Mercer Manor Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Aledo, Illinois.
- Location
- 309 N W 9th Avenue, Aledo, Illinois 61231
- CMS Provider Number
- 146138
- Inspections on file
- 23
- Latest survey
- April 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Mercer Manor Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure adequate nursing staff and relied on uncertified CNA students as independent caregivers, resulting in repeated reports of delayed care and unmet basic needs. Several residents who required substantial or total assistance with ADLs described call light response times of up to an hour or more, missed or postponed showers, and episodes of incontinence where assistance was not provided in a timely manner. A family member frequently found a resident wet and malodorous, with a urine‑soaked wheelchair cushion, and reported long waits for staff assistance. Staffing schedules and staff interviews confirmed that CNA students, who had not yet completed CNA training or state testing, were regularly assigned their own halls and counted as CNAs, while shifts often ran with fewer CNAs than the four typically expected. Resident council minutes documented complaints about long call light waits, unclean bathrooms between uses, soiled incontinence products left on the floor, and lack of fresh water, despite a facility policy requiring sufficient, competent staff to meet residents’ assessed needs.
The facility failed to ensure nurse aides were fully trained and competent or appropriately enrolled and supervised before working independently, as CNA students were scheduled and counted as regular CNAs with their own hall assignments. Staff interviews indicated that students who had not completed CNA classes or state testing were routinely used to fill CNA positions, contributing to perceived short staffing and workload issues. A CNA student reported being in an in-house CNA course for 1–2 months, completing online coursework and limited clinical days, yet being independently assigned to a hall and additional rooms on other days that were treated the same as clinical hours. The ADON and DON stated that once classroom work and skills sign-offs were done, they considered students able to work their own assignments and counted them as CNA staff on the schedule, affecting all residents in the building.
Nursing staff failed to protect resident health information during medication administration. An LPN conducting a medication pass in the dining room and an RN passing medications in a hallway repeatedly left electronic medical records visible on the medication cart computer screen while away from the cart, allowing personal medical information for multiple residents to be seen by visitors, staff, and other residents walking by. Facility leadership later confirmed that nurses are expected to close or hide the computer screen when leaving the cart to maintain confidentiality.
The facility did not complete required quarterly MDS 3.0 assessments for multiple residents within the three‑month interval specified by its own IDT policy. Several residents had quarterly assessments that were significantly overdue, with some eventually completed well past the due date and others still not completed at the time of surveyor review. The MDS Coordinator demonstrated a scheduling report showing numerous overdue assessments and acknowledged the backlog, while the Administrator and a corporate MDS nurse confirmed that corporate staff were aware they were behind on completing MDS assessments, without providing a specific reason for the delays.
A resident with dementia, disorientation, delusional disorder, and chronic pain had ordered doses of Tramadol 50 mg and Tylenol 325 mg that were placed in a pill cup and left on a dining room table without staff ensuring ingestion. Dietary staff later gave the unattended cup, containing two Tylenol tablets and one Tramadol tablet, to an LPN, who brought it to the DON, and then to an RN who stated she had assumed the resident took the medications but admitted she had not observed the resident place them in her mouth. This sequence of events, observed during mealtime for multiple residents dining in the main dining room, did not follow the facility’s policy requiring direct observation of medication administration and prohibiting medications from being left on tables.
Surveyors found that staff failed to properly secure a PPE gown while performing a gastrostomy tube dressing change for a resident with a history of cerebral infarction, feeding difficulties, dysphagia, and severe protein-calorie malnutrition. Despite physician orders for enteral feeding, gastrostomy site care, and Enhanced Barrier Precautions requiring gown and glove use during direct contact and device care, an ADON wore a gown that was not tied at the neck or back, causing it to open toward the resident. The DON and ADON both acknowledged that the gown should have been securely tied in accordance with CDC guidance and the facility’s EBP policy.
