La Bella Of Aurora
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Illinois.
- Location
- 1017 West Galena Boulevard, Aurora, Illinois 60506
- CMS Provider Number
- 145663
- Inspections on file
- 18
- Latest survey
- April 26, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at La Bella Of Aurora during CMS and state inspections, most recent first.
The facility failed to follow its approved menus, standardized recipes, and portion guidelines, resulting in residents receiving undersized protein portions and frequent omissions of planned foods and condiments. During a lunch observation, a protein entree of chicken sausage jambalaya was served in bowls that were mostly rice with minimal sausage, chicken, and beans; when the protein was weighed, it totaled less than 1 oz instead of the 2 oz specified on the recipe and diet spreadsheet. Multiple residents reported very small entree portions, frequent substitutions or omissions from the planned menu, and repeated shortages of items such as juice, butter, cheese, ham, and condiments including sugar, salt, pepper, ketchup, mustard, and mayonnaise, with one resident saving sugar packets to share with another. CNAs and dietary staff confirmed that the facility often ran out of condiments and some food items, that menus were not always followed, and that certain salad components were only provided if they happened to be in stock, contrary to the facility’s written menu planning and standardized recipe requirements.
The facility failed to provide a variety of appealing meal substitutions in line with resident preferences and its own written menu standards. Although the alternate menu listed deli sandwiches, grilled cheese, chef salads, and bread, residents and staff consistently reported that only grilled cheese, and occasionally ham sandwiches without cheese, were offered when residents refused the main meal. Resident council leaders and multiple residents stated they had repeatedly complained about the lack of variety and the removal of prior options such as hamburgers and pizza, without any resolution. CNAs, an LPN, and an RN confirmed frequent resident complaints and the limited substitution choices, while dietary staff and the Food Service Manager acknowledged that budget-driven changes had reduced the alternate menu and that key salad ingredients like tomatoes and cucumbers were not routinely stocked, resulting in monotonous and restricted substitution offerings.
A cognitively intact resident with multiple medical conditions arranged for a receptionist to store her car at the receptionist’s home and allow limited personal use of the vehicle. Over several weeks, the receptionist accepted $1,490 from the resident via an electronic payment app, stating that part of the money paid for release of the resident’s car from impound after the receptionist received a speeding ticket while driving it, and the rest was for car storage. The resident recalled only smaller payments for car cleaning, gas, and a holiday gift, denied paying for storage, and later noticed suspicious bank card transactions in the same city as the facility. The administrator and social worker knew the receptionist was storing the car but were unaware of the payments. This conduct violated facility policies prohibiting staff from accepting money or electronic payments from residents and led the resident to feel terrible and bothered that her hard-earned money may have been taken without her consent.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Staff failed to initiate CPR, call a code blue, or contact EMS for a resident with full code status who was found unresponsive. The resident was not assessed for clinical death or rigor mortis, and staff were unaware of code status and emergency procedures, resulting in Immediate Jeopardy due to noncompliance with facility policy and standards of practice.
The facility did not have a full-time RN serving as DON for an extended period after the previous DON resigned and stopped reporting to work. During this time, a corporate nurse visited only once a week, and no full-time DON was present to coordinate nursing care. This resulted in deficiencies in ADL care, urinary catheter care, IV care, oxygen therapy, medication management, infection control, and care planning for all residents.
Surveyors found that kitchen staff failed to maintain sanitary conditions, with grime and debris on food contact surfaces, improper storage of utensils and the ice scoop, and unresolved equipment issues. An LPN handled the ice scoop and obtained ice without hand hygiene or gloves, and hot foods were served below required temperatures until prompted to reheat, all contrary to facility policy.
The facility did not maintain complete infection surveillance records, failed to ensure staff used required PPE such as gowns during high-contact care for a resident on Enhanced Barrier Precautions, and did not enforce proper hand hygiene among nursing staff during medication administration and resident care. These deficiencies were observed across multiple staff and affected all residents in the facility.
The facility did not maintain complete Antibiotic Surveillance Logs and failed to evaluate infections using standardized criteria, as required by policy. Logs for multiple months were missing key information such as diagnosis, ordering practitioner, and documentation supporting necessity. The assigned Infection Preventionist was untrained and unavailable, and there was no evidence of required education or meeting records for antibiotic stewardship. This deficiency affected all residents in the facility.
The facility did not have a qualified IP with specialized infection control training after the previous DON left, and assigned the role to an MDS Nurse without the required training. Infection control surveillance tracking was incomplete for several months, and no infection control in-service training was provided to staff in the current year, contrary to facility policy.
Four residents with complex medical needs did not have comprehensive care plans addressing their individual requirements, including wound care, oxygen therapy, catheter care, and diabetes management. Observations and record reviews showed that care plans lacked measurable objectives and did not reflect physician orders or the residents' current conditions, contrary to facility policy.
Staff failed to accurately document and account for controlled medications, with discrepancies found between the number of tablets in blister packs and the amounts recorded on controlled drug forms. In one case, a blister pack had broken seals, and in several cases, medications were administered but not immediately signed out by an LPN, contrary to facility policy.
Surveyors found that several medications, including inhalers and insulin, were opened and not labeled with the date of first use, contrary to manufacturer and pharmacy guidelines. A nurse confirmed that these medications should have been dated to determine expiration.
