Haven Of Champaign
Inspection history, citations, penalties and survey trends for this long-term care facility in Champaign, Illinois.
- Location
- 1315 Curt Drive, Suite B, Champaign, Illinois 61821
- CMS Provider Number
- 146017
- Inspections on file
- 43
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Haven Of Champaign during CMS and state inspections, most recent first.
A cognitively impaired resident slipped while being showered by a CNA, who reported catching the resident and did not initially observe a head impact. Another CNA assisted with transfers and later, along with the first CNA, noticed a small amount of blood on the resident’s head while grooming in the room and notified an LPN. The LPN observed minimal bleeding and sent the resident to the hospital, where the resident received staples for a head laceration. Facility documentation later indicated the resident had exhibited behaviors during the shower and bumped the head on the shower room wall, causing a laceration. Despite a facility policy requiring structured neuro checks for 72 hours after any head injury, the ADON confirmed that neurological assessments were not performed because the resident was sent to the hospital and were not initiated when the resident returned the same day.
Missing Food and Refrigeration Temperature Documentation: The facility failed to document food service line temperatures before meal service and failed to maintain complete refrigerator and freezer temperature logs. An LPN confirmed multiple meal temperatures were not recorded, and the Dietary Mgr confirmed staff should be monitoring and documenting food and refrigeration temperatures as required by policy. The logs were incomplete for several meals and several days, and the facility census was 50 residents.
Unpalatable and Tough Meal Service: Multiple residents reported that roast pork served at lunch was dry, tough, and difficult or impossible to chew, while vegetables were pale, mushy, watery, and bland. A cognitively intact resident, a mildly cognitively impaired resident without teeth, and other alert residents all described the food as cold or undesirable, and a regional nurse verified the meat was tough and the vegetables were mushy and pale.
Failure to Provide Dignified, Respectful Care: Three cognitively intact residents who needed staff help with showers, hygiene, transfers, and toileting reported that staff were rushed, disinterested, and made them feel like a burden rather than a person. One resident said showers were not thorough, she was not fully dried before dressing, and soiled bedding was sometimes left in place; observations also found soiled linens on the bed. Another resident reported staff and housekeeping did not take time to provide thorough care or cleaning, and the DON confirmed care should be delivered at the resident's pace with attention to residents' needs and feelings.
A resident with aphasia, right-sided hemiplegia/hemiparesis, dysphagia, and severe cognitive impairment was observed eating breakfast with his fingers while lying in bed, with no utensils on the tray. The resident’s family member stated the resident had difficulty using utensils after a stroke and believed the facility had not done much to help him maintain regained abilities. Records showed he required partial to moderate staff assistance with eating, and staff stated he was a hand eater and was given finger foods, but documentation of restorative program participation was not available.
Failure to assess and monitor psychotropic meds and follow a GDR order. A resident on Seroquel had no baseline assessment, and staff acknowledged a repeated behavior was not being tracked or tied to an intervention. Another resident on Lurasidone did not receive required quarterly psychotropic reviews, and a third resident’s pharmacist-recommended Mirtazapine dose reduction was not communicated to the MD/psychiatrist by the LPN/MDS Coordinator or DON.
A resident with moderate hearing loss had no care plan interventions to support communication, despite being alert and oriented and reporting that he could not hear well and did not have a hearing aid. Staff confirmed they only spoke louder or repeated themselves, no alternative communication devices were used, and the MDS Coordinator stated she was never asked to create a care plan for sensory impairments.
A resident with moderate hearing loss was not provided a care plan intervention or alternative communication support to help him communicate effectively. He reported he could not hear, did not have a hearing aid, and said he had asked the facility for one but did not know what happened with the appointment. Staff confirmed he was hard of hearing, had no hearing aid, and that they only spoke louder or repeated themselves; no alternative communication devices were available, and paper and pen were needed to communicate.
Failure to Follow Oxygen Orders and Monitor Oxygen Therapy: Three residents had oxygen-related care that did not match orders or care plans. One resident received O2 at a higher flow than ordered without a physician order, another was observed with an empty portable O2 tank despite orders for continuous oxygen, and a third was repeatedly found lying flat while receiving oxygen at higher-than-ordered flow rates, with an empty humidification canister noted. Staff stated the resident’s oxygen was sometimes turned up because of SOB and that oxygen tanks should be monitored and replaced before becoming empty.
Failure to maintain EBP for a resident with open wounds. A cognitively intact resident with multiple diagnoses, including PVD, CKD III, CHF, COPD, and an unstageable pressure ulcer on the left heel, had no EBP sign posted, no PPE available in or near the room, and no dirty linen or red trash container observed. The resident denied that staff wore gowns or gloves during daily wound care, and the DON and ADON/IP confirmed the resident should have been on EBP but precautions were not in place.
Failure to Track Antibiotic Use and Document Criteria for Antibiotic Initiation: The facility did not complete infection surveillance documentation or verify that a resident met criteria for starting an antibiotic. A cognitively intact resident with multiple chronic conditions and wounds received Bactrim for a wound infection and later sulfamethoxazole-trimethoprim after hospitalization for a ruptured scrotal abscess, but the resident was missed on infection tracking, no McGeer Criteria or other antibiotic stewardship assessment was found, and no cultures were documented.
The facility did not provide RN coverage for at least eight consecutive hours on one day, as required, when the scheduled RN called off and the DON did not cover the shift. This affected all 50 residents present in the facility.
A resident with multiple chronic conditions experienced increased pain and swelling after a fall from a sit-to-stand lift, which limited her ability to perform daily activities and participate in social events. Despite physician orders for increased pain medication and a care plan addressing pain management, the facility did not effectively manage her pain according to these directives or the resident's preferences, resulting in a decline in her functional abilities.
A resident with significant physical debility and hand weakness was transferred by a CNA using a sit-to-stand mechanical lift without the required safety belt and without a second staff member present. The resident, unable to maintain her grip, fell during the transfer. Facility policy mandates two trained staff and use of the safety belt for such transfers, but these protocols were not followed.
A resident with multiple chronic conditions and recent injury did not receive her physician-ordered Norco for several days because the facility failed to maintain an adequate supply. The resident reported ongoing pain, and staff confirmed the medication had run out and was not reordered in time, resulting in a lapse in pain management.
The facility failed to respect residents' dignity and ensure timely response to call lights, leading to distress among residents. Incidents included staff dismissing residents' requests, leaving a resident on the floor for over an hour, and causing emotional distress through rude behavior. Despite documented concerns, the Administrator was unaware of specific issues, indicating a lack of communication and follow-up.
The facility failed to follow up on and document actions for grievances reported by residents, affecting all 51 residents. Despite policies requiring documentation and resolution of grievances, the facility's Grievance Log only recorded a few follow-up actions. Residents reported ongoing issues with call light wait times, late medications, and missing items, and were unsure of the grievance process. Staff confirmed medication administration delays and acknowledged repeated issues without proper documentation of follow-up actions.
The facility did not employ a full-time DON and failed to provide RN services for eight consecutive hours daily. This issue persisted over several days, with the facility lacking RN coverage on specific dates. The absence of a full-time DON since early February was confirmed by the Assistant DON and the Administrator.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 51 residents. The Dietary Manager, supervising dietary operations, lacks a valid Food Safety/Dietary Manager Certificate, which expired over a year ago. The facility's assessment requires a full-time dietician or qualified nutrition professional for daily and emergency support.
The facility failed to ensure that dietary aides had the necessary training and food handler's certificates, as required by Illinois law, potentially affecting all 51 residents. Observations showed aides preparing and distributing meals without proper certification, confirmed by the Dietary Manager and acknowledged by the Administrator.
The facility failed to annually implement and evaluate a performance improvement plan, affecting all 51 residents. The QAPI Plan requires annual self-assessment and prioritization of activities, but there was no evidence of follow-up or evaluation of interventions in the PIPs for skin care and showers. The administrator, new to the role, could not find documentation of implementation or evaluation, citing the former administrator's practice of discarding records.
The facility did not hold the required quarterly Quality Assurance meetings, as outlined in their QAPI Plan, since the current Administrator's tenure began. Only one meeting was conducted in January 2025, with missing meetings in the previous year, potentially affecting all 51 residents.
