Monmouth Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Monmouth, Illinois.
- Location
- 117 South I Street, Monmouth, Illinois 61462
- CMS Provider Number
- 146057
- Inspections on file
- 33
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 25 (1 serious)
Citation history
Health deficiencies cited at Monmouth Rehab And Nursing during CMS and state inspections, most recent first.
Delayed Response to Resident Call Lights: Staff failed to answer resident call lights in a timely manner. Grievances and Resident Council minutes documented repeated complaints that call lights were especially delayed in the morning and at mealtimes, with some residents reportedly waiting over an hour or being told to wait until the next shift. During observation, an LPN and an RN walked past a sounding bathroom emergency light while a resident was in the bathroom requesting assistance.
Resident Council grievances were not consistently answered with responses, actions, or rationale, and multiple complaints remained unresolved across several meetings. A former council president said concerns were repeatedly raised but nothing was fixed, and residents reported they did not receive follow-up on grievances submitted through council. The facility also lacked a grievance/suggestion box for anonymous submissions, and the Administrator confirmed grievances were routed to the relevant dept manager after being given to the Administrator by the Activity Director.
Failure to complete a Legionella risk assessment and follow EBP for two residents. The facility had no completed annual Legionella assessment despite 37 residents in the building, and staff were observed not using gown/PPE requirements during high-contact care for two residents with EBP orders. An LPN handled contaminated lotion bottles and provided care without a gown, and one resident also lacked an EBP sign and PPE outside the room.
A facility failed to maintain a reliable nurse call light system in resident bathrooms and bathing areas. Staff, an ombudsman, and a resident reported that call lights were malfunctioning, with one activation triggering other lights, indicators not lighting up, and the nurses’ station board sounding without showing which room needed help. An RN’s testing confirmed multiple call light failures, and CNAs reported they had to go room to room to identify the source of the alarm.
Failure to Monitor Changes in Condition and Document Assessments The facility did not consistently assess or document residents’ changes in condition, including acute respiratory illness, refusals of care, agitation, falls, and post-hospital status. Records lacked timely VS, respiratory and neuro assessments, urinary assessments, and follow-up documentation after transfers, while one resident with Influenza A had no documented targeted or general assessments during isolation and another resident with dementia had a fall, unsafe room conditions, and incomplete documentation of behaviors and interventions. A resident with urinary retention later became unresponsive and was sent out with severe sepsis, and another resident with COPD and a prior CVA had falls, abnormal lung findings, facial trauma, and worsening mental status without documented ongoing assessments or discharge follow-up.
Nonfunctioning bedside lights affected three residents’ rooms. One resident reported being unable to turn on the overbed light from bed because the pull chain was missing, another resident’s light behind the bed had no switch or pull cord and the ceiling light was too bright to use, and a third resident also lacked a reachable overbed light control. Resident council minutes had already noted concerns about light bulbs needing replacement.
Failure to provide written transfer information to the hospital for a resident sent to the ER with leaning, drooling, and slurred speech. The resident had COPD, PNA, and sepsis, but the chart lacked a full assessment, VS, blood sugar, and pulse ox documentation, and the RN confirmed no written transfer form was sent with the resident’s assessment findings, meds, family contact info, or AD status.
A resident with a documented transfer program to walk to and from meals with a FWW, gait belt, and SBA was observed using a wheelchair instead, and the walking task was documented as N/A for all shifts over multiple months. Staff interviews showed the CNA was unaware of a walking program, the resident said staff no longer walked her to meals, and the COTA and DON confirmed there was no walking documentation during the review period.
Improper Catheter Flush and Aseptic Technique: An LPN failed to maintain aseptic technique during a Foley catheter flush for a resident with an indwelling catheter. The LPN handled supplies and catheter components in a way that allowed cross contamination of clean areas, including placing items on the bedside table, disconnecting the drainage bag, and allowing the resident to handle the bag during the procedure.
Failure to reweigh a resident after significant weight loss. A resident with diagnoses including hemiplegia/hemiparesis after CVA, noncompliance with cares, and a displaced trimalleolar fracture had a documented 14.5-lb weight loss between two recorded weights. The facility’s weight policy required admission weights, weekly weights for four weeks, and a next-day reweigh for any 5-lb or greater change, but the DON confirmed there was no documentation of the required weekly admission weights or any reweigh after the loss.
A resident on neuro checks after a fall with head trauma had missing post-fall neuro documentation in the electronic record. When a Neuro/Head Trauma Assessment form was produced, the entries were all in the same handwriting even though different staff initials were used, and the DON and Administrator agreed the record appeared to be falsified.
A resident receiving hospice care had incomplete hospice communication and documentation. The care plan lacked specific hospice interventions and did not identify use of a self-adjusting alternating pressure mattress, and the hospice binder at the nurse's station was missing an updated POC, visit notes, provider responsibilities, and correspondence. An LPN noted a change in condition and said hospice needed to be called, while the DON found the mattress was not powered on and later unplugged; the record did not document that hospice was notified, and a hospice visit was initialed without a note or status update.
Incomplete vaccine consent documentation was cited after surveyors found the facility did not ensure Influenza and Pneumococcal immunizations were properly offered and documented for three residents. Records showed one resident’s representative signed a consent form that did not identify the vaccine or confirm vaccine information was provided, another resident’s form did not show which vaccines were accepted or declined, and a third resident’s form only reflected refusal of Influenza and did not show that vaccine information was given. The DON/IP reviewed the forms and agreed they were incomplete.
Incomplete COVID-19 Vaccine Consent Documentation: The facility failed to properly document COVID-19 vaccine education, acceptance, or refusal for three residents reviewed for immunization compliance. One resident’s record did not show whether the vaccine was given or refused, and two residents had incomplete consent forms that did not identify which vaccines were accepted or declined or confirm that vaccine information was provided. The DON/IP reviewed the forms and agreed they were incomplete.
A resident with Alzheimer’s/dementia, poor safety awareness, and a documented history of elopement and exit-seeking behaviors was not consistently protected by appropriate elopement interventions. Despite prior elopement incidents and assessments identifying elopement risk, the resident did not have a wander guard in place, and a reported refusal to wear one was not documented. On one occasion, staff last observed the resident ambulating in the hallway with a walker, later realized the resident was missing, and found the resident offsite at a nearby coffee shop after EMS had been called by a concerned citizen. The event was not documented in the resident’s EMR, and required incident documentation per facility policy was not completed, demonstrating a failure to provide adequate supervision and to follow elopement assessment and documentation procedures.
The facility failed to maintain complete and accurate clinical records for two residents when incident-related documentation was not entered into their medical charts. For one resident who eloped, there was no nurse progress note or assessment describing the elopement, staff response, or the resident’s condition upon return, despite subsequent care plan and MD order updates for a wander guard. For another resident with Alzheimer’s disease and dementia, a healing bruise under the eye was noted, but there was no documentation of how the bruise occurred or any follow-up assessment or investigation. The DON reported that incident and accident information was documented only in an internal risk management system that does not populate the residents’ EMR.
A resident with neuromuscular conditions fell from a wheelchair during an outing, resulting in immediate hand pain and swelling. Despite ongoing complaints and visible worsening of the injury, staff did not promptly notify the physician as required by facility policy. The delay led to a late diagnosis of multiple hand fractures, with staff interviews confirming missed opportunities for earlier intervention.
A resident who was cognitively intact experienced repeated intrusions by another resident, including being struck with a shoe, having water thrown at her, and finding her room soiled with urine and feces. Despite reporting these incidents and expressing fear to facility leadership, the only action taken was installing a bathroom door lock, which did not prevent further unauthorized entries through the main door. The resident continued to feel unsafe and her right to a dignified, safe environment was not maintained.