The facility failed to provide an ongoing program of activities for residents in the Memory Care Unit due to insufficient activity staff and unrealistic expectations for CNAs to lead activities. Observations revealed residents sitting idle without engagement, and scheduled activities were not conducted. The activity director acknowledged staffing shortages and the unsuitability of certain activities for residents' needs.
The facility failed to document appropriate indications for antipsychotic medication use for several residents, lacking specific behaviors or symptoms in their care plans. Despite facility policy requiring documentation of behaviors and responses to non-pharmacological interventions, residents were prescribed medications like Haloperidol and Risperidone without proper justification. The Director of Nursing acknowledged the issue, noting that some staff believed medication was the solution to behavioral issues, contributing to the problem.
A facility failed to include a resident's oxygen use in their comprehensive care plan, despite a physician's order for oxygen at 2 liters per minute via nasal cannula for dyspnea or chest pain. Observations confirmed the resident was using oxygen, but the care plan lacked information or goals regarding this need. The care plan coordinator confirmed the omission.
A facility failed to follow a care plan for a resident with CHF, neglecting to document daily weights and report significant weight changes to the cardiologist as ordered. The MAR showed missing weight entries and unreported weight gains over several months, despite clear discharge instructions. The DON confirmed the oversight, acknowledging the cardiologist should have been notified.
A facility failed to assess and document a pressure ulcer for a resident, identified as having multiple open areas on the coccyx. The facility's policy requires weekly assessment of skin impairments, but the wound was consistently documented as irritant contact dermatitis without measurements. The DON confirmed reliance on telehealth wound care doctors and acknowledged the wound's location over a pressure point, yet it was not documented as a pressure ulcer.
A facility failed to change a resident's oxygen equipment as ordered, with the nasal cannula and humidifier bottle not being replaced weekly as required. The resident's Physician Order Sheet specified weekly changes for infection control, but records showed the last change was documented mid-month, with no updates for subsequent weeks. Observations confirmed the equipment was not updated, and the DON acknowledged the oversight.
A registered nurse failed to follow infection control protocols during medication administration for a resident with a gastric tube. The nurse placed a medication cup on the resident's bed, causing it to tip over and spill pills onto the sheet. The nurse picked up the pills and administered them, acknowledging later that the bed sheet was not clean.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from a memory care unit due to inadequate alarm systems and supervision. The resident was found outside with significant injuries, including facial and cervical spine fractures, after exiting the facility unnoticed. The facility failed to update the resident's care plan and did not report the elopement to the State Agency, contributing to the severity of the incident.
Facility dietary staff failed to have their hair restrained while handling and preparing food, potentially affecting all 60 residents. Observations revealed multiple instances of non-compliance, including a Dietary Assistant serving food without a hair net, another with loose hair hanging from a cap, and a Dietary Cook with an improperly worn hair net. The Dietary Manager confirmed the requirement for full hair restraint.
The facility failed to provide twice-weekly showers for a resident diagnosed with Dementia and Parkinson's Disease, who required assistance for all ADLs. Despite being scheduled for showers on Wednesdays and Saturdays, the resident only received 20 out of 34 scheduled showers. Staff confirmed the missed showers and noted that the resident enjoyed showers and did not resist them. The DON verified the missing shower records.
