Manor Court Of Freeport
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Illinois.
- Location
- 2170 West Navajo Drive, Freeport, Illinois 61032
- CMS Provider Number
- 146102
- Inspections on file
- 39
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Manor Court Of Freeport during CMS and state inspections, most recent first.
Insufficient nursing staff on multiple shifts led to delayed medication administration for several residents. On a weekend day when a scheduled nurse called off and was not promptly replaced, two LPNs reported that an entire hallway did not receive morning meds on time and that one nurse sometimes had to pass meds to 38 residents. Multiple residents reported receiving morning, midday, and pain medications, as well as blood glucose checks and insulin, significantly later than scheduled, often after meals. Medication administration records confirmed that doses such as insulin, antihypertensives, carbidopa-levodopa, gabapentin, and other routine meds were given well past their ordered times. Resident council minutes from the prior month also documented ongoing concerns about second-shift pills being passed late at night.
Multiple residents did not receive medications and blood glucose checks at their prescribed times when one of three scheduled day-shift nurses called off, leaving the unit short-staffed. An LPN discovered an entire hallway had not received morning medications until late morning, resulting in residents receiving anticonvulsants, diuretics, neuropathic pain medications, antihypertensives, and insulin significantly past their scheduled administration times and, in some cases, after meals. Residents reported having to seek out nurses for overdue medications and experiencing frequent delays, while the DON acknowledged that medications and insulin are required to be administered per MAR schedules and prior to meals.
The facility failed to ensure residents were free from significant medication errors when, on a short-staffed weekend day, an entire hallway did not receive morning medications on time and several residents reported and demonstrated delayed medication and blood glucose administration on their MARs. One resident with multiple conditions, including type 2 DM and seizures, received blood sugar checks and morning medications, including insulin, well after breakfast and outside ordered time frames. Another resident with Parkinson’s disease and hip pain received carbidopa-levodopa and gabapentin hours after their scheduled times, while a third resident with hypertensive heart disease received hydralazine late despite elevated BP. A fourth resident with DM had blood sugars checked and glargine insulin administered later than ordered and after meals, contrary to the DON’s stated expectation that medications and blood sugars be given according to the MAR and prior to meals.
A resident with severe cognitive impairment and dementia was found in bed with a pillow over her face while her severely cognitively impaired roommate, who has Alzheimer’s disease and a history of nighttime wandering, was standing over her. Two CNAs discovered the situation during a bed check, removed the pillow, and took the standing resident from the room; the resident in bed did not initially appear distressed but became agitated when awakened before calming after reorientation. The CNAs reported difficulty finding a nurse and each believed another staff member was reporting the event, leading to a significant delay before the Memory Care Director, DON, and administrator were notified, despite facility policy requiring immediate reporting of alleged abuse.
A resident with dementia and severe cognitive impairment was found in bed with a pillow over her face and her severely cognitively impaired roommate standing over her, after the roommate had been wandering and redirected back to the room. Two CNAs discovered the situation during a bed check, removed the pillow, and separated the residents, but did not immediately report the incident to nursing staff or appropriate authorities. Subsequent staff coming on shift were not informed of the event, and leadership only learned of it later that day, despite a facility abuse policy requiring immediate reporting of alleged abuse.
A resident with dementia, impaired mobility, and identified risk for pressure ulcers did not receive consistent, documented weekly skin assessments or timely treatment for a developing pressure injury. Although the care plan called for skin checks each shift and assistance with turning and repositioning, there were no physician orders for weekly skin assessments, and after staff first noted an unstageable pressure injury on the hip, several days passed without documented treatment orders or care. A wound physician later documented a full-thickness Stage 3 pressure ulcer that had been present for more than one day, which progressed and, after surgical debridement, was staged as a Stage 4 ulcer. Interviews with RNs, the DON, and the wound care physician confirmed that routine skin assessments were not consistently completed or documented, and that the wound’s condition indicated it should have been identified earlier.
A resident with multiple chronic conditions had a physician order and POLST indicating DNR/No CPR, but the EMR banner listed the resident as “Full Code,” and the POLST was not timely scanned into the record. After the resident fell, an RN informed EMS that the resident was a full code based on the EMR banner, and EMS initiated full resuscitative efforts when the resident became pulseless. The DON and wound care nurse reported that residents are treated as full code until paperwork is received and that the admitting nurse would not have entered a DNR order without having the POLST, indicating the facility possessed the DNR documentation but failed to update the EMR banner, resulting in resuscitation contrary to the resident’s advance directive.
A resident with a stage 4 sacral pressure ulcer and CT-confirmed osteomyelitis did not receive the ordered oral antibiotic linezolid as prescribed, resulting in multiple missed doses. The wound physician ordered ciprofloxacin and linezolid for an extended course, but only linezolid was entered as a physician order, and the MAR showed that only a fraction of scheduled doses were administered. Facility staff reported that the contracted pharmacy flagged linezolid as a high-cost medication, supplied only a few days’ worth, and that the DON and others were attempting to secure coverage through the VA while continuing ciprofloxacin. The family was told they could not bring in cheaper medications from an outside pharmacy, and the administrator stated that high-cost drugs must go through the contracted pharmacy or VA. The DON later reported that the resident’s POA declined treatment after learning the cost, and that they discussed holding the medication and IV alternatives with the physician, but these discussions were not documented in the record until later, contrary to the facility’s policy requiring medications to be administered as prescribed.
A resident's HPOA was not notified by staff after the resident fell from bed, despite facility policy and documentation indicating the intent to notify. The HPOA only learned of the fall from another family member, and staff later acknowledged the failure to notify immediately after the incident.
A resident with limited mobility and cognitive impairment was manually lifted back into bed by staff after a fall, rather than being transferred with a mechanical lift as required. Staff used a blanket as an improvised sling, and the DON confirmed this was not an approved method for resident transfer.
