Park View Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5888 North Ridge, Chicago, Illinois 60660
- CMS Provider Number
- 145765
- Inspections on file
- 42
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Park View Rehab Center during CMS and state inspections, most recent first.
A resident with multiple medical and psychiatric conditions, documented wandering, and a completed elopement risk assessment indicating they were an elopement risk and not safe for unsupervised community access repeatedly attempted to exit through a stairwell door and was redirected earlier in the day. Later that evening, the resident was observed pacing and exit-seeking, but at the time of elopement there was no CNA actively monitoring the hallway because an LPN was passing meds there, despite a facility practice of continuous hallway/dining room observation. The resident then pushed through the alarmed stairwell door, ran down the stairs and out the back door in cold, snowy weather wearing only a sweater, pants, and shoes without socks, and eloped from the building. Staff pursued briefly but were unable to stop the resident, who remained outside until located by police and transported to a hospital, where foot pain and redness were documented before the resident was returned.
The facility failed to prevent resident-to-resident abuse when two cognitively intact, ambulatory roommates with psychiatric diagnoses engaged in escalating verbal conflict that led to one resident pushing the other in the face after threats and verbal abuse over music from a phone. Staff heard the argument and later documented that both residents cursed at each other and that the push occurred, and facility leadership acknowledged this behavior met their own definitions of physical and verbal abuse. In a separate incident, a deaf, nonspeaking resident with schizophrenia communicated through written questions and head nods that another resident had hit him and that he felt afraid and hurt, while documentation also showed a report that this deaf resident had kicked the other resident. These events show that residents were not adequately protected from physical and mental abuse by other residents.
Multiple residents were physically assaulted by other residents despite facility policies guaranteeing freedom from abuse. In one case, a cognitively intact resident with psychiatric diagnoses was punched repeatedly in his room by another cognitively intact resident with schizophrenia after a brief interaction about cigarettes, resulting in a subdural hematoma and nasal bone fracture. Staff reported that the aggressor had prior behavioral incidents with peers and property damage, yet he was not on 1:1 monitoring at the time, and the assault occurred during hours when staff were expected to monitor hallways to prevent residents from entering others’ rooms. In separate incidents, a cognitively intact resident sitting in a hallway and another cognitively intact resident exiting a public restroom were each struck in the face by a cognitively impaired resident with schizophrenia, with staff hearing the victims yell to stop and observing the aggressor near them making a fist or swinging her arms. Facility investigations substantiated these events as abuse, confirming that residents were struck in the face by other residents.
The facility failed to notify physicians after an allegation of resident-to-resident physical abuse. A cognitively intact resident with osteoarthritis, HTN, and psychosis reported being struck in the face by another resident near a bathroom. An RN heard the allegation and informed the administrator but did not complete the abuse protocol, which required notifying the MD and family for both the alleged victim and perpetrator. An LPN reported not receiving direction to complete the protocol and did not contact either resident’s MD or family. The psychiatric services director confirmed that no psychiatrist notification occurred, despite facility policy requiring MD notification for such incidents. Record review showed no documentation of physician contact or related orders, and census data contradicted the incident report’s statement that the alleged perpetrator was sent to the hospital, demonstrating that required notifications and actions were not carried out.
A resident who is bedbound and cognitively intact was denied visitation from her best friend after a roommate objected to the visitor's presence. Staff escorted the visitor out, and no alternative arrangements were made to support the resident's right to receive visitors, despite facility policy and staff acknowledgment of this right.
A medication error rate of 24% was identified after several instances where nurses administered incorrect dosages, failed to notify physicians when medications were withheld or unavailable, and did not follow proper medication administration protocols. Errors included giving the wrong dose of Risperidone, withholding Metoprolol without physician notification, improper measurement of Sucralfate, and administering the wrong strength of Simethicone.
A resident with rheumatoid arthritis did not receive required hand splints for over a year after they went missing, despite physician orders and care plan interventions. Staff interviews confirmed the absence of splints, and facility records lacked documentation of their use or monitoring, contrary to facility policy.
Two residents experienced repeated delays in receiving scheduled medications, with audit records confirming that morning and evening doses were often administered hours late. An LPN withheld a blood pressure medication due to low readings but still gave other medications late, while another resident reported frequent late evening medication administration. The DON acknowledged that new nursing staff may have contributed to these delays, which were not in accordance with the facility's medication administration policy.
A resident, who was cognitively intact, reported a missing clock radio and stated it was stolen, involving police intervention. Despite informing staff and the police visiting the facility, the incident was not documented or reported to the Abuse Coordinator as required by facility policy. An LPN acknowledged awareness of the allegation but did not report it, and the Administrator was not informed, resulting in a failure to follow mandated reporting and investigation procedures.
Multiple residents were subjected to physical abuse by peers, including hitting, pushing, and punching, resulting in injuries such as a laceration requiring stitches. In several cases, staff were not present or failed to provide adequate supervision, leaving residents vulnerable to harm. Facility protocols for monitoring and separating residents with behavioral issues were not effectively implemented, contributing to repeated incidents of abuse.
Multiple residents with mental health diagnoses were involved in physical altercations, resulting in minor injuries. In one case, two residents engaged in a fight in an elevator, both sustaining scratches before staff could intervene. In another case, a resident was struck in the head by a peer in the dining room. Staff responded after the incidents began, and both events were substantiated as abuse.
A resident with insomnia and anxiety disorder did not receive medications as scheduled, with instances of late administration and lack of physician notification. The resident reported not receiving Ambien one evening, despite its availability. Staff interviews confirmed that medications should be administered within one hour of the scheduled time, but this protocol was not followed.
