Graham Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Illinois.
- Location
- 210 West Walnut Street, Canton, Illinois 61520
- CMS Provider Number
- 145572
- Inspections on file
- 18
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Graham Hospital during CMS and state inspections, most recent first.
Failure to implement ordered pressure relief and update the care plan led to facility-acquired pressure injuries. A cognitively intact resident who was dependent for care had a stage II pressure injury to the right gluteus and a stage IV pressure ulcer to the right big toe/foot. The care plan did not include current pressure-relieving interventions, charting showed prolonged sitting without repositioning, and the resident was observed without heel protectors despite orders for turning/repositioning q2h and heel protectors at all times.
Care plans were not individualized to reflect each resident's specific needs, conditions, and preferences. The DON stated he was responsible for initiating and revising care plans for all residents, but the facility's EMR could not customize interventions for individual residents. He confirmed that all 21 residents had care plans based on diagnoses, but individualized interventions were not reflected.
Unsafe Food Handling and Cross-Contamination During Meal Prep: A cook was observed cleaning food prep areas with a wash rag while food on the steam table remained uncovered, then using the same rag to clean a food thermometer and handle food-related items. The cook did not perform hand hygiene or wear gloves, and the Dietary Supervisor and DON confirmed staff are expected to use hand hygiene, gloves, and clean thermometers between uses; the DON also stated the facility had no policy to guide proper food temperature checks.
The facility failed to maintain an effective infection prevention and control program by not tracking resident and staff illnesses or distinguishing facility-acquired from community-acquired infections. The Infection Control Nurse said employee illness was not being tracked, and the resident infection log did not consistently identify infection source or include all illnesses. The facility also failed to use EBP during incontinent care for a resident with an indwelling catheter and wounds, as two CNAs wore gloves but no gowns while providing direct care.
The facility failed to ensure the designated Infection Preventionist completed required IPC training before serving in the role. The Administrator stated there was no certification of completion on file, and the Infection Control Nurse said she had been serving as the Infection Preventionist since July 2025 but had not finished the required modules or received certification. The facility’s CMS Form 671 documented 21 residents in the facility.
A resident with severe cognitive impairment and an indwelling urinary catheter had her drainage bag left uncovered and visible from the room doorway while she sat in a recliner with the door open. The bag was hanging on the side of the bed facing the door and was partially filled with yellow urine. The Administrator stated the bag should be covered with a dignity bag if it could be seen from the room.
Inaccurate MDS coding was found for two residents in Section P. Both residents had physician orders for bilateral upper side rails for positioning and bed mobility, but their MDS assessments coded the side rails as daily restraints. The DON stated the side rails were used for positioning and were not restraints, and the MDS Coordinator confirmed the coding was inappropriate and reported no formal training in Section P coding.
A resident with severe cognitive impairment and stroke-related right-sided deficits had documented ROM limitations and impaired mobility, but the care plan did not include any restorative program to address these needs. The resident was observed with a flaccid right arm and leg, a private caregiver reported staff never performed ROM, and the DON stated the resident received no restoratives or ROM exercises and the facility had no restorative nurse to assess or establish such programs.
Failure to Assess Bed Rail Entrapment Risk: The facility failed to complete a bed rail assessment to identify entrapment risk and failed to document alternatives tried before installing bilateral upper rails for a resident with anxiety/depression, hx of CVA, and generalized weakness. The resident was moderately cognitively impaired, dependent for rolling and transfers, and had quarter side rails in place; the DON confirmed no bed rail assessment or documented alternatives had been completed before the rails were used.
The facility failed to use temperature testing strips for dishwashing, maintain cleanliness of kitchen light covers, and record cool down temperatures for prepared meats, potentially affecting all 22 residents. The Dietary Manager admitted to not using test strips or maintaining cool down logs, and the Director of Plant Operations confirmed the lights were not cleaned by the contracted company.
The facility failed to implement restorative programs for several residents with range of motion limitations due to a lack of a restorative aide. Residents and family members reported not receiving prescribed exercises, and documentation was missing for extended periods. The Director of Nursing confirmed the absence of restorative programs, contributing to the deficiency.
A facility failed to refer a resident for a Level II PASRR evaluation after the resident exhibited new behavioral symptoms and was prescribed Zyprexa for Refractory Depression with Psychotic Symptoms. Despite the facility's policy requiring such referrals for significant changes in condition, no referral was made, and the administrator admitted to not requesting the necessary evaluation.