Two residents were subjected to physical abuse by another resident, including being struck with a shoe and having hair pulled, while staff failed to conduct required abuse investigations or notify the State Agency. Despite staff witnessing and reporting these incidents to facility leadership, no formal investigations were initiated, leaving residents feeling unsafe.
The facility did not follow its abuse policy by failing to immediately report and investigate two separate incidents of resident-to-resident physical abuse. In both cases, staff and administration did not promptly notify the State Agency or initiate required investigations after one resident struck another with a shoe and, in a separate event, when a resident grabbed another's hair and walker.
Two separate incidents of alleged abuse occurred in which one resident struck another with a shoe and, in a separate event, a resident grabbed another's hair and attempted to take her walker. In both cases, the Administrator and other relevant parties were notified, but no immediate abuse investigation was initiated and the State Agency was not informed as required.
The facility did not investigate two separate abuse allegations involving three residents. In one case, a staff member saw a resident strike another with a shoe, and in another, a resident grabbed another's hair and clothing. The administrator acknowledged both incidents as potential abuse but did not initiate required investigations as outlined in facility policy.
A resident with a history of multiple falls and high fall risk, as documented in the care plan, was repeatedly observed without required gripper socks while seated in common areas. Staff confirmed the resident should have been wearing gripper socks at all times, but this intervention was not implemented as directed.
Two residents requiring continuous oxygen therapy did not receive care in accordance with physician orders and facility policy. Staff failed to date and label oxygen tubing and humidifier bottles, and one resident received oxygen at a higher flow rate than prescribed, while another was observed without oxygen despite a continuous order.
Two residents with cognitive impairment or recent decline experienced multiple falls without appropriate safety interventions or therapy evaluations, as required by facility policy. One resident suffered a foot fracture and repeated falls, while another sustained rib and arm fractures and was later placed on hospice. Staff interviews and documentation revealed inadequate care plan updates, lack of therapy involvement, and issues with supervision and equipment such as nonfunctional call lights.
A resident with cognitive impairment and poor safety awareness was provided with half bed rails as a fall intervention without a completed entrapment assessment prior to their application. Staff interviews confirmed that the required assessment was not initiated until after the rails were in use and was never completed, contrary to facility policy that mandates evaluation before bed rail installation.
Two residents with cognitive impairments exited the facility unsupervised, with one found outside in the grass and another in the parking lot. Additionally, a resident at risk for falls was transferred by a single CNA instead of the required two, resulting in skin tears. These incidents highlight failures in supervision and adherence to care plans.
The facility failed to ensure residents met infection standards and lacked policies for those with symptoms not meeting infection criteria, leading to inappropriate antibiotic prescriptions for two residents. The facility's undated policy on antibiotic stewardship lacked standardization, and there was no education provided to healthcare providers on this matter, potentially affecting all 40 residents.
The facility failed to adhere to guidelines for psychotropic medication use, including appropriate indications, gradual dose reductions, and limiting as-needed use to 14 days. A resident was prescribed Seroquel without documented behaviors or dose reduction attempts. Another resident received Abilify for depression enhancement without behavior documentation. A third resident was on Olanzapine and Bupropion without dose reduction attempts. Lastly, a resident was prescribed Lorazepam without a stop date, contrary to policy.
A resident expressed her desire to change her doctor, as she did not like the current one. Despite her communication to the facility staff, the doctor continued to see her. The Social Service Director confirmed that residents have the right to choose their own doctor, but was not informed of the resident's request.
The facility failed to ensure that the electronic medical records and care plans of three residents matched their POLST regarding CPR code status. One resident's physician's order indicated a full code, but the POLST indicated comfort-focused treatment/DNR. Another resident's physician's order documented a DNR, but the POLST indicated selective treatment. A third resident's physician's order and care plan documented a DNR, but the POLST indicated selective treatment. The administrator acknowledged the need for care plans to match the POLST forms.
A resident with a bruise on the knee provided inconsistent accounts of its origin, and the facility failed to report this injury of unknown origin to the state agency as required by their policy. Despite the resident being cognitively intact and staff being unaware of any incident, the facility did not adhere to its reporting obligations.
A facility failed to accurately document a resident's hospice services in the MDS. The resident, with multiple diagnoses including Traumatic Brain Injury and Dementia, was admitted to hospice services as per a physician's order. However, the MDS entries incorrectly indicated the resident was not on hospice services, an error confirmed by the LPN/MDS Coordinator.
The facility failed to coordinate and document hospice care plans for two residents, resulting in incomplete care plans lacking specific hospice interventions. Staff relied on facility care plans without access to hospice records, and hospice binders were found empty. The absence of a hospice policy and reliance on hospice agreements for outlining responsibilities contributed to the deficiency.
A facility failed to follow policy when a resident's G-tube became clogged, leading to its replacement with an indwelling urinary catheter without a physician's order. The catheter was used for enteral feeding, causing the resident to experience emesis and loose stools, resulting in hospitalization. The facility did not notify the physician or verify the catheter's placement, contributing to the deficiency.
A resident experienced emesis and diarrhea for two days, leading to hospitalization, after the facility failed to notify the physician of abnormal radiology results and a change in condition. The resident's G-tube was replaced with an indwelling urinary catheter without physician consultation, and the physician was not informed of the resident's vomiting and diarrhea.
A resident with a G-tube experienced emesis and diarrhea after an LPN, lacking proper training, replaced the G-tube with an indwelling urinary catheter and administered feedings without verifying placement. The facility failed to ensure nursing staff were competent in G-tube care, leading to the resident's hospitalization.
The facility failed to ensure that four CNAs completed the required 12 hours of annual education, including dementia management training. This deficiency, confirmed by the Clinical Director, affects the care of 41 residents.
The facility failed to report an allegation of neglect to the State Agency as required by its policy. A resident was found in a neglected state during a medical appointment, and despite an internal investigation, the State Agency was not notified.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner. The facility’s policy stated that calls for assistance shall be answered timely and that the communication system cords must be left in place in resident rooms, but grievance records documented repeated complaints that call lights were not being answered timely, especially first thing in the morning and at mealtimes. One grievance noted that the issue had been ongoing for some time and that a grievance filed on 07/31/2025 regarding call light wait times had not been resolved. Resident Council meeting minutes also documented extended call light times and residents being told to wait for the next shift when lights were answered due to charting. During a Resident Council meeting on 3/18/26, alert and cognitively intact residents reported that call lights were not being answered timely. One resident stated that residents in the back hallway would start yelling because staff were not answering their call lights, and she would go to the nurses’ station in the front of the building to alert staff that a resident needed assistance. The Ombudsman confirmed that long wait times for call lights had been an issue for several months. On 3/19/26, a bathroom emergency light between rooms was lit and sounding while an LPN and an RN walked past it, turned around, walked past it again, and continued to the nurses’ station; a resident was in the bathroom on the toilet and had turned on the emergency light for assistance. On 3/20/26, the Activity Director was unable to identify the residents named in grievances who reported waiting over an hour for call lights to be answered or being told to wait until the next shift.