The facility did not ensure that residents' POLST forms and physician orders were consistent, resulting in conflicting information about code status for several residents. In multiple cases, residents had signed DNR orders on their POLST forms, but their physician orders or care plans indicated full code status or lacked corresponding orders. Staff interviews revealed confusion and inconsistent processes for verifying code status in the EMR, leading to discrepancies in honoring residents' treatment wishes.
Three residents who required staff assistance for ADLs, including personal hygiene and grooming, were observed with unaddressed needs such as dirty fingernails and unshaven facial hair. Despite documented care plans and residents' requests for help, staff did not provide necessary grooming care or document refusals, resulting in unmet hygiene needs.
A nurse failed to further assess and document a change in a resident's breathing, and did not notify the physician as required by facility policy. The resident had multiple complex medical conditions and was observed making coughing-type noises while breathing, but no additional assessment or physician notification occurred.
A resident with a history of UTI and requiring toileting assistance was observed with an unsecured indwelling urinary catheter. During care, CNAs did not secure the catheter tubing or use a security device, and staff interviews confirmed that the catheter should have been anchored to prevent pulling and dislodgement.
A resident with significant weight loss and multiple medical conditions did not receive double protein portions as ordered by the physician, due to a lack of communication between nursing and dietary staff and the absence of a policy for notifying dietary of diet order changes. The resident consistently received only single portions at meals, despite ongoing weight loss and requests for more food.
A resident receiving IV antibiotics for osteomyelitis had a midline catheter dressing that was soiled and did not allow for visibility of the insertion site, preventing proper assessment and measurement. The dressing was not changed as ordered, and required documentation of site assessments and measurements was incomplete or inaccurate.
Two residents receiving oxygen therapy did not have their physician's orders for oxygen administration followed, and the facility failed to change and label oxygen and nebulizer tubing as required by policy. One resident received oxygen at a higher rate than ordered and lacked documentation of weekly tubing changes, while another reported tubing had not been changed in over a week and lacked proper labeling.
Two residents did not have pharmacy medication regimen review (MRR) recommendations addressed by facility staff or physicians. For one, recommendations regarding the ongoing use of scheduled guaifenesin and an as-needed psychotropic were not reviewed or documented, and for another, recommendations for lab monitoring and vitamin D supplementation were not acted upon. Required documentation and sign-off were missing, and staff responsible for handling these recommendations were unavailable.
Two residents with dysphagia and orders for thickened liquids were served ice cream and a nutrition shake that did not meet their prescribed consistency requirements. Staff provided these items despite care plans and facility policy specifying the need for nectar or honey thick liquids, and the speech language pathologist confirmed that the items given were not appropriate for the residents' dietary needs.
Two residents' room refrigerators were found to lack temperature monitoring, required thermometers, and proper labeling of stored foods, with staff interviews revealing confusion about responsibility for daily checks. Facility policy requiring daily temperature logs and labeling of prepared foods was not followed.
The facility failed to follow proper food storage and thawing procedures and did not maintain food service areas in a clean and sanitary manner. Observations included debris on the dish machine conveyor belt, smears and rust in the freezer, improperly stored and undated food items, and a dusty ice maker screen. The kitchen floor was also covered in dust and debris.
The facility failed to provide necessary splints and supportive equipment to two residents with hemiplegia and hemiparesis, resulting in a lack of treatment to maintain or improve their range of motion. Both residents were observed without the required devices, and recommendations for appropriate splints were made only after screenings by an occupational therapist.
The facility failed to implement fall interventions for a high-risk resident (R41) with hemiplegia, dementia, and other conditions. Despite a care plan requiring chair and bed alarms, these were not consistently used, leading to multiple falls, including a hip fracture. The facility's Fall Prevention Program policy was not adequately followed.
A resident with chronic respiratory conditions was observed using continuous oxygen without a physician's order, and the humidifier bottle was empty. The oxygen tubing and humidifier bottle were not labeled, and the nebulization mask was left uncovered, posing a risk of contamination. The Director of Nursing confirmed these deficiencies, which are against the facility's policy on oxygen administration.
The facility failed to maintain intact blister packs for controlled medications, compromising their safe and effective use. Observations revealed that blister packs of Lorazepam for three residents had broken seals that were taped over, contrary to facility policy. The DON confirmed that tampered packs should be destroyed to prevent drug theft and ensure medication safety.
The facility failed to ensure that a resident received a monthly medication regimen review (MRR) by a licensed pharmacist. The resident, with multiple medical diagnoses and on psychotropic medications, had no MRRs completed as required by the facility's policy. The Director of Nursing confirmed the absence of MRRs for the resident.
