Serenity Estates At Morris
Inspection history, citations, penalties and survey trends for this long-term care facility in Morris, Illinois.
- Location
- 1223 Edgewater, Morris, Illinois 60450
- CMS Provider Number
- 146077
- Inspections on file
- 24
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Serenity Estates At Morris during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and multiple comorbidities, who identified her daughter as her POA and decision-making partner, reported not knowing why her therapy ended and not recalling any notice of termination. Record review showed that while a NOMNC/SNFABN was signed by the resident for the end of Part A skilled therapy, there was no documentation that her POA was notified, and no NOMNC or ABN was issued or documented for the end of Part B therapy. The Social Services Director confirmed that no NOMNC was sent to the POA and that the resident’s Alzheimer’s diagnosis was not taken into account, despite facility policy requiring issuance of NOMNC/ABN to the resident or representative whenever Medicare-covered services end.
A CNA recorded and posted a collage of videos of two residents on a personal social media account without any written consent, showing one resident in a gown being lifted with a mechanical lift, performing personal hygiene in the bathroom, sitting in a wheelchair organizing personal items, and engaging in ball activities, as well as an “In Loving Memory” card with that resident’s birth and death dates and funeral home name. The other resident was also depicted participating in ball activities. One resident had a signed audio, video, and photographic release form from the POA specifically prohibiting release of the resident’s name or photograph outside the facility without written authorization, and the other resident had no consent on file. The DON and Activity Director acknowledged that no consents had been obtained and that staff were not allowed to post residents on personal social media, contrary to the facility’s social media policy prohibiting unauthorized photographs or recordings of residents or their private space.
A resident with multiple complex conditions, including hemiplegia, dementia, diabetes, and communication deficits, reported that neither she nor her POA had ever attended a care plan meeting since admission. The Social Services Director acknowledged that care plan conferences had not been conducted as required and could not produce any documentation of a conference for this resident, and the Administrator confirmed there was no record of such a meeting, despite facility policy requiring interdisciplinary, person-centered care plan conferences with the resident and representative at least every 90 days or with significant change.
Multiple residents reported receiving cold meals, both in their rooms and in the dining area. Staff observations confirmed that hot food was not consistently maintained at appropriate temperatures during plating and delivery, with temperature checks showing some items below the standard for palatability. The facility lacked both adequate equipment and a policy to ensure food was served at an appetizing temperature.
A resident who was cognitively intact and dependent on staff for showering was left alone and undressed in the shower room by a CNA, who left to assist another resident and returned about 15 minutes later to find the resident shivering and cold. Facility leadership confirmed that residents should not be left alone or naked during shower care.
Two residents with a history of repeated falls, dementia, and poor safety awareness were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Staff interviews confirmed the non-skid mats were not consistently used, and facility records showed multiple falls for both residents over several months.
Two cognitively intact residents with complex medical conditions did not receive their prescribed medications in a timely manner after admission due to delays in order entry, lack of staff access to medication storage, and missed opportunities to request STAT pharmacy deliveries. Staff did not follow facility policies for obtaining unavailable medications or notifying physicians about the delays, resulting in missed doses of critical medications.
A resident with dementia and high fall risk was improperly transferred using a mechanical lift, resulting in a fall and head injury. The CNAs involved failed to secure the lift sling properly, causing the resident's wheelchair to tip backward. The facility's policy on safe transfers was not followed, leading to the incident.
A resident with a history of aphasia and hemiplegia suffered fractures due to improper transfer assistance. A new CNA performed a one-person pivot transfer, contrary to the care plan requiring a two-person assist with a mechanical lift. The resident was initially assessed with no injuries but later confirmed to have fractures after expressing pain. Facility staff confirmed the CNA did not follow the safe transfer policy.
The facility failed to maintain sufficient dietary staff, impacting meal preparation for all residents. The Dietary Manager reported staffing shortages, leading to meal schedule changes and mismatches with the menu, affecting residents' meal choices. The facility's staffing schedule showed numerous days with insufficient staff, falling short of the required levels to meet residents' needs.