A facility failed to ensure the availability and proper administration of anti-anxiety medication for a resident with schizophrenia and paranoia, leading to hospitalization. The resident's medication administration record showed inconsistencies, and the anti-anxiety medication was unavailable. The resident expressed concerns about inconsistent medication administration, and the DON acknowledged the importance of proper documentation and administration.
A resident with a history of traumatic brain injury and falls was injured during a bed-to-wheelchair transfer due to inadequate assistance. Despite requiring two-person assistance, only one CNA was present, leading to the resident falling and hitting her head. The facility's policy of using a gait belt for transfers was not followed, contributing to the incident.
The facility failed to date prepared food items in the refrigerator and ensure dietary staff wore hair coverings, as observed during a survey. Undated food items, including salads and sandwiches, were found in the refrigerator, and a cook was seen with improper hair covering while handling food. These actions are against the facility's policies and have the potential to affect all 119 residents receiving an oral diet.
The facility failed to adhere to infection control protocols, with staff not following Enhanced Barrier Precautions (EBP) and hand hygiene practices. Instances included improper handling of soiled linen, inadequate hand hygiene during wound care, and lack of EBP signage for residents with medical conditions requiring such precautions. These deficiencies were observed across multiple staff members and residents, potentially increasing infection risks.
The facility failed to conduct timely care plan conferences and involve residents in their care plans, affecting four residents. A resident with a BIMS score of 15 reported not being invited to care plan meetings since their last conference over a year ago. Another resident with moderate cognitive impairment also reported never meeting with staff to discuss their care plan, with the last recorded meeting several years ago. The MDS Nurse and DON confirmed the lack of recent care plan meetings, highlighting a systemic issue in involving residents in their care planning process.
A resident reported an uncovered cable box receptacle with exposed wires in their room, which had been left unattended for 8 months. The Maintenance Director confirmed it should have been covered, and the LPN was unaware of the hazard. The Maintenance Log showed no reports of the issue, despite the facility's policy to maintain a hazard-free environment.
The facility failed to manage medications properly, with expired medications and loose pills found in a medication cart. An LPN noted the unreadable expiration dates and the risk of medication errors from loose pills. The DON confirmed the need to remove expired medications and discard loose pills, but a specific storage policy was not found.
A facility failed to maintain the privacy of a resident's urinary drainage bag, which was observed exposed and attached to the bed frame without a privacy bag. The resident, who is cognitively intact and has several medical conditions, expressed a preference for the bag to be kept in a privacy bag. A CNA confirmed the absence of the privacy bag, and the DON affirmed the importance of using privacy bags to promote dignity, as per facility policy.
A resident was found with an inhaler in her room without a proper assessment or doctor's order for self-administration. The facility failed to include self-administration in the resident's care plan, and staff acknowledged the oversight, noting the need for an assessment and specific order. The facility's policies require an interdisciplinary team assessment and physician's order for self-administration, which was not followed.
The facility failed to provide a homelike environment for two residents. One resident's room had a missing light fixture and an improperly sealed AC unit, which were reported but not addressed. Another resident had a broken dresser drawer that was not documented or fixed. These issues were not recorded in the maintenance log, indicating a lapse in communication and follow-up.
A facility failed to accurately complete the MDS for a resident with schizophrenia, incorrectly indicating no serious mental illness in the PASRR section. The MDS Nurse acknowledged the error, and the DON emphasized the importance of accurate MDS assessments for guiding care plans.
The facility failed to ensure medications were signed out when administered to two residents. A resident with cognitive impairments did not have several medications signed out in the eMAR, and the responsible nurse admitted to forgetting. Another resident's medication was administered but not signed out by an LPN, who acknowledged the risk of double dosing. The facility's policy requires licensed nurses to document medication administration immediately.
A facility failed to date a humidifier bottle for a resident receiving oxygen therapy. The resident, with multiple diagnoses including seizures and congestive heart failure, was observed with an undated humidifier bottle. A nurse confirmed the oversight, which contradicted the facility's policy requiring weekly and as-needed changes and dating of humidifier bottles.
A resident with dysphagia was given a turkey sandwich instead of the prescribed mechanical soft diet, risking choking and aspiration. The CNA did not communicate the resident's dietary needs, and the dietary staff did not verify the resident's identity or dietary requirements before providing the meal.
A resident's personal refrigerator was found at 44°F, above the facility's policy of 41°F or below, risking food spoilage. Staff were unsure who was responsible for monitoring temperatures, and records showed no monitoring on two days. The resident, who is cognitively intact, has a history of paraplegia and multiple stage 4 pressure ulcers.
A resident, who is cognitively impaired, experienced sexual abuse when another resident exposed themselves in the facility elevator. The incident was reported and substantiated, leading to the affected resident being moved to a different floor and placed under 1:1 supervision. The facility staff acknowledged the incident as a form of sexual abuse, highlighting a deficiency in protecting residents from abuse.