Failure to Follow Approved Menus, Portion Standards, and Maintain Food/Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to serve protein entrees and other menu items according to the facility-approved menus, standardized recipes, and portion guidelines for all residents receiving oral diets other than pureed diets. On the identified survey date, the census was 58 residents, with 7 on pureed diets, 1 NPO, and the remainder on regular, mechanical soft, low concentrated sweets, or no added salt diets. During lunch service, multiple residents were observed receiving bowls of jambalaya that contained mostly rice with only a few pieces of sausage, chicken, and beans. A test tray was obtained, and when the protein components were separated and weighed in the presence of the Administrator, the total protein was less than 1 ounce, despite the facility’s recipe card and diet spreadsheet specifying that the jambalaya entree should be served with an 8‑ounce spoodle and provide 2 ounces of protein. The Food Service Manager acknowledged that the cook should have served two 4‑ounce scoops to meet the required portion and stated that cooks were expected to review recipes to determine correct serving sizes and utensils. Residents, including the Resident Council President, reported that entree portions were very small, such as small squares of fried fish, and that the facility often did not serve the planned menus or ran out of foods like apple juice, butter, cereal, cheese, ham, and other items. Several residents stated that the facility frequently ran out of condiments such as sugar, salt, pepper, ketchup, mustard, and mayonnaise, and that juice was sometimes unavailable when it was listed on the menu. One resident reported having to save sugar packets from previous meals and share them with another resident because sugar was not provided with coffee. Residents also stated that they had repeatedly voiced these concerns during resident council meetings and at meals, but no resolutions were provided, leading at least one resident council leader to stop speaking up. Staff interviews and kitchen observations corroborated these concerns. CNAs reported that residents complained the facility ran out of condiments and that the planned menus were not always followed, with juice sometimes unavailable when it was supposed to be served. Kitchen staff, including cooks and food service workers, stated that the facility had been out of butter packets for at least a week and out of salt and pepper packets for several days, and that items such as cucumbers, tomatoes, and onions were not in stock. The Food Service Director confirmed that the facility was out of sugar, salt, pepper, and butter packets and that brown sugar was not available. The Food Service Director also explained that chef salads on the substitution list were limited to lettuce, American cheese, and deli meat, and only included tomato or cucumber if those items happened to be on the menu and in stock, as they were not specifically ordered for substitution salads, despite the facility’s written requirements that menus and standardized recipes be followed and that diet spreadsheets reflect appropriate portions for regular and therapeutic diets.
Failure to Provide Variety and Choice in Meal Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a variety of appealing meal substitutions consistent with resident preferences and the facility’s own policy. The facility census showed 58 residents, with 57 on oral diets, and the Alternate Menu listed deli sandwiches, grilled cheese, chef’s choice salad, and bread as substitution options. However, interviews and observations revealed that in practice residents were typically only offered grilled cheese sandwiches, with occasional ham sandwiches that were served without cheese. The Food Service Manager reported that hamburgers, hot dogs, and pizza had been removed from the substitution menu after a budget review, and that the alternate list was reduced to deli sandwiches and grilled cheese. Multiple residents, including resident council leaders, stated they did not like the food served and that the only consistent substitution offered was grilled cheese, despite the facility’s written list of other options. Residents reported that they had previously been offered a wider variety of substitutions such as pizza and hamburgers, but those options were no longer available. Some residents stated they had repeatedly voiced concerns at meals and during resident council meetings about the lack of variety and appealing choices, but no changes were made, leading at least one resident to stop speaking up because complaints did not result in any resolution. Staff interviews corroborated the residents’ complaints. Several CNAs and nursing staff stated that residents frequently complained about the food, the lack of variety, and the limited substitutions, confirming that grilled cheese was essentially the only substitute offered. The Food Service Manager acknowledged that the chef salad on the substitution list was limited to lettuce, American cheese, and deli meat, and that items like tomato and cucumber were only included if they happened to be on the main menu and in stock, as they were not ordered specifically for substitution salads. During a lunch observation, kitchen staff confirmed that there were no cucumbers, tomatoes, or onions available, and grilled cheese sandwiches were seen prepared in a steamtable pan on the serving line, further demonstrating the restricted and repetitive nature of the substitution offerings.
Failure to Prevent Staff Financial Exploitation of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial exploitation and misappropriation of funds by a staff member. The resident had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus without complications, generalized muscle weakness, unspecified lack of coordination, and anxiety disorder, and was assessed as cognitively intact on a recent MDS. After a car accident and admission to the facility, the resident arranged for the facility receptionist to store her car at the receptionist’s home, with the understanding that the receptionist could use the car for personal errands. The resident later noticed suspicious transactions on her bank statements showing use of her bank card in the same city as the facility and reported that she did not recognize the charges. During interviews, the receptionist admitted that from January through February she received a total of $1,490 from the resident via a phone-based electronic payment application. The receptionist described that the resident would state she wanted to give money for storing the car, and the resident would enter the amount and tap her credit card on the receptionist’s phone to complete the transaction. The receptionist stated that $500 of this amount was used to pay for the release of the resident’s car from impound after the receptionist received a speeding ticket while driving the car, and that the remaining $990 was given randomly as payment for storing the car. The receptionist also stated she did not know she was prohibited from receiving money or financial compensation from residents. In contrast, the resident recalled giving the receptionist money for cleaning the car, gas on at least two occasions, and some money around Christmas, all sent through the phone, but denied paying for car storage. The resident expressed suspicion that the receptionist might be using her bank card but could not be certain. The administrator and social worker both acknowledged knowing that the receptionist was storing the resident’s car but denied knowing that the receptionist was receiving money from the resident or that the resident paid for the car’s release from impound due to the receptionist’s speeding ticket. Facility policies in effect prohibited abuse, exploitation, and misappropriation of resident property and specifically barred staff from requesting, borrowing, soliciting, or accepting money, gifts, or electronic payments from residents. The resident stated she felt terrible and bothered at the thought that someone from the facility might be taking her hard-earned money without her consent and that she might lose sleep over it.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Initiate CPR and Emergency Response for Full Code Resident
Penalty
Summary
Facility staff failed to perform CPR according to standards of practice, did not call a code blue, and did not contact emergency medical services (911) for a resident who was identified as full code on physician orders and in accordance with facility policy. The resident, who had a history of right femur fracture, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea, and cerebral infarction, was admitted for rehabilitation and was documented as a full code. The resident was found unresponsive, without a pulse, and cool to the touch by a registered nurse, who did not immediately initiate CPR, did not bring the crash cart, and did not use the intercom system to announce a code blue. The nurse was unaware of the resident's code status at the time and sought guidance from a former DON by phone, who instructed her to stop compressions and not to call 911. No assessment for clinical death or rigor mortis was documented. Other staff present during the incident also failed to take appropriate action. An LPN responded to a call for assistance but did not assess the resident, did not call a code blue, did not bring the crash cart, and did not call 911. A CNA entered the room to assist with cleaning the resident but did not initiate emergency procedures or call for help. Staff interviews revealed a lack of knowledge regarding code blue procedures, use of the intercom system, and the process for pronouncing death. The facility did not have a policy regarding nurses determining or pronouncing death, and there was no investigation conducted regarding the resident's death at the time. The facility's policy required immediate action in medical emergencies, including initiation of CPR, announcement of code blue, and calling 911 for residents with full code status. However, these procedures were not followed for the resident in question. The deficiency was identified as Immediate Jeopardy, affecting multiple residents with full code status, due to the failure to provide basic life support and follow established emergency protocols.
