Oregon Living And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oregon, Illinois.
- Location
- 811 South 10th Street, Oregon, Illinois 61061
- CMS Provider Number
- 145476
- Inspections on file
- 26
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Oregon Living And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its own policy requiring at least once‑per‑shift assessments, including full vital signs and respiratory checks, for residents receiving skilled services. An LPN and the DON both stated that skilled residents should have daily or every‑24‑hour vitals and, when on oxygen, additional O2 saturation checks, but chart reviews for three skilled residents showed infrequent and inconsistent documentation of blood pressure, pulse, respirations, temperature, and oxygen saturation over multiple days. Two residents also reported that their blood pressure and pulse were only checked occasionally, supporting the documented gaps in required monitoring.
A resident with pelvic and rib fractures and fragile respiratory status experienced ongoing, poorly controlled pain because hydrocodone-acetaminophen orders were repeatedly entered and maintained incorrectly. Hospital and orthopedic instructions specified 10/325 mg every 4 hours PRN for moderate pain, but the resident initially received 5/325 mg every 4 hours, then 10/325 mg every 6 hours, and the MAR was never corrected to the every-4-hour regimen. Pain assessments and provider notes documented frequent to almost constant pain interfering with sleep and daily activities, with pain scores up to 9/10. Staff recognized the discrepancy, faxed the physician for clarification, but did not follow up when no response was received, leaving the inaccurate order in place and the resident’s pain inadequately managed.
The facility failed to accurately reconcile and control its controlled substances, leading to unaccounted medication for a resident. Surveyors found multiple mathematical and documentation errors on the controlled substance card-sheet count (CCS), including incorrect totals after additions/removals, unexplained changes in counts across shifts, missing CCS sheets, and a decrease in the number of controlled substance bottles without documented removal or waste. The DON acknowledged the CCS errors, reported that a nurse’s initials had been forged on a CCS sheet, and confirmed the facility could not determine when a resident’s hydrocodone-acetaminophen went missing or who took it. The only written guidance was a brief controlled substance section within the Medication Administration policy, which did not address wasting, witnessing waste, storage, handling of completed CCS sheets, responsibility for maintaining them, or reconciliation between CCS sheets.
A resident with dementia and no documented pain received a pharmacy delivery of hydrocodone-acetaminophen, but the facility could not produce the corresponding February controlled substance count sheets or the CCS for the period after delivery, and there was no record of destruction of the medication. MARs showed almost no administration of the PRN narcotic despite consistent pain scores of 0/10, and staff, including an LPN and CNAs, reported rarely or never seeing the resident in pain or needing to give the PRN narcotic. An LPN who stated she received and logged the narcotic later disputed initials attributed to her on a CCS entry, alleging they were not hers and that she had left work earlier than the documented time, suggesting a possible forgery. The DON acknowledged that the facility could not account for the resident’s hydrocodone-acetaminophen, and the Administrator recognized the missing records, documentation gaps, and potential forgery in the context of the facility’s abuse prevention policy on misappropriation of resident property.
A facility failed to report an allegation of misappropriation of a resident’s hydrocodone-acetaminophen to the State Agency and local law enforcement as required by its Abuse Prevention Program. After a narcotic count discrepancy was identified, facility staff attributed it to documentation errors such as missing PRN sign-outs and incomplete narcotic logs, and concluded the concern was unsubstantiated. The resident’s MAR showed only one documented PRN dose despite a standing PRN order and a pharmacy delivery of 60 tablets, which the DON later stated could not be accounted for and for which controlled substance count sheets were missing. The Administrator later acknowledged the allegation should have been reported but confirmed it was not.
A cognitively impaired, wandering resident with dementia and a history of entering other residents’ beds was care planned with diversional and structured activity interventions but was left unsupervised long enough to leave the common area and enter a male resident’s room. An activity aide assigned to remain in the common area did not engage the resident in 1:1 activities and could not state when the resident left or whether she herself had left the area. Staff later found the fully dressed female resident lying in bed with an unclothed male resident, with both appearing calm and showing no signs of injury, while the male resident later reported that the woman had come into his room, sat on his bed, and would not leave despite his requests.
A resident with a history of dysphagia and cognitive impairment was served diced ham instead of ground ham, contrary to dietary recommendations for a mechanical soft diet. This led to a choking episode requiring a CNA to perform the Heimlich maneuver. Staff interviews revealed confusion about proper food texture, and facility policies and spreadsheets specifying ground ham were not followed.
A beautician at an LTC facility used inappropriate language while providing hair care to a resident with severe cognitive impairment, asking if the resident likes to 'b***h a lot.' The incident was overheard, leading to the beautician's removal and an investigation. The resident, who has dementia, did not recall the incident. The facility's policy emphasizes respect and dignity, which was not upheld in this case.