Inadequate Staffing and Use of Uncertified CNA Students Leading to Unmet Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to meet residents’ needs and the use of uncertified CNA students as independent staff. Multiple residents who require substantial or total assistance with ADLs reported prolonged call light response times and unmet toileting and hygiene needs. One resident with spinal stenosis, neuropathy, osteoarthritis, CHF, and other conditions, who requires substantial to maximal assistance for toileting, stated that it took an hour for staff to answer a morning call light when she needed to use the bathroom. She reported that, after waiting and hoping staff would at least transfer her to the toilet, she was unable to wait any longer and had a bowel movement in her pants. Another resident, admitted with multiple myeloma, convulsions, anemia, and other diagnoses, is alert, oriented, has an unsteady gait and poor balance, and is dependent for all care except eating. This resident reported that call light responses on second and third shifts frequently take an hour or more, and that on one occasion the call light was placed on the privacy curtain out of reach, requiring the roommate to retrieve it. A third resident, with flaccid hemiplegia, spinal stenosis, and other conditions, is dependent on staff for most care and reported that there are often not enough CNAs, that there is high turnover, and that showers were missed due to short staffing, including a night when only two CNAs were on second shift and the resident’s shower was postponed. Additional residents and a family member corroborated staffing concerns. One resident stated that staffing is "a joke," reporting that there was only one CNA on a recent Saturday and that call light responses sometimes take up to an hour and a half. Another resident’s daughter reported frequently finding her mother wet and smelling of urine, including on the day of observation when the resident’s pants and wheelchair cushion were wet and odorous, and she described a 20‑minute wait for assistance. A largely independent resident reported that call light responses for requests such as ice water and bedding changes often take over an hour several days per week, and that on third shift there is usually only one CNA, with her incontinent roommate’s bedding often not changed until just before bedtime. Review of staffing schedules for the prior two weeks showed that CNA students were regularly assigned their own halls and counted as CNAs on multiple dates, with schedules frequently showing only 2–3 CNAs on first and second shifts instead of the 4 CNAs staff reported as needed for the south end. CNAs reported that students, who had not completed CNA classes or testing, were given independent assignments after limited clinical sign‑off, and that this contributed to difficulty answering call lights and completing showers. One CNA stated they had given notice due to staffing issues and confirmed that students were being used as regular staff. The ADON and DON acknowledged that typical staffing often ran with fewer CNAs than planned, that students were counted as independent staff once signed off on skills, and that weekends were particularly difficult due to call‑ins. Resident council minutes documented complaints about call light wait times, bathrooms not being cleaned between uses, soiled incontinence products left on the floor, lack of fresh water, and staff saying they would return but not doing so. The facility’s written staffing policy states that the facility will provide sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and to help residents attain or maintain their highest practicable well‑being, based on resident assessments, plans of care, and the facility assessment. Despite this policy, observations, interviews, and record review showed that the facility did not ensure adequate numbers of qualified CNAs on duty and used CNA students as independent staff members before certification, resulting in repeated reports and observations of delayed responses to call lights, missed or delayed showers, and residents remaining wet or soiled.
Use of CNA Students as Independent Staff Without Completed Training and Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides had completed a training and competency evaluation program or were appropriately enrolled and supervised prior to working independently. Surveyors reviewed the resident roster showing 58 residents in the building and examined nursing and CNA schedules for the prior two weeks, which showed CNA students assigned their own halls on multiple dates. Staff interviews revealed that CNA students were being scheduled and counted as regular CNAs, assigned full hall responsibilities, and included in staffing numbers once they were “signed off” on certain skills, despite not having completed CNA certification or state testing. The facility’s DON acknowledged counting CNA students as independent staff members on the schedule once their skills were signed off and avoiding scheduling them in memory care only because there was a single CNA there. CNA staff reported that students were frequently working as part of the regular staffing pattern, being given their own assignments without being paired with a CNA for training. One CNA stated that there were supposed to be four CNAs on the south end but that they were short staffed and that students who had not finished class or testing were being given hall assignments. Another CNA reported struggling to complete showers and answer call lights while working with students who were treated as fully capable staff. A CNA student confirmed being in the facility’s CNA course for 1–2 months, taking online classes with clinical hours twice weekly, but also picking up additional days that were no different from clinical days, and being independently assigned to a hall and additional rooms. The ADON and DON both indicated their understanding that once classroom work and skills sign-offs were completed, students could work their own assignments prior to certification, which conflicted with the requirement that nurse aides be trained and competent or appropriately enrolled and supervised within the first four months of employment.