Removal Plan
- Administrator/designee will provide training for all staff on Medical Emergency Response and CPR policy. This includes the employee who first witnesses or is first on the site of a medical emergency will initiate immediate action. The training also includes if a resident experiences cardiac arrest or unresponsiveness, the facility staff will provide basic life support including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives. The training will continue until all staff have attended. Agency staff and staff who missed the training will receive training prior to working their next scheduled shift.
- Administrator/designee will provide training for all staff on Resident Rights regarding Treatment and Advance Directives.
- Provide Mock Code evaluation drills in a Mandatory Meeting and continue until all staff have attended a drill. The Mock Code Blue Audit tool will be used during the drill as a guide for staff roles and tasks during a Code Blue. The Administrator/designee will provide the training. The training will continue until all staff have been trained.
- The Maintenance Director will provide training on the use of the intercom system, to announce Code Blue on the overhead page, to all staff, as part of the Mock Code evaluation drills. The training will continue until all staff have been trained.
- The facility developed a process to determine if a resident has executed an advance directive. The Social Service Director reviewed Advance Directive with the residents, and the process is ongoing.
- Upon admission, the Nurse will ensure a resident with an advance directive, will communicate the resident's choice to the Health Care Practitioner and obtain the order, and provide a copy of the Advanced Directive to Social Services/designee, and ongoing.
- The Facility Quality Assurance Committee (Administrator, Regional Director of Operations, Regional Clinical Director and Medical Director) met to review the F678 IJ (Immediate Jeopardy).
- The Facility created a Quality Assurance audit tool to be used by the DON (Director of Nursing)/Designee, for all Licensed Nurses, for Medical Emergency Response. The Audit will be done with every nurse and then twice weekly with random nurses. The results of the Audits will be reviewed with the QA (Quality Assurance) Committee at their monthly meetings.
- The Facility created a QA audit tool to be used by Social Service/designee to assess all new admissions and readmissions for Code Status and or POLST orders, care plan and update the list of resident code status. The audit tool will be done daily, then monthly and then quarterly.
Failure to Maintain Full-Time DON Results in Multiple Care Deficiencies
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was assigned to serve as a full-time Director of Nursing (DON) to coordinate nursing care and supervision for all 52 residents. According to the facility's records and staff interviews, the designated DON resigned and did not return to work after April 4, 2025, despite initially stating her resignation would be effective May 2, 2025. The facility did not receive an official resignation letter, and the DON did not perform her duties from April 4 onward. During this period, a corporate nurse visited only once a week, and there was no full-time RN serving as DON until a new DON was hired to start on April 22, 2025. During the survey conducted from April 15 through April 18, 2025, it was observed that the absence of a full-time DON led to deficiencies in several areas, including activities of daily living (ADL) care, urinary catheter care, intravenous (IV) care, oxygen therapy and care, medication labeling, controlled medication inventory and storage, addressing pharmacy recommendations, infection control surveillance, advance directives, and care plan development. These deficiencies affected all residents in the facility during the period without a full-time DON.
Failure to Maintain Sanitary Kitchen Practices and Food Safety Standards
Penalty
Summary
Surveyors observed multiple unsanitary practices in the facility kitchen affecting all 52 residents who received food prepared there. The hand sink area was found to be soiled with unknown grime and contained used scrub pads, which were reportedly used for prewashing dishes due to limited space. The kitchen's two-door steel refrigerator had visible grime and smears on its handle and surface, and a pan of stagnant water was placed inside to catch drips from an unresolved leak that had been previously identified in the last annual survey. Additional observations included a prep station drawer and shelves beneath a workstation that stored cooking utensils and pans, all of which had accumulated dust, food debris, and grime. The ice scoop was stored on a dusty workstation with unknown debris, and staff were unclear about proper storage procedures for the scoop. Further, an LPN was seen entering the kitchen, taking the ice scoop from the unclean workstation, and using it to get ice for a water pitcher without washing hands or wearing gloves. During meal service, the cook was prompted to check food temperatures, revealing that pureed spaghetti and garlic bread were below the required 135 degrees Fahrenheit, necessitating reheating. The facility's own policies require clean and sanitized storage of utensils and equipment, proper handling and storage of ice and scoops, and monitoring of food temperatures to prevent foodborne illness, all of which were not followed as observed during the survey.