Staff failed to consistently use wheelchair footrests when transporting residents, resulting in unsafe mobility and an incident where a resident fell from a wheelchair and sustained a head laceration requiring sutures. Multiple staff acknowledged the expectation to use footrests for safety, but this was not consistently practiced, and there was no formal written policy in place.
A resident with severe cognitive impairment missed an evening dose of medication, which was later found by a family member and returned to an LPN. The LPN disposed of the pills but did not document the incident or notify the physician, and the facility lacked a policy for medication errors. The required medication error report and physician notification were not completed.
A resident with severe cognitive impairment did not receive her prescribed evening medications, which were later found in her room by a family member. An LPN disposed of the missed medications without documenting the incident or reporting it, and the MAR incorrectly showed the medications as given. The facility lacked a clear medication error policy, and required documentation was not completed at the time of the error.
A resident with SIADH and other complex medical conditions was not administered prescribed sodium chloride for 12 days due to failure in order entry and verification processes by nursing staff. This omission led to critically low sodium levels, confusion, hallucinations, and a prolonged hospital stay to correct the imbalance.
A resident with severe cognitive impairment and a history of falls was found without a call light and left unsupervised, leading to a fall. The facility failed to adhere to the resident's care plan, which required constant supervision and a functioning call light. Staff were unaware of the missing call light, and the facility lacked a designated fall policy.
Two residents experienced unsafe transfer practices in the facility. One resident fell and sustained head lacerations requiring sutures after a CNA's hand slipped off the gait belt during a transfer without a walker. Another resident was transferred without a gait belt, contrary to facility policy. The facility's policies mandate the use of gait belts for all transfers unless contraindicated.
A resident, identified as a high fall risk, fell and sustained multiple fractures and a skin tear during a transfer due to not wearing non-skid footwear and the CNA not holding the gait belt. The resident was wearing slippery socks and no shoes, and the CNA was only guiding the resident by the waist, leading to the fall.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall and new onset pain, but the facility failed to notify a physician immediately. Despite signs of significant pain observed by CNAs, the resident received only initial Tylenol and no further assessment or pain management was documented. The physician was not contacted until the following day, resulting in a 19-hour delay before the resident was transferred to the hospital, where fractures were confirmed.
A resident with severe cognitive impairment and multiple health issues experienced a fall and fractures due to improper transfer methods at a facility. The CNA used a stand aid without a gait belt, leading to the resident's legs giving out and a fall. Staff interviews revealed inconsistencies in transfer methods and a lack of communication regarding the resident's declining ability to bear weight.
The facility failed to manage pressure ulcers for three residents, resulting in severe complications. A resident developed a necrotic sacral wound leading to sepsis and surgery due to improper identification and treatment. Another resident's heel wounds progressed to necrotic eschar due to lack of regular assessments and missing pressure-reducing devices. A third resident's wound care was inadequately documented and treated, with dressings not changed as scheduled. The facility's staff acknowledged lapses in wound assessments and documentation.
The facility failed to implement timely interventions for three residents experiencing significant weight loss. One resident lost 9.91% of their weight in a month without receiving nutritional supplements, and their care plan was updated 20 days late. Another resident lost 10.40% in a month, with a high-calorie diet implemented 17 days late. A third resident lost 18.55% over three months, with delayed protein supplement increases. Meal intakes were not documented for these residents, and the facility's weight monitoring policy was not effectively followed.
The facility failed to implement COVID-19 outbreak interventions, contact isolation precautions, and enhanced barrier precautions. Visitors and residents were not wearing masks in affected areas, and a resident with potential C-diff was not isolated. Staff did not use required PPE for residents needing enhanced barrier precautions, despite clear signage and policy.
The facility failed to treat residents with dignity, as staff engaged in loud arguments and used dismissive language, disturbing residents and making them feel disrespected. Additionally, staff frequently used personal cell phones in resident care areas, detracting from their focus on residents. The DON acknowledged these issues, noting that arguments should not occur in hallways and staff should use more respectful language.
The facility failed to ensure proper labeling and storage of medications in two medication carts. An open insulin pen and bottles of valproic acid lacked resident identifiers and open dates, violating the facility's Pharmaceutical Procedures Policy. Unidentified medication tablets were also found in a cart drawer.
A resident requiring substantial assistance for personal hygiene had persistently dirty nails and hands, despite repeated requests from the spouse to clean them. The CNA confirmed handwashing practices, but the DON acknowledged the need for better hygiene practices, including cleaning under the nails.
A facility failed to prevent cross-contamination during a dressing change for a resident with a local skin infection. A CNA, assisting an LPN, used the same gloves to adjust the bed and handle the wound area without changing gloves or washing hands, contrary to the facility's aseptic guidelines. The DON confirmed the CNA's actions risked contamination.
A resident with multiple diagnoses, including peripheral vascular disease and mild cognitive impairment, did not receive restorative exercises as recommended. The facility's MDS Coordinator admitted to missing the resident in the setup of restorative programming, and the resident, who was in hospice care, reported not being offered exercises. The facility lacked a dedicated Restorative Nurse or Aide, relying on floor staff to perform exercises, which were not documented as completed.
A resident with multiple medical conditions expressed concerns about food quality and service, noting issues like overcooked food and lack of kitchen staff presence at Food Committee meetings. The facility lacked documentation for recent meetings, and the Dietary Manager had not attended due to staffing shortages.
A facility failed to provide treatment per physician's orders for a resident following a fall with injury. The resident, with multiple diagnoses, was observed without a splint or elevated arms as instructed by the hospital discharge summary. The registered nurse and Director of Nursing confirmed the absence of necessary orders in the resident's chart, acknowledging a mistake in the admission process.
