Prairie Village Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Illinois.
- Location
- 1024 West Walnut, Jacksonville, Illinois 62650
- CMS Provider Number
- 145294
- Inspections on file
- 17
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Prairie Village Healthcare Ctr during CMS and state inspections, most recent first.
A resident with dementia and a history of prostate cancer experienced a delay of several days in obtaining an ordered urine culture, during which time his condition worsened. The Administrator inserted a Foley catheter instead of the ordered straight catheter to obtain a specimen, left it in place when no urine was obtained, and the resident was later found in the hospital to have a mispositioned Foley with a partially inflated balloon in the urethra causing obstruction, hematuria, infection, urosepsis, and septic shock, ultimately resulting in death from sepsis and UTI. Surveyors also observed multiple CNAs and a nurse providing catheter and peri‑care to several residents without following EBP/PPE requirements, using improper glove and hand hygiene practices, failing to rinse and dry after cleansing, omitting ordered barrier creams and catheter securement devices, and not performing complete incontinence care to the peri‑area, buttocks, and inner thighs, contrary to facility policies for catheterization, catheter care, perineal care, and suprapubic catheter care.
Staff failed to follow infection control requirements for multiple residents on Contact Isolation or Enhanced Barrier Precautions (EBP). In several cases, an LPN and CNAs entered rooms clearly marked with isolation or EBP signage and available PPE to perform wound care, g-tube care, toileting, peri-care, and catheter care while wearing only gloves and no gowns or other required PPE. One LPN reconnected a g-tube and handled the device without full PPE and left the room without performing hand hygiene. A CNA provided peri-care and catheter care using a single pair of soiled gloves for both dirty and clean tasks and for handling linens, without changing gloves or performing hand hygiene. Staff interviews revealed inconsistent understanding of EBP, despite facility policies requiring gown and glove use for high-contact care, proper glove changes, and hand hygiene before and after resident contact and PPE use.
A resident with severe cognitive impairment, incontinence, and existing pressure injuries did not consistently receive ordered pressure ulcer treatments, and staff failed to follow updated wound care orders and infection control practices. Physician orders for a hydrocolloid dressing to the buttock were not documented as completed according to the prescribed schedule, and after hospitalization, new orders for Triad paste and moisture barrier were in place. During observed wound care, an LPN and a CNA entered a contact isolation room without appropriate PPE, removed an undated hydrocolloid dressing that was no longer ordered, minimally cleansed the wound, applied Triad paste, and left the resident without a dressing or brief, while the LPN later acknowledged that the hydrocolloid dressing should not have been used. The DON and IP stated that nurses are expected to discontinue outdated orders and follow current TAR entries for wound care.
A resident with COPD, chronic respiratory failure with hypoxia, dependence on supplemental O2, and obstructive sleep apnea had physician orders for CPAP/BiPAP at nap time and night to maintain SpO2 > 92%, and for 3 L O2 via NC if CPAP was refused or unavailable. Progress notes show the resident complained of SOB at bedtime, required a nebulizer treatment, and was placed on continuous O2 via NC after staff noted the CPAP mask was broken and needed replacement. The following day, documentation again noted the broken mask and indicated a new mask would arrive the next day, while the resident remained on O2 via NC. The DON stated that broken masks are reported to the medical supply provider and that a physician should be notified if a resident with respiratory failure has SOB and no mask available, and the supplier confirmed a replacement mask was sent the day after the problem was documented.
Two residents did not receive medications as ordered, including an antibiotic for a UTI and an anticonvulsant. One resident with a suprapubic catheter and UTI returned from the hospital with an order for Cefdinir every 12 hours but received only one dose over several days, despite the drug being available in the dispensing machine and the order remaining active. The same resident also received an incorrect dose of folic acid when stock 400 mcg was given instead of the ordered 1 mg. Another resident with CKD on dialysis and a seizure history had Levetiracetam ordered on specific days but missed a scheduled dose when an LPN stated the facility was out of the medication, even though Keppra was available in the dispensing machine. These events occurred despite a facility policy requiring administration of medications as prescribed, use of backup supplies, and adherence to the five rights of medication administration.