Infection Control Deficiencies: Incomplete Surveillance, Improper PPE, and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by incomplete infection surveillance, improper use of personal protective equipment (PPE), and inadequate hand hygiene practices among staff. The infection surveillance logs for January, February, and March 2025 were missing critical data such as infection site, organism, lab/culture results, symptoms, isolation/precautions, and whether infections were acquired in the facility. Additionally, there was no infection surveillance conducted for April 2025, and the designated Infection Preventionist had not received appropriate training. During direct care, staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with multiple medical diagnoses, including paraplegia and a urinary tract infection, who had an indwelling urinary catheter and intravenous catheter. Certified Nursing Assistants provided high-contact care activities such as peri-care, catheter care, and transfers without wearing required isolation gowns, although they did change gloves and sanitize hands between tasks. Nursing staff also failed to perform proper hand hygiene during medication administration and resident assessments. One nurse wore the same gloves while performing multiple tasks, including blood glucose checks and handling the medication cart, without changing gloves or performing hand hygiene. Another nurse moved between residents and tasks, such as adjusting oxygen tubing, checking blood glucose, and administering medications, without performing hand hygiene between residents or tasks. These actions were inconsistent with the facility's hand hygiene policy, which requires hand hygiene before and after resident care, between tasks, and between residents, regardless of glove use.
Incomplete Antibiotic Surveillance and Lack of Infection Evaluation
Penalty
Summary
The facility failed to maintain complete documentation on its Antibiotic Surveillance Log and did not evaluate the presence of infection using standardized criteria as required by its own policy. The Antibiotic Surveillance Logs for January, February, and March were incomplete, with missing information such as diagnosis for antibiotic use, ordering practitioner, documentation supporting necessity, and whether the antibiotic was ordered upon admission. For example, in January, 4 out of 11 residents lacked a diagnosis for antibiotic use, and 10 out of 11 had missing data in key columns. Similar patterns of incomplete documentation were observed in the logs for February and March. Additionally, there was no Antibiotic Surveillance Log available for April, and the staff member assigned as Infection Preventionist was not trained and unavailable for interview. The facility was unable to provide completed assessment forms that defined infections using recognized criteria such as McGeer, Loeb's Minimum, or NHSN surveillance definitions. Furthermore, there were no records of antibiotic stewardship meeting minutes or documentation of education provided to physicians, staff, residents, or families, as outlined in the facility's policy. This deficiency applied to all 52 residents in the facility, indicating a systemic failure to implement and monitor the antibiotic stewardship program as required.
Failure to Designate Qualified Infection Preventionist and Maintain Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was designated and responsible for the infection prevention and control program. The previous IP, who was the Director of Nursing, left the facility on April 4, 2025, and the duties were assigned to the MDS Nurse, who had not completed specialized training in infection prevention and control. The Administrator confirmed that there was no staff member onsite who had completed the required specialized training in infection control at the time of the survey. Additionally, infection control surveillance tracking provided for January, February, and March 2025 was found to be incomplete, and there was no tracking available for April 2025. The most recent infection control in-service training for staff was conducted in December 2024, with no further training provided in 2025. The facility's policy requires the IP to lead surveillance activities, maintain documentation, and report findings, but these responsibilities were not being fulfilled due to the lack of a qualified IP and incomplete surveillance documentation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the individualized needs of four residents, as identified through observation, interview, and record review. One resident with multiple diagnoses, including diabetes and a stage 3 pressure ulcer, did not have a care plan addressing the pressure ulcer or its prevention, despite ongoing wound care and physician orders for barrier cream. Another resident receiving continuous oxygen therapy for acute respiratory failure and chronic obstructive pulmonary disease lacked a care plan for oxygen administration or management of respiratory conditions, even though physician orders specified oxygen requirements and the resident was observed using oxygen. A third resident with a urinary catheter and moderate cognitive impairment required assistance with grooming and hygiene but had no care plan addressing ADL support or catheter care. Observations revealed the resident's catheter was not secured, and nail and facial hair care were not provided, despite the resident's cooperation during care. Staff did not offer or document grooming services, and the care plan did not reflect these needs. The fourth resident, admitted for wound care following a partial foot amputation due to diabetic complications, had no care plan addressing diabetes management or wound care, even though the resident was observed with a wound dressing and ambulating independently. Facility policy requires that comprehensive, person-centered care plans be developed within seven days of completing the MDS assessment, addressing all identified needs and services. However, the care plans for these residents did not include measurable objectives or timeframes for their specific medical, nursing, and psychosocial needs, as required by professional standards and facility policy.
Failure to Accurately Account for and Store Controlled Medications
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications and did not maintain proper storage of narcotic medications in sealed packaging. During a medication count with a nurse, it was observed that one resident's blister pack of Tramadol had broken seals on two tablets. For three other residents, the number of controlled medication tablets remaining in their blister packs did not match the amounts recorded on the controlled drug receipt/record/disposition forms. In each case, the nurse stated that the medication had been administered but not yet signed out on the required documentation. The facility's policy requires that controlled medications be documented in the Medication Administration Record and signed out on the controlled drug record immediately after administration. Additionally, any controlled medication with a broken seal should be disposed of with a witness to prevent discrepancies or diversion. These requirements were not followed, resulting in discrepancies between the physical count of medications and the documentation, as well as improper storage of controlled substances.