Resident Council Grievances Not Addressed or Followed Up
Penalty
Summary
The facility failed to provide the Resident Council with responses, actions, and rationale regarding concerns raised in council meetings. The facility’s policies state that the Resident Council is intended to give residents input into facility operations and discuss concerns, and that grievances are to receive follow-up within 72 hours. However, the Resident Council minutes documented multiple unresolved complaints over several meetings, including complaints from July, October, November, December, and January that had not been resolved. The grievance logs from 7/31/25 through 2/23/26 documented 22 grievances, and all 22 were filed in Resident Council meetings. During interview, a former Resident Council president stated she stopped serving because concerns were repeatedly brought up but nothing was ever fixed or changed, and staff never provided feedback while problems continued. At a Resident Council meeting attended by the Ombudsman and several cognitively intact residents, all residents present reported they did not receive follow-up on grievances submitted in Resident Council. Residents also stated grievances were filed in Resident Council to remain anonymous, and the facility did not have a grievance/suggestion box for anonymous submissions. The Administrator confirmed grievances were routed to the department manager involved, and the Activity Director stated she gave grievances and Resident Council minutes to the Administrator.
Failure to Complete Legionella Risk Assessment and Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to complete an annual Legionella Risk Assessment to assess where Legionella and other opportunistic waterborne pathogens can grow and spread. The Facility Resident Census Roster documented 37 residents in the facility, and the Legionella Risk Assessment, which should be completed annually or upon disruption of the water source, was not dated and was not completed. On 3/19/26, the Maintenance Director stated the Legionella Risk Assessment had not been completed since he had been there for approximately 3 1/2 years. The facility also failed to use Enhanced Barrier Precautions as ordered for two residents. One resident had a physician order for Enhanced Barrier Precautions and a care plan noting a wound and that isolation PPE should be available at the room entrance and worn for high-risk activities, but an LPN was observed applying lotion to the resident's bilateral lower extremities, handling the lotion bottle, and placing it on the treatment cart without disinfecting it, and without donning a gown during high-contact care. The resident did not have an Enhanced Barrier Precaution sign posted or PPE available outside the room during the survey. A second resident had a physician order for infection precautions with staff to wear gown and gloves during direct patient contact, and the care plan documented Enhanced Barrier Precautions during personal care; an LPN was observed removing elastic wraps, assessing and rubbing the resident's lower extremities, applying lotion, then handling the contaminated lotion bottle with bare hands and placing it on the treatment cart without disinfecting it, and without donning a gown during high-contact care. The DON confirmed gloves and gowns should be worn during high-contact care.
Unreliable Resident Call Light System
Penalty
Summary
The facility failed to ensure a reliable operating nurse call light system in resident bathrooms and bathing areas. The facility’s policy required a communication system that relays calls directly to staff from each resident’s bedside, toilet, and bathing facilities, and stated the system should be checked regularly for operability. The maintenance director’s job description included assuring proper maintenance and running condition of all nurses’ call station systems, but the grievance log documented that call lights were not working and that quotes and a repair plan were being pursued. During observation and testing, multiple call light problems were identified. In the resident council meeting, the ombudsman reported a “ghost light system” in which activating one call light could trigger other call lights or turn them all off, requiring staff to go room to room. A resident reported being awakened at night by staff asking if it was her call light because staff could not tell which light was on. Surveyors observed bathroom call lights blinking and sounding when no residents were present, and staff confirmed the shower room emergency light could activate call lights in other rooms. Testing by an RN showed some room call lights activated indicators outside other rooms, some bathroom emergency call lights did not light the indicator outside the room, and one room call light activated neither the outside indicator nor the nurses’ station board. At one point, the nurses’ station call light board sounded without any lights showing which call light was activated, and CNAs reported they had to check each room to find the source.
Failure to Monitor and Document Changes in Condition, Falls, and Hospital Follow-Up
Penalty
Summary
The facility failed to monitor, assess, and document changes in condition for multiple residents, including residents with acute illness, falls, behavioral changes, and post-hospital returns. The report states that for 5 of 5 residents reviewed, the facility did not ensure timely assessments, interventions, notifications, or follow-up after changes in condition. Documentation was missing or incomplete for targeted assessments, general skilled nursing assessments, vital signs, neurological checks, discharge disposition follow-up, and investigation of outcomes after hospital transfers. For one resident who returned from the hospital with Influenza A and was placed on contact and airborne precautions, the record did not contain respiratory assessments, vital signs, or other physical assessments after admission while the resident remained acutely ill. The report notes no vital signs were documented on multiple days during the isolation period, and the Regional Administrator confirmed there were no targeted or general physical assessments after hospitalization while the resident was in transmission-based precautions. The facility policy required full assessment, physician and family notification, and vital signs every shift for at least 72 hours or until stable. Another resident with dementia, atrial fibrillation, cellulitis, heart failure, and osteoarthritis had refusals of care and agitation documented, but the record did not show assessments or interventions for the new behaviors. The resident later fell and was found with a forehead hematoma and bruising, with notifications made and hospital transfer completed. The record also lacked urinary assessments despite later abnormal urinalysis and antibiotic treatment. Surveyors also observed the resident’s call light was not within reach and the room light was not usable as intended, despite the care plan requiring a reachable call light and safe environment. A resident with a thoracic spine fracture, urinary retention, diabetes, and neurogenic bladder had a documented complaint of lower abdominal and penile pain with catheter change and relief of pain, but there was no further nursing documentation or vital signs for a period before the resident was later found unresponsive with severe hypotension, hypoxia, bradycardia, and rapid respirations and transferred to the hospital with severe sepsis, altered mental status, and UTI with hematuria. The record did not include inquiry into the hospitalization outcome, discharge disposition, or a completed discharge summary. Another resident with a cerebral infarct, dementia, and COPD had a fall, cough, abnormal lung sounds, another fall with nasal fracture and facial trauma, and later worsening lethargy, decreased orientation, fluctuating blood pressure, decreased oxygen saturation, and pinpoint nonreactive pupils, but the record did not show neurological or body system assessments after return from the ED, nor documentation of the 4 Plex test, interdisciplinary review, hospitalization outcome, discharge disposition, or discharge summary.
Nonfunctioning Bedside Lights
Penalty
Summary
The facility failed to ensure residents had functioning lights in their rooms for three residents reviewed for a comfortable home-like environment. Record review showed the Maintenance Director’s job description included maintaining the orderly functioning of equipment in the facility, and Resident Council meeting minutes dated 01/19/26 documented concerns that some light bulbs needed replacement. During the 03/18/26 Resident Council Meeting, an alert and oriented resident reported he was unable to turn on his overbed light from bed because there was no chain or string on the light, and stated this had been the case since he moved into the room. He also reported the Maintenance Director had previously been aware of the missing chain or string and had observed the condition in his room. During observation between 11:50 AM and 1:00 PM on 03/18/26, one resident’s overbed light did not have a string that could be reached from the bed, and another resident’s light behind the bed did not have a knob, switch, or pull cord to turn it on or off. A roommate stated that resident’s light had not worked since she moved into the room and that the ceiling light switch was by the door, but the ceiling light was too bright to use because it blinded them. The resident was unable to reach the lights and relied on the roommate for help. A third resident’s overbed light did have a string attached and could be turned on and off from bed.