The facility failed to implement its water management plan and infection control policies, affecting all residents. The Maintenance Director did not perform necessary water checks, and an LPN improperly cleaned a resident's pressure wound. Additionally, there was a lack of Enhanced Barrier Precautions (EBP) signage and PPE for residents with catheters, and staff were not adequately trained on EBP, leading to improper use of protective equipment.
The facility failed to ensure residents' access to personal funds, as four residents reported being unable to obtain money on weekends when the Business Office Manager was absent. The facility's policy allows fund access during business hours, but no alternative arrangements were made for weekends, leading to the deficiency.
The facility did not provide quarterly statements for personal fund accounts to several residents, as required by their policy. Following a change of ownership, the Business Office Manager confirmed that statements had not been distributed, affecting residents with personal fund accounts and balances ranging from $381.00 to $5,199.75.
The facility failed to provide scheduled showers for two residents who required assistance with activities of daily living. One resident, with severe cognitive impairment, did not receive any documented showers over two months, while another resident on hospice care received fewer showers than scheduled over three months. The facility's policy requires documentation of all shower-related activities, including refusals and bed baths, which was not adhered to in these cases.
The facility failed to provide immunization education, obtain consent, and administer vaccinations for five residents. There was no documentation in their medical records regarding education, consent, or administration of vaccines. The Corporate Nurse confirmed the lack of documentation, despite the facility's policy requiring the offering of immunizations unless contraindicated.
A resident was found with a Combivent inhaler at their bedside, which they self-administered without a physician's order. The facility's policy requires a physician's order for medications to be kept at the bedside, but the resident's records did not document such an order. A nurse confirmed the absence of the order, and the ADON stated that an assessment and physician's order are necessary for self-administration of medications.
A facility failed to implement physician-ordered treatments and monitoring for a resident with lymphedema and CHF. The resident's leg wraps were not consistently applied and removed as ordered, and their care plan lacked specific interventions for their conditions. Weight monitoring was inconsistent, with significant weight gains not reported to the physician. Staff acknowledged the lack of documentation and adherence to orders, contributing to the deficiency.
A facility failed to obtain a treatment order and monitor a newly discovered pressure ulcer for a resident with multiple health conditions. The resident's medical record lacked documentation of the pressure wound, and treatment was delayed. An LPN improperly applied a Calcium Alginate dressing, covering unaffected skin. The facility's policy on pressure wound prevention was not followed.
The facility failed to provide adequate catheter care for two residents, leading to deficiencies in hygiene and documentation. One resident's catheter tubing was observed dragging on the floor, and the drainage bag was touching the floor. The CNA did not clean the resident's labia/perineal area as required. Another resident received inadequate catheter care from a CNA who reused the same area of the wipe multiple times. These deficiencies highlight lapses in the facility's adherence to proper catheter care protocols.
Two residents experienced medication administration errors, leading to a 7.14% error rate. An LPN failed to check a resident's blood pressure before administering Lisinopril, and another resident swallowed Zofran whole instead of allowing it to dissolve under the tongue. These actions deviated from physician orders and manufacturer recommendations.
A resident in hospice care did not receive the prescribed thickened liquids due to a failure in updating the diet order in the facility's records. Despite the resident's need for thickened liquids to manage coughing and congestion, meal trays contained regular consistency liquids. The oversight was confirmed by CNAs and dietary staff, revealing a lapse in communication and documentation of the diet order.
The facility did not have an RN on duty for eight consecutive hours on two occasions due to staff illness, affecting 46 residents. The Director of Nursing confirmed the absence of RN coverage, as both the DON and another RN were out sick with COVID-19.
The facility experienced significant delays in meal service due to inadequate dietary staffing, affecting several residents. During a COVID-19 outbreak, kitchen staff shortages resulted in breakfast being served as late as 11:00 AM, with lunch and supper also delayed. Staff, including an LPN and the Social Services Director, confirmed the delays and the need for additional help in the kitchen. The dietary manager, new to the role, acknowledged the staffing issues and noted improvements were underway.
The facility failed to maintain a clean and sanitary kitchen, potentially affecting all 46 residents. Observations revealed dust, debris, and dirt buildup around the range and prep table, with dried splatters on nearby surfaces. The Dietary Aide confirmed that cleaning tasks were not completed as required, and the Dietary Manager lacked a cleaning log or schedule, despite the facility's Cleaning Schedule mandates.
During a COVID-19 outbreak, the facility failed to maintain an adequate supply of N95 respirators and ensure staff wore appropriate PPE. Staff were observed wearing KN90 and KN95 masks, which were not changed between COVID-19 positive and negative rooms, and masks were often worn incorrectly. Housekeeping practices were insufficient, with high-touch surfaces disinfected only every other day, contributing to the spread of the virus among all 46 residents.
The facility failed to maintain functioning call lights for four residents, resulting in significant delays in staff response. Residents, including those with cognitive impairments and incontinence, were forced to use handheld bells, leading to prolonged waits for assistance. Staff confirmed the call lights had been non-functional for weeks, and the administrator cited budget constraints as a barrier to repairs.
The facility failed to maintain a clean and homelike environment due to insufficient housekeeping staff, affecting three residents. Residents reported that their rooms were not cleaned daily, with observations of sticky floors, overflowing garbage, and unclean bathrooms. The facility's housekeeping schedule showed gaps in staffing, and the Housekeeping Supervisor confirmed that laundry staff had to cover housekeeping duties when staff were out sick, impacting the daily cleaning routine.
A resident, dependent on staff for bathing, did not receive scheduled showers for two weeks during a COVID-19 outbreak at the facility. The resident, who is cognitively intact, prefers weekly showers but was last given a shower at the beginning of the month. A staffing shortage due to the outbreak was confirmed by a Registered Nurse, and the Certified Nursing Assistant responsible for showers verified the missed schedule.
A resident with Type 2 Diabetes Mellitus was not provided with the physician-ordered Controlled Carbohydrate diet. Instead, the resident received a regular diet meal, including items not suitable for their condition. The error was due to an oversight on the Diet Order Form, where the Controlled Carbohydrate diet was not marked, leading to incorrect meal tray documentation.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 49 residents. The dietary schedule showed no dietary manager until late July, and the Administrator had been cooking due to staff shortages. A new dietary manager was hired, but there was no documentation of her certification or credentials.
The facility failed to provide adequate staffing in the dietary department, resulting in delayed meal services for residents. The administrator and DON had to step in to cook due to a lack of trained staff, causing residents to experience significant delays in receiving meals. The dietary manager was overworked, leading to an absence, and a staff member exhibited stress-related behavior towards a resident.
Two residents were subjected to verbal and mental abuse by a cook in the facility. The cook yelled at a severely cognitively impaired resident, threatened to stop serving dinner, and made the resident eat last. A CNA intervened to prevent physical harm. Another resident witnessed the incident and reported it to the Resident Care Coordinator. The facility's policy on abuse prevention was not adhered to, leading to this deficiency.
The facility failed to follow its abuse prevention policy when a cook allegedly threatened a resident during a meal. A CNA witnessed the incident but did not report it immediately, allowing the cook to leave the facility without being removed from resident contact. The incident was later reported by the Resident Care Coordinator to the DON and Administrator.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 47 residents. The Administrator and DON have been covering cooking duties after the previous Dietary Manager left after five days. The facility's job summary requires a qualified individual to manage food services, but no such person was present during the survey.
The facility failed to ensure that dietary aides and a cook were qualified, affecting all 47 residents. The facility's assessment required food and nutrition services staff to be present for 14 hours daily, but the dietary aides and cook lacked necessary certifications. Interviews with the DON and Administrator confirmed the absence of required cooking/sanitation and food handler's certificates. The cook, employed for over a week, was unaware of the certification requirement until the survey.
A facility failed to administer a dietary supplement as ordered for a resident with TIA and Cerebral Infarction. The resident's Physician Order Sheet required Med Pass 2.0 Supplement twice daily, but records show it was not given on multiple occasions. The DON confirmed the omissions, despite the care plan and facility policy requiring adherence to physician orders.