Failure to Date Opened Medications for Expiration
Penalty
Summary
Surveyors observed that multiple medications in the facility were not labeled with the date they were opened, as required to determine their expiration dates. Specifically, an inspection of the medication cart revealed that Incruse Ellipta and Fluticasone Furoate/Vilanterol Ellipta inhalers, as well as Insulin Lispro and Insulin Lantus, were opened but not dated. Manufacturer and pharmacy guidelines for these medications require dating upon opening to ensure proper disposal after a specified period. A corporate nurse confirmed that these medications should have been dated when first opened.
Inconsistent Documentation of Advance Directives and Code Status Orders
Penalty
Summary
The facility failed to ensure that residents' advance directives, specifically their POLST forms and physician orders, were consistent and accurately reflected their treatment wishes in the event of a medical emergency. In three cases, residents had signed POLST forms indicating Do Not Attempt Resuscitation (DNR), but their physician orders and care plans either indicated full code status or did not have corresponding orders, resulting in conflicting information about their code status. For example, one resident with multiple diagnoses, including end-stage renal disease and a kidney transplant, was cognitively intact and had a signed POLST indicating DNR, but the active physician order and care plan listed the resident as full code, instructing staff to attempt resuscitation. Staff interviews revealed confusion and reliance on different sources within the electronic medical record (EMR) to determine code status. LPNs reported checking the EMR dashboard and active orders, but these did not always match the signed POLST forms. In one instance, a nurse acknowledged the conflicting information between the dashboard, active order, and POLST, and another nurse was unable to locate the POLST in the EMR due to unfamiliarity with the system. The facility's process involved social services uploading POLST forms and updating care plans, but only nursing staff entered orders, leading to gaps in communication and documentation. The facility's policy required that advance directives be reviewed upon admission, communicated to staff, and periodically reviewed during care planning. However, in these cases, the policy was not followed, resulting in discrepancies between residents' documented wishes and the orders available to staff during emergencies. This failure to ensure consistency and proper communication of advance directives affected multiple residents and was confirmed through record review and staff interviews.
Failure to Provide Grooming and Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene assistance to residents who required help with activities of daily living (ADLs). One resident was observed in the dining room with black and brown substances under her fingernails, brownish discoloration of the nail beds, and curly facial hair on her chin. Despite being pleasant and cooperative during peri-care and catheter care, staff did not offer nail care or shaving, and there was no documentation of refusal or a care plan indicating non-compliance. The resident's Minimum Data Set (MDS) indicated a need for assistance with personal hygiene. Two additional residents, both with significant physical or cognitive limitations, were observed with long, unshaven facial hair and both expressed a need and desire for staff assistance with shaving. One had contractures in both hands and was moderately cognitively impaired, while the other was legally blind and required total assistance for personal hygiene. Both residents' care plans documented their dependence on staff for ADLs, yet staff failed to provide the necessary grooming assistance as observed and confirmed by interviews.
Failure to Assess and Notify Physician After Change in Resident's Breathing
Penalty
Summary
A deficiency occurred when a nurse failed to further assess a resident after observing a change in breathing during an overnight shift. The resident, who had multiple diagnoses including a right femur fracture, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea, and a history of cerebral infarction, was noted to be making coughing-type noises while breathing during rounds. Despite this observed change, the nurse did not conduct a further assessment or document the observation in the resident's progress notes. Additionally, the resident's physician was not notified of the change in condition, which was contrary to the facility's policy requiring physician notification and documentation when there is a change in a resident's status that may require new treatment.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infection and requiring assistance with toileting and hygiene was observed with an unsecured indwelling urinary catheter. During multiple observations, the resident was seen in a wheelchair with the catheter bag hanging under the seat and the catheter tubing hanging loosely, without any securing device in place. Certified Nursing Assistants providing peri-care and catheter care did not secure the catheter or apply a security device. Interviews with nursing staff confirmed that the catheter should have been secured to prevent pulling, dislodgement, and to ensure proper placement.
Failure to Provide Double Protein Portions for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when a resident with a history of significant weight loss and multiple medical conditions, including hemiplegia, aphasia, end-stage heart failure, chronic kidney disease, and metastatic prostate cancer, did not receive double portions of protein as ordered by the physician. The resident's diet order specified a general diet with mechanical soft texture, regular/thin consistency, and double proteins at each meal, along with super cereal at breakfast. Despite this, the resident consistently received only single portions of protein at meals, as confirmed by both the resident and direct observation during meal service. The diet card and dietary spreadsheet reflected only a single portion, and the dietary manager was unaware of the double protein order. Interviews revealed that the dietitian had recommended super cereal but was not involved in the double protein order, which originated from nursing and was documented in the physician order sheet. The regional director of operations confirmed that the facility lacked a policy or procedure for notifying dietary staff of diet order changes. The resident's care plan included interventions to provide diet and supplements as ordered, but these were not implemented, resulting in the resident not receiving the prescribed nutritional support despite ongoing weight loss and expressed requests for additional food.
Failure to Maintain Visible and Clean IV Dressing for Resident with Midline Catheter
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) antibiotics for osteomyelitis was found to have a midline catheter dressing that did not allow for proper assessment of the insertion site. The dressing consisted of gauze, which was soiled with dry blood, covered by a transparent dressing that was stained, wrinkled, and loose at the edges. The insertion site was not visible for assessment, and the dressing had not been changed in accordance with physician orders, which specified weekly changes and as needed if soiled. The resident was unable to recall when the dressing was last changed, and observations over multiple days confirmed the dressing remained unchanged and soiled. Nursing staff reported difficulty in accurately measuring the IV line and arm circumference due to the non-visible insertion site, despite documentation requirements to record these measurements every shift. The Medication Administration Record (MAR) showed inconsistent or missing documentation for arm circumference and dressing changes. The resident's care plan required regular assessment of the IV site for signs of infection or complications, but the site was not visible due to the dressing method used. These actions and inactions resulted in the failure to ensure the safe and appropriate administration of IV fluids and proper monitoring of the IV site.