Failure to Implement Pressure Relief and Update Care Plan
Penalty
Summary
The facility failed to implement physician-ordered pressure relieving interventions for a resident who was cognitively intact, dependent on staff for toileting, rolling left and right, and personal hygiene, and identified as at risk for pressure ulcers. The resident’s most recent MDS documented a stage II facility-acquired pressure ulcer and that the resident was on a turning and repositioning program. The facility’s wound prevention policy required interventions to reduce pressure, maintain skin integrity, and incorporate prevention measures into the plan of care. Record review showed the resident’s care plan, active since 7/20/25, identified high risk for impaired skin integrity but did not include pressure relieving interventions to prevent pressure ulcers or interventions to address the resident’s current pressure ulcers to the right gluteus and right foot. Wound clinic notes documented a stage two pressure injury to the right gluteus with a date acquired of 7/29/25 and a stage four pressure ulcer to the right foot/base of the big toe with a date acquired of 10/20/25. The right foot wound had necrotic tissue and eschar and required open wound debridement. Off-loading orders included a pressure relieving cushion to the wheelchair, turning and repositioning every two hours, and heel protectors at all times. Electronic charting showed the resident remained in the same seated position in a chair for prolonged periods on 3/30/26 and 3/31/26, with no documentation that the resident refused repositioning. During those same timeframes, the resident was observed seated in a padded wheelchair with bilateral heels resting on the footrests and was not wearing heel protector boots. Later, the resident was lying on the right side in bed without heel protectors. The DON stated the resident had a physician’s order to be turned and repositioned every two hours, that turning and repositioning every two hours was the facility’s standard, and that the care plan did not include pressure relieving interventions or current interventions for the wounds. The wound nurse practitioner confirmed the resident had orders for turning and repositioning every two hours and heel protector boots at all times, and confirmed the right gluteus and right big toe wounds were caused by pressure and were facility acquired.
Care Plans Not Individualized
Penalty
Summary
The facility failed to ensure residents' comprehensive care plans were individualized to reflect each resident's specific needs, conditions, and preferences. The facility's Care Plan Policy revised 3/10/25 states the individualized care plan is used to outline the care patients shall receive during their stay, with goals that are realistic, individualized, patient centered, measurable, dated, and reviewed daily. The Patient/Resident Care Plan and Care Conference policy revised September 2025 states residents shall have an individualized care plan. The CMS Form 671 dated 3/30/26 and signed by the Administrator documented 21 residents in the facility. During interview on 4/01/2026, the DON stated he was responsible for initiating and revising care plans for all residents and that he develops comprehensive care plans based on resident diagnoses and revises them as new diagnoses are identified. He further stated he did not have the capability within the facility's EMR system to customize interventions for individual residents and planned to eventually switch to a new system better suited for LTC. The DON confirmed that all 21 residents currently residing in the facility did not have individualized interventions reflected in their care plans.
Unsafe Food Handling and Cross-Contamination During Meal Preparation
Penalty
Summary
Sanitary conditions were not maintained during food preparation and service when a cook was observed cleaning main food preparation areas with a wash rag while food on the steam table remained uncovered. The same wash rag was then placed on the counter and used to clean a food thermometer between temperature checks of food on the steam table. During the observation, the cook also wiped sauce from the lasagna with her fingers onto the same wash rag used to clean the counters and thermometer. When checking hamburger temperatures, the initial holding temperature was 142 F, and the cook stated the hamburgers would be returned to the steamer for reheating. The cook handled the pan using the same contaminated wash rag and placed the rag back on the counter. At no time during the observation did the cook perform hand hygiene or don gloves, and the same wash rag continued to be used for cleaning surfaces and the thermometer throughout food handling activities. The Dietary Supervisor stated staff are expected to perform hand hygiene and wear gloves when handling food, and thermometers should be cleaned between uses with an alcohol swab. The Dietary Director stated that if a wash rag is used for cleaning a thermometer, it should be clean and used for a single purpose only, and confirmed the cook should have performed hand hygiene, worn gloves, and not used the same rag for multiple tasks. The Dietary Director also stated the facility does not have a policy or procedure to guide staff on proper techniques for obtaining food temperatures.