Failure to Protect Resident Health Information During Medication Pass
Penalty
Summary
The deficiency involves failure to maintain privacy and confidentiality of residents' medical records during medication administration. Facility policy on Medication Administration-General Guidelines, dated November 2021, requires that the medication cart be kept closed and locked when out of sight, that no medications be kept on top of the cart, and that privacy be maintained at all times for resident information, including the Medication Administration Record (MAR), when not in use. On 1/20/2026 at 11:26 AM, an LPN (V6) was observed conducting a medication pass in the dining room and repeatedly left resident information visible on the computer screen each time she left the cart to administer medications to residents R5, R12, and R58. This made their personal medical records visible to visitors, staff, and residents passing by the medication cart. When questioned, V6 acknowledged that the screen should have been hidden and indicated she should have used the icon to hide the screen before leaving the cart. On 1/21/2026 at 11:15 AM, an RN (V7) was observed passing medications to residents R1, R37, and R51 in the hallway outside the dining room and similarly left resident information visible on the computer screen each time she left the cart to administer medications. This again made personal medical records visible to anyone passing by the cart. When asked, V7 stated she realized too late that she had left the screen up and agreed she should have closed the screen so nobody could see it. At 11:31 AM on the same day, the DON (V2) stated that when passing medications, nurses should either close their computer screen or press the hide screen icon before leaving their carts to protect patient information, confirming that the observed practice was inconsistent with facility expectations and policy.
Failure to Complete Quarterly MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to ensure that each resident’s assessment was updated at least once every three months using the standardized MDS 3.0 assessment tool, as required by its own Interdisciplinary Team (IDT) policy dated 11/1/15. The policy specifies that quarterly assessments must be completed no less than every three months, but seven residents (R2, R6, R9, R16, R27, R45, R53) had quarterly MDS assessments that were either significantly overdue or not completed at all. For example, one resident’s quarterly assessment due on 11/13/25 was not completed until 1/14/26, making it 46 days overdue, and another resident’s assessment due on 11/14/25 was completed on 1/14/26, 47 days overdue. Additional residents had quarterly MDS assessments that remained incomplete past their due dates at the time of the survey. One resident’s assessment due on 1/5/26 was 16 days overdue and still not completed, while others had due dates in late December and early January and were between 20 and 24 days overdue without completion. During an interview and demonstration of the Clinical-MDS Scheduler report, the MDS Coordinator showed that the report identified MDS assessments that were not completed and how long they were overdue, and acknowledged that many assessments were overdue. The Administrator stated that corporate oversees the MDS process, and during a phone call, the Corporate MDS Nurse confirmed that the corporation was aware they were behind on completing the MDS assessments. No specific reason for the delays or failures to complete the assessments was provided in the report.
Unsupervised Oral Medications Left on Dining Table and Not Verified as Ingested
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in a safe manner and in accordance with its own medication administration policy. Surveyors observed an unlabeled pill cup containing three pills on a medication cart; an LPN stated the cup contained a specific resident’s medications that dietary staff had handed to her after finding the cup left on a dining room table. The LPN reported that the resident was not on her assignment and that she intended to take the medications to the DON. The DON then took the cup to an RN, explaining that the cup had been found on a dining room table. The RN identified the medications as two 325 mg Tylenol tablets and one 50 mg Tramadol tablet and acknowledged that she believed the resident had taken the pills. The RN further stated that she did not actually see the resident place the pills in her mouth and admitted she should have ensured the medications were taken before walking away. The resident involved had diagnoses including delusional disorder, unspecified disorientation, unspecified pain, and unspecified dementia of unspecified severity, and had physician orders for Tramadol 50 mg one tablet three times daily for pain and Tylenol 325 mg two tablets three times daily for pain. The facility’s written policy required that medications be administered as prescribed, that residents be observed after administration to ensure the full dose is ingested, and that medications not be left unattended. The DON confirmed that nurses are expected to remain with residents and watch them take their medications and that medications should never be left on a table.
