Parker Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Streator, Illinois.
- Location
- 516 West Frech Street, Streator, Illinois 61364
- CMS Provider Number
- 145989
- Inspections on file
- 42
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Parker Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with a recent CVA and an order for pureed foods with thin liquids, plus mechanical soft upon request, was repeatedly served pureed meals even though staff knew she was not eating them. The resident said she was unaware of the mechanical soft option and had asked multiple times for different food; the Dietary Mgr initially did not recognize the alternate diet order, and the resident experienced significant unplanned weight loss.
Incorrect Meal Portion Sizes Served: The facility failed to serve the correct portion size of turkey tetrazzini for the noon meal, affecting all residents. The cook plated regular and pureed turkey tetrazzini using a #6 scoop, while the meal spreadsheet required an 8-oz portion for regular diets and two #8 scoops for pureed diets. The report states that none of the residents received the correct portion, and mechanical soft diets were served the same as regular diets despite the tray line policy requiring proper portion checks.
Dish machine and 3-compartment sink sanitizer concentrations were not maintained at the required levels. A dietary aide tested the low-temp chlorine dish machine and the strip did not change colors, then the dietary manager retested it and found it barely at 50 ppm, though she stated it should be 100 ppm. The dietary manager also checked the quat solution in the 3-compartment sink and found it at 100 ppm, stating it should be 200 ppm.
Failure to verify CNA annual in-service training. The facility could not provide documentation showing that several CNAs had completed the required 12 hours of yearly in-service education. CNAs interviewed said they had received in-services but were unsure whether they had met the required hours, and the Administrator said the facility was still working on a system to track training completion. The facility policy required annual training in dementia care, abuse prevention, and other resident care topics.
PRN psychotropic meds lacked required stop dates for several residents. Orders for anxiolytic and antipsychotic meds such as alprazolam, lorazepam, Ativan, and olanzapine had no stop dates, and for some residents the EMR did not show the required 14-day assessments and new orders. The DON stated she was responsible for ensuring PRN psychotropic meds had 14-day stop dates and that the physician should be notified if longer use was needed.
A resident on hospice was not treated with dignity and respect when an LPN refused to get the resident up despite the resident wanting to get up, and then argued with the resident's daughter/POA. Another LPN witnessed the argument near the resident's room and said it could be heard in the hallway and at the nurse's station. The DON stated staff should have honored the resident's and family's requests and treated them with respect.
A resident was found with two cups of oral meds left on the bedside table instead of being observed taking them. The resident said this depended on which nurse was working. The ADON stated meds should not be left at bedside and nurses should observe the resident take them. The resident had no order to self-administer, and the MAR listed multiple scheduled AM meds.
Medication administration errors occurred when an ADON failed to give two ordered meds to a resident during a med pass. The meds, Allopurinol and Benztropine, were not in the cart, and the ADON said they had to be reordered from the pharmacy and were not part of the facility’s on-site med supply. Surveyors found 2 errors in 33 opportunities, resulting in a 6.06% med error rate.
Failure to Carry Out Antipsychotic Medication Order: A resident with schizoaffective disorder, dementia, and PTSD had ongoing auditory and visual hallucinations, and an NP increased Latuda to address her psychotic symptoms. The order was not carried over to the POS or MAR, and the resident continued receiving the prior doses, including an 80 mg dose given at 8 AM instead of 8 PM, resulting in 48 missed doses of the increased medication.
Failure to perform hand hygiene during wound care: An ADON and a CNA entered a resident’s room using EBP, but during wound care for a stage 4 sacral pressure ulcer with drainage, gloves were removed and replaced multiple times without hand hygiene between glove changes. The ADON later stated hand hygiene should be done after each glove removal and before donning new gloves unless hands are visibly soiled.
Two residents, both with behavioral and medical diagnoses, engaged in a physical altercation in the dining room, with one resident striking the other multiple times and staff unable to immediately stop the incident. Video surveillance and staff interviews confirmed the abuse, which occurred despite facility policies prohibiting such actions.
