmed the abuse, highlighting a failure to protect residents from such treatment.
Two residents reported abuse by agency CNAs, but the facility failed to notify the Administrator and State Agency promptly. Despite being aware of the abuse prevention policy, staff delayed reporting the incidents, and the CNAs were only asked to leave after the complaints. The Administrator did not report the incidents as abuse, affecting all residents in the facility.
The facility failed to immediately suspend two agency CNAs after a resident reported mental and physical abuse, allowing them to continue working and potentially harm other residents. Despite allegations from three residents, the CNAs were not promptly removed, violating the facility's abuse policy. Additionally, there was no documentation of abuse training for the CNAs involved, highlighting a compliance gap.
The facility did not provide mandatory QAPI training to its staff, affecting all 60 residents. Despite a January 2024 assessment stating annual training would occur, a CNA with over eight years of experience reported never hearing of QAPI training. The administrator confirmed the lack of ongoing training and documentation for the past year.
The facility failed to provide required annual Ethics training to staff, potentially affecting all 60 residents. A CNA with over eight years of service was unaware of any Ethics training, and the Administrator confirmed the lack of ongoing training and documentation.
The facility did not ensure nurse aides received the required twelve hours of in-service training, including dementia management and abuse prevention, affecting all 60 residents. The Administrator and HR staff lacked documentation of such training, highlighting a deficiency in compliance with training requirements.
The facility failed to protect two residents from physical abuse. One resident with Alzheimer's and Dementia wandered into another resident's room, leading to a physical altercation where both residents sustained injuries. The facility's administrator confirmed the incident and acknowledged that the altercation should not have occurred.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident, contrary to its Abuse Prevention and Reporting policy that affirms residents’ right to be free from abuse and prohibits physical abuse such as hitting and pushing. According to the Abuse Investigation Checklist, an allegation of physical abuse occurred when two residents were in the hallway and one resident (R2) reached out with a flat hand and pushed the other resident (R1) in the chest. A housekeeper (V6) witnessed the altercation, observed the push, and heard R1 yell, “Ouch, he pushed me.” R1 later stated that he and R2 had been talking in the hallway when R2 pushed him in the chest with his hand. R1’s MDS documents that he is cognitively intact. A second incident of physical abuse between the same two residents was documented when a CNA (V7) observed R2 strike R1 on the right forearm while R2’s wheelchair was in the hallway. R1 reported that R2’s wheelchair had become caught on a piece of equipment and that when he attempted to assist by moving the wheelchair, R2 struck him on the right forearm. R2’s MDS documents moderate cognitive impairment with fluctuating disorganized thinking, and R2’s care plan identifies mood disturbances related to dementia and directs staff to monitor and report indicators that R2 may be at risk of harming others, such as increased anger, agitation, or feelings of being threatened. The Administrator (V1) and DON (V2) confirmed both incidents and stated that R1 sometimes enters R2’s personal space, which R2 dislikes and sometimes responds to with physical behaviors.