A resident with multiple diagnoses, including Depression and PTSD, reported being verbally abused by a CNA who raised her voice, yelled, and cursed when the resident requested hot chocolate. The incident left the resident feeling embarrassed and humiliated. The CNA was terminated following an investigation.
The facility failed to provide sufficient RN hours on four days, potentially affecting all 49 residents. Nursing schedules showed only four hours of RN coverage on three days and no RN coverage on one day. This was confirmed by the Resident Care Coordinator.
Failure to Perform Post–Head Injury Neurological Assessments per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological assessments after a head injury in accordance with its neurological assessment policy. A cognitively impaired resident was being showered by a CNA who reported that the resident was standing in the shower, holding onto the rail, while the CNA hurried to complete the task because the resident was confused and did not enjoy showers. The CNA stated the resident started to slip, and the CNA caught the resident under the arms and assisted the resident back into the shower chair, denying seeing the resident hit their head. Another CNA assisted with transfers to and from the shower chair and later reported being told by the first CNA that they had slipped but the resident had been caught, with no mention of the resident hitting their head. Both CNAs later noticed a small amount of blood on the resident’s head while brushing the resident’s hair in the room and then notified the nurse. The LPN reported seeing the resident in the room with only a small amount of blood observed and immediately sent the resident to the hospital. A nursing assessment documented that a CNA had reported the resident hit the back of the head and sustained a 4 cm laceration on the left back side of the head during the shower. The hospital summary documented that the resident received two staples for the head laceration, and the facility’s investigation report documented that the resident had behaviors during the shower and bumped the head on the shower room wall, resulting in two sutures. The facility’s neurological assessment policy required neurological checks for 72 hours after head injuries at specified intervals. The ADON stated that neurological checks were not done because the resident went to the hospital and acknowledged they should have been done when the resident returned the same day, indicating that the required post–head injury neurological assessments were not completed per policy.
Missing Food and Refrigeration Temperature Documentation
Penalty
Summary
The facility failed to record and maintain documentation for food temperatures taken prior to meal service and for refrigerator and freezer temperatures used to store facility food. The Service of Food policy, last revised in June 2023, states that foods will be held between 135 and 140 degrees Fahrenheit or higher for service and that food temperatures should be taken on the food service line by the culinary team prior to each meal and recorded in a temperature logbook. On 2/22/26 at 1:15 PM, V8 confirmed he did not document food service line temperatures on the log sheets for that day's noon meal and also confirmed there were other meals on the log with no temperatures documented. The Weekly Food Temperature Sheet for February 2026 was missing documentation for meal temperatures for nine meals from 2/1/26 through 2/22/26. The Record of Refrigeration Temperatures log for February 2026 was missing refrigerator and freezer temperatures for three days (2/19, 2/20, and 2/21) and only recorded temperatures once per day. The Food Storage policy, last revised in June 2023, states the facility will monitor refrigerator and freezer temperatures twice daily and record them on temperature monitor log sheets. On 2/23/26 at 2:50 PM, V7 Dietary Manager stated staff should be monitoring refrigerator and freezer temperatures twice daily and recording them on the temperature monitor log sheets, and should be taking temperatures on the food service line prior to serving each meal and recording them on the log sheet. The facility census was 50 residents.
Unpalatable and Tough Meal Service
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and in a form residents could easily consume for six residents reviewed during dining observations. The facility’s policy stated that food was to be served in a safe, accurate, timely, and acceptable manner, with hot foods held at 135–140 degrees F or higher and cold foods at 40 degrees F or below. During the survey, multiple residents were observed receiving the same lunch meal of roast pork, mashed potatoes, Brussels sprouts, a cookie, and beverages, and several residents reported that the pork was tough, dry, and difficult or impossible to chew. R31, who was cognitively intact, stated the pork was really tough and could not be cut with a butter knife; the pork appeared dry and the Brussels sprouts appeared pale and mushy. R20, who was mildly cognitively impaired and did not have teeth, stated he could not eat the meat because it was tough and had to spit out pieces he attempted to chew; the pork appeared dry and the Brussels sprouts appeared pale and mushy. The surveyor sampled the pork roast and Brussels sprouts and found the meat very difficult to cut and chew even with gravy, dry, and the Brussels sprouts mushy, watery, and lacking taste. A regional nurse verified the pork was tough and the Brussels sprouts were mushy and pale. Additional residents voiced similar concerns. An RN stated R7 and R19 had complained several times about cold and undesirable food. R19, who was cognitively intact and on a no-added-salt, regular-texture, thin-liquid diet, stated she was often served cold food, especially breakfast, and that steamed vegetables were mushy, bland, and unappealing; she was observed with uneaten pork, Brussels sprouts, and mashed potatoes that appeared extremely dry, and she could not cut the pork with her fork. R7, who was cognitively intact and on a no-added-salt/low-concentrated-sweets diet with regular texture, stated she had received cold, tough pork loin and that breakfast meals were often cold. R28, alert and oriented, ate only 75% of her pork roast because it was too tough, and R10, alert and oriented, stated the meat was tough even though she liked the mashed potatoes and Brussels sprouts.
Failure to Provide Dignified, Respectful Care
Penalty
Summary
The facility failed to treat residents with dignity and respect and to provide care in a manner that promotes quality of life for three cognitively intact residents who required staff assistance with showering, transfers, hygiene, and toileting. One resident stated staff rushed through care, made her feel like a task rather than a person, did not provide thorough showers, did not fully dry her before dressing, and sometimes left soiled bedding in place by putting another sheet over it. At the time of observation, her bed had multiple blankets, including one that appeared soiled, and later the same bed still had the same blankets with an additional visibly soiled folded sheet in the middle of the bed. Two other residents reported similar concerns about staff demeanor and care delivery. One resident stated staff were always rushed, disinterested, and made residents feel like they were bothering them. Another resident stated staff appeared rushed or had bad attitudes, made it seem like they never had time to care for residents, and that housekeeping quickly cleaned around items without moving them or thoroughly cleaning floors, edges, or underneath objects. The DON confirmed staff should move at the resident's pace, not make residents feel rushed, and should complete care thoroughly with residents' needs and feelings in mind.
Failure to Provide Feeding Assistance and Preserve Dignity During Meals
Penalty
Summary
The facility failed to provide necessary feeding assistance and to honor the resident’s right to be treated with respect and dignity and to retain and use personal possessions. On 02/22/2026, the resident was observed lying in bed with the head of the bed elevated and eating breakfast with his fingers, with no eating utensils present on the tray. The meal included scrambled eggs, a pancake with syrup, sausage, cream of wheat, cranberry juice, and water. The resident was unable to answer questions and responded only with yes/no answers. The resident’s family member stated the resident wants to be independent, but his stroke affected his right side and made it harder to use utensils with his left hand. The family member also stated the resident had previously regained some abilities during therapy at the hospital after his stroke, but believed the facility had not done much to help him maintain those abilities. The resident’s record documented aphasia, right-sided hemiplegia or hemiparesis, dysphagia, and severe cognitive impairment, and the MDS showed he required partial to moderate staff assistance with eating. The care plan documented that he was dependent on staff to complete ADLs and required one-person assistance. Facility staff stated he was a hand eater and was provided finger foods, but the restorative CNA could not provide documentation showing participation in the restorative program as outlined in the care plan, and the DON stated she did not believe he had participated in OT.
Failure to assess and monitor psychotropic medications and follow GDR orders
Penalty
Summary
The facility failed to assess residents receiving antipsychotic and other psychotropic medications, failed to identify and track resident-specific targeted behaviors, and failed to follow a physician-ordered gradual dose reduction for three residents. For one resident, Seroquel 25 mg twice daily was started for major depressive disorder and anxiety, but no baseline assessment was completed when the medication was ordered. The DON confirmed the resident was observed repeatedly reaching toward invisible objects from the floor, stated this occurred all the time, and acknowledged the facility was not tracking that behavior or identifying an effective intervention related to it. For another resident with diagnoses including schizoaffective disorder, bipolar disorder, anxiety, and depression, Lurasidone was started for bipolar disorder and later increased, but the facility's behavior and psychotropic medication reviews did not include that antipsychotic. A regional clinical nurse confirmed quarterly psychotropic assessments were not completed for the medication. For a third resident with psychiatric diagnoses including anxiety, depression, psychotic disorder, and schizophrenia, the pharmacist recommended a gradual dose reduction of Mirtazapine after determining the condition was stable, but the LPN/MDS Coordinator did not communicate the recommendation to the psychiatrist or attending physician, and the DON stated she had not contacted the physician about it.