Infection Control Surveillance and Enhanced Barrier Precautions Failures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not performing surveillance to track and monitor resident and staff illnesses and by not differentiating between resident facility-acquired and community-acquired infections. The Infection and Prevention Control Program Plan stated that surveillance of infections, both community acquired and healthcare acquired, would be conducted, and the Infection Prevention Surveillance Policy required review of data sources such as elevated temperatures, respiratory difficulty, wounds, diarrhea, and rash, with collected data recorded and tabulated by site and other factors. However, review of the infection control surveillance logs from January 1, 2026 through March 31, 2026 showed no tracking log of resident illnesses or employee illnesses and no identification of whether resident illnesses were facility-acquired or community acquired. During interview, the Infection Control Nurse stated she had not been tracking employee illness since starting the position in July 2025 and said she had been told not to track employee illnesses because the facility was not allowed to ask why staff called in. She also verified that although an antibiotic tracking log was maintained for residents each month, it did not consistently specify whether an infection was house-acquired or community acquired and did not include a comprehensive record of all resident illnesses other than infections treated with an antibiotic. The facility's Investigation Protocol for Infection Surveillance also stated that the hospital shall investigate infections and determine whether staff are well and have no contagious symptoms present. The facility also failed to implement Enhanced Barrier Precautions while providing incontinent care for a resident who had an order for Enhanced Barrier Precautions, an indwelling urinary catheter, and wounds to the right foot and right gluteus. The resident had a sign on the doorway indicating Enhanced Barrier Precautions. While two CNAs were providing incontinent care to the resident, both wore gloves but did not wear gowns. One CNA stated they did not have time to put on gowns, and the Infection Control Nurse later stated that all employees providing direct care to any resident placed in Enhanced Barrier Precautions should be wearing gowns and gloves while providing direct care.
Infection Preventionist Lacked Required IPC Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist completed specialized Infection Prevention and Control (IPC) training before performing the role. The facility’s Infection and Prevention Control Program Plan, dated March 2024, states that the Infection Control Professional is a registered nurse with knowledge of epidemiology practices, microbiology, and infectious disease who has completed or shall complete a course in infection control approved by the CDC and directs the Infection Control Program. During interview, the Administrator stated that the Infection Control Nurse had not completed IPC training to her knowledge and could not provide a certification of completion. The Infection Control Nurse stated that she had been the Infection Preventionist since July 2025 and had not yet completed the required training, explaining that she had started some infection control modules but did not finish them all and therefore never received a certification of completion. The facility’s CMS Form 671 dated 3/30/26 documented that 21 residents resided in the facility.
Uncovered urinary catheter bag observed in resident room
Penalty
Summary
The facility failed to ensure a resident's indwelling urinary catheter drainage bag was covered to maintain dignity for one resident reviewed for dignity. The resident, who was severely cognitively impaired and had an indwelling catheter, had physician orders for the catheter in place. During observation, the resident was sitting in a recliner in her room with the door open, and her urinary catheter drainage bag was seen hanging on the side of her bed facing the door without a dignity bag covering it. The bag was one fourth full of yellow urine. The Administrator later stated the catheter bag should be covered with a dignity bag if it could be seen from the resident's room and acknowledged uncertainty as to why the resident did not have a privacy bag covering the catheter bag.
Inaccurate MDS Coding for Side Rail Restraints
Penalty
Summary
The facility failed to accurately code the MDS assessments for two residents, R5 and R8, in Section P regarding restraints and alarms. CMS RAI Manual Section P states that assessors must record only devices that meet the definition of a physical restraint or alarm during the seven-day look-back period. R8’s physician order documented bilateral upper side rails for positioning and bed mobility, and her MDS coded the side rails as a daily restraint even though, during interview, she stated she used the side rails to position herself in bed and that they did not restrain her. R5’s physician orders also documented bilateral upper side rails for positioning and bed mobility, yet her MDS likewise coded side rails as a daily restraint. The DON stated that R5 and R8 used side rails for positioning and that the side rails were not being utilized as restraints. The MDS Coordinator stated she had not received formal training regarding coding Section P and confirmed that R5 and R8 did not use side rails as restraints, and that their Section P assessments were inappropriately coded.