Two residents with histories of trauma and mental health conditions reported sexually explicit remarks and unwanted advances from another resident, but staff failed to promptly report or investigate the allegations as required by policy. The affected residents were left unprotected, resulting in their withdrawal from social activities and ongoing distress, while the alleged perpetrator continued to have access to them. Multiple staff members did not escalate the complaints, and management did not initiate an investigation or protective measures until days later, leading to an Immediate Jeopardy finding.
The facility did not follow its discharge planning and unplanned discharge procedures for several residents, including failing to notify APS or emergency contacts when residents left unexpectedly, and not providing active discharge planning for residents who expressed a desire to leave. Staff confirmed that discharge planning was not initiated unless specifically requested, and documentation showed no evidence of required actions being taken.
A resident with multiple comorbidities and a history of falls was found on the floor with a laceration after staff failed to keep the bed in the low position and did not place a floor mat as required by the care plan. The resident, dependent for care and requiring a mechanical lift, attempted to reach for a drink and fell, sustaining an injury that required sutures.
A resident experienced an episode of incontinence and reported being subjected to derogatory remarks and laughter from CNAs during cleanup, leading to emotional distress. The incident was communicated to an LPN and the DON, but was not immediately reported to the facility abuse coordinator as required by policy, resulting in a failure to follow abuse reporting procedures.
A resident reported being subjected to derogatory remarks and laughter from three CNAs during an episode of incontinence. The incident was relayed to an LPN by the resident's daughter and subsequently reported to the DON, but the Administrator was not informed and no investigation was conducted, contrary to facility policy.
A resident with multiple health issues fell from a wheelchair while being lifted into a van, but the LTC facility failed to notify the resident's POA as required. The resident continued to dialysis treatment without the dialysis center being informed of the fall. The dialysis nurse later contacted the facility, which then attempted to reach the POA. The resident was discharged without proper documentation or notification, later admitted to the hospital, and passed away after transitioning to hospice care.
A resident with multiple medical conditions fell from a wheelchair during transport, and the facility failed to conduct timely neurological checks or notify dialysis staff. The resident was later diagnosed with a subdural hematoma and T8 fracture. The facility lacked a system to ensure wheelchair safety during public transport.
A resident with multiple medical conditions experienced a fall, and the facility failed to document the incident accurately and timely. The incident note and progress note were completed days after the fall, and medications were inaccurately documented as administered when the resident was not present. The Director of Nursing and Administrator acknowledged the documentation deficiencies.
A resident with pressure ulcers and MRSA was not provided proper infection control measures during wound care. Staff failed to wear appropriate PPE, and wounds were not cleansed according to facility policy, increasing the risk of cross-contamination.
The facility failed to provide scheduled showers to three residents, leading to a deficiency in maintaining their ability to perform activities of daily living. One resident, moderately impaired for cognition, reported not receiving showers for about two weeks, while another, cognitively intact, had only two showers since admission. A third resident, requiring total assistance, also missed scheduled showers. Staff interviews revealed inconsistencies in shower documentation and adherence to the schedule.
The facility failed to ensure that two residents who required thickened liquids had access to fluids at night. Nursing staff ran out of thickener, and since the kitchen was locked, they could not replenish their supply, leaving the residents without necessary fluids.