Insufficient Nursing Staff Leading to Delayed Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to administer medications according to scheduled times for all five residents reviewed. On a specific Saturday, one of three scheduled day-shift nurses called off, leaving only two nurses to cover the unit, and the DON did not come in to assist. An LPN reported discovering at 10:00 AM that an entire hallway had not yet received morning medications, and stated that when three nurses are scheduled, two split the memory care unit so there is not always a nurse present there. Another LPN stated that on weekends they are “lucky” to have three nurses, that the morning med pass is very heavy and stressful even with three nurses, and that she sometimes administers medications for 38 residents. The nurse schedule for that day showed only 3.5 nurses on the 6:00 AM–2:30 PM shift, and resident council minutes from the prior month documented concerns that second-shift nurses were not passing pills on time at night, with some residents not receiving medications until 9:00 PM. As a result of this staffing shortage, multiple residents experienced delayed medication administration. One resident reported not having his blood sugar checked or receiving his morning medications, including insulin, until almost 10:45 AM, though his medications were scheduled for 6:00–7:00 AM and before a 7:30 AM breakfast; his MAR confirmed administration times around 10:27 AM. Another resident stated he had to go down the hall to find a nurse because his morning and lunch medications were very late; his MAR showed morning and midday doses of carbidopa-levodopa and gabapentin given significantly after their scheduled times. A third resident reported frequent late medications and long waits for pain medication; her MAR showed hydralazine for elevated blood pressure given nearly two hours after the scheduled time. A fourth resident stated that insulin was given after breakfast and that his blood sugar was not checked before lunch; his MAR showed a blood sugar check and insulin administration occurring later than scheduled. A fifth resident reported that staff said there were only two nurses on most shifts that weekend, and staff interviews corroborated that no one passed medications on one whole hallway for a period of time.
Delayed Medication and Insulin Administration Due to Inadequate Nursing Coverage
Penalty
Summary
Failure to administer medications according to physician orders occurred when multiple residents did not receive their prescribed medications and blood glucose checks at the scheduled times. On a weekend day when one of three scheduled day-shift nurses called off, an LPN reported discovering at 10:00 AM that an entire hallway had not yet received morning medications. One resident, who was supposed to receive morning medications including insulin before a 7:30 AM breakfast, reported not having his blood sugar checked or receiving his medications until almost 10:45 AM; his MAR showed Depakote, furosemide, gabapentin, and lispro insulin all administered at 10:27 AM, significantly later than their scheduled times. Another resident stated his medications were so late he had to go find the nurse; his MAR showed carbidopa-levodopa and gabapentin doses given well after their scheduled 7:00 AM and 11:00 AM times. Additional residents also experienced delayed medication administration. One resident reported there were not enough nurses scheduled and that she often received medications late; her MAR documented hydralazine for elevated blood pressure of 172/68 given at 8:54 AM instead of the scheduled 7:00 AM. Another resident stated that insulin was given after breakfast and that his blood sugar was not checked before lunch; his MAR showed a blood sugar check at 12:36 PM instead of the scheduled 10:00 AM and insulin given at 9:20 AM, after the 7:30 AM breakfast. The DON confirmed that medications are to be given according to the scheduled time or time frame on the MAR and that blood sugars and insulin should be administered prior to meals, and the facility’s Medication Administration Policy requires all medications to be administered as prescribed by the physician.
Delayed Medication Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when multiple residents did not receive medications and blood glucose monitoring within the ordered time frames. On a weekend day when one of three scheduled day-shift nurses called off, night nurses stayed to help pass medications, but an entire hallway had not received morning medications by 10:00 AM. An LPN reported she became busy with her assigned hallways and was unaware of what the night nurses were doing, discovering the delay only at 10:00 AM. One resident with conversion disorder with seizures, type 2 diabetes, intervertebral disc degeneration, low back pain, edema, and hereditary and idiopathic neuropathy reported not having his blood sugar checked or receiving his morning medications, including insulin, until almost 10:45 AM, although they were scheduled before a 7:30 AM breakfast. His MAR showed blood sugar checks scheduled for 6:00 AM–10:00 AM were completed at 10:45 AM, and Depakote, furosemide, gabapentin, and lispro insulin ordered for 7:00 AM or within a 6:00 AM–10:00 AM window were all administered at 10:27 AM. Another resident stated his medications were so late that he had to go down the hall to find the nurse, and that both his morning and lunch medications were delayed. His MAR showed carbidopa-levodopa for Parkinson’s disease with dyskinesia, scheduled at 11:00 AM, was given at 1:07 PM, and gabapentin for left hip pain, scheduled at 7:00 AM and 11:00 AM, was administered at 9:52 AM and 1:07 PM. A third resident reported often receiving medications late; her MAR showed hydralazine for hypertensive heart disease with heart failure, scheduled at 7:00 AM, was given at 8:54 AM for a blood pressure of 172/68. A fourth resident with diabetes mellitus reported that insulin was given after breakfast and that his blood sugar was not checked before lunch. His MAR showed blood sugar monitoring ordered before meals and at bedtime (7:00 AM, 10:00 AM, 5:00 PM, 8:00 PM) was performed at 12:36 PM for the 10:00 AM check, and glargine insulin ordered between 6:00 AM–8:00 AM was administered at 9:20 AM, after a 7:30 AM breakfast. The DON stated that medications are to be given following the scheduled time or time frame on the MAR and that blood sugars and insulin should be completed prior to meals, consistent with the facility’s medication administration policy and posted meal times.
Failure to Protect Resident From Abuse and Delay in Reporting Pillow-Over-Face Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when one severely cognitively impaired resident was found placing a pillow over the face/head area of her severely cognitively impaired roommate. In the early morning hours, two CNAs entered the shared room to perform a bed check and observed one resident standing over the other holding a pillow over her face, or a large pillow already over the resident’s face. The resident in bed, who had dementia and severe cognitive impairment and required supervision with mobility, was initially sleeping and did not appear in distress; when awakened, she became agitated, questioned the CNA’s actions, and grabbed the CNA’s arm before calming after reorientation. The resident who placed or was holding the pillow had Alzheimer’s disease with severe cognitive impairment and a history of wandering at night and being redirected back to bed. The CNAs reported difficulty locating a nurse at the time of the incident and each believed another CNA was reporting the event, resulting in a delay in notifying supervisory staff. The Memory Care Director and DON were not informed until later that afternoon, several hours after the incident occurred, despite the facility’s abuse policy requiring that any employee or agent who becomes aware of alleged abuse or neglect immediately report the matter to the administrator. A nurse who was on the unit around the time of the event stated she was not told of the incident. The facility’s own abuse investigation documented the conflicting CNA accounts about whether the pillow was being held over the resident’s face or already covering it, and confirmed that the incident was not promptly reported as required by policy.