Failure to Supervise Identified Elopement-Risk Resident Leading to Unauthorized Exit
Penalty
Summary
The facility failed to provide appropriate supervision to prevent elopement for a resident who had been formally identified as an elopement risk and not safe for unsupervised community access. The resident was admitted with multiple medical and psychiatric diagnoses, including generalized anxiety disorder, major depressive disorder, substance use disorders, gait and mobility abnormalities, unsteadiness on feet, encephalopathy, and a history of falling. An elopement risk review completed shortly after admission documented that the resident was at risk for elopement, and a community survival skills assessment indicated the resident was not capable of unsupervised outside pass privileges. Nursing documentation noted the resident required constant redirection due to wandering the halls and entering other residents' rooms. The resident’s care plan identified elopement risk, including attempting to leave the facility without a responsible escort and wandering behaviors. On the day of the incident, multiple staff observed the resident exhibiting escalating exit-seeking and pacing behaviors. In the late afternoon, the resident attempted to leave through the 2nd floor back stairwell door, triggering the alarm, and was redirected back to his room by social services staff. Staff reported that later that afternoon and early evening, the resident was restless, pacing back and forth from hallway to hallway, dining room to his room, and was described as trying to escape using the back door stairwells. Despite these behaviors and the resident’s known elopement risk status, supervision was provided through a rotating CNA hallway/dining room watch system, and at the time of the actual elopement, there was no CNA specifically monitoring the hallway because the nurse was passing medications there. Staff interviews indicated that although there was an expectation that a staff member continuously monitor the hallway and dining room, this was not occurring at the moment the resident exited. Around the early evening, the 2nd floor back stairwell alarm sounded as the resident pushed through the door. A CNA heard another staff member telling the resident to stop and then heard the alarm, and the LPN on duty reported running after the resident down the stairwell and out the back door. The resident, wearing only a sweater, pants, and shoes without socks in cold, snowy weather, ran away from the facility despite the nurse’s verbal attempts to redirect him and brief physical attempt to hold him. The nurse, not wearing a coat, returned to the building due to the weather, and staff then began searching the surrounding area. The resident later reported that no one was watching him when he left, that he ran as fast as he could, and that he walked and ran for about an hour in the cold before sheltering in an apartment lobby, where a bystander called the police. Hospital records documented that the resident had been walking outside in shoes without socks, developed right foot pain, and was found to have callous and slight skin redness, for which he received Tylenol, Flexeril, and socks before being returned to the facility. The facility’s elopement binder already listed the resident as an elopement risk with his picture and face sheet prior to this event.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse. An altercation occurred between two cognitively intact, ambulatory roommates, R4 and R6, both with psychiatric diagnoses. On the date of the incident, staff reported that R4 was verbally aggressive and loud toward R6, demanding that R6 turn off music playing from R6’s phone. R6 responded by pushing R4 in the face after R4 came onto his side of the room, threatened to break the phone, and verbally abused him. Staff, including LPNs, heard the verbal disagreement and later documented that both residents cursed at each other and that R6 admitted to pushing R4 away. The Administrator and Social Services Director both characterized the verbal aggression and pushing as forms of abuse, and the facility’s own investigation concluded that abuse occurred between the two residents. Interviews and progress notes show that staff were aware of escalating verbal conflict between the roommates but did not intervene in time to prevent the situation from becoming physically abusive. One LPN reported hearing R4 in the hallway having a verbal disagreement with co‑residents and that the residents became aggressive, agitated, and combative. The Social Services Director later stated that residents are supposed to be monitored by staff and that interventions should be taken before resident‑to‑resident issues escalate to aggression, acknowledging that when R6 pushed R4 and when R4 cursed at R6, these actions constituted abuse. The facility’s Abuse Prevention Program policy defines physical abuse as the infliction of injury on a resident other than by accidental means and verbal abuse as the use of disparaging or derogatory language, aligning with how the events were characterized by leadership. A separate incident involved R13, a deaf, nonspeaking resident with schizophrenia and unspecified psychosis, whose cognitive status was not scored on the MDS. R13 communicates with staff through written yes/no questions and written responses or head nods. During an interview using this method, R13 nodded yes when asked if he had been hit by R4, and indicated that he was afraid and hurt when R4 hit him. Nursing progress notes also document that R4 reported R13 had kicked him on the left leg. These documented resident‑to‑resident physical contacts, combined with the facility’s own abuse definitions and staff acknowledgments that such pushing, hitting, and verbal aggression are forms of abuse, demonstrate that the facility failed to ensure that residents remained free from physical and mental abuse by other residents.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Head Trauma and Repeated Assaults
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by other residents, resulting in multiple substantiated abuse incidents. One resident with intact cognition and diagnoses including traumatic subdural hemorrhage, nasal bone fracture, schizophrenia, and bipolar disorder reported being physically assaulted in his room by another cognitively intact resident with schizophrenia and other psychiatric diagnoses. According to the injured resident, he initially went to the aggressor’s room to borrow a lighter, was told there was no lighter, and then returned to his own room. Shortly thereafter, the aggressor entered his room, demanded to know where his cigarettes were, and then punched him in the face repeatedly with a closed fist. A nurse heard a loud noise, saw the aggressor leaving the injured resident’s room, and found the injured resident lying on his bed with his face covered in blood. The injured resident was sent to the hospital and diagnosed with a subdural hematoma and a nasal bone fracture, with hospital documentation noting facial trauma including left periorbital swelling and a right nasal bone fracture. The aggressor in this incident had a documented history of mental illness, hallucinations, and delusions, and staff and the Psychiatric Rehabilitation Services Coordinator acknowledged that he had prior behavioral incidents with other peers, including breaking shelves at the nursing station and two prior incidents with another resident, though not as severe as the assault that caused the subdural hematoma and nasal fracture. Staff interviews indicated that when residents exhibit aggressive behavior they may be placed on one‑on‑one monitoring and receive psychiatric evaluation, and that staff are expected to monitor hallways, particularly at night, to prevent residents from wandering into other residents’ rooms. At the time of the assault, the aggressor was not on one‑on‑one monitoring, and the event occurred in the early morning hours when residents do not have scheduled smoking times. The administrator, who serves as the Abuse Coordinator, stated that it is not expected for residents to be physically abused by other residents and that the facility must keep residents safe, and the physician stated that abuse is not an expectation and that behaviors should be managed to maintain safety. Additional substantiated abuse incidents involved another resident with schizophrenia and severe cognitive impairment who physically struck two cognitively intact residents on separate occasions. In one incident, a cognitively intact resident with schizophrenia, hypertension, and