Failure to Follow Ordered Diet and Communicate Mechanical Soft Option
Penalty
Summary
The facility failed to ensure that a resident received the diet ordered, including failure to implement and communicate an ordered diet alternative. The resident, who had diagnoses including polyneuropathy, major depressive disorder, bipolar disorder, and a recent cerebral infarction, had an order for a general diet with pureed texture and thin liquids, with allowance for mechanical soft texture upon request. The resident stated that she was not aware she could request mechanical soft foods and reported that she had asked staff multiple times for an alternate diet but was still served pureed food. A CNA stated she knew the resident was not eating pureed foods but was not aware of the mechanical soft option, and the Dietary Manager initially stated there were no alternatives before confirming the order included mechanical soft upon request. Meal observations showed the resident was served pureed meals and ate only mashed potatoes, while the resident stated she disliked pureed foods and therefore did not eat most meals. The Dietician confirmed the resident had weight loss and that interventions included supplements and pureed foods the resident would eat, but also confirmed the double portions were not effective because the resident was not eating pureed food. The resident later stated she was happy because she was served real food and ate all of it. Weight records showed an unplanned 15.8 lb, 11.1% weight loss over approximately six weeks, meeting criteria for significant weight loss. The care plan did not include a focus area or interventions related to nutrition or weight loss, and the facility policy stated it would follow physician orders and provide essential care as ordered.
Incorrect Meal Portion Sizes Served
Penalty
Summary
The facility failed to ensure residents received the correct portion size for the noon meal, affecting all 63 residents in the facility. The menu for the noon meal listed turkey tetrazzini, California blend, a dinner roll, cake, and a beverage of choice. During observation, the cook was plating the meal and used a #6 scoop for both regular turkey tetrazzini and pureed turkey tetrazzini. The facility’s meal spreadsheet stated that regular turkey tetrazzini should be served as an 8-ounce portion using an 8-ounce spoodle or two 4-ounce spoodles, while pureed turkey tetrazzini should be served as two #8 scoops. The report states that none of the residents received the correct portion of turkey tetrazzini, and mechanical soft diets were served the same as regular diets. The cook later stated she should have served two scoops of the #6 scoop for both, although that still did not match the documented portion size. The facility’s tray line policy required all meals to be checked for accuracy and proper portion sizes before serving.
Dish Machine and Sink Sanitizer Concentrations Not Maintained
Penalty
Summary
The facility failed to ensure the dish machine was sanitizing at the appropriate concentration. During observation, a dietary aide was washing silverware in the dish machine, and the cook identified it as a low temperature, chlorine dish machine. When the dietary aide tested the machine, the test strip did not change colors. The dietary manager later tested the dish machine again and the strip changed to a light grey color barely at 50 ppm, while she stated it should be at 100 ppm. When she checked it again, the test strip did not change colors and remained white. The facility also failed to ensure the 3-part sink sanitizing solution was at the proper concentration. The dietary manager checked the quat sanitizing solution in the 3-compartment sink and the test strip showed 100 ppm, while she stated it needed more solution and should be at 200 ppm. The facility’s policies required the dishwashing machine to be operated according to manufacturer instructions and the final rinse to be tested at the beginning of each washing session, and the 3-compartment sink sanitizing solution to be checked frequently using a test strip and prepared according to the chemical manufacturer’s guidelines.
Failure to Verify CNA Annual In-Service Training
Penalty
Summary
The facility failed to have a system in place to verify that Certified Nursing Assistants (CNAs) had completed the required 12 hours of annual in-service training. The deficiency applied to all 63 residents in the facility. During record review on 4/1/26, the surveyor requested training files for V8, V9, V14, V15, and V16, all CNAs, but the facility could not provide documentation showing that these CNAs had received the required annual training. A sign posted by the time clock dated 11/19/25 instructed CNAs, including V8 and V9, to complete required training. When interviewed on 4/1/26, V8, V9, and V14 said they had received in-services but were not sure whether they had met the required training hours. The Administrator stated the facility was in the process of implementing a system to track CNA training hours to ensure completion of the required 12 hours of annual training. The facility policy stated CNAs must complete 12 hours of annual in-service training, including dementia management, resident abuse protection, training addressing areas of weakness or potential weakness, and training needed to carry special needs residents, and that there must be a process to track staff participation in trainings.