Failure to Timely Report Alleged Physical Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse when one severely cognitively impaired resident was found with a pillow being held over her face by her severely cognitively impaired roommate. In the early morning, around 5:30 AM, two CNAs entered the shared room during a bed check and observed one resident standing over the other holding a pillow over her face, or a large pillow already over the resident’s face. One CNA removed the pillow and the other removed the aggressor from the room. The resident in bed, who had dementia and severe cognitive impairment and required supervision with mobility, was initially sleeping, became agitated when awakened, and then calmed after being reassured. The roommate, who had Alzheimer’s disease with severe cognitive impairment and required supervision with mobility, had been wandering earlier and had been redirected back to bed. Despite witnessing this event, the CNAs did not immediately report the incident to a nurse or other appropriate authority. One CNA stated she never told the nurse what she had witnessed, and the other CNA reported that she did not report the incident at the time and only called the Memory Care Director later that afternoon after waking up from sleep. Staff who worked the following morning shift, including a CNA and an RN, reported they were not informed of the incident in report. The DON and Administrator both stated they were notified later in the afternoon, and the DON indicated the incident should have been reported when it occurred. The facility’s abuse policy requires that any employee or agent who becomes aware of alleged abuse or neglect immediately report the matter to the facility administrator, which did not occur in this case.
Failure to Perform Skin Assessments and Timely Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for one resident at risk for skin breakdown. The resident had diagnoses including dementia without behaviors, right hip pain, depression, and a documented Stage 3 pressure ulcer to the right hip. A facility assessment showed the resident had moderate cognitive impairment, required partial to moderate assistance with rolling, and was at risk of developing pressure ulcers. The care plan identified increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness, and need for staff assistance with transfers, and included interventions such as assisting with turning and repositioning and performing skin checks each shift. Despite these identified risks and care plan directives, the facility did not perform or document weekly skin assessments for the resident, and there were no physician orders for weekly skin assessments during the relevant period. On a documented date, staff identified what appeared to be an unstageable pressure injury to the right ischial protuberance, measuring 2 x 2 cm, with a completely dry wound bed and indurated edges. A bordered foam dressing was applied and staff indicated they would contact the primary provider for treatment orders and endorsed this to the next shift. However, there were no treatment orders or documentation of any treatments for the pressure wound for several days following this initial identification. Subsequent wound physician notes documented that the wound was a Stage 3 pressure wound of the right hip, full thickness for more than one day, with light serous exudate, and later described necrotic tissue, slough, and granulation tissue. A surgical excisional debridement was performed to remove necrotic tissue and establish viable margins, after which the wound was staged as a Stage 4 pressure wound of the right hip. Interviews with nursing staff and the DON revealed that skin assessments were reportedly done weekly or on shower days, but that if no skin alterations were reported by aides, nurses did not complete skin assessments, and there were no shower sheets. The wound care physician stated that a full-thickness wound of this type would not have developed within a few days and emphasized that facility staff are responsible for completing skin assessments on all residents to identify even small wound alterations. The DON acknowledged the absence of documented weekly skin assessments for this resident and that the wound being found at a late stage was an issue.
Failure to Honor Resident DNR Due to Inaccurate Code Status in EMR
Penalty
Summary
The facility failed to honor a resident’s advance directive by allowing resuscitation efforts to occur despite documented Do Not Resuscitate (DNR) orders. The resident had diagnoses including COVID-19, rib contusion, chronic kidney disease, depression, and venous insufficiency. The physician’s orders specified DNR, and a POLST form indicated “No CPR: Do not attempt resuscitation.” However, the electronic medical record banner listed the resident as “Full Code,” and the POLST form was not scanned into the electronic record until a later date. The facility’s policy required that advance directives be documented in the medical record and specified on the face sheet, and that all advance directives be uploaded into the medical record system and stored in the clinical record. When EMS arrived in response to the resident’s fall, they found the resident prone on the floor, breathing and moaning in pain. A staff member standing next to the resident informed EMS that the resident was a full code, and EMS initiated full resuscitative measures after the resident became pulseless, including manual chest compressions, BVM ventilation with oxygen, IO access, multiple doses of epinephrine, and use of a mechanical CPR device. CPR was continued until arrival at the hospital, where it was discontinued after hospital staff produced a valid DNR on file. The RN later stated she told EMS the resident was a full code because that was what the chart banner showed, and that she relied on the banner as the source of code status. The DON and wound care nurse stated that everyone is treated as full code until paperwork is received and that the admitting nurse would not have entered a DNR order without seeing the POLST, indicating the facility had the POLST but had not updated the banner to DNR, leading to confusion about the resident’s code status.