A resident requiring IV flushes did not receive them on multiple occasions due to the unavailability of RNs, as LPNs were not permitted to perform this task. The facility lacked a specific policy for peripheral IV maintenance, leading to missed flushes primarily during night shifts when an RN called off.
The facility failed to provide a homelike environment by not replacing a broken clock in the dining room, despite repeated requests from residents who wanted to keep track of time during meals and activities. The administration considered the clock a decoration and offered unsatisfactory alternatives, leaving the issue unresolved.
The facility failed to properly sanitize dishes and handle sanitized items, affecting all 66 residents. The dish machine was not dispensing sanitizer, and staff used a three-compartment sink but did not submerge dishes for the required 60 seconds. Additionally, the Cook did not follow proper sanitization procedures for food processor components.
The facility failed to label expiration dates on opened multi-dose vials and bottles of medication for five residents. During a review of the medication cart, it was found that insulin pens and eye drops were opened without expiration dates. The DON confirmed that medications should be dated when opened, as per the facility's policies.
The facility failed to provide the correct portion size of pureed hamburger to residents on pureed diets. A cook served meals using a three-compartment plate, placing pureed bread and hamburger in one section, resulting in only a half scoop of hamburger being served. The Dietary Manager confirmed that a full scoop should have been provided.
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents with medical conditions requiring such measures. A resident with a urinary catheter and another with a tracheostomy lacked appropriate signage and PPE outside their rooms. Additionally, two residents with wounds and catheters did not have EBP signage or PPE available. The facility's policy and CDC guidelines were not followed, as evidenced by the absence of necessary precautions for these residents.
A resident received medications and insulin from a Wound Nurse who did not prepare them, contrary to facility policy. The LPN prepared the medications and insulin but did not administer them, leading to a breach in professional standards. The facility's policies require the nurse who prepares the medication to also administer it to ensure accuracy.
A facility failed to ensure proper assessment for a resident with dysphagia after a choking incident and did not follow safe transfer protocols for two residents. One resident was not referred back to speech therapy after choking, and another was transferred without a gait belt. Additionally, a resident fell during a transfer due to unlocked bed wheels.
A facility failed to maintain a resident's urinary catheter tubing and drainage bag below the bladder level, risking infection. The resident had a catheter due to urinary incontinence and neuromuscular dysfunction. A CNA was observed holding the catheter bag at waist level, causing urine backflow. The DON confirmed the need to keep the bag below the bladder to prevent UTIs, as per facility policy.
Two residents were not properly monitored during medication administration, leading to a deficiency. One resident with dementia had an unconsumed pill left on her bedside table, while another resident was found with a pain medication left on his bed, which he intended to take later. The facility lacked documentation for self-administration assessments, contrary to their policy.
A facility failed to act on a pharmacist's repeated requests for an end date on a resident's PRN Lorazepam order. Despite policy requiring a 14-day limit for PRN psychotropic medications, the order was renewed without criteria for extended use. The DON acknowledged that recommendations should be implemented within 48-72 hours, but this was not followed, resulting in a deficiency.
The facility failed to ensure PRN anti-psychotic medications had a stop date of fourteen days for two residents. One resident's lorazepam order for agitation lacked a stop date, and another's lorazepam order for anxiety was renewed without criteria for use beyond fourteen days, despite repeated requests from the consulting pharmacist. The facility's policy requires a time limit for PRN psychotropic medications, with physician evaluation after fourteen days.
A resident experienced significant delays in receiving their scheduled medications, resulting in a medication error rate of 17.86%. The LPN, unfamiliar with the residents, administered medications late, including insulin after the resident had eaten, contrary to the facility's policy. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not followed.
Two residents experienced significant medication administration errors in an LTC facility. One resident received their medications, including insulin, late due to an LPN being behind schedule, resulting in insulin being administered after breakfast. Another resident was given an excessive dose of Tramadol by a former nurse, who realized the mistake during a narcotics count. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not followed.
A resident with severe cognitive impairment and a history of wandering behaviors choked on floral foam from a recent activity due to inadequate supervision. Despite the care plan indicating the need for close monitoring, the resident accessed the foam and choked during dinner. Staff initiated the Heimlich maneuver, and the resident recovered after expelling the foam.