Failure to Care Plan for Hearing Loss and Communication Needs
Penalty
Summary
The facility failed to develop a care plan to address a resident's moderate hearing loss and failed to implement interventions to maintain or improve his communication. The resident's MDS documented that he was alert and oriented with moderate hearing loss, but his care plan, reviewed on 1/27/2026, did not include any interventions for his hearing impairment or for assisting him to communicate his needs effectively. During observation on 2/22/2026, the resident was sitting at bedside eating breakfast and did not respond when spoken to, even when the surveyor used a loud tone of voice. The resident gestured toward his ear and stated, "I cannot hear," and reported that he did not have a hearing aid, had told the facility he wanted one, and did not know what happened with the appointment that was supposed to be scheduled. He stated he could not hear anything out of his left ear and only a little out of his right ear. No alternative communication devices were available in the room, and the surveyor had to use paper and pen for communication. On 2/23/2026, the resident was able to understand the surveyor when he could read lips. Staff interviews confirmed he was hard of hearing, did not have a hearing aid, and no alternative communication devices were used other than speaking louder and repeating themselves. The DON stated the resident kept losing hearing aids, and the SSD stated he was seen by audiology on 1/27/26 but did not think he would wear hearing aids. The MDS Coordinator stated she was never asked to create a care plan for residents with sensory impairments such as impaired hearing.
Failure to Support Communication for Resident With Hearing Loss
Penalty
Summary
The facility failed to ensure appropriate intervention was provided to assist a resident with moderate hearing loss in communicating his needs effectively. The resident’s MDS documented that he was alert and oriented with moderate hearing loss, but his care plan did not include interventions for the hearing loss or for helping him communicate. During observation, the resident did not respond when spoken to, gestured to his ear, and stated, “I cannot hear.” He reported that he did not have a hearing aid, that he had told the facility he wanted one, and that he did not know what happened with the appointment that was supposed to be scheduled. He also stated he could not hear anything out of his left ear and only a little out of his right ear. No alternative communication devices were available in his room, and paper and pen were needed for communication. Staff interviews confirmed the resident was hard of hearing and did not have a hearing aid. An LPN stated that no communication devices were used other than speaking louder and repeating themselves. The DON stated the resident did not have a hearing aid because he keeps losing them and confirmed there were no alternative communication devices, only louder speech. The SSD stated the resident was hard of hearing, had been seen by audiology, and that staff generally communicated by speaking normally and repeating themselves. The facility policy on sensory impairments states staff will help identify sensory impairments and may help obtain a hearing evaluation, hearing aid, or use written or other means to communicate with the individual.
Failure to Follow Oxygen Orders and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to follow physician’s orders for oxygen for three residents. For one resident, the physician’s order authorized oxygen at 2 liters per minute as needed, but progress notes documented that the resident received oxygen at 3 liters per minute for an extended period without an order for that higher flow rate. The Director of Nursing verified that the oxygen flow was increased without a physician’s order and stated the nurse should have called the doctor to obtain an order as soon as possible after increasing the flow rate. A second resident, who had diagnoses including COPD, obstructive sleep apnea, and chronic respiratory failure with hypoxia, was observed in a wheelchair in the dining room with a portable oxygen tank on the back of the chair. The tank was empty, with the gauge needle in the red zone indicating no oxygen. The resident’s physician’s order called for oxygen at 2 liters per minute via nasal cannula every shift, and the care plan stated the resident used oxygen continuously at 2 liters per minute. Staff stated that the red zone means the tank is empty and that nurses are expected to monitor oxygen tanks and replace them before they become empty. A third resident with COPD, acute respiratory failure with hypoxia, chronic pulmonary embolism, and shortness of breath with exertion, at rest, and when lying flat was observed multiple times lying flat in bed while receiving oxygen from a concentrator at 6 liters, 5.5 liters, and 4.5 liters. The humidification water canister attached to the concentrator was empty during one observation. The resident’s care plan directed staff to keep the head of the bed elevated and position the resident in Fowler’s position to help breathing, but the resident was repeatedly observed lying flat. Staff stated the resident was often left at 6 liters because of shortness of breath and that staff and hospice sometimes turned the oxygen up.
Failure to Maintain Enhanced Barrier Precautions for Resident With Open Wounds
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when the facility failed to implement enhanced barrier precautions (EBP) for one resident with open wounds. The resident had diagnoses including a left artificial hip joint, cardiac pacemaker, malignant neoplasm of the abdomen, cataract, atrial fibrillation and flutter, hypertension, chronic obstructive pulmonary disease, congestive heart failure, a wound of the left great toe, peripheral vascular disease, and chronic kidney disease stage III. The resident’s MDS documented cognitive intactness, and the wound assessment documented an unstageable pressure ulcer on the left heel. During observation, the resident’s door was open and there was no sign posted to indicate EBP, no dirty linen or red trash container in or near the room, and no PPE in or near the room. The resident was seated on the edge of the bed, had a gauze wrap on the left foot and ankle, wore a heel protector, and denied that staff entering the room wore gowns or gloves during daily wound care. On the following day, the same conditions were observed, with no visible EBP signage, no dirty linen or red trash container, and no PPE in or near the room. The DON and ADON/Infection Preventionist stated the resident should be on EBP and, after checking the room, verified that precautions were not in place. The facility policy stated that clear signage should be posted outside the resident’s room indicating the precautions, required PPE, and high-contact care activities requiring gown and gloves.
Failure to Track Antibiotic Use and Document Criteria for Antibiotic Initiation
Penalty
Summary
The facility failed to complete infection surveillance documentation and failed to ensure one resident met criteria for initiation of an antibiotic. R25’s care plan listed multiple diagnoses including atrial fibrillation, hypertension, COPD, CHF, peripheral vascular disease, CKD stage III, and wounds of the left great toe and left heel. R25’s MDS documented that he was cognitively intact, and the wound assessment documented unstageable pressure ulcers of the left heel and left great toe. R25’s February MAR showed an order for Bactrim for wound infection with cellulitis, which was not given after the resident was hospitalized. The hospital record documented the hospitalization was for a ruptured abscess of the scrotum. After return from the hospital, R25 received sulfamethoxazole-trimethoprim for abscess, but the facility’s infection tracking and trending for February did not include R25. There was no documentation that R25 met criteria for starting the antibiotic or that the antibiotic selected was appropriate, and no cultures were documented in the medical record. The Assistant DON/Infection Preventionist stated R25 was missed on tracking and she could not locate a McGeer Criteria or other Antibiotic Stewardship Assessment. The DON verified that R25’s infection should have been included in tracking and that an assessment for appropriate antibiotic use should have been completed but was not.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required. Review of the facility's daily assignment sheets showed that there was no RN coverage on December 25, 2025. The Director of Nursing confirmed that the RN scheduled for that day called off and the Director did not come in to cover the shift. The facility assessment indicated that staffing would be based on resident needs and required guidelines, and the room roster documented that 50 residents were residing in the facility at the time of the deficiency. This lapse in RN coverage was confirmed through interview and record review, and it was acknowledged by the Director of Nursing that the required RN presence was not maintained for the specified period.