Failure to Provide Ordered Antibiotic Therapy Due to Cost and Procurement Issues
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when an ordered antibiotic for osteomyelitis was not provided as prescribed. The resident had multiple diagnoses including Parkinson's disease, a stage 4 sacral pressure ulcer, Alzheimer's disease, and dementia, and a CT scan showed findings consistent with osteomyelitis of the coccygeal segments. A wound physician documented that the CT scan of the stage 4 sacral pressure wound demonstrated osteomyelitis and recommended ciprofloxacin 500 mg twice daily for 42 days and linezolid 600 mg twice daily for 42 days. However, the physician’s orders reflected only linezolid 600 mg twice daily, and the medication administration record showed that, over a nine-day period, the resident received only 4 of 16 scheduled doses of linezolid. The resident’s daughter reported that the facility told her rules and regulations did not allow the family to bring in less expensive medications and that she had to contact the VA to obtain coverage for linezolid. She stated that the medication was started two days after it was prescribed and that this delay would have been longer if she had not intervened regarding VA coverage. Nursing staff later stated that linezolid had been discontinued, but the RN interviewed did not know who discontinued it or why, only that it appeared the facility did not have the medication. The DON and wound care nurse explained that the pharmacy identified linezolid as a high-cost medication, that only a few days’ worth of doses were initially supplied, and that they were attempting to secure coverage through prior authorization and the VA while continuing ciprofloxacin. The administrator stated that high-cost private pay medications are handled by informing families of the cost and that the facility must use its contracted pharmacy or the VA, not outside pharmacies. The wound physician emphasized that linezolid was important for treating the resident’s suspected osteomyelitis and that it was the only recommended oral antibiotic option, noting that IV alternatives would require RN availability. The DON later stated that the resident’s son/POA declined treatment after learning the cost of the medication and that they discussed holding the medication and possible IV alternatives with the wound physician, but no documentation of these conversations existed in the resident’s progress notes until several days after the issues arose. The facility’s medication administration policy required that all medications be administered as prescribed by the physician, which did not occur in this case, resulting in missed doses and interruption of the ordered antibiotic therapy.
Failure to Notify Power of Attorney After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's Healthcare Power of Attorney (HPOA), who is also the resident's daughter, after the resident experienced a fall from her bed. The resident's face sheet identified her daughter as the HPOA. According to the progress note, the resident fell out of bed at 2:00 AM and was assessed by a nurse, who found no injuries. The nurse documented an intention to call the HPOA around 6:00 AM but did not follow through with the notification. The HPOA was not informed of the fall by facility staff and instead learned about the incident from the resident's sister, who had visited and been told about the fall by the resident herself. During interviews, the HPOA expressed frustration at not being notified immediately, stating her expectation to be informed of any changes regardless of the time. The nurse later acknowledged forgetting to call the HPOA and believed another nurse may have notified her later that day. The Director of Nursing confirmed that family should be notified immediately of any changes in condition, including falls, and that notification is important for informed decision-making. The facility's policy also requires notification of both the physician and the POA following a resident fall.
Failure to Use Mechanical Lift for Post-Fall Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a mechanical lift to safely transfer a resident following a fall. The resident, who had a history of osteopenia, femur fracture, gait abnormalities, and moderate cognitive impairment, was found on the floor next to her bed during overnight rounds. The resident's medical records indicated she had range of motion limitations on one side of her body and used a wheelchair for mobility, with no ability to walk. After the fall, the resident was assessed by a nurse and found to have no injuries at that time. Despite facility protocol requiring the use of a mechanical lift for post-fall transfers, three staff members, including a CNA, an RN, and an LPN, manually lifted the resident back into bed. Accounts from the staff confirmed that they either picked up the resident by her upper and lower body or used a blanket as an improvised sling, rather than using the mechanical lift. The Director of Nursing confirmed that bedding is not an approved lifting device and that a mechanical lift should have been used to prevent injury.
Failure to Ensure Use of Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure safe mobility for residents by not requiring the use of footrests on wheelchairs when staff transported residents. This deficiency was observed in four out of six residents reviewed for safety. In one incident, a resident with multiple diagnoses including vascular dementia, encephalopathy, and muscle weakness was being pushed in a wheelchair without footrests. The resident planted her feet on the floor, resulting in her falling forward out of the wheelchair and sustaining a laceration to her forehead that required three sutures. Staff interviews confirmed that the resident did not have foot pedals assigned to her wheelchair, and the CNA involved did not follow the facility's stated rule for resident safety regarding footrests. Additional observations revealed that other residents were also transported in wheelchairs without footrests. One CNA was seen pushing a resident into the dining room without footrests in place and admitted to forgetting to use them, despite acknowledging that footrests should be used for safety. Another LPN pushed a resident whose foot was sliding across the floor due to the absence of footrests and stated that foot pedals are supposed to be used when pushing residents. Staff consistently reported that footrests are stored in blue bags on the back of wheelchairs and should be used during transport, but this practice was not consistently followed. The facility did not have a written policy specifically addressing the use of footrests on wheelchairs, although staff training and in-service education indicated that all residents using wheelchairs must have foot pedals in place when being pushed. The lack of adherence to this expectation, combined with the absence of a formal policy, contributed to unsafe conditions and resulted in at least one resident injury. Interviews with the administrator and DON confirmed that while staff were trained on the importance of using footrests, there was confusion regarding the existence of a formal policy, and the practice was not consistently enforced.
Failure to Notify Physician and Document Medication Error
Penalty
Summary
A medication error occurred involving a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and a cognitive communication deficit, who resided on the memory care unit. The resident's family member discovered a cup containing the resident's evening medications left in the room and returned it to an LPN. The LPN identified the pills as the resident's missed evening medications from the previous night, disposed of them, but did not document the incident or notify anyone, including the physician. The Director of Nursing later confirmed that the expected procedure in such cases would be to complete a medication error report and notify the physician, but this was not done at the time of the incident. The facility did not have a policy for medication errors, and the required documentation and physician notification were not completed following the discovery of the missed medication dose. The failure to notify the physician and document the medication error was confirmed through staff interviews and record review. The resident was observed to be alert but confused, ambulating independently, and participating in activities at the time of the survey.
