Pearl Of Hillside,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillside, Illinois.
- Location
- 4600 North Frontage Road, Hillside, Illinois 60162
- CMS Provider Number
- 145946
- Inspections on file
- 42
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pearl Of Hillside,the during CMS and state inspections, most recent first.
Two residents did not receive catheter care according to standard practice and MD orders. A resident with severe cognitive impairment and a urinary catheter had stool on the catheter, and a CNA was observed wiping the catheter toward the urethra instead of from the insertion site outward; the spouse reported repeated infections and hospitalizations for UTI and sepsis. Another resident with a suprapubic catheter had a dirty insertion site with dry blood extending several inches around it, despite MD orders to cleanse the site daily and PRN with soap and water.
A resident with mild cognitive impairment and malignant neoplasm of the mouth missed multiple outside oncology and infusion appointments because staff did not arrange transportation in accordance with the facility’s appointments and transportation policy. Records showed that the resident was transported only to a cardiology visit while scheduled oncology and infusion appointments on the same day, as well as a separate oncology appointment, were not attended. An oncology clinic NP reported that the resident missed several appointments with various providers and that the resident attributed these missed visits to lack of transportation, poor communication, and failure to document appointments for staff follow-up, while the DON acknowledged that staff are responsible for setting up such appointments.
A cognitively intact, Spanish-speaking resident with a history of spinal fracture, hepatic encephalopathy, and prior falls, who was non-ambulatory and required substantial/maximal assistance and a transfer device with two staff for transfers, was assessed as low fall risk and later developed severe left-sided pain and immobility. Staff reported the resident complained of left arm and leg pain after lying on his left side, EMS documented pain beginning the prior night with denial of falls, and the resident was sent to the ER to rule out stroke, where imaging revealed multiple acute and chronic fractures, intracranial and intra-abdominal hemorrhages, and bruising estimated to be several days old. Hospital documentation noted the resident at one point accepted that someone hurt him but was reluctant to provide details, while a facility liaison later recorded the resident’s account that he attempted to get out of bed, fell toward the window, and was helped back to bed by staff; in a later interview with an interpreter, the resident said he did not remember falling. Numerous CNAs, LPNs, and RNs denied witnessing a fall or knowing what happened, no fall incident report was available, and staff consistently described the resident as unable to get out of bed or walk independently, while the physician stated the injuries were consistent with a fall and that the resident should never have been rated low fall risk.
A resident with Mild Alzheimer's and on Eliquis sustained a depressed orbital floor fracture and orbital globe rupture after an incident involving a CNA and a broken necklace. The first clinician on the scene documented the resident’s immediate allegation that the CNA hit him, observed the CNA’s agitation and anger, and reported these findings, including that a staff member had called 911 to report an assault. The facility’s investigation omitted these critical observations from the report to law enforcement, concluded the injury was accidental and self-inflicted, did not clinically evaluate whether the necklace or a self-blow could cause such trauma, and did not consider the resident’s cognitive impairment or have a neutral advocate present when the resident allegedly recanted. As a result, an incomplete and medically implausible account of the incident was provided to law enforcement.
Two residents experienced issues with gnats in their rooms, including gnats around full trash cans and food items, while gnats and a mosquito were also observed in the kitchen dishwashing area. The maintenance director linked the pest issue to unemptied trash, and a pest control inspection confirmed fruit flies in the kitchen, with recommendations for floor maintenance.
A resident with hemiplegia and moderate cognitive impairment, who was dependent on staff for toileting and always incontinent, was not provided incontinence care for over four hours. The resident was found with a saturated brief, wet bed pad, and dried urine stain on the sheet, despite staff and care plan requirements for care every two hours.
A resident with a history of falls, cognitive deficits, and unsteady gait did not have a specific fall care plan or adequate supervision upon admission. The resident, who had limited English proficiency, was found urinating on the floor and subsequently slipped in the urine, resulting in a head injury and hospitalization for intracranial bleeding. Staff interviews revealed that the resident's needs for supervision and toileting assistance were not adequately addressed, and the assigned CNA was attending to another resident at the time.