A resident with an open lesion on the right foot was found by a podiatrist to have insects between the toes, but the nurse who cleaned the area did not document the presence or removal of insects in the medical record. Other staff were unaware or did not observe insects, and the facility's documentation policy requiring all changes in condition to be recorded was not followed, resulting in an incomplete record.
A resident's medical record was incomplete due to missing documentation from a podiatrist's assessment. The LPN confirmed the podiatrist had seen the resident, but no progress notes were found in the EMR. The administrator stated that the podiatrist does not provide his notes to the facility, while the podiatrist believed his office was sending them as required by facility policy.
Two residents with complex medical conditions did not receive pulse oximetry monitoring as ordered by their physicians. Documentation review showed that required twice-daily oxygen saturation checks were frequently missed or not recorded, and the process for recording and entering these results into the EMR was inconsistent. Staff interviews confirmed that CNAs collected the data and handed it to a nurse for EMR entry, but this did not ensure compliance with orders or facility policy.
A resident with significant risk factors for pressure ulcers, including diabetes, end stage renal disease, and impaired mobility, developed a new stage 2 pressure ulcer in the upper intergluteal cleft that was not identified or documented by staff until found during a skin check with LPNs and a surveyor. Despite care plan interventions and facility policy requiring regular skin assessments and prompt reporting, the wound was not noted in prior documentation.
A resident with diabetes, renal dialysis dependence, and polyneuropathy developed a left heel pressure ulcer that was not promptly identified or treated according to physician orders. The wound was discovered by nursing staff, and documentation showed missed dressing changes and inconsistent risk assessment, despite the resident's impaired mobility and history of pressure ulcers.
The facility did not have a full-time DON for several weeks and failed to provide RN coverage for at least 8 hours a day on multiple days, contrary to its own staffing policy and regulatory requirements. This affected all 46 residents in the facility.
Surveyors found that expired insulin pens, vials, and a multi-use tuberculin vial were not properly dated or disposed of as required. An LPN and an RN confirmed that opened medications were not consistently labeled with open dates, and expired medications remained in use, affecting all residents in the facility.
Surveyors found that bulk food items such as breadcrumbs, flour, sugar, and oats were stored in open bags inside plastic bins without lids, covered only by trash bags. The Dietary Manager confirmed that this method could allow pests to access the food, which is not in accordance with facility policy requiring tight-fitting lids for food storage.
Staff failed to provide adequate privacy and dignity during care, including feeding and wound care, for multiple residents with cognitive impairments and complex medical needs. CNAs assisted residents with meals while standing over them, and LPNs performed personal care and treatments without closing window blinds or privacy curtains, exposing residents to potential view from outside or from roommates. Staff interviews confirmed that proper privacy protocols were not consistently followed.
Nursing staff failed to consistently follow infection control protocols, including proper use of PPE, hand hygiene, and disinfection of reusable medical equipment during wound care and medication administration for several residents on enhanced barrier precautions. Staff entered rooms without required gowns, did not always perform hand hygiene before donning gloves or between glove changes, and placed supplies on unclean surfaces without barriers, contrary to facility policy.
The facility failed to provide 8 consecutive hours of RN coverage, affecting all 48 residents. The schedule did not document an RN working for 8 consecutive hours on multiple dates. The previous DON ended her employment, and the Interim DON quit, resulting in the loss of RN coverage.
An LPN failed to properly disinfect a multi-use blood glucose machine, affecting seven residents. The machine was not fully wiped down as per the instructions on the Microdot Bleach Wipe container, which required a 30-second contact time to kill bacteria and viruses.
The facility failed to follow physician-ordered treatment for a resident's pressure sore on the left heel. An LPN observed that the dressing used was not as per the physician's orders, which required specific moisturizers and dressings. The resident's care plan and facility policy were not adhered to in this instance.