Failure to Administer and Document Resident Medications as Prepared
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia and cognitive communication deficit, did not receive her prescribed evening medications as intended. The medications, which included alprazolam, aspirin, atorvastatin, carvedilol, clopidogrel, and Seroquel, were found in a cup in the resident's room by her family member, rather than being administered. The nurse on duty disposed of the medications after confirming they were missed doses from the previous evening, but did not document the incident or report it at the time. The Medication Administration Record (MAR) incorrectly indicated that the medications had been given, with no notation of a missed dose or medication error. Further review revealed that the facility lacked a specific policy for medication errors, though their medication administration policy required documentation in the event a medication could not be given. The Director of Nursing confirmed that a medication error report should have been completed in this situation, but it was not done until after the incident was discovered. The failure to administer the medications as prepared, document the missed dose, and report the error constituted a deficiency in pharmaceutical services for the resident.
Failure to Administer Ordered Sodium Chloride Results in Critical Medication Error
Penalty
Summary
A resident with diagnoses including permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of the bladder was admitted to the facility with hospital discharge orders for sodium chloride 1gm PO QID. Upon review, there were no physician orders entered for sodium chloride, nor was there any evidence on the medication administration record that the resident received sodium chloride during the entire stay at the facility. The nurse practitioner’s note indicated that sodium chloride was necessary for the management of SIADH, and the expectation was that the medication was being administered as ordered. Interviews with facility staff revealed that the admission nurse was responsible for entering the orders and that a second nurse was supposed to double-check the orders for accuracy. However, both the initial entry and the double-check failed to identify the omission of the sodium chloride order, resulting in the resident not receiving the prescribed medication. As a result of not receiving sodium chloride, the resident developed a critically low sodium level, became confused, and experienced hallucinations. The resident was subsequently hospitalized for 15 days to correct the sodium imbalance. Hospital records confirmed a sodium level of 115, which was identified as a critical lab value. The facility’s policies required accurate transcription and administration of physician’s orders, but these procedures were not followed in this case.
Failure to Provide Call Light and Supervision
Penalty
Summary
The facility failed to provide a call light to a resident, identified as R2, and did not ensure adequate supervision while the resident was in her wheelchair. R2, who has severe cognitive impairment and requires substantial assistance for transfers, was found without a call light in her room. The resident's care plan indicated that she was at risk for falls and should not be left unattended, yet she was found on the floor after being left alone in her room. The facility's accident/incident report noted that R2 had experienced nine falls in the past six months, highlighting the need for strict adherence to her care plan. During the survey, it was observed that R2's call light was detached and not accessible, and staff were not aware of this issue. A Certified Nursing Assistant mentioned that R2 does not use a call light, implying a lack of understanding of the resident's needs. The Interim Director of Nursing acknowledged the absence of the call light and the failure to follow the care plan, which contributed to the resident's fall. Additionally, the facility was unable to provide a fall policy when requested by the surveyor, indicating a gap in their safety protocols.
Unsafe Transfer Practices Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, resulting in one resident sustaining injuries. Resident R1's care plan outlined specific steps for safe transfers, including the use of a walker and a gait belt. However, during a transfer on January 3, 2025, a CNA assisted R1 without the use of a walker, and although a gait belt was applied, the CNA's hand slipped off the belt, leading to R1 falling forward and hitting her head on the floor. This incident resulted in R1 sustaining multiple lacerations to her forehead and under her left eye, requiring sutures. The Director of Nursing noted that R1's slippers might have contributed to the fall due to insufficient grip. Additionally, Resident R3, who is at risk for falls due to weakness, was transferred to the toilet by a CNA without the application of a gait belt, contrary to the facility's policy. The CNA admitted to forgetting to use the gait belt during the transfer. The facility's policies clearly state that gait belts should be used for all transfers unless contraindicated, and the failure to adhere to these policies contributed to the unsafe transfer practices observed.
Failure to Ensure Resident Safety During Transfer
Penalty
Summary
The facility failed to ensure a resident was wearing non-skid footwear and was being held by the gait belt during a transfer, resulting in a fall and injuries. The resident, who was identified as a high fall risk, was being assisted from a recliner to a bed by a CNA. During the transfer, the resident was wearing regular socks, which were slippery, and no shoes. The CNA was not holding onto the resident's gait belt, only guiding him by the waist. As a result, the resident slipped and fell, sustaining a rib fracture, two transverse process fractures of the lumbar vertebrae, and a skin tear. The resident's medical history included a fracture of the neck of the right femur, presence of a right artificial hip joint, Parkinson's disease, muscle weakness, unsteadiness on feet, pain, and a history of falls. The incident was reported, and it was noted that the resident felt he slipped because he was not wearing shoes. The facility's staff, including the LPN and the DON, confirmed the resident was not wearing appropriate footwear and the CNA was not holding the gait belt during the transfer, which contributed to the fall.
Failure to Notify Physician and Assess Resident Post-Fall
Penalty
Summary
The facility failed to immediately notify a physician of a fall involving a resident, identified as R1, who experienced new onset pain and required medical attention. R1, who had severe cognitive impairment and multiple medical conditions including congestive heart failure and Alzheimer's disease, was lowered to the floor during a transfer due to bilateral leg weakness. Despite complaining of pain in the left shoulder, the initial assessment by the nurse found the range of motion to be within normal limits, and Tylenol was administered. However, the nurse did not notify the physician immediately, instead placing a notification form in the nurse practitioner's binder for review on the next visit. Throughout the day following the fall, R1 continued to exhibit signs of significant pain, as reported by multiple CNAs who observed him wincing, screaming, and refusing to eat. Despite these observations, there was no evidence of further assessment or pain management beyond the initial administration of Tylenol. The nurse on duty during the day shift did not document any assessment or administer additional pain medication, and the physician was not contacted until the following day when R1's condition had worsened, showing significant bruising and inability to perform range of motion exercises. The facility's policies required immediate notification of a physician following an incident resulting in injury, as well as ongoing assessment and documentation of a resident's condition post-fall. However, these procedures were not followed, resulting in a delay of 19 hours before R1 was transferred to the hospital for evaluation, where fractures were confirmed. The lack of timely assessment and communication with medical providers contributed to inadequate pain management and delayed treatment for R1.