The facility failed to follow its established menus due to staffing shortages, leading to meal substitutions not aligned with policy. A resident expressed dissatisfaction with the inconsistency, and the Dietary Manager admitted to altering meals because of insufficient staff, which is not permitted by the facility's policy.
The facility failed to maintain proper food safety and sanitation practices, including improper labeling and dating of food items, inadequate sanitization of kitchen equipment, and lack of hair restraints by staff in the kitchen. These deficiencies were observed during meal preparation and storage inspections, posing potential cross-contamination and foodborne illness risks.
The facility failed to implement adequate fall prevention measures for several residents, leading to multiple incidents. A resident on anticoagulants fell out of bed without fall mats in place, another with cognitive impairment had her bed left in a high position against care plan instructions, and a third resident at high fall risk had only one fall mat instead of two. Additionally, exposed metal bed frames posed injury risks, indicating systemic issues in fall prevention and safety measures.
A long-term care facility failed to properly label, store, and dispose of medications, leading to potential safety risks for residents. Insulin pens were found without proper labeling, and controlled substances were improperly stored. Expired medical supplies were not disposed of, and medications were found at residents' bedsides without proper orders or safety assessments. The facility's policies on medication storage and controlled substance accountability were not adhered to, posing a risk of medication errors and potential harm to residents.
The facility failed to follow infection control practices for residents under TBP and during the transportation of dirty linen. A resident with C. difficile was visited by a family member and an occupational therapist without proper PPE or hand hygiene. Another resident under EBP for MRSA had a CNA enter without a gown due to lack of supplies, and the urinary catheter bag was mishandled. Additionally, CNAs failed to change gloves or perform hand hygiene during incontinent care and transported soiled linen improperly.
A facility failed to implement a resident's chosen DNR status, despite it being documented in the POA paperwork and confirmed by family members. The resident, with multiple diagnoses including dementia, had made the DNR decision prior to cognitive changes. The facility lacked a physician's order for the DNR, and the resident was assumed to be a full code, contrary to the facility's policy on communicating code status.
The facility failed to provide adequate ADL care to two residents, resulting in deficiencies in personal hygiene and toileting assistance. One resident was observed with a crusted substance on her eyelid over several days, indicating her face had not been washed. Another resident was not properly assisted with wiping or handwashing after toileting. The facility's policy requires necessary services for residents unable to perform ADLs.
The facility failed to apply assistive devices as ordered for two residents. One resident with Parkinsonism and dementia did not have the prescribed hand rolls to prevent contractures, and staff used makeshift solutions due to the absence of a restorative program. Another resident with a leg fracture had a CAM boot that was not worn as ordered, with staff misunderstanding the requirement for it to be on at all times except during specific activities.
A resident with severe cognitive impairment and urinary retention was found with an indwelling catheter bag positioned above bladder level, risking a UTI. A nurse indicated the bag might have been left in this position by a therapist, and both the RN and DON confirmed the risk of UTI from improper positioning. Facility policy requires catheter bags to be below bladder level.
A resident with a PICC line was found with a dirty, peeling dressing lacking a date or label, and there was no physician order or documentation for regular dressing changes. The facility's policy requires weekly dressing changes to prevent infection, but this was not followed, as confirmed by the RN and DON.
The facility failed to obtain consents for psychotropic medications for two residents and did not follow pharmacy recommendations. One resident was administered Clonazepam and Mirtazapine without consents, while another received Escitalopram and Olanzapine without consents and had a delayed AIMS test. The facility's policy on medication management and monitoring was not followed.
The facility failed to document their yearly Performance Improvement Projects (PIP) for falls, identified as a problem-prone area. During a QAPI/QAA task, the Administrator and ADON could not provide records of QAPI/QAA meetings or data on interventions for the fall PIP. The ADON had interventions in mind but had not documented them, affecting all 90 residents.