unsteadiness on feet was sitting in the hallway after exiting the dining room when the cognitively impaired resident walked out of her room and, without provocation, struck him in the face with her hand. The LPN on duty heard the victim yell “stop hitting me,” saw the aggressor standing close to him making a fist, and separated them. The facility’s final incident investigation concluded that abuse was substantiated, determining that the resident was struck in the face by another resident. In another incident, a cognitively intact resident with osteoarthritis, hypertension, and psychosis was inside a public restroom when she opened the door as the same cognitively impaired resident was walking past. The aggressor was reportedly startled, began swinging her arms, and struck the resident in the face. Staff on the unit intervened immediately and separated the residents. The facility’s final incident investigation again substantiated abuse, concluding that the resident was struck in the face by another resident when the restroom door opened and the aggressor reacted by swinging her arms. Progress notes documented that the aggressor later, without event or provocation, hit another peer in the face and then became physically aggressive toward staff attempting to intervene. Across these events, the facility’s own Residents’ Rights document states that residents must not be abused physically, neglected, or exploited by anyone and that the facility must provide services to keep residents’ physical and mental health at their highest practicable levels. The Abuse Prevention Program Policy defines abuse as physical or mental injury inflicted upon a resident, including hitting, slapping, and kicking, and affirms residents’ right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The administrator confirmed that the allegations involving the residents who were struck in the face were substantiated as physical abuse based on the nature of the incidents and resident statements, meaning that abuse occurred. Despite these policies and expectations, multiple residents were physically assaulted by other residents on different dates, including one incident that resulted in significant head trauma and facial fractures, demonstrating that the facility failed to protect residents’ rights to be free from physical abuse by other residents.
Failure to Notify Physicians Following Allegation of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ physicians of an allegation of abuse as required by its Abuse Prevention Program Policy. One cognitively intact resident, R12, with diagnoses including osteoarthritis, hypertension, and psychosis, alleged on 11/04/2025 that another resident, R5, struck her in the face while she was exiting a public restroom on the second floor. A nurse on duty (V11, RN/Infection Preventionist) heard R12 say “don’t hit me,” found R12 near the nurse’s station and R5 by the bathroom door, and confirmed with R12 that she had been hit in the face. The facility’s Final Incident Investigation Report later documented that the allegation of abuse was substantiated and stated that the resident’s physician was made aware of the allegation and that R5 was sent to the hospital for evaluation per physician orders. Interviews and record review, however, showed that the required physician notifications were not completed or documented. V11 stated that she informed the Administrator (V1) that she was too busy to complete the abuse protocol and that V1 instructed LPN V14 to complete it, which included calling the family and physician for both the alleged victim and perpetrator. V11 acknowledged she did not call the family or physician for either resident. V14 stated she did not receive instructions from V1 to complete the abuse protocol and did not call the family or physician for either resident. Review of the electronic health record revealed no documentation that the physicians or psychiatrist were notified regarding the allegation involving R12 and R5, despite the facility policy requiring that physicians be notified of any incident and that the resident’s representative and physician be notified of the alleged incident and investigation. Further interviews confirmed that no psychiatrist notification occurred following R12’s allegation that R5 hit her. The Psychiatric Rehabilitation Services Director (V12) stated that when a resident makes an allegation of physical abuse, the psychiatrist should be called, and that if the nurse had called, it should have been documented in the electronic health record; V12 later confirmed that no psychiatrist notification was done. The Administrator (V1) stated that any time a resident is struck by another resident, the abuse protocol must be initiated immediately, including separating the residents, placing them on behavior monitoring, and notifying the physician and emergency contact person, and that if notification of the doctor is not documented, it means it did not happen. V1’s review of the reportable and census records also showed that, contrary to the written report, R5 was not sent to the hospital on the date of the incident, further evidencing that the physician notification and related orders described in the report did not occur. These findings demonstrate the facility’s failure to follow its own abuse protocol and policy requiring physician notification for incidents of alleged abuse.
Failure to Ensure Resident Visitation Rights in Shared Room
Penalty
Summary
The facility failed to ensure that a resident's right to full and equal visitation privileges was honored. A cognitively intact resident, who is bedbound and requires assistance with personal care, was denied visitation from her best friend after a roommate objected to the visitor's presence. The roommate, who has resided in the facility for many years, became upset and demanded that the visitor leave, believing the visitor to be a funeral director. Staff, including CNAs, LPNs, and the Social Services Director, responded by escorting the visitor out of the room, despite the resident's wishes to continue the visit. The resident expressed anger and frustration that her right to receive visitors was violated, especially since her friend assists her with essential tasks such as managing her link card, grocery shopping, and laundry. Multiple staff members acknowledged that the resident had an equal right to receive visitors in her room, as supported by facility policy. However, no alternative arrangements were made to facilitate the visit after the roommate's objection, and the visitor was not allowed to return. The Assistant Administrator did not follow up with the visitor or the resident to resolve the situation, and the resident's ability to receive her chosen visitor was not restored. Facility documentation and interviews confirm that the resident's visitation rights were not upheld in accordance with her preferences.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with six errors out of 25 opportunities, resulting in a 24% error rate. Multiple instances were observed where nursing staff did not administer medications according to physician orders. In one case, a nurse prepared and nearly administered an incorrect dose of Risperidone to a resident with dementia, initially placing 3.25 mg in the medication cup instead of the ordered 1.25 mg. The error was only partially corrected after review, and the correct dose was not immediately available. Another incident involved a resident with hypertension who was scheduled to receive Metoprolol Succinate ER 25 mg daily. The nurse withheld the medication due to a low blood pressure reading, despite there being no physician-ordered parameters to hold the medication. The nurse did not notify the physician of the withheld dose, nor did they inform the physician when a medication was unavailable for another resident. Additionally, a resident prescribed Sucralfate 1 gm/10 ml for gastrointestinal issues was nearly given an incorrect volume due to improper measurement technique, which was only corrected after intervention. Further, a resident was administered the wrong dosage of Simethicone due to the unavailability of the prescribed strength, with the nurse giving 125 mg tablets instead of the ordered 80 mg. The nurse was unaware of the dosage discrepancy and had already administered the incorrect dose earlier in the day. These events demonstrate repeated failures to follow medication administration protocols, including verifying correct dosages, ensuring medication availability, and communicating with physicians when deviations from orders occurred.