Failure to Implement Care-Planned Low Bed Intervention Resulting in Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as high risk for falls and bleeding. The resident’s care plan documented multiple diagnoses including severe Parkinson’s disease with dyskinesia, prior stroke with no use of the left arm, atrial fibrillation on anticoagulant therapy, dysphagia, protein-calorie malnutrition, and other chronic conditions. The care plan, initiated months before the incident, specified that the resident was non–weight bearing, totally dependent on staff for all ADLs, and at high risk for falls, with an intervention added for the bed to be kept in a low position and the resident to be positioned in the middle of the mattress. The resident was also identified as being at high risk for bleeding due to anticoagulant use, and the MDS documented that the resident was cognitively intact but totally dependent for functional status. On the night of the unwitnessed fall, the CNA assigned to the resident reported that she had seen the resident sleeping in bed around 1:00 a.m., then went to the nurse’s station to eat with other staff. Afterward, when she resumed rounding, she observed the resident’s feet on the ground from the doorway and found the resident on the floor next to the bed, lying on the left side and propped up on the right arm. The resident stated he had been hollering for help and that his chest hurt. The CNA and other staff, including two LPNs and another CNA, responded; the resident was assessed and returned to bed using a mechanical lift. Multiple staff, including the assigned CNA, another CNA, and an LPN, consistently described the bed as being at about waist height with side rails up at the time the resident was found on the floor. The assigned CNA stated she was new, was unaware the resident was a fall risk, and did not know the bed was supposed to be in a low position. Subsequent hospital records from the same date documented that the resident, who could not get out of bed or ambulate independently and was on a blood thinner, was found on the floor with an unknown time on the floor and complained of mid-sternal and right-sided rib pain. Imaging showed acute right 3rd through 6th rib fractures, with old rib fractures also noted, and the resident was admitted for pain control and monitoring for bleeding. During the surveyor’s observation, the resident confirmed that he had rolled out of bed, had been calling for help, and that his bed was usually higher than its current position, indicating it was normally at about the surveyor’s waist level. The DON confirmed that the care plan contained interventions for the bed to be in a low position and for the resident to be positioned in the middle of the mattress, and acknowledged that the bed should not have been in a high position while the resident was sleeping. Facility policies on incidents/accidents and fall prevention required safety interventions to be implemented and consistently maintained for residents at risk, and assigned nursing personnel were responsible for ensuring ongoing precautions were in place.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive impairments. In one incident, a resident with Alzheimer's Disease and a history of combative behavior struck another cognitively intact resident in the dining room. The altercation was witnessed by a CNA, who attempted to intervene but was unable to prevent the physical contact. The aggressor resident was also noted to have been involved in prior altercations with both staff and other residents, and their care plan included interventions to monitor their whereabouts and behaviors. Another incident involved two residents, both with dementia or Alzheimer's Disease, where one resident struck another in the arm after a verbal exchange. This event was witnessed by a CNA and a family member, and the aggressor resident was documented as having severe cognitive impairment and exhibiting verbal and physical behaviors towards others. The care plan for this resident included recognition of their behavioral risks, but the physical altercation still occurred. A third incident involved two residents with Alzheimer's/Dementia, where one resident, known to have aggressive behavior and at risk for abuse/neglect, struck another resident on the thigh after a verbal confrontation. This resulted in a small red mark. Staff were aware of the ongoing verbal conflicts between these two residents and had interventions in place to redirect and separate them, but the physical abuse still occurred. In all cases, the facility's policies affirming residents' rights to be free from abuse were not effectively implemented, leading to physical altercations among residents.
Failure to Update Care Plans and Implement Interventions for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement appropriate interventions to address dementia-related behaviors for multiple residents diagnosed with dementia or Alzheimer's disease. Specifically, there were documented incidents where one resident with a history of mood swings and aggression physically struck other residents in the dining room. These altercations were witnessed by staff and involved the resident hitting another on the arm and slapping another on the face. Despite these incidents, the resident's care plan was not updated with new interventions, and there was no documentation of evaluation by psychiatric services following the altercations. Additionally, staff interviews and record reviews revealed that seating arrangements intended to prevent further altercations were not consistently followed, and some staff were unaware of the required seating changes. The care plan for the aggressive resident included general interventions, such as monitoring whereabouts and reporting behaviors, but lacked updates or new strategies after the incidents. Staff also expressed uncertainty about what new interventions, if any, had been implemented following the altercations, indicating a lack of communication and follow-through on care planning for residents exhibiting dementia-related behaviors.