The facility did not conduct QAA meetings quarterly and lacked required members, including the Medical Director, in recent sessions. The last official meeting was in June 2024, and subsequent sessions were introductory, not formal QAA meetings.
Failure to Notify Resident’s POA of End of Medicare-Covered Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Power of Attorney (POA) of the end of Medicare-covered therapy services, as required by facility policy. The resident had multiple diagnoses including hemiplegia and hemiparesis, muscle disorders, difficulty in walking, cognitive communication deficit, diabetes, Alzheimer’s disease, visual disturbance, depression, hearing loss, and dementia. The resident reported that her daughter was her POA, that she used to receive therapy, and that she did not know why it ended. She stated she did not remember receiving or signing a letter stating therapy would be ending and that, had she received such a letter, she would have given it to her daughter, with whom she makes decisions. The resident’s Power of Attorney for Health Care document identified her daughter as POA and authorized the agent to make decisions starting immediately and continuing after the resident was no longer able to make them herself. Record review showed that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN/NOMNC) was issued and signed by the resident in mid-December for the end of Part A skilled therapy services, but there was no documentation that the POA was notified of the last covered day of skilled services. The Social Services Director stated she issued a NOMNC to the resident when skilled therapy ended in December but did not issue a NOMNC when Part B therapy ended in March and did not send any NOMNC to the resident’s POA. She acknowledged she did not take into consideration the resident’s Alzheimer’s diagnosis. The EMR contained no documentation of a NOMNC or other notification to the resident or POA for the end of Part B therapy with last covered dates in late February and early March. The facility’s Advance Beneficiary Notices Policy required that a NOMNC be issued to the resident or representative whenever Medicare-covered services are ending, and specified the use of the appropriate CMS forms for Part A and Part B services, but the facility was unable to provide evidence that these requirements were met for the resident’s POA at the end of therapy services.
Unauthorized Social Media Posting of Residents Without Consent
Penalty
Summary
The facility failed to protect residents’ rights to privacy and confidentiality when a CNA recorded and posted multiple videos of two residents on a personal social media account without consent. One resident, R7, who had central cord syndrome of the cervical spinal cord, CHF, quadriplegia, anxiety, major depressive disorder, and benign prostatic hyperplasia, was shown in a TikTok video collage wearing a gown and being lifted by a mechanical lift, in the washroom performing personal hygiene, in his room in a wheelchair organizing personal items, and engaging in ball activities. Another clip showed a resident in a gown holding a rosary and a death notice with a picture of a female, and the final clip displayed an “In Loving Memory” card with R7’s date of birth, date of death, and the funeral home name. The video ended with the social media site name and the CNA’s username. The Administrator confirmed that the residents in the video were R7 and R8, that the CNA had been employed at the facility until shortly before the survey, and that no permission had been obtained from R7, R8, or R7’s family to take or post any videos or pictures. Record review showed that R7’s Audio, Video and Photographic Release Form, signed by his POA, specifically directed the facility not to use his name or photograph within the facility in certain circumstances and not to release his name or photograph outside the facility without specific written authorization. Progress notes documented that R7 was on hospice care, nearing end of life, and later expired, with subsequent removal by a funeral home. R8’s EMR contained no written consents for photography, video recording, or social media posting, and the facility was unable to provide any audio, video, or photographic consent for R8. The DON stated that sharing resident videos was wrong and violated the facility’s social media policy and HIPAA, and the Activity Director stated she had never obtained written consents for R7 or R8 and that employees were not allowed to post residents on personal social media. The facility’s Social Media Use Policy prohibited taking, keeping, or distributing unauthorized photographs or recordings of residents or their private space without written consent and barred transmitting resident-related images that could violate privacy or confidentiality, which was not followed in this case.