Failure to Perform and Document Required Vital Signs for Skilled Residents
Penalty
Summary
Surveyors identified that the facility did not follow its policy for obtaining vital signs and completing assessments for residents receiving skilled services. The facility’s Resident Examination and Assessment Policy dated 3/21/25 requires that residents receiving skilled services have an assessment completed at least once per shift, including vital signs (blood pressure, pulse, respirations, temperature) and, for respiratory assessments, oxygen saturation. The DON stated that residents at the facility for skilled therapy have a full assessment and vitals taken every 24 hours and as needed, and an LPN stated that residents on the skilled unit have vitals taken daily and as needed, with oxygen saturation checks being important for residents on oxygen. Despite these stated practices and policies, record review showed that required vital signs and assessments were not consistently obtained or documented for three residents on skilled services. For one resident admitted for therapy for a fractured sacrum and receiving 4 L oxygen via nasal cannula for shortness of breath and COPD, the vitals summary over a 13‑day stay showed oxygen saturation was checked only once, with pulse checked on 4 of 13 days, blood pressure on 5 of 13 days, respirations on 5 of 13 days, and temperature on 6 of 13 days. For a second resident admitted for skilled services, over 34 days blood pressure was checked on 19 days, oxygen saturation once, pulse on 15 days, respirations on 15 days, and temperature on 16 days; this resident reported that staff checked his blood pressure only every few days. For a third resident on skilled services for 16 days, blood pressure and pulse were each checked on 9 of 16 days, oxygen saturation once, respirations on 7 days, and temperature on 8 days; this resident reported that staff checked her pulse and blood pressure only occasionally. These observations, interviews, and record reviews demonstrate that the facility did not consistently perform and document the frequency of vital signs and assessments required by its policy for residents receiving skilled services.
Failure to Ensure Accurate Opioid Orders and Effective Pain Control
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management for a resident admitted for subacute rehab following a fall that resulted in a pelvic fracture, multiple rib fractures, and fragile respiratory status. Hospital discharge instructions and an orthopedic after-visit summary specified hydrocodone-acetaminophen 10/325 mg every 4 hours as needed for moderate pain. However, upon admission, the physician called in an incorrect order for hydrocodone-acetaminophen 5/325 mg every 4 hours as needed, which staff later recognized was not adequately controlling the resident’s pain. A progress note on 3/26/26 documented that the resident’s pain was not well controlled with the 5/325 mg dose and that, after investigation, staff discovered the hospital discharge paperwork specified 10/325 mg every 4 hours as needed. The physician then gave approval to change the order to hydrocodone-acetaminophen 10/325 mg every 4 hours as needed for moderate pain. Despite this, the Medication Administration Record (MAR) shows the resident continued to receive the 5/325 mg dose from 3/25/26 to 3/30/26, and when the dose was changed on 3/31/26, it was entered as 10/325 mg every 6 hours as needed instead of every 4 hours. The April MAR continued to reflect the incorrect 10/325 mg every 6 hours as needed order until the family initiated discharge. Pain assessments documented that over multiple 5-day periods the resident’s pain frequently or almost constantly interfered with sleep and day-to-day activities, with pain intensities recorded as high as 9 out of 10, and the nurse practitioner noted the resident was having a lot of pain, difficulty moving, trouble sleeping, and poor mood due to pain. The DON stated that staff had faxed the physician to verify the order discrepancy but did not receive a response and failed to follow up, resulting in the MAR remaining incorrect and the resident’s pain not being managed in accordance with the prescribed every-4-hour regimen and the facility’s pain management policy.
Inadequate Controlled Substance Reconciliation and Missing Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate reconciliation and disposition of controlled substances and to maintain adequate policies governing these processes, resulting in the facility being unable to account for a resident’s controlled medications. Surveyors reviewed the North Unit Controlled Substance Accountability Record Card-Sheet Count (CCS) and found that the facility could not produce the CCS for a period covering several days when a resident’s hydrocodone-acetaminophen was delivered. The CCS is intended to track all controlled substance cards, bottles, patches, and the corresponding count sheets. However, multiple CCS entries contained mathematical and documentation errors that were carried forward across shifts before being identified or corrected, including instances where the number of sheets at the end of a shift did not match the additions and removals documented, and where counts changed without any recorded additions or subtractions. Specific CCS discrepancies included an entry where one sheet was removed and six added, but the total number of sheets remained unchanged, with this error carrying forward through several subsequent counts. Another entry showed one sheet removed and three added, but the total reflected an incorrect increase, followed by a shift where the total decreased without any documented changes. Additional entries showed inflated totals after adding new sheets, unexplained write-overs, and subsequent shifts with different starting counts that did not reconcile with prior entries. There were also instances where a sheet was documented as removed but the total number of sheets remained the same, and these errors continued across multiple days until the count changed without explanation. In one case, the number of controlled substance bottles decreased between shifts without any documented removal or wasting. The DON explained that the CCS is used as a deterrent to prevent staff from removing controlled substance count sheets and corresponding medication cards without detection, and acknowledged that the identified CCS errors did not add up. The DON stated she was not aware of the bottle discrepancy and confirmed that a CCS sheet was missing during the time frame when a resident’s hydrocodone-acetaminophen was delivered, and that a nurse reported her initials had been forged on the next available CCS sheet. The facility was unable to determine when the resident’s hydrocodone-acetaminophen went missing or who might have taken it. When the facility’s controlled substance policy was requested, only a section within the Medication Administration policy was provided, which addressed signing out controlled substances, counting at shift change, and documenting additions and removals. The policy did not address wasting of controlled substances, witnessing waste, storage requirements, handling of completed CCS or count sheets, responsibility for maintaining them, or reconciliation from one CCS sheet to the next.