Failure to Provide Effective Pain Management Following Resident Injury
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple medical conditions, including generalized weakness, polyarthralgia, lymphedema, obesity, gout, physical debility, osteoarthritis, hypertension, and diabetes. After a fall from a sit-to-stand lift, the resident experienced increased pain and swelling in her left hand and knee, which significantly limited her ability to perform daily activities such as getting out of bed, propelling her wheelchair, and participating in social and religious activities. Observations confirmed visible swelling and limited mobility in the resident's left hand and knee, and the resident reported ongoing pain that interfered with her independence and comfort. Nursing notes did not document the fall incident but indicated that the resident began complaining of excessive pain following the event and subsequently refused to get out of bed. The resident was sent to the emergency room for evaluation and later admitted to the hospital for pain management, where her pain medication was increased. Upon return to the facility, physician orders reflected an increased frequency for pain medication administration, and the care plan noted the need for pain assessment and medication as ordered. Despite these orders, the facility did not effectively manage the resident's pain according to physician instructions, the care plan, or the resident's preferences, resulting in a decline in her ability to participate in routine activities of daily living.
Unsafe Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a sit-to-stand mechanical lift without following established safety protocols. The resident, who had multiple medical conditions including generalized weakness, lymphedema, obesity, gout, osteoarthritis, and physical debility, was unable to fully grip the lift's grab bar due to swelling and pain in her left hand. Despite the resident's repeated attempts to inform the CNA of her inability to hold on, the CNA proceeded with the transfer alone, without the required safety belt and without a second staff member present. During the process, the resident lost her grip and fell to the floor. The facility's policy requires that mechanical lifts be operated by two trained staff members and that the safety belt always be used. Interviews with facility leadership confirmed that all CNAs are trained and must pass competency evaluations for lift use, but documentation of the CNA's training could not be located. The incident was not documented in the resident's nurse notes, but subsequent reports to the state health department confirmed the fall and the resident's resulting pain and medical evaluation.
Failure to Provide Prescribed Pain Medication Due to Medication Supply Lapse
Penalty
Summary
The facility failed to acquire, dispense, and administer a resident's prescribed pain medication as ordered by the physician. A resident with multiple medical conditions, including generalized weakness, polyarthralgia, lymphedema, obesity, gout, physical debility, osteoarthritis, hypertension, and diabetes, reported increased pain in her left hand and knees following a fall from a mechanical lift. The resident stated that her physician had prescribed Norco (Hydrocodone/Acetaminophen) to be taken every four hours as needed for pain, but she had not received this medication for about a week. Instead, she was only receiving Tylenol three times per day, which she reported was ineffective for her pain. Review of the resident's Medication Administration Record confirmed that she had not received Norco since 4/21/25, and the Controlled Drug Receipt/Record/Disposition Form showed that her supply of Norco had run out on that date. The nurse on duty confirmed that there had been no Norco available for three days and that the medication cart did not contain any of the prescribed pain medication. The failure to ensure timely ordering and availability of the resident's pain medication resulted in the resident not receiving her physician-ordered pain management.
Failure to Respect Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to respect the residents' right to dignity and respect, as evidenced by multiple incidents involving staff attitudes and behavior. Residents reported that call lights were not answered in a timely manner, with some waiting up to an hour or more. Certified Nursing Assistants (CNAs) were observed saying "not my resident" when asked to provide care, and residents expressed concerns about staff needing attitude adjustments. Specific incidents included a resident being left on the floor for an hour and a half after a fall, and another resident being brought to tears by a staff member's dismissive attitude regarding meal options. In one incident, a resident was upset and tearful after a CNA expressed frustration about additional work due to the night shift not completing their tasks. The resident felt scolded and disrespected by the CNA's tone of voice. Another resident reported that CNAs were loud and upsetting when waking them up early, causing distress. These incidents were reported to the Social Service Director and the Administrator, but the Administrator claimed to be unaware of the issues with staff attitudes and dignity/respect. The facility's Resident Council Minutes documented ongoing concerns with staff attitudes, including CNAs and nurses using phrases like "not my job" and "not my resident." Residents also reported that kitchen staff refused requests and that CNAs were often on their phones instead of attending to call lights. Despite these documented concerns, the Administrator stated that they had not been made aware of any specific issues with the staff involved, indicating a lack of communication and follow-up on reported grievances.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances and document actions taken for six residents reviewed for grievances, potentially affecting all 51 residents in the facility. The facility's Resident Council Policy and Grievance policy require grievances to be documented and addressed, but the facility did not adhere to these policies. The Resident Council Minutes from September 2024 to February 2025 documented numerous concerns, including issues with meal service, laundry, housekeeping, and staff attitudes, but the facility's Grievance Log only documented follow-up actions for a few of these concerns. During a resident council meeting, several residents reported ongoing issues such as call light wait times, late medications, and missing personal items. These residents were unsure of the grievance reporting process and the facility's actions to address their concerns. Observations and interviews with staff confirmed that medications were not administered within the required time frame, and there was a lack of documentation for follow-up actions on grievances reported in the council meetings. The facility's staff, including the Activity Director and Social Services Director, acknowledged the repeated issues brought up in the resident council meetings. However, there was a lack of awareness and documentation regarding the follow-up actions taken for these concerns. The Social Services Director admitted to not having documentation for grievances from September 2024 to November 2024 and recognized the need to review resident council meeting minutes to ensure grievances are followed up on and documented.
Failure to Maintain Required Nursing Staff
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) and did not provide the services of a Registered Nurse (RN) for eight consecutive hours, seven days a week. This deficiency was observed over several days, specifically on 2/24/25, 2/27/25, 2/28/25, 3/1/25, and 3/2/25, where the facility lacked RN coverage for the required hours. Additionally, the facility has been without a full-time DON since 2/1/25, following the departure of the previous DON on 1/31/25. These findings were confirmed by the Assistant Director of Nursing and the Administrator, who acknowledged the absence of consistent RN coverage and a full-time DON, as documented in the facility's nursing working schedule and assessment.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 51 residents. The Dietary Manager, who was actively supervising dietary operations, was hired a couple of weeks ago but does not currently hold a valid Food Safety/Dietary Manager Certificate, as it expired over a year ago. The Dietary Manager is scheduled to take the certification test next month, but at present, does not meet the State of Illinois standards to be a food service manager or dietary manager. The facility's assessment indicates the need for a full-time dietician or other clinically qualified nutrition professional to provide competent support and care for the resident population every day and during emergencies. The facility's application for Medicare and Medicaid documents that 51 residents reside in the facility.
Lack of Certified Dietary Staff in Food Service
Penalty
Summary
The facility failed to employ dietary support staff with the necessary competencies to effectively carry out the functions of the food and nutrition service, potentially affecting all 51 residents. Observations and interviews revealed that dietary aides were involved in preparing and distributing residents' meals without having the required training or food handler's certificates. Specifically, on two separate occasions, dietary aides were observed preparing food and assisting with meal distribution without proper certification. The Dietary Manager confirmed that four out of six kitchen staff members, including those observed, did not possess a Food Handler's certificate. The facility administrator acknowledged this deficiency, which is in violation of the Illinois Public Act requiring food handlers in non-restaurant settings, such as nursing homes, to have completed the necessary training since January 1, 2017.
Failure to Implement and Evaluate Performance Improvement Plan
Penalty
Summary
The facility failed to annually implement and evaluate the effectiveness of a performance improvement plan, which has the potential to affect all 51 residents. The facility's Quality Assurance Performance Improvement (QAPI) Plan requires an annual self-assessment and prioritization of activities, policies, and procedures, with continuous monitoring for improvement. However, the facility did not follow through with this requirement. The QAPI Plan includes input from staff, residents, and family members, as well as adverse events, performance indicators, survey findings, and complaints/grievances. Despite having a documented plan, there was no evidence of follow-up, monitoring, tracking, or evaluation of the interventions listed in the Performance Improvement Plans (PIPs) for preventative skin care and showers/baths. The administrator, who assumed the role in December 2024, acknowledged that the only PIPs available were from April, focusing on preventative skin care and showers/baths. These PIPs outlined specific goals and interventions, such as staff training, skin assessments, and hygiene schedules. However, there was no documentation of the implementation or evaluation of these interventions. The administrator was unable to locate any records of follow-up actions, attributing the lack of documentation to the former administrator's practice of discarding records. This oversight in maintaining and evaluating the PIPs indicates a significant deficiency in the facility's quality assurance processes.