Failure to Conduct and Document Required Care Plan Conference
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a care plan conference for a resident and their representative as required by facility policy. The resident was admitted with multiple significant diagnoses, including hemiplegia and hemiparesis, muscle disorders, difficulty walking, cognitive communication deficit, diabetes, Alzheimer’s disease, unspecified visual disturbance, depression, hearing loss, and dementia, according to the face sheet. During an interview, the resident reported that neither she nor her POA had attended a care plan meeting since admission. Review of the resident’s EMR showed no evidence that a care plan conference had been conducted. The Social Services Director acknowledged that care plan conferences had not been done as they should have been and stated that if a care plan conference had been held for this resident, it would have been documented in progress notes, but she was unable to provide such documentation. The Administrator also confirmed that there was no documented record of a care plan conference for this resident and stated that care plan conferences should occur at least every 90 days or with a significant change. The facility’s Comprehensive Care Plans Policy requires development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, prepared by an interdisciplinary team that includes the resident and resident representative to the extent practicable. Despite this policy, the facility could not provide any documentation that a care plan conference with the resident or her POA had been conducted.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable and acceptable temperature for residents, as evidenced by multiple resident interviews and direct observation. Thirteen residents reported that their meals were served cold, both in their rooms and in the dining room. Residents described the food as 'not really hot,' 'ice cold,' and 'not very edible.' During meal service, it was observed that hot food items were plated under a heating lamp, covered with metal lids, and transported on trays using a free-standing cart covered by a plastic liner. Only one insulated enclosed cart was available for a specific unit, and the facility did not use heating pellets for each plate. Temperature checks conducted by the Dietary Manager after the last meal tray was served showed that the Italian roast beef sandwich was at 104.5°F and potato wedges at 134.9°F, while the standard for palatability was stated by the facility dietitian to be between 110-120°F. The facility lacked a policy regarding the palatability of food, and staff confirmed the absence of necessary equipment to maintain appropriate food temperatures during delivery. These actions and inactions resulted in residents consistently receiving meals at temperatures below acceptable standards.
Resident Left Unattended and Undressed During Shower
Penalty
Summary
A resident with diagnoses including intervertebral disc disorder with radiculopathy, acute respiratory failure with hypoxia, generalized muscle weakness, chronic pain, and dizziness, who was cognitively intact and dependent on staff for showering, reported being left alone and naked in the shower room by a CNA. The resident stated that the CNA turned on the water and left to attend to another resident in a different shower room, returning approximately 15 minutes later to find the resident shivering and cold, unable to wash himself. Facility leadership confirmed that residents should not be left alone or naked in the shower room during care.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement recommended fall prevention measures for residents identified as high risk for falls. Two residents with multiple medical diagnoses, including repeated falls, unsteadiness, lack of coordination, and dementia, were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Observations on several occasions showed these residents sitting in their wheelchairs or being assisted by staff without the non-skid mats in place. Staff interviews confirmed that the non-skid mats were not consistently used, and one CNA stated she had never seen a non-skid mat on one resident's wheelchair. The facility's fall incident log documented multiple falls for both residents over a period of several months. The care plans for both residents, which were updated following these incidents, included the use of non-skid mats as a specific intervention to address their high risk for falls due to poor safety awareness, dementia, and other medical conditions. Despite these documented interventions, direct observations and staff interviews revealed that the non-skid mats were not in use at the times observed, indicating a failure to follow the established fall prevention measures for these high-risk residents.
Failure to Provide Timely Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that medications were readily available to newly admitted residents, resulting in delays in medication administration for two residents. One resident, who was cognitively intact and had multiple diagnoses including COPD, depression, and chronic respiratory failure, was admitted after the pharmacy's medication order cut-off time. The assigned LPN did not have access to the medication storage and was unaware of the process to obtain medications after hours or request a STAT delivery. As a result, the resident did not receive several scheduled medications on the evening of admission and the following morning, with documentation showing that medications were not delivered until the afternoon of the next day. Another cognitively intact resident with complex medical conditions such as diabetes, congestive heart failure, and stage 4 kidney disease also experienced delays in receiving medications. The resident's medication orders were not entered into the computer until the evening of the day after admission, and medications were not administered until the following day. The resident missed multiple doses of oral medications and insulin, and family members had to retrieve medications from the previous care setting due to the delay. There was no documentation that physicians were notified about the delays in medication administration. Facility policies required immediate action when medications were unavailable, including notifying the physician and obtaining alternative orders or emergency deliveries. However, staff did not follow these procedures, and there was a lack of communication and timely action to ensure that newly admitted residents received their prescribed medications as ordered.