Unaccounted Controlled Substance and Missing Narcotic Records for Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s controlled substance medication from misappropriation and to maintain accurate controlled substance accountability records. The resident was admitted with dementia, anxiety, and depression, and a recent MDS showed she was unable to respond to questions, could not complete a mental status interview, and had short- and long-term memory problems. Her MDS and MAR documentation for February showed she had no documented pain and had not received PRN pain medication in the prior five days, with pain assessments consistently recorded as 0/10. Despite this, the resident had an active PRN order for hydrocodone-acetaminophen 5-325 mg every 12 hours as needed for pain, with only one documented administration in mid-February and no further documented administrations in February or early March prior to the order being changed to scheduled dosing. Pharmacy records showed that 60 tablets of hydrocodone-acetaminophen were delivered for the resident on 2/18/26, which at a twice-daily maximum frequency should have lasted approximately 30 days. However, the facility could not produce the controlled substance count sheets for this medication for February or the corresponding Controlled Substance Accountability Record Card-Sheet Count (CCS) for the period immediately following the delivery. The only hydrocodone-acetaminophen count sheets available for the resident began on 3/6/26, and the CCS records had a gap between the morning of 2/18/26 and the evening of 2/20/26. The DON acknowledged that the facility was unable to locate the February hydrocodone-acetaminophen count sheets or the CCS for the time period in question and that there was no record the medications were destroyed, stating that the facility could not account for the resident’s hydrocodone-acetaminophen. Staff interviews further highlighted irregularities in the documentation and handling of the controlled substance. An LPN reported she was the nurse who received the hydrocodone-acetaminophen on 2/18/26, completed the controlled substance count sheets, documented receipt of two new cards on the CCS, and placed the cards in the locked medication cart. She later disputed initials attributed to her on the 2/20/26 CCS entry, stating they were not hers and that she had left work earlier than the time documented, and expressed anger that someone had forged her initials. The DON confirmed that this LPN disputed the initials on the CCS. Multiple nursing staff, including LPNs and CNAs, stated they rarely or never observed the resident in pain and could not recall administering or needing to administer PRN hydrocodone-acetaminophen, despite the pharmacy delivery and lack of corresponding count sheets. The Administrator acknowledged missing count sheets, a missing CCS for the relevant period, minimal documented pain, the early refill denial, and the potential forgery of initials, while the facility’s abuse prevention policy defined misappropriation as wrongful use of a resident’s belongings or money without consent.
Failure to Report Alleged Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident’s narcotic medication to the State Agency and local law enforcement as required by its Abuse Prevention Program. On 3/4/26, the Administrator (V1) was informed of a potential misappropriation involving a resident’s hydrocodone-acetaminophen after a discrepancy was identified between narcotic count records and documented administration. The facility’s investigation report attributed the discrepancy to possible documentation errors, including failure to sign out PRN narcotic medications at the time of administration, incomplete or missing entries on narcotic log sheets, and improper paper handling, and concluded the concern of narcotic misappropriation was unsubstantiated. Despite this initial concern and the facility’s own policy defining misappropriation of resident property and requiring immediate reporting of such allegations to the Department of Public Health and local law enforcement when there is reasonable suspicion a crime has been committed, the allegation was not reported. Record review showed that the resident’s February 2026 MAR included an order to screen for pain every shift, with staff documenting a pain score of 0 on a 0–10 scale for the entire month. The MAR also showed an order for hydrocodone-acetaminophen 5-325 mg to be given every 12 hours PRN for pain, with only one documented administration on 2/14/26 at 2:34 PM from an order that began on 11/11/25 and was discontinued on 3/4/26. Pharmacy records showed 60 tablets of hydrocodone-acetaminophen were delivered for this resident on 2/18/26, which, at a maximum frequency of twice daily, should have lasted approximately 30 days. The DON (V2) stated the facility was unable to locate the resident’s controlled substance count sheets for this medication and that the 60 tablets delivered on 2/18/26 could not be accounted for. On 4/2/26, the Administrator acknowledged that, in hindsight, this allegation should have been reported to the State Agency and confirmed it had not been reported to local law enforcement, contrary to the facility’s Abuse Prevention Program policy.