Improper Catheter Management and Incomplete Incontinence Care Leading to UTI and Sepsis
Penalty
Summary
The deficiency involves failures in timely urine specimen collection, proper catheter insertion, and adherence to infection control and perineal care practices for multiple residents. One resident with metabolic encephalopathy, dementia, and a history of prostate cancer post‑prostatectomy had an MDS indicating dependence on staff for toileting hygiene and documentation that he was always continent of urine, yet his care plan listed bladder incontinence and interventions to report signs of UTI. Progress notes documented agitation and aggression and an order for urine culture and sensitivity, but facility staff did not obtain a urine sample for four days. During this period, the resident experienced decreased level of consciousness and urine output, nausea, and vomiting, and was ultimately transferred to a hospital where ED labs showed cloudy urine with mucus, bacteria, and elevated red blood cells, and imaging identified a decompressed bladder with a Foley catheter in place. On the day of transfer, the Administrator inserted a Foley catheter to obtain a urine specimen despite the physician’s standing order for straight catheterization for specimen collection. The Foley catheter was left to drainage because a specimen could not be obtained. The resident was sent to the hospital with the Foley catheter in place due to a change in condition, including not opening eyes, not eating or drinking, and blood‑tinged urine. Hospital records documented that the Foley catheter was mispositioned, with the balloon partially inflated in the urethra, causing obstruction, hematuria, and infection. The resident required ICU care for septic shock secondary to Foley‑associated UTI and urosepsis in the setting of the mispositioned Foley catheter, with associated mild hydronephrosis and traumatic hematuria, and ultimately died; the death certificate listed sepsis and UTI as the cause of death, and the physician agreed that urosepsis could cause death. Additional deficiencies were identified in catheter care and incontinence care for several other residents. One resident with an indwelling Foley catheter and obstructive/reflux uropathy received catheter care from a CNA who entered the room under enhanced barrier precautions without performing hand hygiene or donning a gown, and who cleansed the groin, penis, and catheter tubing with soapy water but did not rinse or dry the resident. Another resident with a suprapubic catheter, chronic kidney disease, acute kidney failure, cystitis, and other comorbidities had orders for enhanced barrier precautions, routine suprapubic catheter site care, securement device changes, and barrier cream application. A CNA providing peri‑care and catheter care to this resident failed to don PPE despite an EBP sign, used the same soiled gloves throughout cleansing of the suprapubic site, groins, penis, and scrotum, did not apply the ordered cream, and did not secure the catheter, leaving it hanging freely. Further, residents with urinary incontinence and skin integrity issues did not receive complete incontinence care as ordered and per facility policy. One resident with moderate cognitive impairment, frequent bowel and bladder incontinence, and orders for enhanced barrier precautions and barrier cream was assisted to the toilet and wiped twice from front to back while standing, but the peri‑area and vagina were not cleansed, the soiled brief was pulled back up, no new brief was applied, no barrier cream was used on visibly reddened and slightly excoriated buttocks and anal area, and there was no hand hygiene or glove change between soiled and clean areas. Another resident with severe cognitive impairment, frequent incontinence, and a care plan for skin integrity and moisture management had a slightly wet brief removed during wound care, but no incontinence cleansing or new brief was provided, with the nurse stating she preferred to let the resident “air out.” In a separate observation, a resident dependent on staff for toileting hygiene and frequently incontinent of bowel and bladder had a saturated brief with urine and stool removed while standing; the CNA initially wiped visible stool with a wet towel, then left and returned with gloves and wipes, but only swiped from the back while the resident stood, without cleansing the inner thighs or buttocks or drying the area. These observed practices conflicted with the facility’s written policies on intermittent catheterization, urinary catheter care, perineal care, and suprapubic catheter care, which require verification of physician orders, proper specimen collection technique, documentation of urine characteristics and resident condition, and thorough cleansing, rinsing, and drying of the perineal and catheter areas using appropriate infection control measures. The policies also specify front‑to‑back cleansing for female residents, separate washcloths and water for labia and rectal areas, and proper care of suprapubic catheter sites to prevent skin irritation and urinary tract infection. The survey findings showed that these procedures were not consistently followed by staff during the provision of catheter care and incontinence care to the affected residents.