Unsafe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in an accident. The resident, who has a history of dementia, weakness, Meniere's disease, and hearing loss, was identified as high risk for falls. The care plan specified the use of a mechanical lift with two staff members for transfers. During a transfer from a wheelchair to a bed, the resident's wheelchair was lifted along with the resident, causing the wheelchair to tip backward and the resident to fall, hitting his head on the floor. The incident occurred because the mechanical lift sling was not securely attached to the metal hook, and the staff were focused on the issue with the wheelchair rather than ensuring all hooks and slings were properly secured. The incident was witnessed by two CNAs who were conducting the transfer. One CNA was operating the lift controls while the other was positioned on the side of the resident, leaving no one behind the wheelchair to prevent it from tipping. The resident's wife, who was not present during the incident, reported finding the resident on the floor with a bruise on his head. The resident was sent to the hospital and diagnosed with a scalp hematoma before being discharged back to the facility. The facility's policy on safe resident handling and transfers was not adhered to, as it requires ensuring all slings are securely placed and the resident is positioned safely during transfers.
Failure to Provide Safe Transfer Assistance
Penalty
Summary
The facility failed to provide safe transfer assistance for a resident, resulting in an acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. The resident, who has a medical history of aphasia, hemiplegia, and hemiparesis following a cerebral infarction, was being transferred from an electric wheelchair to a bed via a pivot transfer when the incident occurred. The transfer was conducted by a CNA who was new to the facility and performed the transfer alone, despite the resident's care plan indicating that a two-person assist with a mechanical lift was required. The resident was lowered to the ground after becoming weak during the transfer, and subsequent assessments initially did not reveal any obvious injuries. The resident later expressed pain in the right lower extremity and was sent to the emergency room, where initial evaluations did not indicate fractures. However, continued pain led to further X-rays, which confirmed the fractures. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that the CNA was not familiar with the facility's procedures and did not seek assistance for the transfer, which was against the facility's policy for safe resident handling and transfers. The policy clearly states that two staff members must be utilized when transferring residents with a mechanical lift.
Insufficient Dietary Staffing Affects Meal Preparation
Penalty
Summary
The facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Services, impacting meal preparation for all residents receiving oral nutrition. The Dietary Manager, identified as V9, reported that the facility was short-staffed, with only two staff members, including herself and the cook, available on certain days. This staffing shortage led to changes in the meal schedule, such as switching meals between days and serving meals that did not match the menu, which affected the residents' ability to choose their meals. For instance, a resident, R205, expressed dissatisfaction with receiving meals that did not match the menu, such as being served tuna salad on white bread instead of toast. The facility's staffing issues have persisted for at least two months, with the Dietary Manager having to adjust meal plans and even the facility's Administrator assisting in the kitchen due to insufficient staff. The facility's staffing schedule highlighted numerous days with insufficient staff, totaling 33 out of 111 days. The facility's assessment tool indicated a need for a specific number of dietary staff to meet residents' needs, but the current staffing levels fell short of these requirements. The Dietary Manager emphasized the importance of feeding residents on time and the challenges posed by the lack of staff, which sometimes led to meal substitutions and disruptions for the residents.