A resident with significant medical needs reported a leaking bathroom sink that had gone unrepaired for two weeks, with staff placing a bucket under the sink to collect water. Despite the facility's work order system, the maintenance issue was not reported or addressed until the survey, resulting in an unsanitary and non-functional environment for the resident.
The facility failed to provide annual dental exams and routine monitoring for dental care needs for several residents, as required under the State health plan. Five residents did not have documented dental visits or evidence of declining services, despite being covered by Medicaid or a combination of Medicare and Medicaid. Staff provided inconsistent information about dental visit frequency and insurance impact, and there was no documentation to support claims of service provision.
A resident with severe cognitive impairment and neuromuscular dysfunction of the bladder developed a catheter-associated UTI due to inadequate care at the facility. The resident's urinary catheter was found with maggots, indicating poor hygiene. Staff reported challenges in cleaning the catheter and a lack of documentation on catheter care and output. The resident was hospitalized with proteus bacteremia and a complicated UTI.
A resident with severe cognitive impairment and high fall risk fell during a smoke break due to inadequate supervision. The nurse monitoring the resident stood over seven feet away, and when the resident dropped a cigarette, he attempted to pick it up and fell from his wheelchair, sustaining a nasal fracture and laceration. The resident had been given a reacher for safety but forgot to use it.
Failure to Follow Standard and Ordered Catheter Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow standard practice and physician orders for urinary catheter care for two residents. One resident with severe cognitive impairment had a urinary catheter with stool present on it. A CNA was observed providing catheter care by wiping the catheter toward the urethra and then away from it, rather than from the insertion site outward as described by the DON as standard practice. The resident’s spouse reported that the resident had been sent to the hospital for a severe infection and alleged that staff were not changing gloves between care, which was causing infection. Health status notes documented multiple hospital admissions for this resident for UTI and sepsis on several prior dates. Another resident with intact cognition and a suprapubic catheter was observed in bed with the suprapubic catheter insertion site dirty and surrounded by dry blood extending almost four inches around the site. The physician’s orders for this resident directed staff to cleanse the suprapubic catheter insertion site daily and as needed with soap and water unless otherwise ordered. At the time of observation, the suprapubic catheter site was not clean as ordered, and the DON stated that the suprapubic catheter should have been kept clean to prevent potential infection.
Failure to Arrange Transportation for Oncology and Infusion Appointments
Penalty
Summary
The deficiency involves the facility’s failure to follow its appointments and transportation policy by not arranging transportation for a resident’s outside oncology and infusion appointments. The resident is an adult male with mild cognitive impairment and an admitting diagnosis that includes malignant neoplasm of the mouth, as documented on the MDS. On one observation, he was noted in bed with swollen lips and was unable to communicate effectively. The facility’s policy, reviewed on 4/16/2025, states that when a resident has an appointment outside the facility, staff will make transportation arrangements unless the responsible party chooses to make them. The DON acknowledged not remembering why the resident missed appointments and stated that the resident has the right to go for an appointment and that staff are supposed to set it up. Record review showed that the resident had multiple scheduled outside appointments, including cardiology, oncology, and infusion visits. Physician orders documented that on 2/4/26 he was scheduled for a cardiology appointment at 9:05 AM, an oncology appointment at 12:00 PM, and an infusion appointment at 2:00 PM. The transportation schedule and nursing progress notes from 2/1/26 through 2/6/26 showed that he was sent only to the cardiology appointment and not to the oncology or infusion appointments. A review of the January transportation schedule and nursing progress notes from 1/25/26 through 1/30/26 further documented that he was not sent to an oncology appointment scheduled for 1/27/26 at 11:40 AM. The oncology clinic nurse practitioner reported that the resident missed around five appointments with various care providers, and that the resident stated he missed appointments due to lack of transportation, communication, and not writing the appointments in the records for staff to follow up after setting transportation. The nurse practitioner stated the resident is at high risk for relapse if he misses his oncology appointments.