Failure to Provide Written Transfer Information to Hospital
Penalty
Summary
The facility failed to transfer a resident to the hospital with a written explanation of the resident’s condition and related information for one resident reviewed for transfer. The facility’s transfer agreement with the local hospital system stated that necessary medical records and pertinent information, including current medical findings, diagnoses, advanced directives, rehabilitation potential, treatment summary, nursing information, ambulation status, and other administrative and social information, would be transferred. The facility’s Resident Transfer and Discharge Policy also stated that the facility properly documents resident transfers and discharges and uses a standardized discharge planning process. Resident R37 was admitted with diagnoses including COPD, pneumonia, and sepsis. During the survey, R37 was able to answer questions appropriately except for difficulty finding the correct word, and when words were provided she could confirm or deny whether that was what she meant. Nursing notes documented that R37 was sent to the ER because of leaning, drooling, and slurred speech. The chart did not show documentation of a full physical assessment, vital signs, blood sugar results, or pulse oximetry. The RN stated she did not complete discharge paperwork because it was only an ER visit and confirmed she did not provide the receiving hospital written information about the resident’s assessment results, actions taken, family contact information, current medications, or advanced directive status. Another RN stated the facility just called report and had not been sending transfer forms for a while, and the Regional Administrator confirmed there was no transfer form in place for R37 and that there should have been.
Failure to Maintain Walking Ability
Penalty
Summary
The facility failed to ensure a resident maintained the ability to walk, despite documentation showing the resident had a transfer program established to walk to and from meals with a front wheeled walker, gait belt, wheelchair follow as needed, and standby assist. The facility’s Activities of Daily Living policy stated residents would receive care and services to maintain or improve ADLs, including walking and restorative plans to prevent or minimize functional decline. However, the resident’s walking electronic documentation task showed N/A for all shifts from 02/01/26 through the present, and throughout the survey the resident was observed propelling herself to and from meals in her wheelchair. Staff interviews confirmed the resident was not being walked as expected. A CNA stated the resident was not on a walking program and usually rolled herself wherever she wanted to be. The resident stated staff used to walk her to and from meals but no longer did so. A COTA stated the resident should be walking to and from meals, could do so with distant supervision, and that staff should be encouraging and/or walking with her to meals; the COTA also stated that if the resident was not walking, staff should document why. The DON confirmed the resident’s walking documentation did not show any walking throughout February and March 2026.
Improper Catheter Flush and Aseptic Technique
Penalty
Summary
Appropriate care for residents with indwelling urinary catheters was not provided when the facility failed to perform a urinary catheter flush in a way that prevented cross contamination of clean areas for one resident reviewed for catheter care. The facility’s Indwelling Catheter policy dated 12/23/2023 stated that only persons who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters, and it included steps for irrigation such as putting on gloves, cleansing catheter tubing with alcohol, connecting the syringe, flushing the catheter, cleansing the ends of the tubing and drain bag with alcohol, and then removing gloves and washing hands. During observation, an LPN donned PPE gloves and a gown outside the room, entered the room, shut the door with gloved hands, removed gloves, washed hands, and donned new gloves. The LPN opened the syringe package, opened the Acetic Acid bottle, drew up solution, and laid the syringe on the bedside table. With gloved hands, the LPN moved the resident’s walker and pulled up the resident’s pants. The LPN opened two alcohol swabs and laid them directly on the outside packaging, disconnected the Foley drainage bag from the inserted tubing, and handed the drainage bag to the resident, who rolled it back and forth in his fingers while care was being performed. The LPN then wiped the insertion end of the catheter tubing with an alcohol swab and began flushing the catheter. The resident asked her to stop after about 25 milliliters of Acetic Acid had been instilled, and the LPN complied. The LPN then wiped both ends of the catheter tubing with alcohol swabs, manipulated the catheter tubing directly outside the resident’s urethra until the resident said okay, pulled the resident’s pants up, returned the walker, moved the bedside table back within reach, removed gloves and gown, and washed her hands.
Failure to Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility failed to provide enough food/fluids to maintain a resident's health when it did not reweigh a resident with a significant weight loss. The facility's Weight Assessment and Interventions dated December 30, 2024, states that nursing staff will measure resident weights on admission and then weekly for four weeks, and that any weight change of 5 pounds or more within 30 days will be retaken the next day for confirmation, with the provider and dietary manager/dietician notified if the weight is verified. The resident was admitted with diagnoses including hemiplegia and hemiparesis after cerebral infarction, noncompliance with cares, and displaced trimalleolar fracture. The resident's weight was documented as 142 pounds on 2/2/26 and 127.5 pounds on 3/5/26, a 14.5-pound difference. On 3/18/26, the DON confirmed the resident did not have admission weights done on the day of admission and then weekly, and that there was no documentation of a reweigh after the 14.5-pound difference.
Inaccurate Documentation of Post-Fall Neuro Checks
Penalty
Summary
The facility failed to ensure medical records were accurately documented for one resident who was on neurological checks after a fall with head trauma. The charting and documentation policy stated that medical record entries must be made by the person providing or supervising the service, and that documentation should include assessment, notifications, interventions, and evaluation. However, when the resident’s record was reviewed, the electronic record did not include the post-fall neurological checks that were expected to be documented. During record review, staff were asked to provide the resident’s neurological assessment monitoring after the fall. The DON provided a Neuro/Head Trauma Assessment form, and each assessment entry from the morning after the fall through the third shift two days later was written in the same handwriting, even though the initials for each entry were different. The Administrator reviewed the form and agreed that the neurological assessments were documented in the same handwriting and stated that the record appeared to be falsified.
Hospice communication and documentation were incomplete for a resident receiving end-of-life care
Penalty
Summary
The facility failed to ensure hospice communication was coordinated and that required hospice documents were available and accessible to staff for one resident, R6, who was admitted with diagnoses including Venous Insufficiency, Alzheimer's Disease, Dementia, and Dysphagia and elected Hospice Benefits on 9/24/25. The resident's current care plan lacked specific hospice responsibilities or interventions and did not identify that R6 was using a self-adjusting and alternating pressure mattress. The hospice binder at the nurse's station contained a hospice plan of care dated 9/24/25 through 12/22/25, but it did not include an updated hospice plan of care, visit notes, visit update notes, identification of hospice providers involved in care, visit frequency, provider responsibilities, or correspondence between hospice and facility staff. On 3/17/26, an LPN performed skin care to R6's bilateral lower extremities and later stated she needed to call hospice to report a change in condition because R6 did not eat supper the prior night or breakfast that morning. The LPN stated she did not know whether hospice staff participated in interdisciplinary team meetings and that the hospice nurse usually received a verbal report from facility nurses before visits. During multiple observations that day, R6's dual-function self-adjusting and alternating pressure mattress appeared not powered on; the DON later confirmed the power light was not on and stated she did not know, then later stated the mattress was unplugged and was now working. On 3/18/26, R6's record did not include documentation that hospice was notified of the change in condition. On 3/19/26, the hospice binder showed the hospice nurse had dated, timed, and initialed a visit, but no note or status update was included. When the Administrator was notified on 3/19/26, it remained unable to be determined whether hospice had been notified of the change in condition, whether the facility or hospice provided the air mattress, or whether there were instructions for its use. R6 was transferred to a private room to pass peacefully on 3/20/26.
Incomplete Vaccine Consent Documentation
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after surveyors found the facility failed to ensure Influenza and Pneumococcal immunizations were offered to three of five residents reviewed for immunization compliance in a sample of 28. The facility’s policies stated that residents or their legal representatives were to receive education on the risks, benefits, and potential side effects of the immunizations, and that evidence of education was to be documented in the medical record with a signed consent form before administration. For one resident, the immunization record showed Pneumococcal vaccine was refused and Influenza vaccine was administered, but the Universal Vaccine Consent Form signed by the resident’s representative did not specify that vaccine information was given or identify which vaccine was being consented for. For a second resident, the record showed Influenza vaccine was administered, but the signed consent form did not indicate which vaccinations were accepted or declined or that vaccine information was given to the representative. For a third resident, the record showed Pneumococcal and Influenza vaccinations were refused, but the signed consent form only indicated refusal of Influenza and did not indicate that vaccine information was given to the resident. The DON/IP reviewed the forms and agreed they were incomplete.