Failure to Use PPE and Hand Hygiene for Residents on Isolation and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring appropriate use of PPE, hand hygiene, and glove changes for residents on Contact Isolation and Enhanced Barrier Precautions (EBP). For one resident with an order for strict Contact Isolation due to abdominal wall cellulitis, a Contact Isolation sign and PPE were present on the door, yet a wound nurse (LPN) and a CNA entered the room to perform wound care without donning any PPE other than gloves. Before, during, and after the wound care, no additional PPE was worn. Another resident had a physician’s order for EBP, and an EBP sign with PPE was posted on the door. Two CNAs were observed assisting this resident with toileting and providing peri-care without donning the appropriate PPE prior to care. A third resident, care planned and ordered for EBP due to an indwelling medical device, had an EBP sign and PPE on the door. An LPN entered to fix the resident’s g-tube, which had become disconnected and was being held by the resident, and only donned gloves while reconnecting the tube and cleaning it with an alcohol pad. The LPN did not don gown or other PPE required under EBP and exited the room after doffing gloves without performing hand hygiene. A fourth resident with a physician’s order for EBP had an EBP sign and PPE on the door when a CNA entered to provide peri-care and catheter care. The CNA did not don PPE and used a single pair of gloves throughout the entire care episode, including obtaining wet washcloths from a water basin with soiled gloves, drying all cleaned areas, and then covering the resident with the sheet and blanket. The CNA did not change gloves or perform hand hygiene when moving from soiled to clean areas, including during catheter care. Staff interviews showed inconsistent understanding of EBP, with one CNA unable to recall what EBP meant, while the DON stated the expectation that staff don appropriate PPE for residents on EBP or isolation and perform hand hygiene before, during glove changes, and after care. These practices were inconsistent with the facility’s written policies on EBP, hand hygiene, transmission-based precautions, and infection control.
Failure to Follow Pressure Ulcer Treatment Orders and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to follow physician orders for a resident with existing pressure injuries. The resident had severe cognitive impairment, was dependent on staff for ADLs, and was frequently incontinent of bowel and bladder. The care plan identified altered skin integrity with a pressure ulcer and noted that wound healing could be hindered by the resident’s preference to lie on her back and noncompliance with turning every two hours. Interventions included regular turning/repositioning, maintaining clean and dry skin, minimizing moisture exposure, keeping linens dry and wrinkle-free, maintaining the head of bed at or below 30 degrees, weekly wound measurements, pain management, and reducing friction and shear. A physician order dated 3/4/26 directed cleansing and application of a hydrocolloid dressing to the right buttock every three days and as needed, but the TAR showed this treatment was only documented as completed on 3/4/26, then not again until 3/8/26 through 3/11/26, indicating missed treatments before the order was discontinued when the resident was hospitalized. After the resident returned from the hospital, new physician orders dated 3/17/26 directed application of moisture barrier with each incontinent episode to the peri area/buttocks and daily application of a dime-thick layer of Triad paste to bilateral buttocks, with documentation on the TAR showing daily completion from 4/1/26 through 4/14/26. During an observation of wound care, the wound nurse and a CNA entered the resident’s room, which had a contact isolation sign and PPE available, without donning PPE other than gloves. The nurse removed an undated hydrocolloid dressing from the coccyx/buttocks, poured normal saline over the wound, patted it dry with 4x4 gauze without cleaning or wiping the wound site, applied Triad paste, and left the resident without a dressing or incontinent brief, stating she liked to let the resident “air out.” The wound nurse later acknowledged that the hydrocolloid dressing should not have been in place because the order had been changed to Triad paste after the hospitalization, suggesting that another nurse had performed the wrong wound care. The IP and DON stated that nurses are expected to follow current physician orders, discontinue outdated orders in the TAR, and enter new orders so they are followed, consistent with the facility’s pressure wound treatment policy.