Failure to Follow Oxygen Therapy Orders and Tubing Change Protocols
Penalty
Summary
The facility failed to follow physician orders for oxygen administration and did not ensure that oxygen and nebulizer tubing were changed and labeled according to facility policy for two residents. One resident with COPD and chronic respiratory failure was observed receiving oxygen at a rate higher than the physician's order, and the oxygen tubing and humidifier bottle were not labeled to indicate when they were last changed. The resident's care plan required weekly changing and labeling of the oxygen tubing, but there was no documentation in the medical or treatment records to show this was done. A registered nurse adjusted the oxygen flow to the correct rate during the observation, and the corporate nurse confirmed that both the physician's order and care plan interventions should have been followed. Another resident with acute respiratory failure and COPD was found receiving oxygen at the ordered rate, but reported that the nasal cannula had not been changed in at least two weeks and the nebulizer tubing had not been changed in over a week. Neither the nasal cannula nor the nebulizer tubing were labeled with the date of last change. Facility policy required weekly changing and labeling of oxygen tubing and changing nebulizer tubing every 72 hours or as needed, but these procedures were not followed for either resident.
Failure to Address Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address pharmacy medication regimen review (MRR) recommendations for two residents reviewed for unnecessary medications. For one resident with multiple chronic conditions, including COPD, heart failure, and morbid obesity, the pharmacist repeatedly recommended reviewing the continued need for scheduled guaifenesin and the appropriateness of a long-standing as-needed lorazepam order. Despite these recommendations, there was no documentation that the physician or facility staff reviewed or acted upon them, and the resident continued to receive guaifenesin as scheduled, while lorazepam had not been administered for several months. For another resident with vascular dementia, schizoaffective disorder, and other neurological conditions, the pharmacist recommended assessing the need for a valproic acid level and considering vitamin D supplementation due to a low lab value. The MRR forms for this resident were not signed off by the attending physician, and there was no documentation that the recommendations were reviewed or addressed. Interviews confirmed that the staff member responsible for receiving pharmacy recommendations was unavailable, and the facility's policy required staff to act upon all MRR recommendations, which was not followed in these cases.
Failure to Provide Properly Modified Diet Consistencies for Residents on Thickened Liquids
Penalty
Summary
The facility failed to provide appropriate modified diet consistencies for two residents who required thickened liquids due to their medical conditions. One resident with diagnoses including Parkinson's disease, dementia, and dysphagia was ordered a pureed diet with nectar thickened liquids, but was observed receiving a bowl of ice cream along with their meal. The resident's meal ticket and care plan both indicated the need for pureed texture and nectar thick liquids, yet the inclusion of ice cream did not meet these requirements. Another resident with a history of cerebral infarction, hemiplegia, vascular dementia, and oropharyngeal dysphagia was ordered a pureed diet with honey thick liquids. This resident was also observed receiving a bowl of ice cream and a nutrition shake (mighty shake) that was not at the required honey thick consistency. The dietary manager stated that ice cream was considered thick and that the shake was already thickened, but the speech language pathologist clarified that ice cream melts to a thin liquid and that the mighty shake was only nectar thick, not honey thick. Facility policy also specified that items like ice cream and shakes that change consistency at room or body temperature are not appropriate for residents on thickened liquids.
Failure to Maintain Safe and Sanitary Resident Refrigerators
Penalty
Summary
The facility failed to maintain resident room refrigerators in a safe and sanitary manner for two residents reviewed for personal food storage. During observations, one resident's refrigerator contained multiple food items, including prepared foods in unlabeled containers, cartons of milk, and other perishable items, none of which were labeled with dates as required by facility policy. Additionally, neither refrigerator had a thermometer inside, and there were no temperature logs present. The resident stated that her family brings the food, but there was no indication that the food was being monitored for safety or compliance with the facility's policy. Interviews with facility staff revealed a lack of clarity regarding responsibility for monitoring the refrigerators. A CNA was unsure who was responsible for checking the refrigerators, while the Housekeeping Director stated that refrigerators are checked only once a month for expired items and cleaned at that time, but temperatures are not monitored. Facility policies require that all prepared foods be labeled and dated, consumed within three days, and that refrigerator temperatures be logged daily and maintained at or below 41 degrees Fahrenheit. These procedures were not being followed, resulting in the deficiency.
Failure to Maintain Sanitary Food Storage and Preparation Areas
Penalty
Summary
The facility failed to follow proper food storage and thawing procedures and did not maintain food service areas in a clean and sanitary manner. During an initial tour of the kitchen, a cook was observed unloading cleaned dishes onto a conveyor belt with unidentifiable debris and food particles. The reach-in freezer had unknown smears, rust, and extensive blackish substance and debris on the inside compartments and racks. Multiple open and undated hamburger patties were stored improperly, and a half-drunk chocolate milkshake was found on the top shelf. The reach-in refrigerator had smears, dust, and a wobbling door, with a large pan collecting water from a leaking condenser. Inside, there were improperly stored and undated deli meats. Additionally, raw frozen meat was improperly thawing in a 3-compartment sink without running water, and the ice maker screen was covered with extensive dust, blowing into the food prep area. The kitchen floor under the stove and shelving was covered in dust and unknown debris. A follow-up visit revealed that the freezer still had extensive blackish substance on the shelving and side compartments, with undated packages of diced chicken and ravioli. The refrigerator continued to have a large pan of water collecting on the top shelf, with unidentifiable streaks, smears, and dust on the outside panel and door handles. The ice maker screen remained dusty, and the floor under the stove and prep areas was still covered in dust and unknown debris. The dietary manager acknowledged that all items placed in the freezer or refrigerators should have been labeled and dated and that the kitchen is cleaned daily and deep cleaned weekly. Facility policies on sanitation and food safety were not adhered to, leading to these deficiencies.