Failure to Conduct Quarterly QA Meetings
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance (QA) meetings, which is a requirement for maintaining compliance and ensuring the quality of care for all residents. The facility's Quality Assurance Performance Improvement (QAPI) Plan outlines the necessity of these meetings to proactively improve care, track and investigate adverse effects, and set quality targets. However, the facility only held one QA meeting in January 2025 since the current Administrator took over in December 2024. The Administrator acknowledged the absence of meetings in July and October 2024 and was unable to provide additional sign-in sheets for any other meetings in the past year. This oversight has the potential to impact all 51 residents in the facility, as documented in the facility's Long Term Care Facility Application for Medicare and Medicaid.
Failure to Implement Water Management and Infection Control Policies
Penalty
Summary
The facility failed to implement its water management plan, as evidenced by the Maintenance Director's admission of not having a test kit for water testing and not performing necessary checks on hot water distribution, eye wash stations, and hot water tanks. Additionally, there was no floor plan for Legionella management, and the Maintenance Director was unaware of where to obtain the necessary items for compliance. This lack of implementation poses a risk to all 51 residents in the facility. The facility also failed to adhere to its Pressure Wound Treatment Policy and Enhanced Barrier Precautions (EBP). An LPN improperly cleaned a resident's pressure wound by using the same side of a gauze pad repeatedly and brought the treatment cart into the resident's room, which is against protocol. Furthermore, there was a lack of EBP signage and PPE availability for residents with indwelling medical devices, such as urinary catheters. Staff members were not adequately trained on EBP, leading to improper use of protective equipment during care procedures, as seen in the cases of two residents with catheters.
Residents Unable to Access Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents have access to their personal funds, as evidenced by the experiences of four residents. The facility's policy states that residents can access their funds during regular business hours, but withdrawals over $60 require a 24-hour notice. However, residents reported that they could not access their funds on weekends when the Business Office Manager, who manages the trust fund accounts, was not present. This issue was highlighted by a resident who stated they could not access their $60 monthly income on weekends, and during a resident council meeting, three other residents expressed similar concerns about not being able to obtain money from their accounts when the manager was absent. The facility's Trial Balance for resident trust fund accounts confirmed that the affected residents had personal fund accounts. The Business Office Manager acknowledged that they manage the accounts and only work one Saturday per month, while the Administrator, who also has access to the accounts, confirmed that no one is available on weekends to access these funds. This lack of access to personal funds on weekends and the absence of an alternative arrangement for fund access when the Business Office Manager is not present led to the deficiency.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal fund accounts for four residents, as required by their Resident Personal Trust Funds policy. The policy, dated 4/15/24, mandates that quarterly statements for all transactions be provided to residents or their legal representatives. However, interviews and record reviews revealed that residents did not receive these statements following a change of ownership on 11/1/24. Specifically, residents with personal fund accounts, including those with balances ranging from $381.00 to $5,199.75, did not receive the required quarterly statements. The Business Office Manager confirmed the oversight, acknowledging that the statements had not been distributed since the ownership change.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for two residents, R9 and R43, who were dependent on staff assistance for their activities of daily living. R9, who has severe cognitive impairment and requires substantial assistance, did not receive any documented showers in February or March 2025, with only one refusal noted. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) confirmed the lack of documentation for R9's showers, bed baths, or refusals, despite the facility's policy of offering bed baths after three shower refusals and documenting all attempts. Similarly, R43, who is on hospice care and has multiple medical diagnoses including dementia and respiratory failure, did not receive the scheduled number of showers in December 2024, January 2025, and February 2025. The ADON reiterated the facility's policy of scheduling two showers per week and documenting all shower-related activities, but the records show that R43 received fewer showers than scheduled, with no documentation of refusals or bed baths. These deficiencies highlight a failure in the facility's adherence to its own policies for providing and documenting personal care for dependent residents.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to provide immunization education, obtain immunization consent forms, and administer vaccinations for five residents reviewed for immunizations. These residents had no documentation in their medical records indicating that they were educated about vaccinations, consented to receive them, or were offered or administered the vaccines. On March 11, 2025, at 2:30 PM, the Corporate Nurse confirmed the absence of documentation for these residents. The facility's policy, revised on January 23, 2020, states that immunizations and vaccinations should be offered to prevent infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director.
Lack of Physician Order for Bedside Medication
Penalty
Summary
The facility failed to have a physician order for a medication found at the bedside for one resident reviewed for self-administration of medications. During an observation, a Combivent inhaler was found on the overbed table of a resident who stated they self-administer the inhaler two to four times per day and keep it in their room. However, the resident's March 2025 Physician Order Summary did not document an active order for the Combivent inhaler or for the resident to keep this medication at the bedside. A Registered Nurse confirmed the absence of an order for the inhaler after reviewing the resident's active physician orders and Medication Administration Record. The Assistant Director of Nursing stated that residents need an assessment and physician's order to keep medications at the bedside and self-administer.
Failure to Implement Physician-Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to implement physician-ordered treatments and monitoring for a resident with lymphedema and congestive heart failure (CHF). The resident reported that their leg wraps, which were supposed to be applied every morning and removed every night, were not consistently managed, sometimes remaining on for several days. The resident's care plan listed diagnoses of lymphedema and CHF but lacked specific problems, goals, and interventions to address these conditions. Additionally, the physician's orders to monitor the resident's weight daily and notify the physician of significant weight gains were not consistently followed, with missing entries in the weight logs and no documentation of physician notification for weight gains. The resident's medical records showed significant weight fluctuations, including a 13-pound gain in one week and a 15-pound gain in five days, without evidence of physician notification. The facility's staff, including registered nurses and the Assistant Director of Nursing, acknowledged the lack of documentation and adherence to the physician's orders. The resident's lymphedema compression machine was also reported to be non-functional, and the facility had not documented the application of leg wraps in the Treatment Administration Record (TAR). The facility's failure to implement and document the necessary care and monitoring for the resident's conditions led to the identified deficiency.
Failure to Obtain Treatment Order and Monitor Pressure Ulcer
Penalty
Summary
The facility failed to obtain a treatment order for a newly discovered pressure area, monitor the area, and follow manufacturer's recommendations for treatment application for a resident with multiple diagnoses, including acute and chronic respiratory failure, type II diabetes mellitus, chronic obstructive pulmonary disease, and cognitive communication deficit. The resident's medical record did not list a pressure wound as a diagnosis, and there was a lack of documentation regarding the pressure area on the resident's buttocks. Hospice notes indicated redness on the buttocks, which later developed into a stage II wound, but the facility did not document or monitor this area in the Treatment Administration Records (TAR) for December 2024. A treatment order was not obtained until January 8, 2025, and the treatment did not commence until January 9, 2025. Additionally, there were no skin assessments for pressure wounds documented in the resident's medical record, and the care plan lacked documentation and interventions for pressure wounds. During an observation, a Licensed Practical Nurse (LPN) improperly applied a Calcium Alginate dressing by cutting it larger than the wound bed and covering unaffected skin, contrary to the manufacturer's instructions. The Assistant Director of Nursing (ADON) confirmed that the dressing should have been cut to fit the wound bed size. The facility's policy on the prevention of pressure wounds emphasized the need for timely and appropriate assessments, recognition, evaluation, reporting, and addressing changes in condition, which were not adhered to in this case.