Failure to Document Resident Altercations and Required Notifications
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurate by not documenting resident-to-resident altercations and failing to record notifications to families and physicians for four residents reviewed for abuse. Specifically, an altercation occurred between two residents with dementia/Alzheimer's disease, where one resident struck another on the arm after a verbal exchange. This incident was witnessed by a CNA and a family member, but there was no documentation of the event or of family and physician notification in either resident's medical record. The nurse responsible at the time confirmed that such documentation would typically be included in a nursing note, but it was not done in this case. A similar deficiency was found in another incident involving two additional residents with Alzheimer's disease/dementia. One resident struck another on the thigh after a verbal altercation, resulting in a visible red mark. This event was also witnessed by a CNA, but again, there was no documentation of the altercation or of family and physician notification in the medical records of the residents involved. The administrator acknowledged that a nursing note summarizing the incident and notifications should have been present, but it was not completed. The facility's own policy requires documentation of significant changes in resident condition, including behaviors and notifications, but this was not followed.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care for two residents, as required by its own policies. One resident, with multiple diagnoses including cerebral infarction, hemiplegia, and diabetes, was documented as requiring staff assistance for activities of daily living and regular incontinence checks. Despite this, there were instances where the resident was left for extended periods without being checked or changed, resulting in the resident remaining in soiled conditions. Family members reported that staff did not return to provide care after being notified, and on one occasion, a family member had to clean the resident themselves, finding dried feces and causing discomfort and skin irritation to the resident. Another resident, who was cognitively intact and required assistance with toileting, experienced significant delays in response to call lights. Observations showed that the resident's call light was on for over 20 minutes before assistance was provided, during which time the resident was left waiting to use the bathroom. The resident reported that such delays had previously caused her to be incontinent, which she found distressing. Staff confirmed that staffing levels were insufficient to meet the needs of the residents in a timely manner, particularly during busy periods such as morning care routines. The facility's policies require that call lights be answered promptly and that incontinent residents be checked at least every two hours, with perineal care provided after each episode. However, the documented events show that these policies were not consistently followed, resulting in residents experiencing prolonged periods without necessary care and assistance, and being left in uncomfortable and undignified situations.
Failure to Accurately Document PRN Opioid Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents who were prescribed as-needed Hydrocodone-Acetaminophen for severe pain. For both residents, the Controlled Drug Receipt Record/Disposition Form showed that an LPN signed out the medication, but there was no corresponding documentation on the Medication Administration Record (MAR) indicating that the medication was actually administered. The facility's guidelines require that the individual administering the medication must record the administration on the MAR immediately after giving the medication, including the date, time, dose, route, and their signature or initials. Both residents involved had complex medical histories, including chronic pain conditions and other significant diagnoses. Interviews with staff confirmed the process for signing out and documenting controlled substances, and the administrator acknowledged that the required documentation was missing from the MAR for both residents, despite the medication being signed out on the controlled drug record. This lack of documentation is not in accordance with the facility's own medication administration guidelines.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident, as evidenced by an incident involving two residents with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease. One resident, known to have a history of aggressive behaviors including screaming, cursing, and physical aggression, was observed by a CNA striking another resident in the back and verbally threatening them. The incident occurred in a common area, with the aggressor yelling at the other resident to be quiet before physically hitting them. Staff interviews confirmed that the aggressor is frequently verbally aggressive towards others and does not like other residents nearby. Following the altercation, the resident who was struck was observed crying and rubbing their arm, indicating psychosocial harm. Multiple staff members and another resident corroborated the aggressor's pattern of abusive behavior, including cursing at other residents. The facility's own Abuse Prevention and Reporting Policy prohibits such abuse, yet the incident and subsequent staff accounts demonstrate a failure to prevent and protect residents from abuse as required.