Failure to Prevent Wandering Resident From Entering Another Resident’s Room and Bed
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent a known confused, wandering resident from entering another resident’s room and bed. The female resident had Alzheimer’s disease, dementia, severe cognitive impairment per BIMS, a history of wandering, and was assessed as high risk for abuse/neglect and for wandering/elopement. Her care plan identified her as an elopement risk/wanderer related to impaired safety awareness, dementia, and Alzheimer’s disease, and included interventions such as providing pleasant diversions, structured activities, walking inside, toileting, and reorientation strategies. Despite these identified risks and planned interventions, she was able to leave the common area unsupervised and enter a male resident’s room. On the evening of the incident, staff documentation and interviews show that the female resident was last seen in the 200-unit common area near the nurse’s station after dinner, seated on a couch around 6:30 p.m., with an activity aide assigned to remain in the common area and keep residents engaged. The activity aide reported that she did not engage the resident in 1:1 activities and later heard commotion down the hall around 7:00–7:30 p.m., at which time she noticed the resident was no longer in the common area. The aide did not know when the resident had left or whether she herself had left the common area. Another CNA stated that the female resident wanders often, goes into other residents’ beds as a typical behavior, and is usually redirected when seen, but on this occasion staff were likely busy and no one saw her walking down the hall. During this period of inadequate supervision and failure to effectively implement the resident’s care-planned interventions, the female resident entered a male resident’s room. The final incident report documented that staff entered the room and observed the fully dressed female resident lying in bed with the male resident, who was unclothed. Both residents’ hands were at their sides or resting on the bed, no movement or sexual activity was observed, and both appeared calm with no signs of distress. Post-incident assessments found no injuries or signs of trauma, and both residents were unable to recall how or why they were in bed together. The male resident later reported that the woman had wandered into his room, sat on his bed, and would not leave despite his requests, and he stated that he did not lie in bed with her or do anything with her. The facility’s failure to prevent the high-risk, cognitively impaired resident from wandering into another resident’s room resulted in both residents being found in bed together and the male resident being inappropriately exposed.
Failure to Provide Appropriately Prepared Food for Resident with Chewing Difficulties
Penalty
Summary
The facility failed to ensure that food was prepared in a form appropriate to meet the needs of a resident with chewing difficulties, resulting in a choking incident. The resident had a documented history of vascular parkinsonism, dementia, anxiety, depression, dysphagia, and cognitive communication deficit. Orders and care plans indicated the resident required a mechanical soft diet, with specific recommendations for ground ham according to the facility's dietary spreadsheet. However, the resident was served diced ham instead of ground ham during a meal, which did not align with the individualized dietary needs outlined for mechanical soft diets. During the meal, the resident began to choke on the diced ham, exhibiting signs of distress such as gurgling sounds, blue lips, and inability to cough up the food. A CNA responded by performing the Heimlich maneuver, after which the resident expelled the food and was able to breathe and speak again. Staff interviews revealed uncertainty and inconsistency regarding the appropriate texture for mechanical soft diets, with some staff believing diced ham was acceptable based on past guidance, despite the dietary spreadsheet specifying ground ham for this diet type. Further review of facility policies and interviews with dietary and clinical staff highlighted a lack of clarity and adherence to individualized dietary modifications. The facility's own policy required that mechanically altered diets be individualized and that staff follow the dietary spreadsheets, which in this case specified ground ham. Despite this, diced ham was served, and staff were not uniformly aware of the specific requirements for the resident's diet, directly leading to the choking incident.
Inappropriate Language Used by Beautician During Resident Care
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident was treated with dignity and respect during a personal care service. A beautician, while providing hair care to a resident with severe cognitive impairment, used inappropriate language by asking the resident if she likes to 'b***h a lot.' This incident was overheard by someone outside the beauty salon, leading to the beautician being removed from the facility and an investigation being initiated. The beautician admitted to using the inappropriate term and stated it was meant to engage the resident, not to harass or threaten her. The resident involved, who has a history of dementia and other medical conditions, did not recall the incident due to her impaired cognition. The facility's administrator was informed of the incident and took steps to address it, including notifying the resident's family and the medical doctor. The beautician had previously attended an abuse in-service training, and the facility's policy emphasizes the importance of treating residents with respect and dignity. Despite the beautician's familiarity with the resident and her admission of poor word choice, the facility's policy and expectations for professional conduct were not upheld in this instance.