Failure to Safely Transfer Resident Results in Injury
Penalty
Summary
The facility failed to perform a safe transfer for a resident, resulting in a fall and subsequent fractures to the resident's left arm and shoulder. The resident, who had severe cognitive impairment and required substantial staff assistance for transfers, was being transferred by a CNA using a stand aid. The CNA attempted to transfer the resident without a gait belt, and the resident's legs gave out during the process, causing him to fall. The CNA was unable to prevent the fall, and the resident sustained significant injuries. The resident's care plan initially indicated the use of a stand aid for transfers, but after the incident, it was updated to require a full mechanical lift with staff assistance of two. The incident report noted that the resident was lowered to the floor during the transfer due to bilateral leg weakness. Despite initial assessments indicating no significant injury, the resident later complained of increased pain, leading to an emergency room visit where fractures were confirmed. Interviews with staff revealed inconsistencies in the transfer methods used for the resident, with some staff using a gait belt and others not. The CNA involved in the incident admitted to not using a gait belt and was unaware of the requirement until after the fall. The Director of Nursing and other staff members acknowledged that the resident's transfer status should have been reassessed due to his declining health and inability to bear weight, which was not communicated effectively among the staff.
Inadequate Pressure Ulcer Management Leads to Severe Complications
Penalty
Summary
The facility failed to properly identify and manage pressure ulcers for three residents, leading to severe complications. Resident R75 was admitted without skin alterations but later developed a sacral wound that was not correctly identified or treated as a pressure ulcer. The wound progressed to a necrotic state, resulting in sepsis and requiring surgical intervention, including debridement and the placement of a colostomy. The wound care nurse and Director of Nursing acknowledged the lack of proper wound assessments and documentation, which contributed to the deterioration of R75's condition. Resident R63 also suffered from inadequate pressure ulcer management. Despite having a care plan that included the use of pressure-reducing devices, R63 was observed without heel protectors, and his wheelchair lacked a cushion. His heel wounds were not assessed regularly, leading to the development of necrotic eschar. The Wound Care Physician noted that the assessment of R63's wounds was incorrect and that early intervention could have prevented the progression of the wounds. Resident R16 experienced a lapse in wound care documentation and treatment. Her pressure injuries, which developed after a fall and subsequent casting, were not properly documented or treated according to the facility's schedule. The dressings on her wounds were not changed as required, and there was no record of refusal for treatment. The facility's Director of Nursing and Wound Nurse admitted to not maintaining records of R16's wounds, relying instead on external wound clinic assessments, which led to gaps in care.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement timely interventions for residents experiencing significant weight loss, affecting three residents in particular. Resident 82 experienced a 9.91% weight loss in one month, with no nutritional supplements provided despite the weight loss being identified. The Registered Dietitian's recommendations were delayed, and the care plan was not updated until 20 days after the weight loss was noted. Additionally, there was no documentation of meal intakes for this resident, and the facility lacked a permanent Registered Dietitian, which contributed to the delay in addressing the weight loss. Resident 70 experienced a 10.40% weight loss in one month. Despite the Nurse Practitioner being notified of the weight loss, no new orders were given initially. The Registered Dietitian recommended a high-calorie diet, but the change was not implemented until 17 days after the weight loss was identified. Similar to Resident 82, there was no documentation of meal intakes for Resident 70, indicating a lack of monitoring of nutritional intake. Resident 83 experienced an 18.55% weight loss over three months and a 12.17% loss in one month. The Nurse Practitioner was notified, but no new orders were given initially. The Registered Dietitian recommended increasing protein supplements and weekly weights, but these interventions were delayed. There was also no documentation of meal intakes for Resident 83. The facility's policy on weight monitoring was not effectively followed, as significant weight losses were not addressed promptly, and the Registered Dietitian's recommendations were not implemented in a timely manner.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement COVID-19 outbreak interventions, contact isolation precautions, and enhanced barrier precaution interventions, potentially affecting all residents. Observations revealed that visitors and residents were not wearing masks in areas where a staff member had tested positive for COVID-19. The Infection Preventionist confirmed that the facility was in outbreak status, and source control should have been implemented on the affected units. However, there was confusion among staff regarding mask-wearing protocols, leading to inconsistent application of source control measures. The facility also failed to implement contact isolation precautions for a resident exhibiting symptoms of Clostridioides difficile (C-diff). Despite the resident's ongoing diarrhea and a physician's order for a stool sample, there was no signage indicating isolation, and the sample had not been sent to the laboratory. The Director of Nursing acknowledged that the resident should have been in contact isolation pending test results to prevent potential spread. Additionally, the facility did not adhere to enhanced barrier precautions for residents with pressure ulcers and other conditions requiring such measures. Staff were observed providing care without the necessary personal protective equipment, despite signage and facility policy indicating the need for gowns and gloves during high-contact activities. This lack of adherence to infection control protocols was noted by the Director of Nursing, who stated that staff should have been aware of the requirements.