Failure to Prevent and Adequately Account for Resident’s Multiple Traumatic Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to protect and prevent a cognitively intact resident from sustaining injuries of unknown origin, including multiple fractures and intracranial and intra-abdominal hemorrhages. The resident was admitted with significant medical history including an unstable burst fracture of T11–T12, hepatic encephalopathy, cirrhosis, pancytopenia, and a history of falls and alcohol dependence. The resident’s primary language was Spanish, and the most recent MDS documented a BIMS score of 15, indicating intact cognition, with use of a wheelchair for ambulation and a need for supervision or touching assistance for transfers. Therapy records and staff interviews consistently indicated that the resident could not walk independently, could not transfer independently, and required substantial/maximal assistance and a transfer device with two staff for transfers. Despite this, the resident’s fall risk assessments categorized him as low risk for falls, and the physician later stated that the resident should never have been rated low risk and that he was high risk for falls. On the day of the incident, the resident complained of left shoulder and left leg pain with limited mobility and inability to move the affected extremities. A CNA who spoke Spanish reported that the resident stated he had slept on his left side for a long time and requested help to turn; she assisted by pulling the incontinent pad to reposition him and notified the RN. Another CNA assigned to the resident that morning observed him in pain, with a swollen left arm, and heard him indicate pain in the left arm, again with the explanation that he had been lying on his left side. The RN assessed the resident, noted extreme pain and numbness in the left upper extremity and limited mobility in the left arm and leg, and obtained orders from the NP to send the resident to the ER to rule out stroke. The EMS run sheet documented that the resident complained of left shoulder and hip pain that began the previous night and denied any falls or trauma. The facility’s initial incident report recorded that the resident denied anyone hurting him and stated he felt safe at the facility. At the hospital, diagnostic imaging revealed multiple acute and chronic fractures, including an acute comminuted and displaced left humeral head fracture, bilateral subcapital femoral neck fractures, sacral fractures, a right L4 transverse process fracture, a small left subdural hematoma, a right parietal subarachnoid hemorrhage, intra-abdominal hemorrhage, and bruising to the anterior chest wall and left shoulder estimated to be 3–4 days old. The ER RN, who spoke Spanish, reported that the resident initially said he did not remember what happened, and hospital documentation noted that at one point he accepted that somebody hurt him but was reluctant to provide details due to fear of police involvement or other social reasons. A facility liaison later interviewed the resident in the hospital; the resident stated he had been doing exercises in bed, felt stronger than normal, attempted to get out of bed, fell toward the window side, and was assisted back to bed by staff, but he reported no pain at that time and said he did not want anyone to get in trouble. During a subsequent in-facility interview with an interpreter, the resident stated he did not know what happened, did not remember falling, and only recalled waking up in pain and being sent to the hospital. Throughout the facility’s internal investigation, multiple CNAs, LPNs, and RNs who worked with or around the time of the incident denied witnessing any fall or knowing what happened to the resident, and no fall incident report could be produced. Staff interviews consistently described the resident as unable to get out of bed, unable to sit on the edge of the bed or scoot, and requiring two-person assistance with a transfer device for any out-of-bed activity. The physician and NP both stated that the resident had not been able to walk since admission and could not independently get up from bed or dangle his feet to exercise. The physician opined that the resident’s injuries were consistent with a fall and that he was a high fall risk. The administrator and DON maintained that the resident did not fall based on staff interviews, and one CNA who worked the night before the resident’s complaints denied picking the resident up from the floor. However, when shown pictures of night CNAs, the resident identified that CNA as the person who picked him up from the floor. The facility’s abuse prevention policy defined injury of unknown source as an injury not observed and not explainable by the resident, with suspicious extent or location, and the facility concluded that none of the staff knew what happened or the cause of the resident’s injuries.