Incomplete COVID-19 Vaccine Consent Documentation
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered to three residents reviewed for immunization compliance. The facility’s COVID-19 Vaccination policy dated 7/15/21 states that all residents are to be offered the COVID-19 vaccine unless medically contraindicated, and that residents or their representatives are to receive education on the benefits, risks, and potential side effects, with documentation in the medical record showing whether the vaccine was accepted or refused. For R6, the immunization record did not document that the COVID-19 vaccine was administered or refused, and the Universal Vaccine Consent Form signed by the resident’s representative did not specify that vaccine information was provided or identify which vaccine was being consented for. For R17, the immunization record documented refusal of the COVID-19 vaccine, but the consent form signed by the resident’s representative did not indicate which vaccinations were accepted or declined or that vaccine information was provided. For R37, the immunization record documented refusal of the COVID-19 vaccine, but the consent form signed by the resident only indicated refusal of the influenza vaccine and did not indicate that vaccine information was provided to the resident. The DON/IP reviewed these forms and agreed they were incomplete.
Failure to Supervise and Implement Elopement Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement interventions for a resident with a known history of elopement and exit-seeking behaviors, resulting in an elopement event. The facility’s Wandering & Elopement Assessment and Prevention policy requires all residents to be assessed for elopement/unsafe wandering and defines elopement as a resident unable to protect themself who departs the facility or enters a non-resident area unsupervised or undetected. The resident was admitted in February 2023 and had documented elopement risk on assessments dated 9/7/23 and 4/3/25, including a history of leaving the facility and exhibiting exit-seeking behaviors. The care plan documented Alzheimer’s/dementia, poor safety awareness, fall risk, and the need for staff supervision when ambulating with a walker. Despite this known history, the resident did not have a wander guard in place prior to the elopement event, and the administrator later stated that the resident had refused a wander guard, but this refusal was not documented. The administrator confirmed the resident had previously eloped in September 2023 and was found walking on a street, and the resident’s friend reported another prior elopement shortly after admission when the resident left to go to a parade and was found walking on a busy street. On the date of the cited elopement, multiple CNAs reported seeing the resident ambulating in the hallway with a walker shortly before staff realized the resident was missing. Staff then searched the facility and perimeter, and the administrator drove offsite and found the resident at a local coffee shop two blocks away, where EMS had responded after a concerned citizen called 911 upon seeing the resident walking with a walker. The facility also failed to document the elopement event in the resident’s electronic medical record, despite the policy requirement that an incident report be completed noting investigative procedures, witness statements, and pertinent information. The DON stated she was made aware that staff were looking for the resident and joined the search, and later acknowledged there was no documentation in the chart regarding the elopement and that such documentation should have been present. A nurse progress note dated two days after the event documented that the resident remained on 15-minute checks for safety and observation after a recent exit-seeking episode, but there was no progress note or assessment specifically addressing the elopement that occurred. These actions and omissions led surveyors to determine that the facility failed to ensure adequate supervision and implementation of interventions to prevent elopement for a resident at known risk.
Removal Plan
- In-service all staff members on the elopement policy and procedure.
- In-service all remaining staff members via telephone prior to their next shift on the elopement policy and procedure.
- Conduct an audit of medical charts to ensure interventions are in place and documentation of the event with all actions taken is recorded.
- In-service all nurses on incident charting and completion.
- Complete updated wandering/elopement assessments for all residents.
- Review care plans for accuracy.
Incomplete Clinical Documentation for Incidents and Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with its own Charting & Documentation Policy for two residents. For one resident with an elopement event, the electronic medical record contained no nurse progress note or assessment regarding the elopement, no description of the event itself, no documentation of staff response, and no record of the resident’s condition after being returned to the facility. Although the resident’s care plan and physician orders were updated the following day to include a wander guard, there was no contemporaneous documentation of the incident in the resident’s chart. The DON later confirmed that this documentation was missing and the Administrator stated she was not aware the incident had not been documented. For another resident with documented Alzheimer’s disease and dementia, whose care plan identified risks for falls and elopement/wandering and included a wander guard, a nurse progress note recorded a healing bruise under the left eye. However, there was no documentation in the resident’s chart explaining how the bruise occurred, nor any follow-up assessment or investigation related to this injury. The DON stated that all incident/accident documentation had been recorded in the facility’s internal risk management system, which does not interface with or carry over into the resident’s electronic medical record, and that assessments related to incidents would therefore not be found in the residents’ charts.
Failure to Timely Notify Physician After Resident Fall and Change in Condition
Penalty
Summary
The facility failed to ensure timely and complete physician notification following a resident's accident and subsequent change in condition. A resident with Myasthenia Gravis and Cerebellar Ataxia, both affecting muscle strength and mobility, fell from her wheelchair during a supervised outing when traversing a grassy area without foot pedals. The resident landed on her knees and hands, and immediately reported pain in her right hand to staff at the scene. Upon return to the facility, the resident was assessed, and initial documentation indicated minimal pain and mild swelling, with ice applied to the hand. Over the next several hours, the resident's right hand became increasingly swollen, bruised, and painful, with the resident unable to grip with the hand. Multiple staff, including CNAs and an LPN, observed and documented the worsening condition and the resident's complaints of pain. Despite these observations and the facility's policy requiring immediate physician notification for significant changes in condition, the physician was not promptly notified of the resident's increased pain and swelling. The DON directed staff to monitor the resident rather than seek further evaluation, and staff reported being discouraged from escalating concerns. It was not until the following day that the medical director was contacted and an X-ray was ordered, which revealed prominent displaced fractures in the resident's right hand. Interviews with staff and the medical director confirmed that the physician expected to be notified of such changes and would have ordered emergency evaluation if made aware of the resident's pain and swelling sooner. The delay in physician notification resulted in the resident experiencing excruciating pain and a delay in diagnosis and treatment of her injury.
Failure to Protect Resident Rights and Dignity Due to Repeated Room Intrusions
Penalty
Summary
The facility failed to maintain a resident's right to a dignified existence and safety by not preventing repeated intrusions and inappropriate behaviors from another resident. One cognitively intact resident reported multiple incidents where another resident entered her room without permission, struck her with a shoe, threw water at her, and defecated and urinated on her floor and bed. Despite the resident expressing fear and reporting these incidents to the Administrator and Director of Nursing multiple times, the only intervention implemented was placing a lock on the shared bathroom door, which did not prevent further unauthorized entries through the main room door. Nursing progress notes and interviews confirm that the resident continued to experience distressing and undignified situations, including being awakened to find the other resident standing over her, taking her clothing, and soiling her living space. Staff and social services were aware of the ongoing issues, and the resident continued to express fear and discomfort due to the lack of effective measures to prevent these intrusions and maintain her right to a safe and homelike environment.