Failure to Ensure Resident Dignity and Respectful Care
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, as required by resident rights policies. Multiple residents reported and staff confirmed that a Certified Nursing Assistant (CNA) engaged in unprofessional and disrespectful behavior towards residents. One cognitively intact resident reported being intentionally hit in the stomach and described the CNA as mean, while also stating that the CNA left a former roommate to wait for an hour before attempting to use the bathroom independently. Staff assignment records confirmed the CNA worked in the relevant hallway during the reported period. Another resident, also cognitively intact, required varying levels of assistance due to a femur fracture and was not assisted with toileting as needed. A third resident with severe cognitive impairment was spoken to in an unprofessional manner by the same CNA, as witnessed by another CNA who was also the resident's Power of Attorney. The CNA in question had a documented history of disciplinary actions for unprofessional conduct, including written warnings and suspensions for inappropriate language and actions with residents and their families, as well as failure to provide necessary assistance. Staff interviews corroborated ongoing concerns about the CNA's behavior, including rough handling and lack of responsiveness to resident needs. Despite these incidents and repeated reports to facility administration, the CNA continued to provide care to the affected residents. Facility policies emphasized the importance of respectful, prompt, and professional care, but these standards were not upheld in the cited cases.
Failure to Implement Abuse Prevention and Reporting Policy
Penalty
Summary
The facility failed to implement its Abuse Prevention and Reporting Policy when an incident occurred involving one resident hitting and yelling at another resident. A Certified Nursing Assistant (CNA) reported the incident to the Administrator, but the Administrator did not notify the State Agency or conduct an investigation as required by facility policy. Additionally, there was no documentation in either resident's medical record indicating that the incident was reported to the State Agency or to the residents' representatives. Interviews confirmed that the CNA notified the Administrator of the altercation, but the residents' representatives were not informed of the event. The facility's policy requires prompt investigation and notification of both the State Agency and the residents' representatives in cases of alleged abuse. The lack of documentation and failure to follow reporting procedures resulted in the facility not meeting its own standards for abuse prevention and reporting.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident physical and verbal abuse to the state survey agency, as required by policy. Two residents with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease were involved in an incident where one resident was witnessed by a CNA hitting and yelling at another resident. The incident was reported by the CNA to the facility administrator, but no investigation was initiated, and there was no documentation of the incident in either resident's medical record. Additionally, there was no abuse investigative file created for the altercation, nor was the incident reported to the state survey agency. Multiple staff interviews confirmed knowledge of the incident, with one CNA stating they witnessed the altercation and another staff member reporting that the affected resident was visibly upset and stated they had been hit. The facility's own Abuse Prevention and Reporting Policy requires prompt investigation and reporting of all abuse allegations to the state agency and documentation of all incidents, but these steps were not followed in this case.
Failure to Thoroughly Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse involving two residents. According to the facility's Abuse, Neglect and Exploitation Policy, an immediate and comprehensive investigation is required when abuse is suspected or reported. However, the incident narrative provided was undated and incomplete, lacking critical details such as the time of the incident, the date and time of required notifications, and documentation of which staff and residents were interviewed, the results of those interviews, and the date and time of those interviews. The investigation was not documented chronologically, and there was no evidence of subsequent monitoring or assessment of the residents' psychosocial outcomes following the incident. The incident involved one resident physically hitting another in the back and verbally threatening them, as witnessed by a CNA. Nursing staff separated the residents and assessed the victim for injury. Despite these actions, the facility's documentation did not meet policy requirements for a thorough investigation, including notification of the attending physician and the resident's family or legal representative, as well as ongoing monitoring and documentation of the residents' conditions after the event.
Delayed Call Light Response Times in Facility
Penalty
Summary
The facility failed to provide timely responses to call lights for four residents, leading to significant delays in receiving necessary assistance. Residents reported waiting times of up to 45 minutes or more for staff to respond to their call lights, particularly during the afternoon and midnight shifts. This delay in response was corroborated by multiple residents, including those with cognitive impairments and those requiring substantial assistance with daily activities such as bathing and toileting. The issue was highlighted during a resident council meeting, where residents expressed ongoing dissatisfaction with the call light response times, indicating that the problem had been raised in previous meetings without resolution. Specific instances included a resident who had to wheel down the hall to find staff to assist their roommate, and another resident who experienced incontinence due to delayed assistance. The facility's call light policy mandates timely responses to residents' requests, yet the ongoing complaints suggest a failure to adhere to this policy. The facility administrator acknowledged awareness of the issue and noted that despite staff education efforts, residents continued to report delays. The activity director confirmed that call light response times had been a recurring concern in resident council meetings.