Failure to Timely Replace Broken CPAP Mask for Resident With Respiratory Disorders
Penalty
Summary
The deficiency involves the facility’s failure to timely replace a broken CPAP mask for a resident with significant respiratory conditions. Progress notes document that on one evening the resident complained of shortness of breath at bedtime, received a nebulizer treatment, and had an SpO2 that improved to 92%. The same note states the CPAP mask was broken and required replacement, and that the resident was placed on continuous oxygen at 4 L via nasal cannula. A subsequent progress note the next afternoon documents that the resident’s CPAP mask was broken and that the medical supply company would bring a new mask the following day, with oxygen at 3 L via nasal cannula in use while the mask was unavailable. The resident’s face sheet reflects diagnoses including COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and obstructive sleep apnea. Physician orders include use of CPAP/BiPAP at nap time and at night to maintain oxygen saturation greater than 92%, and an order for oxygen at 3 L via nasal cannula if the resident refuses CPAP or if it is not available for any reason. The DON stated that when something is wrong with a mask, the medical supply provider is notified and the mask is sent out, sometimes the same day or the next day, and that if a resident with a history of respiratory failure has shortness of breath and no mask available, the physician should be notified. The medical supply provider reported that a CPAP mask was sent to the facility the day after the broken mask was documented. The facility’s CPAP/BiPAP policy describes the purpose of CPAP support for residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease and emphasizes comfort and safety, but the resident did not have a functioning mask as ordered during this period.
Failure to Administer Ordered Antibiotic and Other Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered, including an antibiotic for a resident with a diagnosed urinary tract infection (UTI), and failure to follow physician orders for two residents. One resident (R21) had a chronic suprapubic catheter and urinary retention, with a care plan requiring maintenance of a closed catheter system and monitoring of urinary output and characteristics. After being sent to the hospital with decreased urination and a urinalysis consistent with UTI, R21 was treated with IV antibiotics and discharged back to the facility with an order for Cefdinir 300 mg every 12 hours for 10 days for UTI. The Medication Administration Record shows that from the time the order was written on 4/10/26 until 4/13/26, R21 received only one dose of Cefdinir, despite the order being active and the medication being available in the medication dispensing machine. The DON confirmed that the night shift nurse gave one dose from the machine but did not administer subsequent scheduled doses, and that the pharmacy had initially not sent the medication due to an allergy alert, yet nursing staff did not obtain the medication from the machine or promptly clarify the allergy with the physician until 4/13/26. In addition to the missed antibiotic doses, R21’s folic acid order was not followed correctly. A physician order dated 12/20/25, later re-ordered on 4/10/26, required folic acid 1 mg once daily at 6:00 AM. During an observation in R21’s room, surveyors noted a light yellow pill on the bedside table and two medicine cups containing creams, including a mixed cream that an LPN believed was intended for application to the resident’s bottom. The LPN stated that no medications had been given that morning because the resident’s medications were scheduled for 6:00 AM. Upon reviewing the medication cart, the LPN determined that the nurse had given stock folic acid 400 mcg instead of the resident’s prescribed folic acid 1000 mcg from the card, indicating that the resident did not receive the correct ordered dose. A second resident (R22), with multiple diagnoses including chronic kidney disease stage 4, dependence on renal dialysis, CHF, type 2 diabetes, seizures, and atrial fibrillation, had physician orders for Levetiracetam (Keppra) 500 mg. The orders specified dosing on Sunday, Tuesday, Thursday, and Saturday at 08:00 AM, and a separate order for 1000 mg (two 500 mg tablets) on Monday, Wednesday, and Friday at 08:00 AM. During medication pass, an LPN reported that R22 was supposed to receive Levetiracetam that day but did not receive it because the facility was out of the medication and it would not arrive from the pharmacy until the next day. The LPN told the resident she would have to wait until the following day for the dose. Subsequent staff interviews revealed that Keppra was available in the medication dispensing machine and that the nurse should have obtained it from there, documented the situation, and notified the physician, consistent with the facility’s medication administration policy. The policy requires that medications be administered as prescribed, that missing medications prompt a search of available supplies and contact with the pharmacy or use of emergency supplies, and that the five rights of medication administration be followed.