PRN Psychotropic Medications Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had stop dates for 4 of 5 residents reviewed for psychotropic medication use. R4 had orders for alprazolam 0.5 mg per PEG tube every 8 hours as needed for anxiety and Ativan 0.5 ml 2 mg/ml every 2 hours as needed for anxiety, as well as Ativan 0.5 ml by mouth every 6 hours for agitation and restlessness, and none of these orders had stop dates. R24 had an order for Ativan oral tablet 1 mg, 1 tablet by mouth every 6 hours as needed for restlessness, with no stop date. The DON stated she was responsible for ensuring PRN psychotropic medications had 14-day stop dates and that the physician should be informed if the medication needed to continue longer than 14 days. R9 had active orders for lorazepam 1 mg by mouth every 4 hours as needed for restlessness and olanzapine 10 mg IM every 8 hours as needed for agitation, with no stop dates. R9’s MAR showed lorazepam was administered on multiple days in March, and the EMR did not show documented assessments and new orders every 14 days for psychotropic or antipsychotic medication. R49 had an active order for olanzapine 5 mg IM every 8 hours as needed for anxiety/agitation with no stop date, and the EMR also failed to show documented assessments and new orders every 14 days for psychotropic or antipsychotic medication. The facility’s Psychotropic Drug Usage policy stated that residents receiving psychotropic medications would have gradual dose reductions and behavioral interventions unless contraindicated, and that residents receiving PRN psychotropic medications would be evaluated if the medication was extended longer than 14 days, with the rationale documented in the medical record.
Failure to Maintain Resident Dignity During End-of-Life Care
Penalty
Summary
The facility failed to treat a resident with dignity and respect for 1 of 17 residents reviewed. The resident was on hospice and actively declining toward end of life, and the resident's daughter/POA reported that when the resident wanted to get up, an LPN refused and ignored the request. The daughter said the LPN argued with her, and she believed the resident heard the argument. Another LPN stated she witnessed the daughter and the LPN arguing near the resident's room, with the argument audible in the hallway and at the nurse's station, and said the resident had been wanting to get up lately. The LPN involved said she thought the resident was not supposed to be up per the DON's direction, and the DON stated staff should have honored the resident's and family's requests and ensured they were treated with respect. The facility policy on dignity states staff will always be polite and respectful and will not speak in a manner that could be interpreted as minimally condescending, critical, or argumentative.
Medication Left at Bedside Without Supervision
Penalty
Summary
The facility failed to ensure a resident was supervised during medication administration for 1 of 17 residents reviewed for pharmacy services. On 3/30/26 at 9:33 AM, R20 was observed lying in bed with 2 clear medication cups on the bedside table containing pills, including one cup with a large white pill and another cup with 7 pills: 2 large white pills, 1 pink pill, 1 green pill, 1 blue pill, and 2 small white pills. R20 stated that sometimes staff leave the pills for her to take and sometimes they do not, depending on which nurse is working. On 3/31/26 at 8:51 AM, the ADON stated that medications should not be left at the resident bedside and that nurses should observe the resident take the medication. The facility reported that no residents had orders to self-administer medications, and R20’s MAR showed multiple 8:00 AM oral medications, including Acidophilus, Amlodipine, Levothyroxine, Lisinopril, Omega 3, Toprol XL, Glyburide, Metformin HCL, and Dicyclomine HCL. R20’s Physician Order Summary did not include any order for self-administration, and the facility’s medication administration policy stated that nurses should remain with the resident during medication administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors occurred when the facility failed to give medications as ordered. During a medication pass observation of V3, the Assistant Director of Nursing, two medications for R37 were not administered at 8:33 AM: Allopurinol and Benztropine. V3 stated the medications were not in the cart and had to be reordered from the pharmacy, and also stated these medications were not part of the facility’s on-site medication supply. R37’s Physician Order Summary showed active orders for Allopurinol 100 mg, 2 tablets daily for gout, and Benztropine Mesylate 1 mg twice daily. R37’s Medication Administration Summary showed Allopurinol due at 8:00 AM and Benztropine due at 8:00 AM and 8:00 PM. Surveyors identified 33 opportunities with 2 errors, resulting in a 6.06% medication error rate.