Failure to Provide and Document Required Hand Splints for Resident with Rheumatoid Arthritis
Penalty
Summary
The facility failed to provide hand splints for a resident diagnosed with rheumatoid arthritis, despite documented orders and care plan interventions indicating the need for bilateral hand splints as tolerated and for comfort. The resident reported that hand splints were previously applied by staff but went missing after a deep cleaning nearly a year prior, and were never replaced despite informing staff. Observations confirmed the resident's left fingers were closed inward, and the resident described ongoing weakness, particularly in the left hand, and the inability to keep the left fingers open without assistance. Interviews with nursing staff, restorative staff, and the Director of Nursing revealed that none had seen the resident with hand splints for an extended period, with some stating the splints had not been present for over a year. The facility's records, including the order summary and care plan, documented the need for splints and monitoring for their use and condition, but there was no documentation in the progress notes or ADL records regarding the application or presence of hand splints. The facility's policy required documentation and monitoring of such devices, which was not followed in this case.
Failure to Administer Medications Timely and According to Professional Standards
Penalty
Summary
The facility failed to administer medications in accordance with professional standards and scheduled times for two residents. One resident's morning medications, including Hydroxyzine Pamoate, Lamotrigine, Levetiracetam, Metoprolol Succinate Extended Release, and Potassium Chloride, were repeatedly given late, with documented instances of administration occurring several hours after the scheduled 9:00 AM time. On one occasion, the Metoprolol was withheld due to low blood pressure, but the other medications were still administered late. The Medication Administration Record and audit reports confirmed multiple late administrations over several days. Another resident reported that evening medications were administered late on several occasions, sometimes as late as almost 11:00 PM, despite being scheduled for 5:00 PM and 9:00 PM. Audit reports corroborated these claims, showing repeated late administration of medications such as Haloperidol, Vitamin C, Donepezil Hydrochloride, and Naproxen. The Director of Nursing acknowledged that new nurses may have contributed to the delays, and the facility's policy requires medications to be administered at the right time as ordered by the physician.
Failure to Report and Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to report and investigate an allegation of misappropriation of property involving a resident who reported a missing clock radio. The resident, who was cognitively intact according to the most recent MDS assessment, stated that the item was stolen and that the police had been involved. The resident informed staff about the missing item and the police visit, but there was no documentation of this incident in the resident's electronic medical record. Another resident confirmed that police had visited and inquired about any altercations, but denied any involvement. A Licensed Practical Nurse (LPN) acknowledged that the resident had called the police and mentioned something was taken, but did not provide details and the LPN did not report the incident to the facility's Abuse Coordinator, who is also the Administrator. The LPN stated she did not consider it abuse due to the lack of details, but recognized it should have been reported. The Administrator confirmed that all allegations, regardless of detail, must be reported immediately for investigation and state notification. Facility policy requires staff to report any suspicion or allegation of abuse, neglect, or misappropriation of property to the Administrator or supervisor, but this procedure was not followed in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by peers, resulting in several incidents where residents were physically hit, pushed, or punched by other residents. In one case, a resident with a history of schizophrenia, bipolar disorder, and mobility issues was struck and pushed by another resident, leading to a fall and a laceration on the forehead that required eight stitches. The incident occurred when the aggressor confronted the victim over alleged theft, and no staff were present at the time to intervene. The staff became aware of the situation only after the injury had occurred, and the nurse on duty was not on the floor during the incident. In another incident, a resident reported being hit by another resident who wandered into their room. The staff responsible for monitoring the residents was on a lunch break and did not inform the nurse, leaving the floor without adequate supervision. The nurse was at the nurse's station and did not witness the altercation, only becoming aware after hearing a commotion. Both residents involved were later hospitalized. The facility's protocol for staff coverage during breaks was not effectively implemented, resulting in a lack of monitoring for residents known to require close supervision. Additional incidents included a resident being hit in the back of the head by another resident while lining up for a smoke break, and a resident physically attacking their roommate while on one-to-one monitoring for behavioral issues. In these cases, staff either witnessed the aftermath or were present but unable to prevent the abuse. The facility's policies on abuse prevention and behavior management were not adequately followed, as residents who posed a risk to others were not consistently separated or monitored to prevent harm.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving physical altercations between residents. In one incident, two female residents, both with mental health diagnoses and intact cognitive function as indicated by their BIMS scores, engaged in a physical altercation in an elevator. One resident reported being pushed and scratched by the other, leading to both residents exchanging blows and sustaining minor scratches. Staff on the unit heard raised voices and intervened, but were unable to separate the residents before the altercation escalated. Both residents were assessed and treated for their injuries, and the incident was substantiated as abuse by the facility. In a separate incident, another female resident with a history of schizoaffective disorder and chronic kidney disease was struck in the head by a peer in the dining room without provocation. The aggressor, who has severe mental illness and unscoreable BIMS, became agitated and refused to answer questions when staff attempted to interview her. Staff intervened immediately to separate the residents, and both were assessed with no injuries reported. The incident was also substantiated as abuse. In both cases, the facility's failure to prevent resident-to-resident physical abuse resulted in physical contact and minor injuries. The incidents involved residents with significant behavioral and mental health diagnoses, and staff intervention occurred only after the altercations had already begun. The facility's abuse prevention policy states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment, but these incidents demonstrate a failure to uphold that standard.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that medication was administered as scheduled per physician order for one resident. The resident, who is cognitively intact with a BIMS score of 15, had diagnoses including insomnia and anxiety disorder. On multiple occasions, medications were administered more than one hour past the scheduled time without notifying the physician. Specifically, Zolpidem Tartrate, Seroquel, and Tamsulosin were administered at 10:35 PM instead of the scheduled 9:00 PM, and other medications like Gabapentin and Hydralazine were given at 6:49 PM instead of 5:00 PM. There was no documentation in the electronic health records indicating that the physician was informed of these late administrations. Interviews with the resident and staff revealed further issues with medication administration. The resident reported not receiving Ambien one evening, despite it being available, and was informed by a nurse the following morning that the medication was indeed available. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and that the physician should be notified if medications are given late. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding the late administration of medications.