Failure to Provide Necessary Splints and Supportive Equipment
Penalty
Summary
The facility failed to provide treatment and services to increase range of motion and prevent a further decrease in range of motion for two residents. Resident 26, who has hemiplegia and hemiparesis following a cerebral infarction, was observed without a splint despite having left side weakness and a history of using a splint at a previous facility. The resident had not been provided a splint since admission to the current facility. An occupational therapist later recommended a hand splint for Resident 26 after a screening was conducted at the request of the Director of Nursing. Resident 43, who also has hemiplegia and hemiparesis following a cerebral infarction, was observed without a splint or supportive device for his right hand and arm, despite having functional limitations in range of motion. The resident's mother provided a splint, which the resident found comfortable. An occupational therapist screened Resident 43 and recommended a right hand splint and right arm sling to prevent contracture and for proper positioning. The therapist also suggested discontinuing the use of a previously ordered pool noodle splint at night in favor of the new devices.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to have fall interventions in place for a resident (R41) who was at high risk for falls. R41, diagnosed with hemiplegia, hemiparesis, dementia, and other conditions, was observed without a chair alarm on multiple occasions despite being assessed as a high fall risk. Interviews with staff revealed that R41 had a history of falls, including a significant fall resulting in a hip fracture. The MDS Coordinator (V4) confirmed that R41 should have had a chair and bed alarm as part of his fall prevention care plan, but these interventions were not consistently implemented. The chair alarm was found in R41's closet instead of being used as intended. R41's care plan documented several falls with various interventions, including reminders to place sandals out of the walking path and supervision during weight-bearing activities. Despite these documented interventions, the facility's failure to consistently use the chair and bed alarms as specified in the care plan contributed to the deficiency. The facility's Fall Prevention Program policy required individualized care and services to minimize fall risks, but the lack of adherence to these protocols for R41 indicates a lapse in following the established guidelines.
Failure to Obtain Physician's Order and Properly Manage Oxygen Administration
Penalty
Summary
The facility failed to ensure that a physician's order was obtained for the administration of oxygen for a resident with chronic obstructive pulmonary disease and acute and chronic respiratory failure. The resident was observed using continuous oxygen via nasal cannula without a physician's order, and the humidifier bottle attached to the oxygen concentrator was empty. Additionally, the oxygen nasal cannula tubing and humidifier bottle were not labeled, and the nebulization mask was left uncovered on the bedside table, posing a risk of contamination. The resident reported dry nostrils due to the empty humidifier bottle, and staff were unaware of when the nasal cannula tubing and humidifier bottle were last changed. The Director of Nursing confirmed that there should be a physician's order for oxygen use and that the humidifier bottle should not be empty when the oxygen concentrator is running. The Director also acknowledged that the oxygen nasal cannula tubing and humidifier bottle should be labeled, and the nebulization mask should be covered when not in use to prevent contamination. The facility's policy on oxygen administration requires a physician's order, proper labeling, and regular changing of humidifier bottles and nebulizer tubing to ensure infection control and proper respiratory care.
Failure to Maintain Intact Blister Packs for Controlled Medications
Penalty
Summary
The facility failed to ensure that blister packs containing controlled medications were maintained intact, compromising the safe and effective use of these medications. During an observation of medication cart #2, it was found that a blister pack of Lorazepam 2 mg for one resident had 28 intact tablets and one additional tablet with a broken seal that was taped over. Similarly, another resident's blister pack of Lorazepam 1 mg had 29 intact tablets and one additional tablet with a broken seal that was taped over. The registered nurse present during the observation was unaware of who had taped the blister packs. In another instance, during an observation of medication cart #1, a blister pack of Lorazepam 1 mg for a third resident was found to have 41 intact tablets and one additional tablet with a broken seal that was taped over. The Director of Nursing confirmed that tampering with blister packs, including taping over broken seals, is not acceptable practice and that such tampered packs should be destroyed to prevent drug theft, misappropriation, and to ensure medication safety. The facility's policies on controlled substance administration and destruction of unused drugs were not followed, as they require the destruction of any tampered blister packs.
Failure to Conduct Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a resident received a monthly medication regimen review (MRR) by a licensed pharmacist. This deficiency was identified for a 75-year-old female resident who was admitted with diagnoses including Dementia, Hypertension, Delusional Disorders, Depression, Hyperlipidemia, Osteoarthritis, and Anxiety. The resident's medication orders included Seroquel for delusional behavior and Venlafaxine Hydrochloride Extended Release for depression. A review of the resident's medical record on May 14, 2024, revealed no completed MRRs by the pharmacist. The Director of Nursing confirmed that no MRRs had been conducted for the resident, despite the facility's policy requiring monthly reviews and the resident's care plan indicating the need for pharmacy consultation.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