Inadequate Catheter Care and Documentation for Residents
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, leading to deficiencies in hygiene and documentation. One resident, who had a urinary catheter due to a history of bladder infections and urinary retention, reported that staff did not routinely clean the catheter or empty the drainage bag as requested. Observations confirmed that the resident's catheter tubing was dragging on the floor and the drainage bag was touching the floor, which was acknowledged by the CNAs as inappropriate. Additionally, the CNA did not clean the resident's labia/perineal area as required by the facility's catheter care policy. The resident's care plan and treatment administration record lacked documentation of catheter care and an active physician order for the catheter. Another resident with a suprapubic catheter received inadequate catheter care from a CNA who failed to use a new wipe for each cleaning stroke, reusing the same area of the wipe multiple times. This practice was acknowledged by the CNA as incorrect. The resident's medical record documented conditions such as Type 2 Diabetes Mellitus with Hyperglycemia and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, which necessitated the use of a catheter. These deficiencies highlight lapses in the facility's adherence to proper catheter care protocols and documentation requirements.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer recommendations for two residents, resulting in a medication error rate of 7.14 percent. For one resident, there was an order for Lisinopril 2.5 mg to be administered once a day, with instructions to hold the medication if the systolic blood pressure was less than 100. On the specified date, an LPN administered the medication without checking the resident's blood pressure at the time of administration, relying instead on a reading taken earlier during the night shift. The LPN admitted that there was no form to document blood pressures at the time of administration, which was confirmed by the Assistant Director of Nurses, who stated that blood pressure should be taken and recorded before administering the medication. For another resident, there was an order for Zofran disintegrating tablet 8 mg to be taken every six hours as needed for nausea and vomiting, with instructions for the tablet to be placed under the tongue to dissolve. However, the LPN placed the Zofran in a medication cup with other medications, and the resident swallowed it whole instead of allowing it to dissolve under the tongue. The LPN acknowledged that the resident usually picks the medication out of the cup to take last, but on this occasion, the resident swallowed it with the other medications. This deviation from the prescribed method of administration contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Follow Diet Order for Thickened Liquids
Penalty
Summary
The facility failed to adhere to a diet order for thickened liquids for one resident, identified as R210, who was part of a sample of 24 residents reviewed for meals. The deficiency was observed when R210's breakfast and noon meal trays contained regular consistency liquids instead of the prescribed thickened liquids. Certified Nursing Assistants (CNAs) confirmed that R210's meal trays did not document the need for thickened liquids, despite the resident's known requirement for them due to coughing and congestion. The facility's Diet Orders policy requires that diet orders be communicated in writing to the dietary department, but this was not followed in R210's case. The March 2025 Physician Order Summary for R210 did not list thickened liquids, and the resident's meal tray card lacked documentation for the required diet modification. A Diet Order Form dated February 22, 2025, indicated that R210 should receive nectar thickened liquids, but this was not reflected in the meals provided. The Assistant Director of Nursing and a Registered Nurse acknowledged the oversight, noting that the diet order from the hospice nurse was not updated in the resident's Physician Order Summary, leading to the failure in providing the correct diet consistency.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day, as required, on two specific dates, 8/4/24 and 8/7/24. This deficiency was identified through interviews and record reviews, which revealed that the facility's August 2024 Nurse Schedule and Nursing Daily Sheets did not document an RN being scheduled to work on those days. During a review of staffing and daily sheets with the Director of Nursing (V2), it was confirmed that there was no RN on duty on the specified dates. The Director of Nursing explained that the absence of RN coverage was due to both V2 and another RN (V3) being out sick with COVID-19. The facility had 46 residents at the time of the deficiency, all of whom were potentially affected by the lack of RN coverage.
Inadequate Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide adequate dietary staff to ensure meals were served on time, affecting four out of five residents reviewed for meals in a sample of 13, with the potential to impact all 46 residents. Interviews and record reviews revealed that during a COVID-19 outbreak, kitchen staff shortages led to significant delays in meal service. Residents reported breakfast being served as late as 11:00 AM instead of the scheduled 8:00 AM, with lunch and supper also delayed by several hours. The facility's dietary manager, who had been employed for only three weeks, acknowledged the staffing issues and noted that meals were considered timely if served within 25 minutes of the scheduled time. Staff members, including a Licensed Practical Nurse and the Social Services Director, confirmed the delays and the need for additional staff to assist in the kitchen. The facility's dietary schedule showed that between August 4th and August 11th, there were multiple days with only one kitchen staff member available, and the dietary manager had to step in as the second staff member. The facility's assessment indicated a staffing plan that included one food and nutrition supervisor, one cook, and one dietary aide for weekdays, with reduced staffing on weekends. Despite these plans, the facility struggled to maintain timely meal service during the staffing shortages.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which has the potential to affect all 46 residents residing in the facility. During a kitchen tour with the Dietary Manager, dust and debris were observed on the floor, and dirt had built up around the range and prep table. Additionally, there were dark, dried splatters on the side of the range and on the wall near the three-sink washing station. The Dietary Aide confirmed that the floors are supposed to be swept and mopped at the end of each shift, which should have been done the previous evening. Despite the facility's Cleaning Schedule requiring a cleaning rotation form for proper sanitation, the Dietary Manager did not have a cleaning log or schedule in place.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement effective infection control measures during a COVID-19 outbreak, affecting all 46 residents. The outbreak began on August 1, 2024, and by August 8, 2024, 24 residents and 16 employees had tested positive for COVID-19. The facility did not maintain an adequate supply of N95 respirators, and staff were observed wearing KN90 and KN95 masks instead, which were not changed between COVID-19 positive and negative rooms. Staff, including CNAs and housekeepers, were not consistently wearing appropriate PPE, such as gowns and gloves, when entering COVID-19 positive rooms, and masks were often worn incorrectly with the lower strap hanging loose. The facility's Director of Nursing (DON) admitted that the facility had a limited supply of N95 masks and had not been routinely ordering them due to the absence of previous outbreaks. When the outbreak began, the facility quickly ran out of N95 masks and relied on KN95 and KN90 masks provided by the local health department. Staff were not adequately trained on the proper use of PPE, as evidenced by multiple staff members wearing masks incorrectly and not changing or disinfecting masks and eye protection between rooms. The facility's policy required N95 masks and eye protection during resident care in outbreak situations, but this was not adhered to. Housekeeping practices were also insufficient, with high-touch surfaces being disinfected only every other day instead of the recommended three times per day. The facility was understaffed in housekeeping, with laundry staff having to cover housekeeping duties, leading to uncertainty about whether resident rooms were cleaned daily. The facility's COVID-19 Control Measures policy required increased cleaning frequency during outbreaks, but this was not consistently implemented, contributing to the spread of the virus within the facility.
Non-Functioning Call Lights Lead to Delayed Resident Assistance
Penalty
Summary
The facility failed to maintain functioning call lights for four residents, leading to significant delays in staff response to resident needs. Observations revealed that residents were using handheld bells as a substitute for non-functioning call lights. One resident reported waiting over 30 minutes for assistance, while another resident had to wait an hour while lying in urine and feces. Staff interviews confirmed that the call lights had been non-functional for weeks, affecting both the North and South Halls of the facility. The residents affected by this deficiency included individuals with varying levels of cognitive impairment and incontinence, all of whom required substantial assistance for toileting. The facility's administrator acknowledged the issue, stating that the call lights had been problematic since February 2024 and that budget constraints had prevented necessary repairs or replacement of the system. Despite evaluations by corporate and sister facility maintenance staff, the call light system remained in disrepair, necessitating the use of handheld bells for resident communication.
Insufficient Housekeeping Staff Leads to Unclean Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment due to insufficient housekeeping staff, affecting three residents. On the specified date, a resident reported that their room was not cleaned daily, with observations of a sticky floor, overflowing garbage, and a bathroom with dried feces. This resident was documented as cognitively intact. Another resident also reported that their room had not been cleaned, with dust and food wrappers present, and mentioned that housekeeping staff were out sick with COVID-19, leading to rooms not being cleaned daily. This resident was also documented as cognitively intact. A third resident expressed concerns about the cleanliness of their room, noting that the facility lacked sufficient housekeeping staff. This resident had a moderate cognitive impairment. The facility's housekeeping schedule showed no housekeeping staff were scheduled for several days, and the Housekeeping Supervisor confirmed that the facility had not been fully staffed for some time. The supervisor also noted that laundry staff had to cover housekeeping duties when staff were out sick, which may have impacted the daily cleaning of resident rooms. The facility's policy required daily cleaning tasks, including sweeping, mopping, and bathroom cleaning.
Failure to Provide Scheduled Showers During COVID-19 Outbreak
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 not receiving a shower for two weeks, despite preferring weekly showers. This lapse occurred during a COVID-19 outbreak at the facility, which led to a staffing shortage. The resident's showers were scheduled for Thursdays, but the last recorded shower was on the first of the month. A Registered Nurse confirmed the staffing shortage due to the outbreak, and a Certified Nursing Assistant, responsible for showers, verified that the resident did not receive a shower on the scheduled day due to the outbreak.