Failure to Conduct Thorough and Credible Abuse Investigation After Severe Eye Injury
Penalty
Summary
The facility failed to conduct a thorough and credible abuse investigation for one resident who sustained a depressed orbital floor fracture and left orbital globe rupture requiring emergent surgical intervention. The resident, who had Mild Alzheimer's and was taking Eliquis (Apixaban), initially alleged that a CNA hit him, an allegation documented by the first clinician on the scene, an agency RN. This RN also observed the CNA in an agitated and angry state over a broken necklace and reported these observations, including the resident’s statement that the CNA hit him and that a staff member had reported the incident as an assault via a 911 call, to the Administrator and management. However, these critical observations and the documented allegation of assault were omitted from the facility’s formal report to law enforcement. The facility concluded that the injury was accidental, suggesting the resident struck his own eye, and did not consider or document the possibility that the necklace chain or pendant could have been the blunt object causing the injury. There was no evidence that the facility consulted a medical professional to assess whether a swinging pendant or a self-inflicted blow by an elderly resident with Mild Alzheimer's could generate sufficient force to cause the documented orbital fracture and globe rupture, or to reconcile how a minor accident could result in severe hemorrhaging requiring emergent surgery in a resident on Eliquis. Additionally, the Administrator reported to police that the resident recanted the allegation, but facility records did not show that the resident’s cognitive impairment or potential suggestibility after traumatic injury were considered, nor that a neutral advocate or social worker was present during the recantation. These omissions and failures in the investigative process resulted in an incomplete and medically implausible narrative being provided to law enforcement and demonstrated that the facility lacked a thorough implementation of an abuse investigation system required by Federal regulations.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest management program, resulting in the presence of gnats in resident rooms and the kitchen area. In one resident's room, multiple gnats were observed flying around two trash cans near the entryway, with more than ten gnats crawling on the outside of a white trash can. The trash can was noted to be full, and the maintenance director attributed the presence of gnats to the trash not being emptied by CNAs. The same resident was also observed with gnats on his bed sheet and around a partially open bag of restaurant food on his bedside table, with several gnats crawling on and inside the food bag and on the wall nearby. Another resident reported having a problem with gnats, and three gnats were observed flying around her bed and bedside table. During a tour of the kitchen, three to four gnats and a large mosquito were observed flying near the handwashing sink in the dishwashing area. The dietary manager confirmed the presence of gnats and a mosquito in this area. A pest control service inspection report documented the presence of fruit flies in the main kitchen area and noted that the kitchen floor needed to be regrouped to prevent fruit flies from breeding. The facility's pest control policy emphasized the importance of maintaining a healthy environment and specifically mentioned the need to keep trash cans lined and emptied regularly.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and hemiparesis, who was documented as always incontinent and dependent on staff for toileting, was not provided incontinence care at least every two hours as required by their care plan. On observation, the resident was found with a saturated adult brief, a wet bed pad, and a dried urine stain on the fitted sheet, indicating that incontinence care had not been provided for over four hours. The resident reported last being changed in the early morning, and the assigned CNA confirmed the last care was provided at 9:00am, despite facility policy and staff statements that care should be provided every two hours and as needed. Documentation and staff interviews confirmed the resident's need for frequent incontinence care due to heavy urinary incontinence.
Failure to Implement Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to develop and implement an adequate care plan with increased monitoring and supervision for a resident who was identified as having poor safety awareness, a history of falls, unsteady gait, and cognitive deficits. Despite being newly admitted with diagnoses including abnormal gait, lack of coordination, hypotension, and aphasia, the resident did not have a fall care plan in place upon admission. Staff relied on a general fall focus system rather than a resident-specific plan, and the resident's needs for supervision and toileting assistance were not sufficiently anticipated or addressed. As a result, the resident was found urinating on the floor and subsequently slipped in his own urine, leading to a fall that caused a bump to the head and a change in consciousness. The resident, who only spoke Mandarin and had limited ability to communicate, was found lethargic and drowsy after the incident and was later diagnosed with intracranial bleeding and admitted to the hospital. Staff interviews confirmed that the resident was unsupervised at the time of the incident, and that the CNA assigned to the unit was attending to another resident. The lack of a tailored fall prevention plan and insufficient supervision directly contributed to the accident.