Failure to Provide Scheduled Showers and Nail Care
Penalty
Summary
The facility failed to provide scheduled showers and nail care for two residents, R206 and R45, as documented in the survey findings. R206, who has moderate cognitive impairment and requires moderate assistance with bathing, reported receiving only one shower since admission, despite being scheduled for showers twice a week. The facility's records confirmed that R206 received a shower on one occasion and had no documented refusals or alternative bed baths. Additionally, R206's nails were not trimmed, as required by the facility's shower documentation guidelines. Similarly, R45, who is cognitively intact and requires substantial assistance with bathing, reported not receiving the scheduled two showers per week. The facility's records showed that R45 received showers on specific dates but also had several refusals without being offered a bed bath. R45's nails were also not trimmed, contrary to the facility's shower documentation requirements. The Director of Nursing acknowledged the failure to provide the scheduled showers and nail care for both residents.
Failure to Supervise Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident, identified as R1, who was at risk for falls due to multiple medical conditions including Parkinson's Disease, right-sided hemiplegia, and severe cognitive impairment. R1's care plan indicated a need for supervision during meals due to these conditions. However, on the day of the incident, R1 was left alone in her room with a meal tray, which was against the care plan's directives. This lack of supervision led to R1 attempting to reach for a call light or to turn on the light, resulting in a fall and a head laceration that required sutures. Interviews with staff members, including Certified Nurse's Aides (CNAs), confirmed that R1 should not have been left unsupervised, especially during meals, due to her confusion and tendency to attempt to get up unassisted. The CNAs acknowledged that R1 required total care and assistance during meals. The facility's Administrator and Director of Nursing also verified that R1 should have been taken to the dining room for her meal to prevent such incidents. This oversight in supervision directly contributed to the fall and subsequent injury.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in injuries. The resident, who was on hospice care and diagnosed with Alzheimer's Disease, Dementia, and other conditions, was dependent on staff for all activities of daily living, including transfers. The facility's policy required the use of mechanical lifts with two caregivers for such transfers. However, a Certified Nurses Assistant (CNA) improperly transferred the resident alone, leading to the resident being hit in the shoulder by the lift equipment, causing a hematoma, and the resident's foot becoming caught in the geriatric chair, resulting in a fracture. The facility's investigation revealed that the CNA admitted to transferring the resident without assistance, contrary to the facility's policy. The incident was observed when the resident exhibited signs of pain and decreased range of motion, and a bruise was noted on the shoulder. The resident was later diagnosed with a distal femoral fracture. The CNA involved was suspended pending investigation and subsequently quit. Interviews with other staff members confirmed that the CNA did not receive assistance during the transfer, despite the facility having adequate staff and emphasizing the importance of safe transfer practices.
Failure to Monitor and Adjust Anticoagulant Therapy Leads to Resident's Death
Penalty
Summary
The facility failed to adhere to physician orders for a resident's anticoagulant medication, Warfarin, resulting in the resident receiving an incorrect dosage for 24 days. The resident was supposed to have their Warfarin dosage decreased from 3mg to 2.5mg, but this adjustment was not made. Additionally, the facility did not conduct the necessary PT/INR tests to monitor the resident's blood clotting time as recommended by the drug manufacturer guidelines. This oversight led to the resident's PT/INR levels reaching critical levels, causing internal bleeding. The resident, who had a complex medical history including conditions such as Transient Cerebral Ischemic Attack, Non-Rheumatic Aortic Valve Stenosis, and the presence of a prosthetic heart valve, was at significant risk due to the facility's failure to monitor and adjust the anticoagulant therapy appropriately. The resident's PT/INR levels were consistently out of range, and despite this, the facility continued to administer the incorrect dosage of Warfarin. The lack of proper monitoring and adjustment of the medication dosage resulted in the resident experiencing Warfarin toxicity. Ultimately, the resident was sent to the hospital with Warfarin toxicity and was admitted with lethal bleeding. The hospital notes indicated severe complications, including a left hemothorax and alveolar hemorrhage. The resident's condition deteriorated, leading to their death, which was documented as being caused by cardiopulmonary arrest with acute respiratory failure and a left hemothorax. Interviews with facility staff, including the Director of Nursing and the Medical Director, confirmed that the facility did not follow the correct Warfarin order and failed to monitor the resident's labs as required.