Failure to Protect Residents from Physical Abuse and Inadequate Abuse Investigation
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, despite having a policy in place to prevent such incidents. In one instance, a resident entered another resident's room and struck her on the shoulder with a shoe, an event witnessed by a CNA. The affected resident reported feeling afraid and stated that the perpetrator had previously thrown a pitcher of water at her and repeatedly entered her room, even after a lock was placed on the bathroom door. The administrator did not conduct an abuse investigation or notify the State Agency, despite being informed of the incident and the resident's fear. Documentation and interviews confirmed that the incident was witnessed and reported to facility leadership, but no formal investigation was initiated. In a separate incident, the same resident was observed grabbing another resident's hair and attempting to take her walker. This event was witnessed by an LPN, who documented the incident and reported it to the administrator and DON, identifying it as potential abuse. However, the administrator did not immediately begin an investigation or report the incident to the State Agency. Both incidents demonstrate a failure to follow facility policy and regulatory requirements for investigating and reporting allegations of abuse, leaving residents unprotected from further harm.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not immediately reporting and investigating two separate incidents of resident-to-resident physical abuse. In the first incident, a staff member witnessed one resident striking another on the shoulder with a shoe. Although the incident was documented and the local police were notified, the State Agency was not notified until several months later, and no abuse investigation was conducted at the time of the event. The facility administrator confirmed awareness of the incident but acknowledged that the required investigation and timely reporting to the State Agency did not occur. In the second incident, a resident was observed grabbing another resident's hair and attempting to take her walker. The involved parties were separated, and notifications were made to the health care power of attorney, physician, administrator, and director of nursing. However, the administrator stated she only became aware of the situation the following day and had not immediately initiated an abuse investigation or reported the incident to the State Agency as required by facility policy. These failures were identified for three residents reviewed for abuse in a sample of five.
Failure to Immediately Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to immediately report two separate allegations of abuse involving three residents to the State Agency, as required. In the first incident, one resident was observed entering another resident's room and striking her on the shoulder with a shoe. Although no injuries were noted and the resident stated she was not hurt, she expressed fear of the other resident. The incident was documented in the nursing progress notes, and the Power of Attorney, Administrator, and Medical Doctor were notified, but the Administrator confirmed that no abuse investigation was initiated and the State Agency was not notified. In the second incident, a resident was seen grabbing another resident's hair and attempting to take her walker. Both parties were separated, and the Health Care Power of Attorney, Physician, Administrator, and Director of Nurses were notified. However, the Administrator stated she only became aware of the situation the following day and did not immediately begin an abuse investigation or report the incident to the State Agency.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate two separate allegations of abuse involving three residents. In the first incident, a staff member reported witnessing one resident strike another on the shoulder with a shoe. The administrator confirmed awareness of this event and acknowledged it as a potential abuse incident but did not initiate an abuse investigation. In the second incident, a resident was observed grabbing another resident's hair and clothing while self-propelling in a wheelchair near the nurses' station. The administrator became aware of this situation the following day and confirmed that an immediate investigation into the allegation of abuse was not started. These failures occurred despite facility policy requiring thorough investigation of all alleged violations of abuse.
Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident identified as high risk for falls. According to the facility's Fall Reduction policy, residents with a high fall risk should have individualized interventions documented and implemented in their care plan. The resident in question had multiple diagnoses, including unsteadiness on feet, dementia, and a history of repeated falls. The care plan specifically required the use of gripper socks as an intervention to reduce fall risk. Despite these documented interventions, observations on two separate occasions showed the resident seated in common areas without gripper socks or any foot coverings, with bare feet on the floor. Staff present at the time confirmed that the resident was supposed to wear gripper socks at all times due to the high risk of falls and previous incidents. The lack of adherence to the care plan's fall prevention measures constituted a failure to provide adequate supervision and implement necessary precautions.
Failure to Properly Administer and Document Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required continuous oxygen therapy. For one resident with diagnoses including Paroxysmal Atrial Fibrillation and Chronic Respiratory Failure, staff did not ensure that oxygen tubing and humidifier bottles were dated as required by facility policy. The resident was observed sitting in a hallway without oxygen, despite a physician's order for continuous oxygen at 3 liters per minute with humidification. The oxygen tubing was found undated and lying in a wheelchair, and the humidifier bottle was also undated. Additionally, the oxygen concentrator in the resident's room was left running while the resident was not present, and undated oxygen tubing was observed on the floor. Staff confirmed the lack of dating and labeling on the equipment and acknowledged the resident's order for continuous oxygen. For another resident with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Cor Pulmonale, Chronic Congestive Heart Failure, and Pan lobular Emphysema, the facility did not date the oxygen tubing or humidifier bottle as required. The resident was observed receiving oxygen at a flow rate of 3 liters per minute, which was higher than the physician-ordered rate of 2 liters per minute. Staff confirmed both the incorrect flow rate and the absence of required dating on the oxygen equipment. These deficiencies were identified through observation, interview, and record review.
Failure to Implement Safety Interventions and Therapy Evaluations After Multiple Resident Falls
Penalty
Summary
The facility failed to implement appropriate safety interventions and complete therapy evaluations for cognitively impaired residents who experienced multiple falls. According to the facility's Fall Reduction policy, residents at risk for falls should receive a therapy screen, and care plans should be reviewed and updated after each fall. However, two residents with a history of falls did not receive therapy evaluations after repeated incidents, and their care plans were not adequately updated with effective interventions. One resident with dementia and poor safety awareness experienced three falls within a 24-day period, resulting in a left foot fracture. The resident was found on the floor multiple times, often attempting to go to the bathroom independently, and was observed without gripper socks or with the bed not in the lowest position. Staff interviews revealed that the resident was confused, especially at night, and unable to remember to use the call light. Despite these risks, the resident's care plan continued to document independence with transfers and mobility, and no therapy evaluation was completed after the falls. Another resident, admitted for rehabilitation after a fall at home, experienced a decline in condition after multiple falls in the facility. This resident sustained a displaced rib fracture and right radial neck fracture following an unwitnessed fall and was subsequently placed on hospice care. Documentation and interviews indicated that the resident was initially alert and oriented but became increasingly unsteady and confused after repeated falls. The call light system in the resident's room was reported as nonfunctional, and there was no evidence of a therapy evaluation or effective intervention following the falls.
Failure to Complete Entrapment Assessment Prior to Bed Rail Use
Penalty
Summary
The facility failed to complete an entrapment assessment prior to the application of bed rails for a resident who was at risk for falls and had poor safety awareness. According to the facility's policy, bed rails are considered restraints and require an evaluation for appropriateness, including a side rail assessment, before installation. In this case, after an unwitnessed fall, half side rails were added to the resident's care plan as a fall intervention, but the required entrapment assessment was not initiated until several days later and remained incomplete as of the survey date. The resident was observed in bed with metal half rails in place, and documentation showed cognitive impairment and no prior record of bed rail use on the Minimum Data Set. Interviews with facility staff revealed a lack of awareness regarding the requirement to complete the assessment before applying bed rails. The staff member responsible for medical entrapment assessments confirmed that the process was not started until after the rails were already in use and was never completed. Additionally, the Maintenance Director stated that he only performed quarterly entrapment prevention checklists for residents with existing bed rails and did not conduct new assessments when bed rails were first applied.
Inadequate Supervision and Transfer Protocols Lead to Resident Incidents
Penalty
Summary
The facility failed to provide adequate supervision to prevent two cognitively impaired residents from exiting the facility without staff supervision. One resident, identified as R4, who was severely cognitively impaired and at risk for elopement, managed to exit the facility and was found lying in the grass outside. The incident occurred when a CNA was attending to another resident and heard the door alarms going off. Despite the alarms, R4 was able to leave the building and was later found with no injuries except for a slight redness on the leg. Another resident, R7, also severely cognitively impaired, was found outside the facility in the parking lot without a coat and holding her purse. R7 had removed her oxygen tubing and was confused, but was safely returned inside by staff without any injuries. The facility also failed to implement the required two-staff assistance for transfers as indicated in a resident's care plan, leading to a fall. Resident R2, who was cognitively impaired and at risk for falls, was being transferred by a single agency CNA instead of the required two staff members. During the transfer, R2's feet slid, causing the CNA to lower R2 to the floor, resulting in multiple skin tears on R2's legs. The care plan for R2 clearly stated the need for two staff members to assist with transfers, but this protocol was not followed, leading to the incident. These deficiencies highlight the facility's failure to adhere to its own policies regarding supervision and transfer protocols, resulting in unsafe conditions for the residents. The incidents involving R4 and R7 demonstrate a lack of adequate supervision to prevent elopement, while the incident with R2 shows a failure to follow established care plans to prevent falls. These lapses in protocol and supervision contributed to the residents' exposure to potential harm.