Improper PPE Gown Use During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves a failure to correctly don personal protective equipment (PPE), specifically a gown, during care of a resident under Enhanced Barrier Precautions (EBP). The facility’s EBP policy, dated 10/28/2024, requires staff to wear a clean, non-sterile gown and gloves during direct resident contact, including device care and wound care, and to follow CDC guidance that the gown be fastened in the back. The CDC sequence for putting on PPE specifies fastening the back of the gown when putting it on. The resident involved was admitted with a principal diagnosis of cerebral infarction due to unspecified occlusion or stenosis of the left anterior cerebral artery, with additional diagnoses including feeding difficulties, dysphagia, and severe protein-calorie malnutrition. The resident had active physician orders for enteral feeding via a gastrostomy tube every shift, gastrostomy site dressing care, and an order for EBP requiring staff to wear gown and gloves during direct contact and device or wound care. On the survey date at 10:45 a.m., the DON and the ADON performed a gastrostomy dressing change for this resident in accordance with the physician’s order. During this procedure, the ADON’s gown was not tied around the neck or back, causing the gown to open and fall forward toward the resident. When questioned, the DON stated that proper procedure for donning a gown is to put it on and tie it, and the ADON acknowledged that the gown should have been tied securely, explaining that her gown would not stay tied. The DON further stated that she should have tied the ADON’s gown. These observations and interviews demonstrated that staff did not follow the facility’s EBP policy and CDC guidance for properly securing PPE during high-contact resident care involving a gastrostomy device and dressing change.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities for residents in the Memory Care Unit, as required by their policy. Observations and interviews revealed that the activity staff were not consistently present on the unit, and the activities listed on the calendar were not being conducted. For instance, on multiple occasions, residents were found sitting idle without any engagement, and the activity staff did not arrive to conduct scheduled activities like 'Parachute Fun.' The lack of activity staff presence was attributed to staffing shortages, with only one activity aide working part-time and another full-time aide not covering the Memory Care Unit on weekends or certain weekdays. The report highlights specific instances where residents were left without meaningful engagement. On one occasion, a nurse and a CNA were unable to facilitate a craft activity due to insufficient staffing and concerns about residents' safety with small craft pieces. Additionally, residents were observed sitting in common areas without any music, television, or accessible activity materials, contrary to their care plans that emphasized the importance of music and other forms of engagement. The activity director acknowledged the inadequacy of the current staffing levels and the unsuitability of certain activities for the residents' needs. The facility's failure to provide adequate activities was further compounded by the lack of resources and support for the nursing staff to lead activities. The activity director admitted that the expectation for CNAs to lead activities was unrealistic given their other responsibilities. The report also noted that there were no activities on weekends and certain weekdays due to the limited availability of activity staff, leaving residents without structured engagement during these times.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure appropriate indications for the use of antipsychotic medications and did not identify or document target behaviors for several residents. The report highlights that six residents were administered antipsychotic medications without proper documentation of specific behaviors or symptoms that necessitated such treatment. The facility's policy on psychotropic medication management requires documentation of specific behaviors and the resident's response to non-pharmacological interventions, which was not adhered to in these cases. For instance, one resident with diagnoses including Frontotemporal Neurocognitive Disorder and Schizophrenia was receiving Haloperidol and Quetiapine, yet their care plan did not include target behaviors justifying the use of these medications. Another resident with Moderate Severity Dementia and Mood Disorder was on Risperidone without having been seen by psychiatric services, and their care plan also lacked documentation of target behaviors. Similar issues were noted with other residents, where antipsychotic medications were prescribed for conditions like dementia and anxiety without clear documentation of behaviors that would warrant such treatment. The Director of Nursing acknowledged the issue, stating that the psychiatric services had only recently started, and some staff believed medication was the solution to behavioral issues, contributing to the problem. The care plans for these residents did not include target behaviors as part of the reason for the psychotropic medications, indicating a systemic issue in the management and documentation of antipsychotic medication use in the facility.