Failure to Document and Address Insects Found on Resident's Foot
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's foot was free of insects. The resident, who was alert and had a care plan for an open lesion between the 4th and 5th toes of the right foot, was observed by a podiatrist to have a 'family of insects' in the webspace of the affected toes. The podiatrist reported this finding to a nurse, who then cleansed the area but did not document the presence or removal of insects in the resident's medical record. The care plan for the resident included regular wound care, skin assessments, and monitoring for signs of infection, but there was no documentation of insects or maggots in the resident's records prior to or after the podiatrist's observation. Multiple staff interviews revealed inconsistent awareness and documentation regarding the presence of insects. The nurse who was informed by the podiatrist admitted to assessing and cleaning the area but did not record the incident, citing being busy and forgetting to document. Other staff, including the acting wound nurse and the DON, stated that they did not observe insects or maggots and were not informed by other staff of such findings. The wound nurse also noted a lack of access to the podiatrist's notes, which contributed to incomplete information in the resident's record. The facility's documentation policy requires that all services provided, changes in condition, and unusual findings be recorded in the resident's medical record, including the date, time, and name of the person providing care. Despite this policy, the presence of insects was not documented at the time of the incident, and the only mention was an addendum added by the podiatrist several days later. This failure to document a significant change in the resident's condition resulted in an incomplete and inaccurate medical record.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident. The resident's face sheet did not document any diagnosis of wounds or skin issues, including maggots, and her Minimum Data Set indicated she was alert. The facility's LPN reported that the facility podiatrist assessed the resident, but there was no documentation of the podiatrist's progress notes in the resident's electronic medical record. The administrator confirmed that the podiatrist does not share or send his progress notes to the facility and never has. The podiatrist stated that his office typically sends progress notes to the facility within a few days after assessments and was unaware that the facility was not receiving or uploading these notes. The facility's policy requires all observations and services performed to be documented in the resident's clinical record.
Failure to Follow Physician Orders for Pulse Oximetry Monitoring
Penalty
Summary
The facility failed to follow physician orders for twice-daily pulse oximetry checks for two residents with significant medical conditions. One resident, with diagnoses including polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, right below the knee amputation, and obstructive sleep apnea, had a physician order for oxygen saturation monitoring twice daily. However, review of the electronic medical record showed that oxygen saturations were not performed twice daily as ordered on 17 occasions within the first 25 days of June, and there were also days with no documentation at all. The resident's care plan did not include oxygen saturation monitoring as a problem or intervention. Another resident, with a history of fibromyalgia, diabetes, chronic obstructive pulmonary disease, asthma, pulmonary hypertension, and congestive heart failure, also had a physician order to monitor oxygen saturations every shift and as needed. Review of documentation for the first 25 days of June revealed that only one day had twice-daily readings, and on 12 days there were no oxygen saturation levels recorded. Interviews with CNAs and an LPN confirmed that CNAs obtain pulse oximetry readings with vital signs, record them on paper, and provide them to the nurse for entry into the EMR, but the process did not ensure compliance with the physician's orders. The facility's policy required documentation of the date and time of the procedure, and reasons for refusal if applicable, but this was not consistently followed.
Failure to Timely Identify and Document New Pressure Ulcer
Penalty
Summary
The facility failed to identify a stage 2 pressure ulcer in a timely manner for a resident with multiple risk factors, including polyneuropathy, diabetes, end stage renal disease, and impaired mobility. During a skin check, a new pressure wound was discovered in the upper intergluteal cleft by two LPNs and the surveyor, with both nurses acknowledging they were previously unaware of the wound. The resident's care plan indicated a high risk for pressure ulcers and included interventions such as regular skin inspections during showers, use of pressure-reducing devices, and prompt reporting of skin breakdown. However, documentation on shower sheets and treatment administration records did not reflect the presence of the new wound prior to its discovery. The resident required supervision and assistance with activities of daily living and was known to have other unstageable pressure ulcers. Despite these risk factors and the facility's policy for routine skin assessments and immediate reporting of developing pressure injuries, the new stage 2 pressure ulcer was not identified or documented until the surveyor's observation. The lack of timely identification and documentation represents a failure to follow established protocols for pressure ulcer prevention and monitoring.
Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
A facility failed to identify and prevent the development of a pressure ulcer for one resident, resulting in the formation of a left heel pressure ulcer. The resident, who has a history of diabetes, dependence on renal dialysis, and polyneuropathy, was found to have an unstageable pressure ulcer with necrotic tissue and moderate drainage. The resident reported not being aware of the ulcer until it was discovered by a nurse, and expressed concern due to a previous amputation related to a non-healing pressure ulcer. Documentation revealed that the dressing was not changed daily as ordered, with a missed treatment noted on the treatment administration record. The wound was observed to have a dressing dated two days prior, and the wound nurse practitioner performed wound care during the surveyor's observation. The resident's care plan identified a risk for pressure ulcers due to impaired mobility, but the Braden Scale assessment did not indicate risk, and the Minimum Data Set did not document a pressure ulcer. Facility policy requires routine skin assessments and immediate reporting of any developing pressure injuries, but the pressure ulcer was not identified until it had already developed. The facility's failure to consistently assess, document, and provide timely wound care contributed to the development and progression of the pressure ulcer.
Failure to Provide Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) and did not ensure that a Registered Nurse (RN) was on duty for at least 8 hours a day, seven days a week, as required. According to the Administrator, the facility had been without a DON for six weeks, and although efforts were made to hire one, there was no DON present during the survey period. The staffing schedule revealed that on 8 out of 17 days, the facility did not have RN coverage for the required 8 hours, and on several days during the survey, no RN was observed on duty. The facility's own staffing policy states that an RN will be scheduled for at least one continuous 8-hour shift each day and that all department directors, including the DON, are to be employed for a forty-hour week. Despite these policies, the facility did not meet these staffing requirements, potentially affecting all 46 residents in the facility at the time of the survey.
Failure to Dispose of Expired Medications and Date Multi-Use Vials
Penalty
Summary
Surveyors identified that the facility failed to properly dispose of expired medications and did not consistently date multi-use medication vials and insulin pens. During a review of the medication cart and medication room, it was observed that a Glargine insulin pen and a Glargine insulin vial had been opened and dated well beyond their recommended usage periods, and a stock vial of Lispro was also found with an outdated open date. Additionally, an open vial of Aplisol (tuberculin) was found in the medication refrigerator without an open date, contrary to facility policy and manufacturer recommendations. Interviews with facility staff confirmed that all insulin pens, vials, and multi-use injectable medications are required to be dated when opened, and that only one Aplisol vial is kept in the facility at a time. Facility policy and manufacturer guidelines specify that opened vials should be dated and discarded after a set period, typically 28 to 30 days. The failure to follow these procedures was observed to have the potential to affect all 46 residents in the facility.
Improper Food Storage Increases Risk of Contamination
Penalty
Summary
The facility failed to store food in a manner that prevents contamination by pests. During a tour of the dry storage area with the Dietary Manager, surveyors observed large plastic storage bins containing open 25-pound bags of breadcrumbs, flour, sugar, and instant oats. These bins did not have lids and instead had trash bags draped over them. The Dietary Manager acknowledged that pests could crawl under the trash bags and access the food. Facility policy requires that plastic containers with tight-fitting lids be used for storing such items and that open products be tightly covered to protect against contamination, including from insects and rodents. At the time of the survey, there were 46 residents living in the facility.