Removal Plan
- All licensed and direct care staff was educated on Administration Procedures for All Medications including but not limited to: medications are administered in accordance with physician order, and physician notification including monitoring and adverse reactions.
- All licensed and direct care staff was educated on referencing and following drug manufacturing guidelines for monitoring of drug side effects, labs, and possible adverse reactions.
- All licensed staff was educated on utilizing the Coumadin Tracking Log to ensure medication dosage, order, and follow-up PT/INR are reviewed and to ensure physician's orders are carried out.
- All licensed and direct care staff was educated on anticoagulant administration, effects, precautions, and monitoring.
- All licensed staff was educated on the facility process to monitor/review/follow-up/coordinate and administer safe use of anticoagulant medications.
- An impromptu QAPI meeting was held with the medical director and staff IDT to discuss deficiency and facility action plan.
- The facility will audit the Coumadin Tracking Log and review resident charts to ensure anticoagulant medication orders were followed, monitoring for anticoagulant side effects, the physician was notified of changes in condition(s) of residents, and that abnormal lab results were reported to the physician. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
- The facility will audit all residents currently receiving an anticoagulant to ensure physician orders are being followed, and monitoring is in place including monitoring side effects, labs, and adverse reactions. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
- Nursing Management will audit all newly admitted and readmitted residents to ensure residents receiving anticoagulant medication are being monitored for side effects and adverse reactions, laboratory orders are in place, and the physician is notified of any change in condition. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
Failure to Address Medication Errors in Quality Improvement Program
Penalty
Summary
The facility failed to implement a quality improvement program to address significant medication errors, resulting in harm to a resident. The Quality Assurance Performance Improvement Program Policy required monitoring and evaluation of resident care, including medication errors, but this was not effectively executed. A resident was prescribed Plavix, an anticoagulant, but was instead administered Warfarin, leading to critical PT and INR levels. Despite physician orders to adjust the Warfarin dosage and conduct follow-up PT/INR tests, the facility continued administering an incorrect dosage for 24 days without conducting the necessary tests. The resident was eventually transferred to a hospital with symptoms of Warfarin toxicity, including internal bleeding, and later died due to a left hemothorax. The facility's quality committee minutes did not reflect any discussion of medication errors, and key personnel, including the Medical Director and Consulting Pharmacist, were unaware of the medication error until after the incident. This lack of communication and failure to address medication errors in quality meetings contributed to the deficiency.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights in a timely manner for five out of twelve residents reviewed for call light responsiveness. This deficiency was identified through interviews and record reviews, revealing that residents experienced significant delays in receiving assistance after activating their call lights. Resident Council Meetings held on three separate dates documented ongoing concerns about prolonged call light wait times across all shifts, with reports of waits lasting nearly an hour during the second shift. On a specific date, multiple residents expressed their frustrations, citing staff shortages and busy schedules as reasons for the delays. The Resident Council President confirmed that long wait times for call lights were a frequent topic of discussion in council meetings.