Failure to Include Oxygen Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive assessment for the use of oxygen for a resident reviewed for care plans. The facility's policy, revised in June 2024, requires an individualized comprehensive care plan with measurable objectives and timetables to meet each resident's needs. However, the resident's Physician Order Sheet from December 2024 included an order for oxygen at 2 liters per minute via nasal cannula as needed for dyspnea or chest pain, but the current comprehensive care plan did not contain information or goals regarding oxygen usage. Observations on two separate days confirmed the resident was using oxygen, yet the care plan coordinator acknowledged the omission of the resident's oxygen needs in the care plan.
Failure to Monitor and Report Weight Changes in CHF Resident
Penalty
Summary
The facility failed to adhere to the prescribed care plan for a resident with congestive heart failure (CHF), specifically regarding daily weight monitoring and reporting significant weight changes to the cardiologist or CHF clinic. The hospital discharge instructions for the resident required daily weighing at the same time and on the same scale, with any weight gain of 3 pounds in one day or 5 pounds in one week to be reported to the cardiologist. However, the Medication Administration Record (MAR) for the resident showed multiple instances of missing weight documentation across several months, including August, September, October, November, and December. Despite documented weight gains that met the criteria for notification, there was no evidence in the medical records that the cardiologist or CHF clinic was informed of these fluctuations. The Director of Nursing confirmed the missing documentation and acknowledged that the cardiologist should have been notified according to the parameters set on the discharge instructions. This oversight in monitoring and communication represents a failure to provide appropriate treatment and care as ordered, potentially impacting the resident's cardiac health management.
Failure to Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and measure a pressure ulcer for one resident, identified as R23, among two residents reviewed for wounds. The facility's Skin Prevention, Assessment and Treatment policy requires weekly assessment and documentation of all skin impairments, including pressure ulcers, by the Wound Nurse or designee. However, R23's wound care assessments consistently referred to the wound as irritant contact dermatitis and did not include measurements or documentation of multiple open areas on the coccyx, despite the presence of four small slit-like open areas observed during a survey. The Director of Nursing (DON) confirmed that the facility does not measure non-pressure ulcers and relies on telehealth wound care doctors who do not perform hands-on assessments. The DON acknowledged that R23's wound was due to immobility and incontinence and was located directly over the pressure point of the coccyx. Despite this, the wound was not documented as a pressure ulcer, and there was no record of the number of open areas present. This lack of thorough assessment and documentation led to the deficiency identified by the surveyors.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment was changed as ordered for a resident, identified as R33, who was reviewed for respiratory care. According to the facility's Oxygen Administration and Storage policy, nasal cannulas or masks should be changed weekly or when soiled, and the humidifier bottle should be labeled with the date of application and changed weekly if refillable. R33's Physician Order Sheet dated December 19, 2024, specified that the oxygen water bottle should be changed on the night shift every Sunday and as needed, with the bottle being dated and initialed, and the oxygen tubing changed every Sunday and as needed for infection control. However, the Treatment Administration Record for December 2024 showed that the last documented change of R33's humidification bottle was on December 15, 2024, with no documentation for the subsequent Sundays, December 22 and December 29, 2024. Observations on January 7 and January 8, 2025, revealed that R33's nasal cannula tubing and refillable humidifier bottle were still dated December 16, 2024. The Director of Nursing confirmed that both the nasal cannula and the humidifier bottle should have been changed weekly, indicating a failure to adhere to the prescribed schedule for changing the oxygen equipment.
Medication Administration Breach in Infection Control
Penalty
Summary
The facility failed to adhere to its Standard Precautions policy during a medication administration for a resident. A registered nurse was observed preparing medications for a resident with a gastric tube. During the process, the nurse placed the medication cup on the resident's bed, which resulted in the cup tipping over and spilling two pills onto the fitted sheet. The nurse then picked up the pills with a gloved hand and returned them to the cup, subsequently administering all the medications via the resident's gastric tube. The nurse later confirmed that the pills had fallen onto the bed and acknowledged that the bed sheet would not be considered clean, indicating a breach in infection control practices.