Deficiency in Infection Standards and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure that residents met the standards for infections and did not have standards in place for residents experiencing infection symptoms that did not meet the criteria for infections. This deficiency was identified for two residents, R4 and R23, who were prescribed antibiotics for urinary tract infections (UTIs) without meeting the McGeer Criteria for infections. The facility's Director of Nursing (V2) confirmed that the infections for these residents in October and November did not meet the McGeer Criteria. The facility's policy on The Core Elements of Antibiotic Stewardship for Nursing Homes was undated and lacked standardization in practices for residents suspected of infections or started on antibiotics. The policy emphasized the importance of improving the evaluation and communication of clinical signs and symptoms, optimizing diagnostic testing, and implementing an antibiotic review process. However, the facility did not have written or verbal standards or policies for residents who did not meet the definition of an infection, leading to inappropriate antibiotic prescriptions. Additionally, the facility failed to educate healthcare providers about antibiotic stewardship, which is crucial for optimizing infection treatment and reducing adverse events associated with antibiotic use. The Director of Nursing admitted that there was no documentation of education provided to healthcare providers regarding antibiotic stewardship. This lack of education and standardized practices has the potential to affect all 40 residents residing in the facility.
Failure to Adhere to Psychotropic Medication Guidelines
Penalty
Summary
The facility failed to provide appropriate indications for the use of antipsychotic medications, attempt gradual dose reductions, and limit the use of as-needed psychotropic medications to 14 days for several residents. Resident 5 was admitted with a diagnosis of dementia without behavioral disturbance and was prescribed Seroquel, an antipsychotic medication, without any documented behaviors or attempts at gradual dose reduction. The Director of Nursing (DON) acknowledged that the resident was not referred to behavioral health as per the facility's typical practice. Resident 16 was admitted with a diagnosis of depression and was prescribed Abilify, an antipsychotic medication, to enhance the effectiveness of an antidepressant. The resident had no documented behaviors since admission, and the DON could not confirm the appropriateness of the antipsychotic medication's indication. Additionally, Resident 19 was prescribed Olanzapine for schizophrenia and Bupropion for major depressive disorder, with no documented behaviors or attempts at gradual dose reduction, despite a pharmacy recommendation for dose reduction. Resident 26 was prescribed Lorazepam as needed for anxiety without a stop date, contrary to the facility's policy of limiting as-needed psychotropic medications to 14 days. The DON admitted to not knowing how this oversight occurred. These deficiencies highlight the facility's failure to adhere to federal regulations and its own policies regarding the use of psychotropic medications.
Resident's Right to Choose Doctor Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose her own doctor, as required by the Illinois Long-Term Care Ombudsman Residents' Rights for People in Long Term Care Facilities. The deficiency involved one resident, R11, who expressed her desire not to be seen by her current doctor, V10, as documented in the nurse's notes on 7/21/24. Despite R11's clear communication to the facility staff that she did not want V10 as her doctor, V10 continued to see her. On 12/19/24, R11 reiterated her preference to not have V10 as her doctor, stating that she did not like him. The Social Service Director, V4, confirmed that residents have the right to choose their own doctor, but was not informed of R11's request to switch doctors.
Discrepancies in Advanced Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that the electronic medical records and care plans of three residents matched their Physician's Order for Life-Sustaining Treatment (POLST) regarding their cardio-pulmonary resuscitation (CPR) code status. For one resident, the physician's order indicated a full code status, but the POLST signed by the resident's Power of Attorney (POA) indicated a preference for comfort-focused treatment only, which is a do-not-resuscitate (DNR) status. Another resident's physician's order documented a DNR status, but the POLST signed by the resident indicated a preference for selective treatment. Additionally, a third resident's physician's order and care plan documented a DNR status, but the POLST signed by the resident's POA indicated a preference for selective treatment. The facility's Advanced Directives policy requires that the plan of care for each resident be consistent with the resident's treatment preferences and/or advanced directives. However, the discrepancies between the physician's orders, care plans, and POLST forms indicate a failure to adhere to this policy. The administrator acknowledged that care plans should identify the resident's advanced directive and that physician orders should match the POLST form, highlighting a gap in the facility's compliance with its own policy and the residents' documented wishes.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R192, to the state reporting agency as required by their policy. The facility's Abuse, Prevention, and Prohibition policy mandates that any allegations of abuse, neglect, or injuries of unknown origin must be reported to the state agency within specific timeframes. In this case, R192 was found to have a faint bruise on the left knee, and when questioned, provided three different accounts of how the injury might have occurred. Despite the inconsistency in the resident's accounts and the policy requirement, the facility did not report the injury to the state agency. R192, who is cognitively intact with a BIMS score of 15/15, complained of knee pain and had a bruise noted on the knee cap. The resident mentioned a possible incident during a mechanical lift transfer but could not recall a specific injury. Staff members, including CNAs and nurses, reported no knowledge of the knee being bumped during transfers, and it was noted that the resident often voiced pain during movement. The facility administrator later confirmed that the bruise should have been considered an injury of unknown origin and reported to the state agency, which was not done, leading to the deficiency.
Inaccurate MDS Documentation for Hospice Services
Penalty
Summary
The facility failed to accurately document the assessment for a resident receiving hospice services in the Minimum Data Set (MDS), which is a federally mandated assessment. The resident in question was admitted with diagnoses including Traumatic Brain Injury, Mood Disorder, Anxiety Disorder, Dementia, and Major Mood Disorder. A physician's order dated March 27, 2023, indicated the resident was to be admitted to hospice services, and the resident's record confirmed this admission to hospice services effective the same date. However, the quarterly MDS assessments dated June 28, 2024, and September 27, 2024, incorrectly documented that the resident was not on hospice services. This error was acknowledged by the LPN and Care Plan/MDS Coordinator, who confirmed that the resident had elected hospice services on March 27, 2023, and remained on hospice services at the time of the survey.
Lack of Coordination and Documentation for Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination and accessibility of hospice care plans for two residents receiving hospice services. For one resident, admitted with conditions including intracranial injury and dementia, the facility's records only included the hospice admission agreement and letter, lacking detailed documentation about hospice services, frequency, or specific interventions. Similarly, another resident with diagnoses such as infective endocarditis and prostate cancer had only a notification of hospice admission documented, with no further details on hospice services or interventions in the care plan. Interviews with facility staff revealed that hospice binders at the nurse's station were empty, and staff relied solely on the facility's care plan, which did not include specific hospice interventions. The Care Plan Coordinator confirmed the absence of a hospice policy and stated that hospice agreements were used to outline responsibilities. The Administrator acknowledged the need for the facility to obtain and incorporate the hospice's plan of care into their records for staff review, which was not done, leading to the deficiency.