Staff Behavior and Cell Phone Use Compromise Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by multiple incidents involving staff behavior. Several residents reported being disturbed by loud arguments between staff members in the early morning hours, which woke them up and made them feel disrespected. The residents described the staff as rude, often responding to their needs with dismissive phrases like 'What do you want?' instead of more respectful language. The Director of Nursing acknowledged the inappropriate behavior, noting that the argument should not have occurred in the hallway and that staff should use more considerate language when addressing residents. Additionally, the facility did not enforce its policy on cell phone usage, leading to further concerns about resident care. A CNA was observed using a personal cellphone in a resident care area, and residents reported that staff frequently used their phones instead of attending to their needs. Meeting minutes from resident council meetings indicated ongoing issues with staff using cell phones during resident care and meal times, which detracted from their focus on residents. The facility's policy prohibits cell phone use in resident care areas to prevent privacy violations and ensure staff attention is directed towards residents.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were clearly labeled and stored properly, as observed in two of the three medication carts reviewed. On one occasion, an open insulin flex pen was found in a medication cart drawer in the dementia unit without any indication of when it was opened or to whom it belonged. Similarly, another medication cart contained an open insulin flex pen with no date or resident identifiers. Additionally, a 500 ml bottle labeled as valproic acid 250 mg was found with over 300 ml of liquid remaining, but the label lacked the full concentration of the medication, legible resident information, and an open date. Another bottle of valproic acid was found wet and stuck to the drawer, also missing an open date and clear resident identifiers. Four unidentified white medication tablets were also found at the bottom of the drawer. The facility's Pharmaceutical Procedures Policy, dated 1/5/23, requires that medication labels clearly indicate the resident's full name, physician's name, prescription number, drug name and strength, administration directions, issue date, expiration date, pharmacist initials, and medication amounts. The policy also mandates that medications with soiled, damaged, incomplete, illegible, or makeshift labels be returned to the issuing pharmacist for relabeling or disposal. Medications without labels should be destroyed according to state and federal regulations. The policy emphasizes proper storage conditions for drug supplies, including sanitation, temperature, light, refrigeration, and moisture, and requires that each resident's medications be kept in their originally received container.
Failure to Maintain Hand Hygiene for Resident
Penalty
Summary
The facility failed to provide adequate hand hygiene for a resident, identified as R64, who required substantial assistance for personal hygiene. On multiple occasions, R64's spouse expressed concerns about the resident's dirty nails and hands, which were observed to have dirt and grime under the nails and a dried red substance on the hands. Despite the spouse's repeated requests to the nursing staff to clean R64's nails, the issue persisted. A Certified Nursing Assistant (CNA) confirmed that R64 did not refuse care and stated that handwashing was performed when hands were soiled and before meals. However, the Director of Nursing acknowledged that staff should be washing residents' hands before meals, when soiled, and after using the bathroom, and also cleaning under the nails for infection control. The Director observed R64's nails and confirmed they were dirty and needed cleaning.
Failure to Prevent Cross-Contamination During Dressing Change
Penalty
Summary
The facility failed to provide a dressing change in a manner that prevents cross-contamination for a resident with multiple diagnoses, including a local infection of the skin and subcutaneous tissue. During a dressing change for the resident's scrotum, a CNA, while assisting an LPN, used the same gloved hands to adjust the bed's height by touching the buttons on the footboard. After adjusting the bed, the CNA returned to the resident and continued to handle the wound area without changing gloves or washing hands, thereby risking contamination. The Director of Nursing confirmed that the CNA should have removed the gloves, washed hands, and donned new gloves before touching the resident again. The facility's policy on wound care emphasizes the need for aseptic techniques and standard precautions to protect wounds from contamination and infection. The actions of the CNA were contrary to these guidelines, as they potentially transmitted infection by contaminating both the resident and the bed controls.
Failure to Provide Restorative Exercises to Resident
Penalty
Summary
The facility failed to provide restorative exercises to a resident, identified as R63, who was reviewed for range of motion. R63 had diagnoses including peripheral vascular disease, pneumonia, pressure-induced deep tissue damage of the left hip, and anxiety disorder. The facility's assessment indicated that R63 had mild cognitive impairment and was supposed to receive restorative nursing programs for active range of motion, bed mobility, and dressing and/or grooming. However, documentation showed that R63 did not receive any restorative services from February 2024 through August 2024, despite a therapy recommendation suggesting restorative programs for transfers and lower body exercises. The Minimum Data Set (MDS) Coordinator, identified as V22, acknowledged that R63 was not on a restorative program and admitted to missing this resident in the setup of restorative programming. V22 mentioned that the facility did not have a dedicated Restorative Nurse or Aide, and the floor staff were responsible for performing the exercises. R63, who was enrolled in hospice care, stated that they had not been offered any exercises and felt hesitant to ask due to the staff's busy schedule. The facility's policy emphasized the importance of providing a program to assist residents in achieving and maintaining their maximum level of function, but this was not implemented for R63.
Failure to Address Resident Food Preferences
Penalty
Summary
The facility failed to consider the food preferences of a resident, identified as R9, who was cognitively intact and had various medical conditions including chronic obstructive pulmonary disease and major depressive disorder. R9 expressed concerns about the food quality and service, noting issues such as not receiving lemon with iced tea, overcooked and undercooked food items, and the inability to request additional items from the kitchen due to staff leaving immediately after meal delivery. R9 also mentioned that kitchen staff had not attended the monthly Food Committee meetings for the past three months, preventing residents from voicing their concerns directly. The facility lacked documentation for the Food Committee meetings for June, July, and August, and the Dietary Manager, V6, confirmed he had not attended these meetings due to being short-staffed. The facility's policy on Menu Preference sheets did not address ensuring resident preferences were considered, and there was no policy or procedure related to the Food Committee meetings. Previous meeting minutes from March to May indicated ongoing concerns about food quality, including cold and overcooked items, and staff leaving before addressing residents' needs.
Failure to Follow Physician's Orders After Resident's Fall
Penalty
Summary
The facility failed to provide treatment per physician's orders for a resident following a fall with injury. The resident, who has diagnoses including traumatic subarachnoid hemorrhage, urinary tract infection, muscle weakness, and osteoarthritis, was observed without a splint or elevated arms as instructed by the hospital discharge summary. The resident expressed discomfort and soreness in her hand, indicating that the prescribed treatment was not being followed. The registered nurse, who was an agency nurse, confirmed that there were no orders in the resident's chart for the splint or arm elevation, and the Director of Nursing acknowledged that the discharge instructions should have been entered into the resident's chart as physician's orders. The deficiency was identified when the therapy department noticed the absence of the splint and brought it to the attention of the registered nurse. The Director of Nursing admitted that it was a mistake by the nurse who admitted the resident back to the facility and that the necessary interventions should have been in place. The facility does not have a specific policy regarding physician's orders but follows standard nursing procedures to enter orders upon a resident's return from the hospital and confirm them with the attending physician.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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