Failure to Provide Restorative ROM Program for Resident with Stroke-Related Impairment
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason, was not met for one resident with impaired mobility and ROM limitations. The facility’s Restorative Range of Motion Policy states the program is intended to maintain and improve joint mobility, prevent contractures, pain, and edema, and maintain or improve ROM for extremities with decreased ability and movement. The policy also states a restorative nurse is to conduct the program on a one-to-one basis, and a physician’s order is required for establishing treatment. R6’s MDS documented severe cognitive impairment, functional limitations in ROM to one upper extremity and one lower extremity, dependence on staff for ADLs, and no restorative nursing programs, including ROM programs. The care plan identified CVA with right-sided sensory deficit and impaired mobility, including compromised ability to move, ROM limitation, decreased muscle strength, impaired coordination, imposed restriction of movement, and reluctance to move, but it did not include any restorative programs to address the impaired mobility. During observation, R6’s right arm and right leg were flaccid, and an agency RN stated R6 had a stroke and was unable to move the right arm or right leg. The private caregiver stated staff had never been seen doing ROM with R6, and the DON stated R6 did not receive any restoratives or ROM exercises and that the facility did not have a restorative nurse to assess or establish restorative programs.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to assess and identify entrapment risk associated with the use of side rails and failed to document alternatives to side rails with outcomes before installing side rails for one resident reviewed in a sample of 21. The facility’s Side Rails and Entrapment Policy, dated February 2026, states that individual bed rail evaluations should include data collection, analysis, and determination of potential alternatives to bed rail use, and that residents or representatives should be educated on the risks and benefits when bed rails are deemed necessary and appropriate. The resident had diagnoses including anxiety with depression, history of completed stroke, general weakness, fall downstairs, strain of left elbow, and neck muscle strain. Physician orders dated 3/30/26 documented bilateral upper rails starting 3/16/26 for positioning, bed mobility, getting in and out of bed, and spatial awareness. The MDS dated 3/18/26 documented that the resident was moderately cognitively impaired, required dependent assistance with rolling side to side and transfers, and used side rails daily. The medical record did not include a side rail assessment for entrapment risk or documentation of alternatives tried before side rails were implemented. During observation on 3/30/26, the resident’s bed had bilateral quarter side rails in the upright position, and the DON verified that a bed rail assessment and documented alternatives had not been completed prior to implementation.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety protocols in several areas, which could potentially affect all 22 residents. Firstly, the facility did not use temperature testing strips to ensure that dishes reached the required surface temperature during the rinse cycle in the dish machine. The Dietary Manager acknowledged that while the dishwasher is a high-temperature machine, the staff only checked the temperature using the gauge on the machine and had stopped using the test strips, which are essential for verifying the correct surface temperature. Additionally, the facility did not maintain cleanliness in the kitchen, specifically with the hanging light covers over the fryer baskets, which were found to be coated with grease and grime. The Dietary Manager was unsure who was responsible for cleaning these lights, and the Director of Plant Operations confirmed that the contracted cleaning company did not include these lights in their cleaning process. Furthermore, the facility did not complete and record cool down temperatures for prepared meats and leftover items stored in the refrigerator and freezer. The Dietary Manager admitted that they did not keep a cool down log for hot foods, which is a deviation from the facility's policy that requires monitoring and recording of cooling temperatures to ensure food safety.
Failure to Implement Restorative Programs for Residents
Penalty
Summary
The facility failed to develop and implement restorative programming for several residents with limitations in range of motion. Specifically, five residents were identified as not receiving the necessary range of motion exercises as outlined in their care plans. For instance, one resident with impaired mobility due to Parkinsonism and a past hip fracture did not receive the prescribed range of motion exercises for 53 days. Another resident, who is cognitively intact and has impairments in both lower extremities, reported not receiving daily exercises despite the care plan's requirement for twice-daily exercises. The facility's lack of a restorative aide contributed significantly to the deficiency. The Director of Nursing acknowledged that the facility had not had a restorative aide for some time, and the recently hired aide quit during orientation. This staffing issue resulted in the failure to complete restorative programs for residents, as evidenced by the absence of documentation for several residents over extended periods. One resident's care plan did not even include interventions to address their limitations in range of motion, highlighting a gap in care planning. Family members and residents themselves expressed concerns about the lack of restorative exercises. A family member of one resident noted never witnessing staff perform range of motion exercises, while another resident expressed a desire for more exercise to improve mobility. The facility's reliance on the restorative aide job description as the policy for performing restorative programs was insufficient to ensure the necessary care was provided, leading to the identified deficiencies.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident to the PASRR State Agency for a Level II PASRR evaluation after the resident experienced a significant change in behavioral and psychiatric symptoms. The resident, who was being reviewed for mental illness, began exhibiting new symptoms such as delusions of dust being present on her face, ears, and other objects, which led to her being prescribed Zyprexa for Refractory Depression with Psychotic Symptoms. Despite these changes, the facility did not initiate a Level II PASRR referral as required by their policy. The facility's policy mandates that any resident with a decline or worsening in behavioral health conditions should be referred to the state agency for a Level II PASRR evaluation. However, the resident's medical record showed no evidence of such a referral being made after the onset of new symptoms and the prescription of an anti-psychotic medication. The facility administrator acknowledged the oversight, stating that a Level II PASRR had not been requested for the resident since the new behaviors and medication were introduced.
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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