Inadequate Alarm System and Supervision Lead to Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the memory care unit exit doors and bracelet alarms were loud and widespread enough to alert staff when activated. This deficiency resulted in a cognitively impaired resident, who was at high risk for elopement, exiting the facility without staff knowledge. The resident was found outside in the parking lot, soaking wet and with significant injuries, including facial and cervical spine fractures, after having eloped from the facility's locked memory care unit. The incident occurred during a time of heavy rain, and the resident was later transferred to a tertiary hospital for intensive care treatment. The resident involved had a history of severe cognitive impairment and was known to be an exit seeker. Despite this, the care plan had not been updated with new interventions since 2023, and the facility failed to follow its own elopement policies. The alarms on the exit doors were not audible enough to alert staff, especially when they were in resident rooms or further up the hall. Staff interviews revealed that the resident had previously managed to exit the building, indicating a pattern of inadequate supervision and alarm system failures. The facility's policies required that all incidents of elopement be reported to the State Agency and result in a comprehensive care plan review and revision. However, the facility did not report the elopement incident to the State Agency, as they believed the resident was still on the property. This oversight, along with the failure to investigate and address previous elopement attempts, contributed to the severity of the incident and the resulting injuries to the resident.
Removal Plan
- An audit of the memory care unit's alarms was conducted and determined that all exit alarms are functioning and audible, including behind closed doors. All 17 rooms were audited on the unit, including the room furthest from the exit.
- All nursing staff present were in-serviced on: Proper monitoring and supervision of residents at risk for elopement - The definition of elopement - Review of the facility's elopement detection and prevention systems - The need to reassess and review a resident's plan of care after an elopement.
- All residents at high risk for elopement have been reviewed and no instances of exiting the building unattended have been identified.
Dietary Staff Non-Compliance with Hair Restraint Policy
Penalty
Summary
Facility dietary staff failed to have their hair restrained while handling and preparing food, which has the potential to affect all 60 residents currently residing in the facility. The facility policy, dated November 5, 2019, directs that hair nets or approved hats covering all hair must be worn while handling or preparing food. However, observations on April 6, 2024, revealed multiple instances of non-compliance. A Dietary Assistant was seen serving food and pouring drinks without a hair net or approved hat, and another Dietary Assistant was observed washing dishes with loose hair hanging from a cap. Additionally, a Dietary Cook was seen with a hair net that did not fully restrain their hair. The Dietary Manager confirmed that all dietary staff are required to have their hair fully restrained while handling and preparing food. The observations were made between 8:30 A.M. and 8:55 A.M. on April 6, 2024. The Dietary Assistant was seen performing various tasks, including plating food, pouring drinks, retrieving and serving brown sugar, and delivering filled plates to residents, all without proper hair restraint. Another Dietary Assistant was observed in the dish room with loose hair hanging from a cap, and the Dietary Cook had a hair net that did not fully restrain their hair. The Director of Nurses verified that 60 residents currently reside in the facility, indicating the potential widespread impact of this deficiency.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide twice-weekly showers for one of four residents reviewed for showers. The facility's policy mandates assisting residents with bathing to maintain proper hygiene and prevent skin conditions. Resident R3, diagnosed with Dementia and Parkinson's Disease, was admitted to the facility and required staff assistance for all Activities of Daily Living (ADLs). According to the facility's shower list, R3 was scheduled to receive morning showers on Wednesdays and Saturdays. However, a review of R3's Certified Nursing Assistant Shower Sheet revealed that R3 only received 20 out of 34 scheduled showers from December 9, 2023, through April 3, 2024. Interviews with Certified Nursing Assistants confirmed the missed showers and noted that R3 enjoyed showers and did not resist them. The Director of Nurses verified that R3 had not been discharged during the specified timeframe and confirmed the missing shower records.
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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