Failure to Carry Out Antipsychotic Medication Order
Penalty
Summary
The facility failed to carry out a physician order as prescribed and failed to increase a resident’s antipsychotic medication, resulting in a significant medication error. The resident had diagnoses of schizoaffective disorder, bipolar type, unspecified dementia, and post-traumatic stress disorder. Her care plan stated that she had a serious and persistent mental illness, required psychotropic medication to manage anxiety, neurosis, and insomnia, and needed staff to carry out the medication regimen as prescribed. The care plan also identified that she required strategies to deal with hallucinations and delusions. A physician progress note documented that the resident reported auditory and visual hallucinations of deceased people that were causing distress, and that these symptoms had occurred recently despite the current medication regimen. The nurse practitioner increased Latuda from 20 mg to 40 mg in the morning and continued 80 mg in the evening to help alleviate her psychotic symptoms. However, the physician order summary and medication administration record showed the resident continued to receive Latuda 20 mg at 8 AM and 80 mg at 8 AM instead of 8 PM as ordered, and the 40 mg dose increase was not carried onto the order summary or MAR. This resulted in the resident missing 48 doses of the medication increase. The DON stated the order was missed and that nurse practitioners were writing orders on paper and giving them to nurses, and the nurse practitioner stated the medication was increased because the resident was having auditory and visual hallucinations despite the current Latuda dose.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure that staff performed proper hand hygiene after removing gloves during wound care for one resident. The resident had diagnoses that included other specified local infections of the skin and subcutaneous tissue and a stage 4 pressure ulcer of the sacral region. The resident’s order summary required wound care every day shift and as needed, along with enhanced barrier precautions because of the wounds. During observation of wound care, the Assistant Director of Nursing and a CNA performed hand hygiene, donned gloves and gowns, and entered the resident’s room. While positioning the resident and preparing wound care supplies, they removed and replaced gloves multiple times, but hand hygiene was not performed after glove removal before donning new gloves. The ADON removed the dressing from the sacrum and coccyx area, which was saturated with yellowish brown drainage, then continued cleansing, dressing application, and barrier cream application with repeated glove changes but no hand hygiene between glove removals and new glove use. After leaving the room, the ADON stated she would usually bring hand sanitizer but had forgotten it on the wound cart outside the room, and stated that hand hygiene is to be performed after each glove removal and before donning new gloves unless hands are visibly soiled.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents in the dining room. One resident, with a history of hemiplegia, hemiparesis, anxiety, and delusional disorder, approached another resident, who had diagnoses including traumatic subdural hemorrhage, drug-induced Parkinson's, and anxiety disorder. Both residents were alert and able to verbalize their needs. During the incident, one resident began yelling, prompting the other to approach and physically strike him multiple times. The second resident retaliated, and the altercation continued until staff intervened. Video surveillance confirmed that the physical altercation involved multiple strikes and that staff were unable to immediately stop the incident. Staff interviews revealed that the nurse on duty was attending to another resident when the altercation began and responded by yelling and attempting to intervene. Additional staff, including human resources and kitchen staff, arrived after hearing the commotion and assisted in separating the residents. Both residents and staff acknowledged that the physical contact constituted abuse. The facility's policy prohibits resident abuse, including physical abuse such as hitting, slapping, and other forms of corporal punishment. Despite these policies, the incident occurred, and staff were not able to prevent or immediately stop the abuse between the residents.
Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and investigate an allegation of sexual abuse involving two residents who reported that another resident made sexually explicit remarks and unwanted advances toward them. Despite the residents expressing fear and distress, and reporting the incidents to multiple staff members, including an activities aide and several certified nurse aides, the allegations were not promptly reported to management or nursing leadership as required by the facility's abuse prevention policy. The staff members who received the initial complaints either deferred responsibility, failed to escalate the concerns, or dismissed the urgency of the situation, resulting in a lack of immediate protective measures for the affected residents. The residents involved had documented histories of trauma and mental health conditions, including anxiety, schizophrenia, major depressive disorder, and post-traumatic stress disorder. Both were assessed as cognitively intact and had no recent behavioral symptoms according to their medical records. The alleged perpetrator also had a history of sexually inappropriate behavior documented in his care plan, yet no immediate action was taken to separate him from the complainants or to initiate an investigation when the allegations were first reported. Instead, the residents were advised to avoid the alleged perpetrator and to report the matter to management at a later time, leaving them unprotected and causing them to withdraw from social activities and remain isolated in their rooms. Multiple staff statements confirmed that the allegations were not investigated in a timely manner, and that management was not notified promptly. Written statements from the certified nurse aides were not followed up with interviews or further inquiry by facility leadership. The administrator and social services director did not initiate an investigation or increase monitoring of the alleged perpetrator until days after the initial report. This failure to respond appropriately to the allegations resulted in the residents continuing to experience fear and distress, and led to a finding of Immediate Jeopardy by surveyors.
Failure to Follow Discharge Planning and Unplanned Discharge Procedures
Penalty
Summary
The facility failed to follow its own policies and procedures for discharge planning and unplanned discharges for multiple residents. For three residents who left the facility unexpectedly, there was no documentation that Adult Protective Services (APS) were notified or that any attempts were made to locate the residents after they left. In one case, a resident left the facility with all her belongings and was later found at a local fast-food restaurant in a disheveled state, but there was no evidence that the facility contacted emergency contacts, APS, or the police, nor did staff attempt to locate her. Similarly, two other residents left the facility, one after refusing to sign an Against Medical Advice (AMA) form, and no further action was taken by the facility to ensure their safety or notify appropriate authorities. Additionally, the facility did not provide adequate discharge planning for three residents who expressed a desire to return to the community or move to a less structured environment. Care plans and progress notes indicated that these residents were cognitively intact and had self-sufficiency skills, yet there was no evidence of active discharge planning or social service involvement to assist them in transitioning out of the facility. In interviews, these residents reported that although they had communicated their wishes to leave, they were not receiving help from the facility to facilitate their discharge. The Social Service Director and other staff confirmed that discharge planning was not initiated unless specifically requested by the resident, and that no active discharge plans were in place for the residents who had expressed a desire to leave. The facility's own policies require the involvement of social work staff in assessing discharge potential and coordinating community services, but documentation and staff interviews revealed that these procedures were not followed. The lack of action and documentation regarding both planned and unplanned discharges resulted in a failure to ensure safe and appropriate transitions for the affected residents.
Failure to Maintain Bed in Low Position and Use Floor Mat Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was in the low position and that a floor mat was in place as required by the resident's care plan. The resident, who was dependent for care and required a mechanical lift for transfers, was found on the floor next to the bed with a laceration above the right eyebrow after attempting to reach for a drink. The bed was observed to be in a high position and the floor mat was missing at the time of the incident. Staff interviews confirmed that the resident was left in bed with the mechanical lift sling under him, and the required safety interventions were not in place. The resident's medical history included significant risk factors such as a history of CVA with right hemiplegia, COPD, atrial fibrillation, CHF, epilepsy, and other chronic conditions. The care plan specifically directed staff to keep the bed in the lowest position and to apply floor mats to the side of the bed. Despite these interventions being documented, they were not implemented, resulting in the resident sustaining an injury that required sutures and evaluation at the emergency room.