Failure to Administer IV Flushes Due to RN Unavailability
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, identified as R1, who required peripheral intravenous access site flushing. R1 was admitted with multiple diagnoses, including hypertension, systemic sclerosis, chronic heart failure, hepatic failure, atrial fibrillation, and reduced mobility. The electronic Medication Administration Record (eMAR) for February 2025 indicated an order for Sodium Chloride Solution 0.9% to be used as a flush every 8 hours. However, the eMAR showed that the IV flushes were not completed on several occasions due to the unavailability of a Registered Nurse (RN) to administer them, specifically on the overnight shifts of 2/2/25, 2/3/25, 2/6/25, and 2/7/25. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed that the facility's policy does not allow LPNs to perform IV flushes, and RNs were responsible for this task. The DON acknowledged that some of R1's flushes were missed, primarily due to an RN calling off during the night shift, and there was no on-call notification system in place to address the absence. Additionally, the facility lacked a specific policy for the maintenance and flushing of peripheral IVs, relying instead on a general policy for catheter insertion and care, which did not cover the necessary procedures for IV flushes.
Facility Fails to Provide Homelike Environment Due to Lack of Dining Room Clock
Penalty
Summary
The facility failed to provide a homelike environment for four residents, as evidenced by the lack of a clock in the dining room, which was a repeated concern raised by the residents. The residents, who were cognitively intact, expressed their dissatisfaction with the absence of a clock, which they deemed necessary for keeping track of time during meals, activities, and appointments. Despite the residents' willingness to purchase a clock themselves, the facility administration, including the Regional Director of Clinical Operations, deemed a clock as a decoration and decided against replacing it. The residents, including the resident council president, consistently brought up the issue of the missing clock in resident council meetings. The previous clock had fallen and broken, and despite ongoing requests for a replacement, the facility did not address the residents' concerns. The residents expressed that knowing the time was important for their daily activities and overall satisfaction, yet their requests were dismissed by the facility's administration. The facility's administration, including the Administrator and the Regional Director of Clinical Operations, acknowledged the residents' requests but maintained that the issue was resolved by suggesting alternative ways for residents to know the time, such as asking staff or checking in their rooms. However, these alternatives did not satisfy the residents' needs, and the lack of a clock in the dining room remained unresolved, contributing to the deficiency in providing a homelike environment.
Improper Dish Sanitization and Handling
Penalty
Summary
The facility failed to ensure proper sanitization of dishes and handling of sanitized items, which could potentially affect all 66 residents. During an observation, the Dietary Manager discovered that the dish machine was not dispensing sanitizer, and maintenance was called to fix it. In the meantime, staff were instructed to use a three-compartment sink for dishwashing. However, the Dietary Aide did not submerge dishes in the sanitizing solution for the required 60 seconds and handled sanitized dishes with unclean hands after touching the trash. Additionally, the Cook did not follow proper sanitization procedures while preparing pureed food for lunch. The Cook failed to submerge the food processor components in the sanitizing solution for the required time, removing them prematurely. The facility's policy and the sanitizer product label both specify a minimum contact time of 60 seconds for effective sanitization, which was not adhered to in these instances.
Failure to Label Expiration Dates on Opened Medications
Penalty
Summary
The facility failed to ensure that opened, multi-dose vials and bottles of medication, including insulin pens and eye drops, were labeled with expiration dates for five residents. During an inspection of the 100-wing medication cart, it was observed that medications for five residents were opened but lacked identified expiration dates. These medications included Glargine insulin for one resident, Fiasp insulin for another, Tresiba and Lispro insulin for a third, Lantus insulin for a fourth, and Latanoprost eye drops for a fifth resident. The Director of Nursing confirmed that insulin pens and bottles of eye drops should be dated when opened to inform staff of their expiration. The facility's Medication Administration policy, dated July 28, 2023, requires that the expiration or beyond-use date on the medication label be checked before administration, and that the date of opening a multi-dose container be recorded on the container. Similarly, the Insulin Administration policy mandates checking the expiration date when drawing from an opened multi-dose vial and recording the expiration date when opening a new vial. The failure to adhere to these policies resulted in the deficiency noted during the survey.