Failure to Administer and Document Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure the availability and proper administration of anti-anxiety medication for a resident diagnosed with schizophrenia, paranoia, psychosis, anxiety, depressive disorder, and parkinsonism. The resident, who has moderate cognitive impairment, was not consistently receiving his prescribed medications, including anti-parkinsonism drugs, on several days in November 2024. This inconsistency in medication administration was not documented as per the facility's policy, which requires nurses to sign the Medication Administration Record (MAR) each time medication is given. The lack of documentation and administration of medication contributed to the resident's increased paranoia and psychotic behavior, leading to hospitalization. During an observation on January 9, 2025, it was noted that the anti-anxiety medication Hydroxyzine was unavailable in the medication cart and room, and the pharmacy was contacted to clarify its status. The resident expressed concerns about the inconsistency in receiving his medications, which he believed were not always administered correctly. The Director of Nursing acknowledged the importance of anti-anxiety medication in managing the resident's behavior and preventing recurrent issues, emphasizing the principle that if medication administration is not documented, it is considered not done.
Failure to Provide Adequate Assistance During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide the required extensive assistance of two staff members during a manual bed-to-wheelchair transfer for a resident, resulting in the resident falling and sustaining a head injury. The resident, who has a history of traumatic brain injury, seizures, and falls, required substantial assistance for transfers due to impairments in both upper and lower extremities. Despite these needs, the transfer was attempted with inadequate supervision, leading to the resident hitting her head on a nightstand and requiring medical attention. On the day of the incident, the resident was in the dayroom and needed her incontinence brief changed. Two CNAs were involved in the process, but one left the room to prepare for incontinence care, leaving the resident with only one CNA. During this time, the resident attempted to stand and lost her balance, resulting in a fall. The CNA present was unable to prevent the fall, and the resident sustained a laceration on her head, necessitating hospital evaluation and treatment. Interviews with staff revealed inconsistencies in the transfer process and a lack of adherence to the facility's policy requiring two-person assistance for transfers. The CNAs involved did not use a gait belt, which is mandatory for all physical assist transfers according to the facility's policy. The incident highlights a failure to follow established procedures for safe resident handling, particularly for residents at high risk for falls.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, as observed during a survey. In the walk-in refrigerator, several food items, including green leaf salads, cold cut sandwiches, and egg salad, were found without dates, indicating a lack of compliance with the facility's policy that requires all refrigerated food to be labeled with the date it was prepared. This oversight was acknowledged by a cook, who stated that the staff is aware of the requirement to date open and prepared items, but the cook from the previous night failed to do so. The Dietary Manager confirmed that all food in the refrigerator should be labeled and dated, and a Dietary Aide reiterated that refrigerated food items should be dated. Additionally, the facility did not ensure that dietary staff adhered to the policy of wearing hair coverings while handling food. A cook was observed pureeing food with a mask hanging at chin level and hair not fully covered, which is against the facility's policy that mandates hairnets and beard guards or masks as necessary. The Dietary Manager confirmed that everyone in the Dietary Department should have a hair net on, and the facility's policy documents that food and nutrition services employees must wear hair restraints at all times in the kitchen. These deficiencies have the potential to affect all 119 residents receiving an oral diet in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and hand hygiene protocols. In one instance, a housekeeper was observed handling soiled linen without proper bagging and failed to perform hand hygiene after doffing gloves, subsequently touching clean linens. This was contrary to the facility's policy, which mandates that all linen be handled in a manner to prevent the spread of infection and that hand hygiene be performed upon removal of personal protective equipment. In another case, a registered nurse was observed performing wound care on a resident with multiple stage 4 pressure ulcers without completing hand hygiene between glove changes. The nurse repeatedly donned new gloves without washing hands, despite the facility's hand washing policy requiring hand hygiene immediately after glove removal. This oversight was acknowledged by the nurse and the Director of Nursing, who affirmed the importance of hand hygiene in preventing contamination and infections. Additionally, several residents who required Enhanced Barrier Precautions due to their medical conditions, such as indwelling catheters, feeding tubes, and wounds, did not have EBP signs on their doors. Staff were observed providing care without the appropriate use of gowns and gloves, as required by the facility's policy. This lack of adherence to EBP protocols was noted in multiple instances, with staff either unaware of the requirements or failing to follow them, potentially increasing the risk of infection transmission among residents and staff.