Failure to Immediately Report Alleged Resident Abuse to Abuse Coordinator
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the facility abuse coordinator as required by policy. The incident involved a resident who experienced a significant episode of loose stools, resulting in soiling of her clothes, the toilet, floors, and walls. During the cleanup, the resident reported that one CNA made a derogatory comment about the situation and told her to clean it up herself, while two other CNAs laughed at her. The resident felt embarrassed and upset by the staff's behavior and subsequently called her daughter to report the incident. The daughter then contacted the LPN on duty, who stated she reported the concern to the DON. However, the DON could not recall if the LPN had called her and mentioned that the resident's daughter may have texted her about the incident. The Social Services Director documented the daughter's concern but did not report the potential abuse to the facility abuse coordinator. As a result, the required immediate reporting of the abuse allegation to the administrator did not occur, contrary to facility policy.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who experienced an episode of incontinence resulting in a significant mess. The resident reported feeling embarrassed and stated that a CNA made a derogatory comment about cleaning up the mess and told the resident to clean it up herself, while two other CNAs laughed at her. The resident did not initially report the incident to nursing staff but called her daughter, who then contacted the LPN on duty. The LPN reported the allegation to the DON, but the Administrator was not made aware of the incident and no investigation was initiated, as required by facility policy. The lack of investigation into the reported abuse constituted a failure to respond appropriately to an alleged violation.
Failure to Notify POA After Resident Fall
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) following a fall incident, which was a requirement according to their guidelines. The resident, who had multiple diagnoses including Hemiplegia, Morbid Obesity, and End Stage Renal Disease, fell out of his wheelchair while being lifted into a public transportation van. Although the resident reported hitting his head, he refused to go to the Emergency Department and proceeded to his dialysis treatment. The dialysis center's nurse noted the fall and contacted the nursing home for more information, discovering that the facility had not informed the POA about the incident. The facility's guidelines required immediate notification of the resident's physician and POA in the event of an accident or significant change in condition. Despite this, the facility did not notify the POA until after the dialysis center's nurse had already done so. Additionally, the facility failed to inform the dialysis center about the fall before the resident's treatment. The resident was later discharged from the facility without documentation of the discharge details or notification to the POA or physician. The resident was admitted to the hospital with septic shock and passed away after being transitioned to hospice care.
Failure to Assess and Intervene After Resident Fall
Penalty
Summary
The facility failed to ensure proper assessment and intervention following a fall incident involving a resident. The resident, who had multiple medical conditions including hemiplegia, morbid obesity, and end-stage renal disease, fell out of a wheelchair while being lifted into a public transportation van. Despite the resident stating they hit their head, no immediate neurological checks or vital sign monitoring were conducted, and the resident was transported to an off-site dialysis unit without notifying the dialysis staff of the fall. The facility's policy required neurological checks for unwitnessed falls, but these were not performed until several hours after the incident, just before the resident was transferred to the hospital for severe pain. The hospital diagnosed the resident with a subdural hematoma and a T8 fracture, indicating significant injuries from the fall. The facility's failure to conduct timely assessments and notify relevant parties contributed to the delay in addressing the resident's injuries. Additionally, the facility did not have a system in place to ensure the safety of residents using public transportation, as evidenced by the lack of intervention to secure wheelchair brakes during transport. The Director of Nursing acknowledged that no intervention was in place to ensure wheelchair brakes were applied for residents using public transportation, and the facility did not communicate with the dialysis staff regarding the resident's fall or the need for safety checks during transport.
Inaccurate and Delayed Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure accurate and timely documentation for a resident who experienced a fall. The resident, who had multiple medical conditions including hemiplegia, morbid obesity, and end-stage renal disease, fell and hit their head. Despite the facility's policy requiring immediate and thorough documentation of such incidents, the incident note was completed more than two days after the fall and the resident's discharge to the hospital. Additionally, the progress note indicating the resident's refusal to be transferred to the hospital was completed three days after the fall. The resident's medical record inaccurately documented the administration of medications and treatments on a day when the resident was not present in the facility, as they had been discharged to the hospital. Furthermore, the facility's report indicated that the resident was monitored post-return from dialysis, but the medical record lacked documentation of the time the resident returned or any ongoing monitoring. The resident was later sent to the emergency department with a thoracic spine fracture and subdural hematoma, yet the medical record did not include details of the resident's condition or assessments related to the transfer. The Director of Nursing acknowledged the lack of documentation for post-fall assessments, the resident's return from the emergency department, and the reason for the emergency department visit. The Licensed Practical Nurse admitted to accidentally charting on the resident's medication administration record, and the Administrator confirmed that the documentation was inaccurate and incomplete, emphasizing the expectation for staff to complete documentation by the end of their shift.