Failure to Maintain Functional and Sanitary Resident Environment Due to Unaddressed Sink Leak
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including diabetes, congestive heart failure, atrial fibrillation, hypertension, acute kidney disease, osteomyelitis, and bilateral leg amputations, reported that their bathroom sink had been leaking for two weeks. The resident, who was cognitively intact and required partial/moderate assistance for mobility, stated that staff had placed a gray bucket under the sink to catch the leaking water but had not arranged for repairs despite being notified. Upon observation, the surveyor found the bucket half full of dirty water and witnessed water dripping into it when the faucet was used. Interviews with facility staff revealed that the Maintenance Director was only made aware of the issue on the day of the survey and began repairs immediately. The Administrator and Director of Nursing both stated they were not previously informed of the leak, despite the facility having a policy and system in place for submitting maintenance work orders, including QR codes for easy reporting. The failure to report and address the leaking sink resulted in the resident's environment not being maintained in a functional and sanitary condition.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that residents received annual dental exams and routine monitoring for dental care needs, as required under the State health plan. This deficiency was identified for five out of seven residents reviewed for dental services. Specifically, one resident had not received a dental visit within the past year, and there was no documentation indicating that the resident declined services. Four other residents had no documented dental visits or evidence of declining services since their admission to the facility. All these residents were covered by Medicaid or a combination of Medicare and Medicaid. During the survey, facility staff provided inconsistent information regarding the frequency of dental visits and the impact of insurance on service provision. The Assistant Director of Nursing was unsure about the frequency of dental visits, while the Social Worker mentioned that an in-house dentist visits twice a month and that transportation is arranged for residents using outside dentists. However, there was no documentation to support these claims for the residents in question. The facility's policy states that it will provide routine and emergency dental services and assist residents with appointments and transportation, but the lack of documentation and follow-through indicates a failure to adhere to this policy.
Inadequate Catheter Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to prevent a resident from developing a catheter-associated urinary tract infection (UTI), which necessitated hospitalization. The resident, a male with severe cognitive impairment and neuromuscular dysfunction of the bladder, was dependent on staff for toileting and hygiene. Observations and interviews revealed that the resident's urinary catheter care was inadequate, with reports of dark, cloudy urine and a lack of proper documentation of catheter care and output. The resident was found to be lethargic and unresponsive, leading to his transfer to the hospital. Upon examination at the hospital, the resident was diagnosed with proteus bacteremia and a complicated UTI, with maggots found in the urinary catheter. This indicated poor hygiene and improper catheter care at the facility. The facility's staff, including a CNA and an LPN, reported challenges in cleaning the catheter due to the resident's contracted lower extremities and noted a lack of urine output documentation. The facility's policy required daily catheter care, but there was no documentation of such care being performed. The facility's failure to document and perform adequate catheter care led to the resident's severe infection and subsequent hospitalization. The lack of documentation and communication among staff members contributed to the oversight in the resident's care. The facility's policy on indwelling catheter care was not adhered to, resulting in the resident's deteriorating condition and the presence of maggots in the catheter, which is a sign of neglect and poor hygiene practices.
Inadequate Supervision During Smoke Break Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise and monitor a resident during a smoke break, resulting in an accident. The resident, who has schizophrenia, dementia with behavioral disturbances, and severe cognitive impairment, was identified as high risk for falls. During a smoke break, the resident dropped a cigarette and attempted to pick it up, leading to a face-forward fall from his wheelchair. The fall resulted in an open fracture of the nasal bone and a nasal laceration requiring sutures. The incident occurred when a nurse, who was not a smoker, took the resident to the smoking area. The nurse stood inside the entrance/exit smoking patio door, monitoring the resident from a distance of seven feet and seven inches. When the resident bent down to pick up the cigarette, the nurse attempted to intervene but was unable to prevent the fall. The resident's jacket slipped off as the nurse tried to grab it, and the resident fell onto the concrete patio. The resident had previously been given a reacher to assist with picking up items from the floor due to poor safety awareness and impulsiveness. Despite this, the resident forgot to use the reacher during the incident. The facility's fall prevention and management policy emphasizes the need for individualized interventions for high-risk residents, but the supervision provided during the smoke break was insufficient to prevent the fall.
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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