Failure to Conduct Timely Care Plan Conferences and Involve Residents
Penalty
Summary
The facility failed to conduct timely care plan conferences and involve residents in the development of their care plans, affecting four residents in a sample of 58. Resident 2, who is cognitively intact with a BIMS score of 15, reported not being invited to participate in care plan meetings since their last conference on June 20, 2023. The MDS Nurse could not recall any recent care plan meetings for this resident. Resident 27, with moderate cognitive impairment and a BIMS score of 12, also reported never having met with staff to discuss their care plan, with the last recorded care conference dated March 22, 2017. Similarly, Resident 59, who is cognitively intact with a BIMS score of 15, stated it had been over a year since their care plan was discussed, with the last meeting recorded on March 31, 2023. The MDS Nurse confirmed the lack of recent care plan meetings for these residents. The Director of Nursing affirmed that care plan meetings should occur quarterly and as needed, with residents and their families invited to participate. However, the facility's records and policies indicate a failure to notify residents and maintain records of care plan meetings, as evidenced by the outdated care conference dates and lack of sign-in sheets. This deficiency highlights a systemic issue in involving residents in their care planning process.
Uncovered Cable Box Receptacle Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R82, by not covering a cable box receptacle, leaving wires and cable cord connectors exposed. This issue was observed on August 18, 2024, and the resident reported that the box had been uncovered for the entire 8 months of their stay in the room. The Maintenance Director acknowledged that the cable box should have been covered, and the Licensed Practical Nurse (LPN) was unaware of the hazard, indicating a lack of communication and reporting within the facility. The Maintenance Log for the first floor showed no reports of the uncovered cable box, despite the facility's policy emphasizing the importance of maintaining a hazard-free environment. The Administrator stated that receptacle testing is part of the preventative maintenance program, which includes checking for cracks and the condition of cover plates. However, the uncovered cable box was not addressed, highlighting a gap in the implementation of the facility's safety policies and procedures.
Medication Management Deficiency
Penalty
Summary
The facility failed to maintain proper medication management practices, as evidenced by the presence of expired medications and loose pills in the 3rd floor medication cart. During an observation, it was found that the medication cart contained twenty-three loose pills, and bottles of Bisacodyl 5mg and Ferrous Sulfate 325mg with unreadable expiration dates. A Licensed Practical Nurse (LPN) acknowledged the issue, stating that the faded expiration dates made it impossible to verify the medications' effectiveness, and emphasized that picking pills from the bottom of the drawer would constitute a medication error due to contamination and lack of identification. The Director of Nursing (DON) confirmed that expired medications should be removed from the carts to prevent reduced potency, which could alter the intended dosage. The DON also noted that loose pills should be discarded and medications reordered to ensure residents have an adequate supply. However, the facility was unable to locate a specific medication storage policy at the time of the survey. The facility's existing policy on labeling and dating medications, dated August 2018, requires medications to be used in accordance with the manufacturer's recommendations and mandates dating of certain medications when first opened.
Failure to Maintain Privacy of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure a resident's urinary drainage bag was kept privately, affecting one resident in a sample of 58. The resident, who is cognitively intact and has a diagnosis of paraplegia, flaccid neuropathic bladder, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy, utilizes an indwelling urinary catheter. On a specific date, the resident's urinary drainage bag was observed to be exposed and attached to the frame of the bed, without a privacy bag. The resident expressed a desire for the urinary drainage bag to be kept in a privacy bag. A Certified Nursing Assistant confirmed the absence of the privacy bag and acknowledged that it should have been used. The Director of Nursing also affirmed that urinary drainage bags should be kept in privacy bags to promote resident dignity. The facility's policy on dignity, dated January 2015, states that urinary catheter bags shall be covered.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's ability to safely self-administer medication, specifically an inhaler for chronic obstructive pulmonary disease (COPD) and asthma. The resident, identified as cognitively intact with a BIMS score of 15, was found to have an inhaler in her room, which was given to her by a nurse without a proper assessment or a doctor's order allowing self-administration. The resident's care plan did not include provisions for self-administration of medication, and there was no documentation or order permitting the resident to keep the medication at her bedside. During the survey, the Assistant Director of Nursing and a Licensed Practice Nurse acknowledged the oversight, noting that the resident was not supposed to have the inhaler in her room without an assessment and a doctor's order. The Director of Nursing confirmed the necessity of an assessment, a specific doctor's order, and a care plan for self-administration to ensure the resident's safety and to inform staff of the care plan. The facility's policies and procedures require an interdisciplinary team assessment and a physician's order before a resident can self-administer medication, which was not followed in this case.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, R83 and R82, as observed during a survey. For R83, the light fixture in their room was missing a fluorescent tube light and cover, and the air conditioning unit was improperly sealed with a pillow. Despite R83 reporting these issues to the Assistant Director of Nursing two weeks prior, they were not addressed. The Maintenance Manager acknowledged being informed about the missing light cover but had not yet resolved the issue. The facility's maintenance log did not document these problems, indicating a lapse in communication and follow-up. For R82, a dresser drawer was missing, which the resident reported had broken a few days earlier. The Maintenance Manager admitted that the missing drawer did not provide a homelike environment, yet the issue was not recorded in the maintenance log. The Director of Nursing confirmed that damaged property in a resident's room would not constitute a homelike environment. Both cases highlight a failure to adhere to the residents' rights to a safe, clean, comfortable, and homelike environment as mandated by state and federal laws.