Inadequate Infection Control and Wound Care Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during the care of a resident with pressure ulcers and MRSA in the sputum. The resident, who had diagnoses including metabolic encephalopathy, Down syndrome, and early onset Alzheimer's disease, was observed in a room with a sign indicating droplet precautions. However, the staff did not adhere to the required PPE protocols. The Wound Care Nurse did not wear a mask or eye protection, and the LPN wore a surgical mask but no eye protection while performing a dressing change on the resident's wounds. Additionally, the wounds were not cleansed properly, as the same gauze pad was used on multiple wounds, and the cleansing technique did not follow the recommended inward to outward method. The Director of Nurses confirmed that the resident was still on droplet precautions due to MRSA and required full PPE, including gowns, gloves, N95 masks, and face shields, which was not followed. The sign outside the resident's room was incorrect and did not reflect the necessary precautions. The facility's policies on wound cleansing and infection control were not adhered to, as the wounds were not cleansed individually with fresh pads, and the risk of cross-contamination was not mitigated. The failure to follow these protocols posed a high risk for cross-contamination between residents.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to three residents, R1, R2, and R3, as per their scheduled shower days, which is a deficiency in maintaining the residents' ability to perform activities of daily living. R1, who is moderately impaired for cognition, reported not receiving showers as scheduled, with no documentation of showers from 9/1 to 9/6, 9/8 to 9/13, and 9/15 to 9/21. R1 expressed the need for assistance with showers and stated she had not received a shower for about two weeks. R2, who is cognitively intact, also had no showers documented from 8/27 to 9/18 and 9/21 to 9/24, and reported only having two showers since admission in August. R2 requires setup support for bathing and expressed a need for a shower before an upcoming doctor appointment. R3, who is cognitively intact and requires total assistance for bathing, had no showers documented from 9/8 to 9/14. R3 had previously filed a grievance in June regarding not receiving showers, which was unresolved. Observations and interviews with staff revealed inconsistencies in shower documentation and a lack of adherence to the shower schedule. CNAs and the LPN confirmed that residents are supposed to receive showers twice a week, but documentation was lacking, and there was no evidence of residents refusing showers. The facility's administrator acknowledged the issue with documentation and noted that R1, R2, and R3 were not receiving showers regularly.
Failure to Provide Thickened Liquids at Night
Penalty
Summary
The facility failed to ensure that residents who required thickened liquids had access to fluids at night. Specifically, two residents, R1 and R2, who had physician orders for honey thick and nectar thick liquids respectively, were unable to receive fluids during the night due to a lack of thickener. On the night of 5/1/24, the nursing staff ran out of thickener, and since the kitchen, where the thickener is stored, was locked, they could not replenish their supply. This resulted in R1 and R2 not having access to the necessary thickened liquids throughout the night. Observations and interviews confirmed that both residents were without drinks during the night. R1 was found awake in bed with an empty cup on the overbed table, and R2 was also lying in bed without any drinks available. The nursing staff, including an agency RN and another RN, confirmed they did not have access to thickener and had run out at the beginning of their shifts. The cook confirmed that the kitchen provides the thickener and that nursing staff do not have access to the kitchen at night. The Director of Nursing acknowledged that residents should be offered fresh drinks throughout the shift and that the facility needed to ensure nursing staff had access to thickener for those who require it.
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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