Failure to Follow Physician-Ordered Diet for Diabetic Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered diet for a resident diagnosed with Type 2 Diabetes Mellitus. The resident, who is cognitively intact, reported not being on a special diet despite having a physician's order for a Controlled Carbohydrate diet. During meal service, the resident was served a regular diet meal that included Salisbury steak, mashed potatoes, bread, and ice cream, which did not align with the prescribed Controlled Carbohydrate diet. The Dietary Manager confirmed that the resident's meal tray card incorrectly documented a regular diet instead of the prescribed Controlled Carbohydrate diet. The discrepancy was attributed to an oversight on the Diet Order Form, where the box for the Controlled Carbohydrate diet was not marked. The facility's menu and dietary guidelines specify modifications for Controlled Carbohydrate diets, such as substituting fruit for dessert and omitting extra bread, which were not followed in this instance.
Lack of Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 49 residents residing in the facility. The facility's assessment indicated that a dietician or other clinically qualified nutrition professional should serve as the director of food and nutrition services. However, the dietary schedule showed no dietary manager until July 25, 2024, and no certified dietary manager was on staff during the month of July 2024. The Administrator admitted to cooking for the last 12-14 days due to a lack of staff, including a dietary manager. Although a dietary manager was hired and started orientation on July 25, 2024, the Administrator could not provide documentation that the new hire was a certified dietary manager or had other credentials to support her knowledge of the role.
Inadequate Staffing in Dietary Department Leads to Meal Delays
Penalty
Summary
The facility failed to provide sufficient and competent staffing in the food and nutrition services department, affecting the timely delivery of meals to residents. The facility's policy requires adequate staffing to meet the dietary needs of residents, but the facility assessment indicated a need for more hours from both a director and staff in food and nutrition services. The administrator reported having to cook for the past 12-14 days due to a lack of staff, including a dietary manager. The dietary schedule showed multiple instances where no cook was scheduled for various meals, leading to delays in meal service. On one occasion, the Director of Nursing was observed cooking breakfast because dietary aides were not trained to cook. Residents expressed dissatisfaction with the delays, with one resident stating they were very hungry and another not receiving breakfast until much later than scheduled. The administrator confirmed that the lack of dietary staff was causing meals to be served late, and the dietary manager had been overworked, leading to an absence. Additionally, an incident was reported where a staff member snapped at a resident due to stress from working alone in the kitchen.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect two residents from verbal and mental abuse, as evidenced by an incident involving a cook, identified as V4, and a resident, R1, who is severely cognitively impaired. On the night of the incident, the dietary department was short-staffed, and V4 was observed yelling at R1, threatening to stop serving dinner if R1 did not comply with his demands. V4 also threatened to make R1 eat last. A Certified Nursing Assistant (CNA), V5, witnessed V4 raise his hand as if to hit R1, but intervened by moving R1 away to prevent physical contact. This incident was corroborated by another resident, R2, who is cognitively intact and reported the event to the Resident Care Coordinator. The facility's Abuse Prevention Program Policy, dated 11/28/2016, affirms residents' rights to be free from abuse, including verbal abuse from staff. Despite this policy, the incident occurred, indicating a failure to adhere to the established guidelines. The administrator, V1, was informed of the incident and acknowledged that V4 had threatened R1 and subsequently terminated V4 for his behavior. However, the report focuses on the deficiency in protecting residents from abuse, as demonstrated by the actions of V4 and the facility's inability to prevent such an incident from occurring.
Failure to Report and Remove Alleged Abuser
Penalty
Summary
The facility failed to implement its abuse prevention policy by not immediately reporting suspected abuse and not ensuring the alleged abuser was removed from the facility. An incident occurred between a resident (R1) and a cook (V4) during the evening meal, where the cook allegedly threatened the resident and raised a hand to hit him. This incident was witnessed by a Certified Nursing Assistant (V5), who intervened to prevent physical contact. Despite witnessing the incident, the CNA did not report it immediately, and the cook was allowed to leave the facility without being removed from resident contact as per the facility's policy. The Resident Care Coordinator (V3) was informed of the incident by another resident (R2) and the CNA later that evening. The RCC then reported the incident to the Director of Nursing (V2) and the Administrator (V1) via text message. By the time the Administrator arrived at the facility, the cook had already left. The facility's failure to immediately report the incident and remove the alleged abuser from resident contact constitutes a breach of their abuse prevention policy.
Lack of Qualified Director of Food and Nutrition
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 47 residents residing in the facility. During the survey conducted from 7/18/24 to 7/19/24, it was observed that the facility did not have a Dietary Manager present. The Administrator, identified as V1, stated that the facility had a Dietary Manager for only five days before the individual abandoned the job, leading to their termination. As a result, V1 and the Director of Nursing (DON), identified as V2, have been taking on cooking responsibilities. V1 mentioned working in the kitchen frequently, including weekends, while V2 confirmed having cooked for the past one and a half to two weeks. The facility's Food Service Manager job summary requires the individual to have taken or be willing to take the Dietary Managers Course and pass the sanitation test or be willing to take a state-approved course. The facility assessment indicates the need for a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services for 8 hours per day.
Lack of Qualified Dietary Staff
Penalty
Summary
The facility failed to provide qualified dietary aides and a cook, which has the potential to affect all 47 residents residing in the facility. The facility's assessment indicated that food and nutrition services staff should be present for 14 hours per day. However, the dietary aides and cook lacked the necessary certifications. The Diet Aide job summary required aides to pass a sanitation test or be willing to take a state-approved course and receive food handler's training within 30 days of employment. On multiple occasions, it was confirmed through interviews with the Director of Nursing (DON) and the Administrator that the cook and dietary aides did not possess the required cooking/sanitation and food handler's certificates. The cook, who had been working for one and a half to two weeks, was unaware of the certification requirement until informed during the survey.
Failure to Administer Dietary Supplement as Ordered
Penalty
Summary
The facility failed to administer a dietary supplement according to physician's orders for a resident diagnosed with Transischemic Attack (TIA) and Cerebral Infarction. The resident's Physician Order Sheet specified that Med Pass 2.0 Supplement, 60 milliliters by mouth twice a day, was to be administered from July 1 to July 31, 2024. However, the Medication Administration Record indicated that the supplement was not given on several occasions: both AM and PM on July 7 and July 11, PM on July 16, and AM on July 19. The Director of Nursing confirmed that the supplement was not administered on these dates. The resident's care plan, dated March 22, 2024, required that supplements be provided and served as ordered. The facility's policy on conformance with physician medication orders, last reviewed in September 2017, mandates that all medications and supplements be given upon written order of a physician.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by a staff member. The incident involved a Certified Nurses Assistant (CNA) who was verbally inappropriate towards a resident diagnosed with Congestive Heart Failure, Depression, Bipolar Disorder, Post Traumatic Stress Disorder, and Neuropathy. The resident, who is cognitively intact, reported that the CNA raised her voice, yelled, and cursed at her when she requested hot chocolate. The CNA's behavior made the resident feel embarrassed, humiliated, and like a burden. The resident reported the incident to the Assistant Director of Nurses and later encountered the CNA again, who snapped at her for getting her in trouble. The facility's Abuse Prevention Program affirms the right of residents to be free from abuse, including verbal and mental abuse. The Abuse Investigation Report confirmed that the CNA engaged in inappropriate and unprofessional behavior directed towards the resident. The CNA was terminated after the conclusion of the investigation. The facility's administrator confirmed that the incident occurred as reported by the resident.
Insufficient RN Coverage
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on four of eighteen days reviewed for RN staffing, potentially affecting all 49 residents. The facility's nursing schedules from April 23, 2024, through May 10, 2024, revealed that on April 23, 25, and 27, only four hours of RN coverage were scheduled for each 24-hour period, and on April 29, no RN coverage was scheduled at all. This deficiency was confirmed by the Resident Care Coordinator on May 9, 2024, who verified the accuracy of the nursing schedule and acknowledged the insufficient RN coverage on the specified dates. The Long-Term Care Facility Application for Medicare and Medicaid report dated May 8, 2024, documented that 49 residents resided in the facility during this period.
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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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