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve meals at an appropriate or palatable temperature, affecting nine residents out of the 17 reviewed for food. The policy titled In-Room Dining, dated 2020, states that meals served in rooms should be periodically checked for palatable food temperatures, with hot foods preferred to be at 120 degrees Fahrenheit or greater. However, observations revealed that meal trays were delivered uncovered to the assisted dining room, and residents were left without assistance to eat. Dietary staff distributed trays to residents, but there was a delay in assistance from Certified Nursing Assistants (CNAs), leading to meals sitting uncovered and potentially cooling down before consumption. Interviews with staff and residents highlighted issues with meal service timing and staffing shortages. A dietary aide mentioned that food carts might sit for 20 minutes waiting for CNAs to pass them, and there were instances of delayed meal service due to insufficient staff. Residents reported receiving cold food and experiencing delays in being served, with some waiting over an hour in the dining room. The Dietary Manager acknowledged that food could sit if staff were not ready to serve and admitted to multiple cold food complaints in the past, indicating a recurring issue with meal temperature and service timeliness.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for a resident who is dependent on staff for bathing. The resident, who is cognitively intact, reported that showers or bed baths are supposed to occur twice a week but sometimes do not happen due to staff being too busy or understaffed. The resident's showers were scheduled for Mondays and Thursdays, but the resident did not receive a shower on a recent Monday. Documentation provided by the Director of Nursing confirmed that there were no recorded showers for the resident in July 2024 and gaps in June 2024, including a period from June 14 to June 19 and June 21 to June 26. The facility's policy requires showers to be offered twice weekly or according to the resident's preference, with documentation in the electronic record, which was not adhered to in this case.
Abuse and Neglect by Agency CNAs
Penalty
Summary
The facility failed to protect residents from mental and physical abuse by staff, specifically involving two agency Certified Nurse Aides (CNAs), V13 and V14. Resident R3 reported that these CNAs were rude and did not listen to her care instructions, causing her physical pain and mental distress. The CNAs ignored R3's request to use a lift to get to the commode, instead rolling her roughly in bed, which exacerbated her existing leg pain. This incident left R3 feeling scared and unsafe, resulting in her urinating in bed out of fear. Multiple staff members, including a Registered Nurse (RN) and a Social Service Director (SSD), confirmed R3's distress, noting her crying and the rough treatment she described. Resident R2 also reported abuse by the same CNAs, stating that they were rude and did not accommodate her physical limitations due to arthritis. R2 was unable to wash her face as instructed by the CNAs, who were dismissive of her condition. Later, the CNAs allegedly handled R2 roughly while transferring her to bed, causing her pain and fear. R2 expressed feeling scared and requested that the CNAs not return to her room. An LPN corroborated R2's account, noting that R2 was yelling and visibly upset after the CNAs' visit. The facility's administrator acknowledged the incidents, confirming that both R2 and R3 experienced physical and mental abuse by the CNAs. The report highlights the failure of the facility to ensure residents' rights to be free from abuse, as outlined in their policy. The incidents involving R2 and R3 were part of a broader issue affecting the facility's ability to provide a safe and respectful environment for its residents.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to notify the Administrator and the State Agency in a timely manner regarding allegations of staff-to-resident abuse involving two residents. The facility's policy on 'Abuse, Neglect and Misappropriation of Resident Property' mandates immediate reporting of any suspected abuse to the Administrator, who is then responsible for notifying the State Agency. However, this protocol was not followed when two residents, who were cognitively intact and dependent on staff for various activities of daily living, reported that two agency CNAs were rude and did not listen to their care instructions. One resident expressed that the CNAs twisted her leg, treated her poorly, and made her wet the bed, causing her distress. Despite being informed of the residents' complaints, the Registered Nurse and LPN involved did not immediately report the allegations to the Administrator. The RN delayed reporting until later in the morning, and the LPN, despite being aware of the abuse prevention policy, did not take immediate action due to other ongoing tasks. The Director of Nursing was also not informed of the abuse allegations when initially contacted about scheduling issues related to the CNAs. The Administrator acknowledged that the CNAs were asked to leave due to their behavior but did not report the incidents to the State Agency as abuse, despite staff having been inserviced on the abuse prevention policy.