Deficiency in Pureed Diet Portion Sizes
Penalty
Summary
The facility failed to ensure that residents receiving a pureed diet were provided with the correct portion size of pureed hamburger. This deficiency was observed in four residents who were on pureed diets and used three-compartment plates for their meals. On the specified date, the cook, identified as V15, served lunch and placed pureed bread and pureed hamburger in one compartment, pureed green beans in the second, and mashed potatoes in the third. Although the correct scoop sizes were available, V15 accommodated the three-compartment plate by placing one full scoop of pureed bread and only approximately a half scoop of pureed hamburger in the same section. The Dietary Manager, V14, later confirmed that each resident should have received a full scoop of pureed hamburger.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for four residents who required such measures due to their medical conditions. Resident 51, who had a urinary catheter, did not have appropriate signage or personal protective equipment (PPE) available outside his room. A Certified Nursing Assistant (CNA) was observed providing care without wearing a protective gown, despite the resident's care plan indicating the need for EBP. Similarly, Resident 10, who had a tracheostomy, lacked signage and PPE outside her room, and she was not included on the facility's list of residents requiring EBP. Resident 13, with a history of methicillin-resistant Staphylococcus aureus infection and open wounds, also did not have EBP signage or PPE available. Resident 14, who had a urinary catheter, was similarly lacking in EBP signage and PPE. The facility's policy and CDC guidelines require EBP for residents with wounds or urinary catheters, but these were not adequately implemented, as evidenced by the absence of necessary signage and PPE for the affected residents.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure professional standards were met during medication administration for a resident, identified as R23. The resident's Medication Administration Record (MAR) included orders for multiple medications, including Depakote, Lantus insulin, Fiasp insulin, Norco, and Pregabalin. On the morning of July 29, 2024, an LPN dispensed R23's morning medications into a cup without reviewing them with another nurse, a Wound Nurse, who was present. The Wound Nurse then administered the medications to R23 without verifying the medications or dosages. Additionally, the Wound Nurse checked R23's blood glucose level, which was 260 mg/dl, and reported it to the LPN. The LPN prepared the insulin pens for Fiasp and Lantus but did not double-check the dosages with the Wound Nurse before handing them over for administration. The facility's policies on insulin and medication administration clearly state that the nurse who draws up the medication must be the one to administer it to ensure accuracy. However, in this instance, the Wound Nurse administered the medications and insulin prepared by the LPN, contrary to the facility's policies. The Director of Nursing confirmed that the nurse who prepares the medication should also administer it to ensure the correct dosage and resident. This deviation from established procedures led to the deficiency in medication administration for R23.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure adequate assessment and intervention for a resident with dysphagia following a choking episode. Resident R10, who has a history of Parkinsonism, tracheostomy status, gastro-esophageal reflux disease, dysphagia, seizures, and traumatic brain injury, experienced a choking incident during a meal. Despite coughing and requiring assistance to clear her airway, R10 was not referred back to speech therapy for evaluation after the incident. The Speech Language Pathologist was unaware of the choking episode and stated that an evaluation should have been conducted. The Director of Nursing confirmed that R10 was sent to the hospital for evaluation but did not have any diet changes or a referral to speech therapy afterward. The facility also failed to ensure safe transfer practices for residents. Resident R51, who has limited physical mobility and is at risk for falls, was assisted to stand by a CNA without the use of a gait belt, contrary to the facility's policy. Additionally, Resident R40 experienced a fall during a transfer when a CNA did not check that the bed wheels were locked, causing the bed to roll away. These incidents highlight lapses in following established safety protocols for resident transfers, contributing to unsafe conditions for the residents involved.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain a resident's urinary catheter tubing and drainage bag below the level of the bladder, which is necessary to prevent infection. The resident, identified as R51, had a urinary catheter due to urinary incontinence and neuromuscular dysfunction of the bladder. The care plan specified that the catheter bag and tubing should be positioned below the bladder. However, during an observation, a Certified Nursing Assistant (CNA) was seen holding the urinary catheter bag at her waist, which was at the level of the resident's head, while the resident attempted to reposition himself in a recliner. This improper positioning led to an observable backflow of urine in the catheter tubing towards the resident. The Director of Nursing confirmed that the catheter bag and tubing should be kept below the bladder to prevent backflow and potential urinary tract infections. The facility's policy also stated that the drainage bag must be positioned lower than the bladder at all times to prevent backflow.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring of medication administration for two residents, leading to a deficiency in pharmaceutical services. On one occasion, a resident with dementia was found with an orange pill left in a medicine cup on her bedside table, which she expressed a desire to discard. This indicates that the nurse did not observe the resident taking her medication, nor did they document her refusal to take it. The resident's admission record confirmed her diagnosis of dementia, which necessitates careful monitoring during medication administration. Another resident was found with a pill in a medicine cup on his bed, which he intended to take later for pain management. The resident reported that the nurse left the medication while he was still asleep, and he preferred to take it in the afternoon when his pain typically began. Despite the resident's routine of taking the medication at a different time, there was no documentation of a physician's order to accommodate this schedule. The facility's policy requires an assessment and documentation for residents self-administering medications, but no such documentation was available for these residents.