Failure to Ensure Resident Privacy and Dignity During Care
Penalty
Summary
The facility failed to provide privacy and promote dignity for six residents during care activities, as observed by surveyors. Certified Nurse Assistants (CNAs) assisted residents with eating while standing over them, rather than sitting at eye level, which did not respect the residents' dignity. Residents involved had significant cognitive impairments and required varying levels of assistance with eating. Staff interviews confirmed awareness that proper feeding assistance should involve sitting with residents, but this was not consistently practiced. Additionally, Licensed Practical Nurses (LPNs) performed wound care and enteral feeding without ensuring adequate privacy. In several instances, window blinds were left open during personal care, exposing residents to potential view from outside or from roommates. Privacy curtains were not always used, and in one case, a resident's buttocks were exposed to an open window while being changed. The residents affected had diagnoses such as Parkinson's Disease, Schizophrenia, Alzheimer's Disease, and severe cognitive impairment. Staff acknowledged after the fact that privacy measures, such as closing blinds and curtains, should have been implemented.
Infection Control Lapses in PPE Use, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
Multiple instances of non-compliance with infection prevention and control protocols were observed among nursing staff during resident care activities. In several cases, staff failed to don required personal protective equipment (PPE), such as gowns and gloves, when providing wound care to residents on Enhanced Barrier Precautions due to open wounds. For example, a nurse entered a resident's room to perform heel wound treatment without wearing a gown, despite signage and physician orders indicating the need for enhanced precautions. In another instance, a wound nurse practitioner provided pressure ulcer care without wearing a gown and handled supplies and equipment in a manner inconsistent with infection control policies. Hand hygiene lapses were also documented, including staff donning gloves without prior hand cleansing, changing gloves without performing hand hygiene in between, and handling clean and soiled items with the same gloves. During medication administration, a nurse was observed dumping pills into her gloved hand before placing them in medication cups, which is not in line with proper hand hygiene and medication handling procedures. Additionally, reusable medical equipment such as scissors was not consistently disinfected between uses, and clean barriers were not always used when placing supplies on resident surfaces during wound care. Facility policies require the use of specific disinfectants for non-critical items, preparation of clean work areas with protective barriers, and strict adherence to hand hygiene before and after resident contact, glove changes, and handling of clean or soiled dressings. The observed practices deviated from these policies, as staff failed to consistently follow established protocols for PPE use, hand hygiene, and equipment disinfection during high-contact resident care activities, particularly for residents with wounds or on enhanced barrier precautions.
Failure to Provide 8 Consecutive Hours of RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage, which has the potential to affect all 48 residents residing in the facility. The schedule dated 3/4/24 - 3/17/24 did not document an RN working for 8 consecutive hours on multiple dates, specifically 3/5/24, 3/6/24, 3/7/24, 3/8/24, 3/10/24, 3/11/24, 3/13/24, 3/16/24, and 3/17/24. The Administrator stated that the previous Director of Nurses (DON) ended her employment on 1/18/24, and the Interim DON worked from 1/18/24 until 3/4/24 before quitting, which resulted in the loss of RN coverage. The Long-Term Care Facility Application for Medicare and Medicaid, dated 4/8/24, documents that 48 residents reside in the facility.
Improper Disinfection of Blood Glucose Machine
Penalty
Summary
The facility failed to properly disinfect a multi-use blood glucose machine for seven residents. An LPN obtained a blood glucose level for a resident and then placed the machine on a clean tissue on her medication cart. She used a Microdot Bleach wipe to gently wrap the machine and set a timer for three minutes but did not rub the entire machine with the wipe. The facility's documentation indicated that the machine was used by multiple residents. The Microdot Bleach Wipe container instructions required a 30-second contact time to kill bacteria and viruses, which was not followed correctly.
Failure to Follow Physician-Ordered Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide the physician-ordered treatment for a pressure sore on a resident's left heel. During a dressing change, an LPN/wound nurse observed that the resident's left heel had a boggy and black circular area and an open area on the left metatarsal. The dressing used on the left heel was not in accordance with the physician's orders, which specified the use of a skin moisturizer, cushion with an abdominal pad or foam heel cup, and securing with kerlix or gauze wrap. The resident's care plan also documented the need for treatments per physician orders. The facility's policy required physician authorization for wound treatments, including dressings and topical agents, which was not followed in this instance.
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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