Failure to Suspend Alleged Abusers Immediately
Penalty
Summary
The facility failed to adhere to its abuse policy by not immediately suspending two agency Certified Nurse Aides (CNAs), V13 and V14, after allegations of mental and physical abuse were made by a resident, R3. Despite R3's report of being mistreated and hurt by these CNAs, they were allowed to continue working and had access to other residents, including R2 and R6, before being removed from the premises. This delay in action exposed other residents to potential harm and violated the facility's policy, which mandates the immediate removal of staff involved in abuse allegations. R3, who is cognitively intact, reported that the CNAs were mean, made her cry, and caused pain in her leg. R2, also cognitively intact and dependent on staff for various activities, alleged physical abuse by the same CNAs, stating they were rough and caused her pain. Despite these allegations, there was no immediate skin assessment or protective measures taken for R2 and R3. Additionally, R6, who is severely cognitively impaired and requires assistance for mobility, also reported negative interactions with the CNAs, describing them as rude and unprofessional. The facility's failure to act promptly on the abuse allegations was compounded by the lack of documentation of abuse training for the CNAs involved. The Human Resources Director could not provide evidence of abuse training for V13 and V14, highlighting a gap in compliance with training requirements. The facility's inaction and inadequate response to the abuse allegations put all residents at risk and demonstrated a significant lapse in following established protocols for handling such incidents.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to its staff, which has the potential to affect all 60 residents residing in the facility. The facility's assessment, dated January 2024, indicated that QAPI training would be provided annually for all staff. However, during an interview on July 3, 2024, a Certified Nurse Aide (CNA) with over eight years of experience at the facility stated they had never heard of QAPI training and that the facility had not communicated about it. Additionally, the facility administrator confirmed that the facility had not provided ongoing annual QAPI training and was unable to provide documentation of such training for the past year.
Failure to Provide Ethics Training
Penalty
Summary
The facility failed to provide staff with required Ethics training, which has the potential to affect all 60 residents residing in the facility. The facility's assessment indicated that Ethics training should be provided annually to all staff. However, during interviews, a Certified Nurse Aide (CNA) who has worked at the facility for over eight years stated that they had never heard of Ethics training and that the facility does not discuss it with staff. Additionally, the facility's Administrator confirmed that the facility has not provided ongoing annual Ethics training and was unable to provide documentation of such training for the past year.
Failure to Ensure Continued Competency for Nurse Aides
Penalty
Summary
The facility failed to ensure continued competency for nurse aides by not providing at least twelve hours of in-service training per year, including dementia management and resident abuse prevention training. This deficiency was identified for four nurse aides, which has the potential to affect all 60 residents residing in the facility. The facility's Facility Assessment Tool requires that all new employees complete an orientation program covering abuse, neglect, and exploitation, and that Certified Nurse Assistants receive the mandated training. However, during interviews, the Administrator and Human Resources staff admitted to not having logs of staff training for abuse or dementia training for the past year, indicating a lack of documentation and oversight in ensuring compliance with training requirements.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical abuse by another resident. This deficiency affected two residents, R1 and R2. R1, who is diagnosed with Alzheimer's Disease, Depression, Dementia, and Anxiety, wandered into R2's room uninvited. R2, who is diagnosed with Hemiplegia, Hemiparesis, Depression, and Anxiety, asked R1 to leave, but R1 refused. As R2 attempted to move around R1's wheelchair, R1 hit R2, causing a skin tear. In retaliation, R2 hit R1 back. Staff intervened and separated the two residents after R2 called for help. The incident resulted in R2 sustaining a skin tear on her right hand and left lower leg. The facility's administrator confirmed the physical altercation and acknowledged that R1 should not have been in R2's room. R1's care plan indicated that she is an elopement risk and tends to wander into other residents' rooms, with staff instructed to distract her with diversional activities and encourage her to stay in common areas. R2's care plan noted that she speaks loudly when upset and has been known to throw things. Both residents were identified as being at risk for abuse due to their respective conditions. Despite these care plans, the facility failed to prevent the altercation, resulting in physical harm to R2.
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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