Failure to Address Pharmacist's Recommendations for PRN Medication
Penalty
Summary
The facility failed to respond to a consulting pharmacist's repeated notifications regarding a resident's PRN anti-anxiety medication order that lacked an end date. The resident, identified as R6, had a physician order for Lorazepam 0.5 mg every 4 hours as needed for anxiety, dated 4/5/24, without a specified stop date. The consulting pharmacist, V17, conducted medication regimen reviews on 4/25/24, 5/16/24, and 6/21/24, each time requesting a stop date for the PRN Lorazepam order. Despite these requests, the facility did not act upon the pharmacist's recommendations. The facility's policy on psychotropic medications requires that new PRN orders for such medications have a time limit of fourteen days, after which the prescribing physician must evaluate the need for continued use. On 6/23/24, a note to the attending physician indicated a third request for criteria beyond 14 days for the PRN Lorazepam order. The physician renewed the order due to the resident's agitation and psychosis. The Director of Nursing, V2, stated that pharmacist recommendations should be implemented within 48-72 hours, but this was not done in this case, leading to the deficiency.
Failure to Implement Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed (PRN) anti-psychotic medications had a stop date of fourteen days, as required by their policy. This deficiency was identified in two residents. The first resident had an order for lorazepam oral concentrate, prescribed for agitation related to unspecified psychosis, which started on December 29, 2023, and lacked a stop date. This oversight indicates a failure to adhere to the facility's policy that mandates a time limit for PRN psychotropic medications. The second resident had a new physician order for lorazepam, prescribed for anxiety, which also did not include a stop date. Despite repeated requests from the consulting pharmacist for a stop date, the order was renewed without the necessary criteria for use beyond fourteen days. The facility's policy clearly states that new PRN orders for psychotropic medications should have a time limit of fourteen days, after which the prescribing physician must evaluate the need for continued use. The consulting pharmacist confirmed the requirement for an end date and the need for physician evaluation after fourteen days.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to administer medications on time and as ordered, resulting in a medication error rate of 17.86%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in the case of one resident, who was supposed to receive multiple medications at specific times. The resident's Medication Administration Record (MAR) indicated orders for Depakote, Lantus insulin, Fiasp insulin, Norco, and Pregabalin, all of which were scheduled for administration at specific times throughout the day. However, on the morning of July 29, 2024, the resident reported not having received any of their morning medications by 9:18 AM, despite them being scheduled for earlier administration. The delay in medication administration was attributed to the LPN being unfamiliar with the residents on the wing, causing them to fall behind schedule. The resident's blood glucose level was checked after they had already eaten breakfast, contrary to the facility's policy of checking it 30 minutes prior to a meal. The LPN and Wound Nurse administered the resident's medications and insulin late, with the insulin being given after the resident had already eaten. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed, leading to significant medication errors for two residents. For one resident, the July 2024 Medication Administration Record (MAR) indicated that medications, including Depakote, Lantus insulin, Fiasp insulin, Norco, and Pregabalin, were not administered at the scheduled times. On a specific day, the resident reported not receiving their morning medications on time, and the LPN admitted to being behind schedule. The resident's blood glucose level was checked after breakfast, contrary to the protocol of checking it thirty minutes prior to a meal. Consequently, the resident received their insulin doses late, after having already eaten breakfast. Another resident experienced a medication error when a former nurse administered an excessive dose of Tramadol, totaling 200 mg instead of the prescribed 50 mg every six hours as needed. The error was discovered at the end of the nurse's shift during a narcotics count. The resident's physician was notified, and the resident was monitored for adverse effects, with no serious side effects noted. The facility's Medication Administration policy mandates that medications be administered safely, timely, and within one hour of the prescribed time, which was not adhered to in these instances.
Inadequate Supervision Leads to Resident Choking on Non-Food Item
Penalty
Summary
The facility failed to supervise a resident with dementia adequately, leading to a choking incident on a non-food item. The resident, who had severe cognitive impairment and a history of wandering behaviors, was known to place non-food items in her mouth. Despite this, the resident was able to access floral foam from a Mother's Day activity, which she subsequently choked on. The incident occurred during dinner when the resident walked into the dining room showing signs of choking. Staff initiated the Heimlich maneuver, and the resident eventually expelled the foam and recovered. The resident's care plan indicated that she required supervision to prevent her from placing non-food items in her mouth. However, on the day of the incident, the staff on duty did not adequately monitor her movements, allowing her to access and ingest the foam. Multiple CNAs and an LPN were present during the incident, and they confirmed that the resident had a habit of wandering into other residents' rooms and taking items. The floral foam was part of a recent activity, and pieces of it were found scattered in various rooms, indicating a lack of thorough cleanup and supervision. The facility's policy on safety and supervision emphasized the importance of making the environment as free from accident hazards as possible and tailoring supervision to individual residents' needs. Despite this policy, the resident was able to access a hazardous item, leading to the choking incident. The staff's failure to monitor the resident adequately and ensure the environment was free from such hazards directly contributed to the deficiency.
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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