Improper Use of Indwelling Urinary Catheter for Enteral Feeding
Penalty
Summary
The facility failed to follow its policy and obtain a physician order for care after a resident's Gastronomy tube (G-tube) became clogged. This led to the replacement of the G-tube with an indwelling urinary catheter, which was used to administer enteral tube feedings for two days. As a result, the resident experienced emesis, loose stools, and was hospitalized. This incident affected one resident reviewed for Gastrostomy Tubes in a sample of three, resulting in an Immediate Jeopardy situation. The facility's policy on the care and treatment of feeding tubes requires that only tubes designed for enteral feeding be used, except under extenuating circumstances and for the shortest time possible. The policy also mandates notifying and involving the medical provider in case of complications. However, the Assistant Director of Nursing instructed a Licensed Practical Nurse to replace the clogged G-tube with an indwelling urinary catheter without obtaining a physician's order or verifying the placement. The nurse, who had not received training or competency in replacing G-tubes, administered bolus feedings through the urinary catheter, leading to the resident's adverse symptoms. The facility's failure to notify the resident's physician, verify the placement of the indwelling urinary catheter, and document the change in the resident's condition contributed to the deficiency. The resident's physician was not informed of the G-tube being clogged or removed, and the facility did not send the resident to the emergency department for evaluation and tube replacement. The lack of proper training and oversight by the nursing staff further exacerbated the situation, resulting in the resident's hospitalization.
Removal Plan
- V15/Regional Director of Operations educated V1 and V2/RN and DON/Director of Nurses on their responsibilities to provide nursing staff with education and resources to provide appropriate oversight. Educational Tools included in the teaching also consisted of Audit tools, Weekly Committee Meeting policy, Rounding forms, Nurse's Skills Checklist Schedule, Monthly Education Calendar, and CNA's (Certified Nurses Aide) Competency schedule. V15 ensured V2/RN/ DON/Director of Nurses was competent to perform the education and in-servicing with the staff.
- Facility nurses were in-serviced, and competencies were completed on Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (one prn staff and one on medical leave) are scheduled to receive training/competency.
- The Employee Orientation Nursing Policies/Agency Orientation included a review of the following policies: Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (1 prn/as needed staff and 1 on medical leave) are scheduled to receive training/competency. The Administrator or Director of Clinical Operations ensures when an Agency staff member books an open position, the DON or Nurse Manager receives the required documentation.
- V8's (Licensed Practical Nurse) Employee Corrective Action Plan Form documented a 3-day suspension for failure to follow department policies and procedures: no MD notification, no documentation of G-tube difficulty or the G-tube was changed. V3's (Assistant Director of Nursing/Registered Nurse) Employee Corrective Action Form documented a 3-day suspension for failure to follow/enforce department policies and procedures, practiced outside of scope, failed to provide nurse manager oversight. The Time Detail Reports documented V3 nor V8 worked.
- The Change of Condition Audit was revised and accurately completed.
- Dietary Order Audit completed by V2/RN and DON/Director of Nurses.
- The Order Recap Report was reviewed for new orders and proper notifications.
- The In-service Education Record documented education to all nurses regarding the Change in Condition Bulletin Board Documentation (Electronic Health Record).
- The New Order Audit tool was reviewed and appropriate for use.
- The In-service Education Report- Admission Policy was attended by V2 (Director of Nursing) and V6 (MDS Coordinator/Care Planning/LPN). Quality Assurance audit tool was reviewed and appropriate for use. Admission policy revised.
- Medical Doctor notified, and policies reviewed.
Failure to Notify Physician of Resident's Condition Change and Abnormal Imaging
Penalty
Summary
The facility failed to notify a physician of abnormal radiology results and a change in condition for a resident, leading to the resident experiencing emesis and diarrhea for two days followed by hospitalization. The resident had a history of dysphagia following cerebral infarction, gastrostomy status, hemiplegia, and aphasia. The resident's Physician Order Sheet documented orders for G-tube site cleaning and feedings. However, the facility did not inform the physician about the resident's condition changes, including vomiting and diarrhea, or the abnormal X-ray results recommending follow-up imaging. The report details that the resident had episodes of emesis and loose stool, and the G-tube was not tolerating bolus feeding. Despite these significant changes, there was no documentation of the physician being notified. The Assistant Director of Nursing and a Licensed Practical Nurse were involved in the decision to replace the resident's G-tube with an indwelling urinary catheter without consulting the physician. This action was taken after the G-tube clogged, and the resident began vomiting early the next day. Interviews with staff revealed that the physician was not informed about the resident's vomiting, diarrhea, or the use of an indwelling urinary catheter as a feeding tube. The Director of Nurses acknowledged that the physician should have been notified of the resident's condition changes and the G-tube issues. The physician confirmed that they were not informed about the staff's actions and would have ordered an evaluation and tube replacement if notified.
Failure in G-tube Care and Competency
Penalty
Summary
The facility failed to ensure that licensed nurses were trained and competent in caring for residents with a gastrostomy tube (G-tube), which affected one resident. The resident, who had a history of dysphagia following a cerebral infarction, was hospitalized after experiencing emesis and diarrhea for two days. The deficiency occurred when an indwelling urinary catheter was mistakenly used in place of the G-tube for feeding, without verifying its placement through an X-ray. The incident began when the resident's G-tube, placed on a previous visit to the emergency department, became non-patent. The Assistant Director of Nursing instructed a Licensed Practical Nurse (LPN) to remove the G-tube and insert an indwelling urinary catheter, which was not verified for correct placement. The LPN, who had not received training or demonstrated competency in replacing G-tubes, administered bolus feedings through the urinary catheter, leading to the resident's adverse symptoms. Despite the resident's ongoing symptoms and a radiology recommendation for follow-up imaging, the facility did not take appropriate action to verify the catheter's placement or send the resident to the emergency department promptly. The Director of Nursing later confirmed that the indwelling urinary catheter should not have been used for feedings and that placement should have been verified by X-ray, which was not done. The facility also had not provided specialized G-tube training to its nursing staff.
Deficiency in CNA Training Hours and Dementia Care Education
Penalty
Summary
The facility failed to ensure that four Certified Nurse Aides (CNAs) completed the required 12 hours of education per year, which is necessary to maintain their competence in providing care to residents. This deficiency was identified through interviews and record reviews, revealing that none of the CNAs reviewed had completed the mandatory training hours. Specifically, CNA V17 completed only 6.91 hours, CNA V18 completed 3.58 hours, CNA V19 completed 3.83 hours, and CNA V20 completed 8.25 hours of training annually. Additionally, none of these CNAs received training in dementia management or care for cognitively impaired residents, despite the facility's requirement for such training. The facility's assessment for 2024-2025 documented the need for in-service training to ensure the continuing competence of nurse aides, particularly in dementia management and abuse prevention. The Clinical Director, V16, confirmed that the CNAs did not meet the 12-hour education requirement. This failure has the potential to affect all 41 residents residing in the facility, as documented in the facility's Resident Listing Report.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency for a resident. The facility's Abuse, Prevention and Prohibition Policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately to the Administrator and subsequently to the State Agency within specified timeframes. However, the Administrator received a call from a nurse at the resident's surgeon's office, reporting multiple concerns of neglect, including incontinence without proper care, multiple falls, and the absence of a mechanical lift sling. Despite conducting an internal investigation, the facility did not notify the State Agency of the allegations as required. The investigation documented that the resident was found in a neglected state during a medical appointment, with issues such as incontinence and a wound on the coccyx that required attention. The nurse at the surgeon's office had to provide incontinence care and re-dress the wound. The Administrator confirmed that the State Agency was never notified of the neglect allegations, which is a clear violation of the facility's policy and regulatory requirements.
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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