Inaccurate MDS Completion for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident diagnosed with schizophrenia, unspecified psychosis, and bipolar disorder. The MDS, dated 7/3/2024, incorrectly indicated that the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) to have a serious mental illness. However, a Notice of PASRR Level II Outcome dated 9/02/2022 confirmed the resident's condition of schizophrenia, which should have been coded as 'yes' in section A1500 of the MDS. The MDS Nurse/Restorative Nurse, a Licensed Practical Nurse, acknowledged the error, stating that section A1500 should be coded as 'yes' for residents identified by PASRR as having a serious mental illness. The Director of Nursing emphasized the importance of accurate MDS assessments to guide the resident's care plan, noting that incorrect MDS completion could result in the facility not identifying all necessary care for the resident.
Failure to Sign Out Medications
Penalty
Summary
The facility failed to ensure that medications were properly signed out when administered to two residents, R71 and R91. For R71, who has a range of diagnoses including cognitive impairments, the issue was identified when the resident reported not receiving medications. Upon investigation, it was found that several medications, including Colace, Lidocaine Patch, Mirabegron, Multivitamin, Sertraline, Clonazepam, Gabapentin, Pregabalin, Prostat, and Vitamin C, were not signed as administered in the electronic Medication Administration Record (eMAR). The nurse responsible, V15, admitted to forgetting to sign them out, acknowledging the importance of signing medications to prevent errors. Similarly, for R91, who has chronic obstructive pulmonary disease and schizophrenia, the deficiency was noted when a surveyor requested to observe the administration of Breo Ellipta inhalation medication. The LPN, V16, admitted to administering the medication but failing to sign it out. The Director of Nursing, V2, confirmed that medications should be signed out immediately after administration to ensure accurate records and prevent potential double dosing. The facility's policy mandates that only licensed nurses prepare, administer, and record medications, emphasizing the importance of documentation on the Medication Administration Record (MAR).
Failure to Date Humidifier Bottle for Oxygen Therapy
Penalty
Summary
The facility failed to date the humidifier bottle for a resident who was receiving oxygen therapy. The resident, who has a range of diagnoses including seizures, hypertension, and congestive heart failure, was observed lying in bed with an oxygen cannula connected to a humidifier bottle that lacked a date. A registered nurse confirmed the absence of a date on the humidifier bottle and acknowledged that it should have been dated to track when it was last changed. According to the facility's policy, humidifier bottles should be changed and dated weekly and as needed, but this procedure was not followed in this instance.
Failure to Provide Correct Diet Consistency
Penalty
Summary
The facility failed to provide the correct consistency diet to a resident, identified as R100, who has multiple medical diagnoses including dysphagia, which increases the risk of choking and aspiration. R100's physician ordered a no added salt diet with mechanical soft, ground meat texture, and thin liquids consistency. However, during an observation, a Certified Nursing Assistant (CNA) provided R100 with a turkey and cheese sandwich, which was not consistent with the mechanical soft diet order. The CNA believed the sandwich was appropriate because the bread was soft, and stated that they were instructed to provide a turkey sandwich when R100 did not eat the meal provided. The Dietary Manager confirmed that R100's diet required the turkey meat to be chopped, as residents on mechanical soft diets typically have swallowing difficulties. The Director of Nursing (DON) acknowledged that providing the wrong food consistency could lead to aspiration. The facility's policy on mechanical soft diets specifies that meat should be mechanically ground unless otherwise indicated. The incident occurred because the CNA did not communicate the resident's dietary needs when requesting the sandwich, and the dietary staff did not verify the resident's identity or dietary requirements before providing the meal.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that personal refrigerators were maintained at safe temperatures, affecting one resident in a sample of 58. The resident, who is cognitively intact, has a medical history that includes paraplegia, flaccid neuropathic bladder, and multiple stage 4 pressure ulcers. During an observation, the resident's personal refrigerator was found to contain multiple containers of leftover food and beverages, with the thermometer reading 44 degrees Fahrenheit, which is above the facility's policy requirement of 41 degrees Fahrenheit or below. Staff interviews revealed uncertainty about who was responsible for monitoring the temperatures of personal refrigerators. A Certified Nursing Assistant confirmed the high temperature, and a Licensed Practical Nurse acknowledged that such a temperature could cause food to spoil. The Director of Nursing also expressed uncertainty about which staff should be monitoring these temperatures, although it was affirmed that temperatures should be checked at least daily. The facility's records showed no temperature monitoring was completed on two consecutive days, contributing to the deficiency.
Resident Exposed to Sexual Abuse in Facility Elevator
Penalty
Summary
The facility failed to protect a resident, referred to as R1, from sexual abuse and mental anguish. R1, who is cognitively impaired with a BIMS score of 10, experienced an incident where another resident, R2, exposed themselves to R1 in the facility elevator. R2, also cognitively impaired with a BIMS score of 12, admitted to the exposure, which was reported by a CNA to the facility's administration. The facility's investigation substantiated the allegation of abuse. Following the incident, R1 expressed feelings of being punished and isolated, as they were moved to a different floor and placed under 1:1 supervision. R1 reported feeling afraid to participate in activities due to the presence of R2, who had previously made inappropriate comments and gestures. The emotional impact on R1 was evident, as they were observed crying and expressing distress over the situation. The facility's staff, including LPNs, the Social Services Director, and the Assistant Director of Nursing, acknowledged the incident as a form of sexual abuse. The facility's policy on abuse prevention and resident rights emphasizes the residents' right to be free from abuse and to be treated with dignity and respect. Despite these policies, the incident occurred, leading to a deficiency in ensuring a safe environment for R1.
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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