Failure to Follow Menu Due to Staffing Shortages
Penalty
Summary
The facility failed to adhere to its established menus, which are required to meet the nutritional needs of residents, as observed during a survey. The Dietary Manager, identified as V9, admitted to altering the menu due to insufficient staffing levels. On a specific Monday, the planned meal of chicken enchiladas was replaced with pulled pork, pasta salad, and pea salad because the preparation time for enchiladas was too long for the available staff, which consisted of only two people instead of the required five. This substitution was not in line with the facility's policy, which does not allow for menu changes due to staffing issues. Additionally, a resident expressed dissatisfaction with the meal changes, stating that meals often did not match the menu, which affected their sense of choice. Further observations revealed that on another day, the lunch served did not match the menu, with chicken enchiladas being served instead of the planned Hawaiian Pork Sliders. The Dietary Manager acknowledged that meal substitutions had occurred on other occasions due to staffing shortages, and even the facility's Administrator had to assist in the kitchen. The facility's policy on menu substitutions only allows for changes when a product is unavailable or for special requests, not for staffing shortages. This inconsistency in meal service highlights the facility's failure to follow its own menu policies, impacting the residents' dining experience.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices in the kitchen, affecting all residents who receive oral nutrition. During a lunch service, a cook was observed placing a thermometer probe on a visibly dirty serving table and then using it to check the temperature of food without sanitizing it. The cook also dropped a lid on the kitchen floor and continued to use the same oven mitts to handle food trays, and later dropped a thermometer on the floor, cleaning only the probe but not the digital display, which then touched food. These actions were identified as potential cross-contamination risks. Additionally, the facility did not ensure proper labeling and dating of food items in storage. Several items in the walk-in refrigerator, freezer, and dry storage were found without labels or dates, including diced chicken, egg products, yogurt, grape salad, ice cream cake, cookies, baking powder, and powdered sugar. Some items were also found to be expired, such as pie crusts and baking powder. The Dietary Manager acknowledged that all food items should be labeled and dated to ensure safety and prevent foodborne illness. The facility also failed to enforce the use of hair restraints in the kitchen. Two CNAs entered the kitchen during meal preparation without wearing hairnets, posing a risk of physical contamination of food by hair. The Dietary Manager confirmed that all staff entering the kitchen should wear hair restraints to prevent contamination. The facility's policies on labeling, dating, and hair restraints were not followed, contributing to the deficiencies observed.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide appropriate fall interventions and maintain a hazard-free environment for several residents, leading to multiple incidents. One resident, admitted with a history of falls and on anticoagulants, was found on the floor with a head injury and skin tear after rolling out of bed. Despite being at high risk for falls, the resident did not have fall mats in place, which were part of the prescribed interventions. The staff admitted to forgetting to replace the fall mat, and the resident had experienced multiple falls since admission. Another resident with severe cognitive impairment and a history of falls was observed with her bed in a high position, contrary to her care plan that required the bed to be in a low position at night. The resident expressed confusion about her bed preference, and staff inconsistently managed the bed height, leaving it high even after providing care. The Director of Nursing was initially unaware of the resident's fall interventions, indicating a lack of communication and adherence to care plans. A third resident, with a history of repeated falls and a subdural hematoma, was found with only one fall mat beside her bed, despite being at high risk for falls. Staff acknowledged that two fall mats should be in place if the bed is not against a wall, but this was not implemented. Additionally, another resident's bed had exposed metal frames, posing a risk of injury, which the Assistant Director of Nursing confirmed should not occur. These findings highlight a systemic issue in the facility's fall prevention and environmental safety measures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly label, store, and dispose of medications, leading to potential safety risks for residents. Several insulin pens were found without proper labeling, including opened and expired pens that were not discarded, as observed with residents R269, R155, R254, R206, and R60. Additionally, controlled substances such as clonazepam and hydrocodone were improperly stored, with some blister packs taped, which could lead to contamination. The medication room refrigerator was not maintained properly, with excess ice buildup and missing temperature logs, indicating a lack of oversight in medication storage conditions. Expired medical supplies were found in the medication room, including catheterization trays and IV administration set tubing, which were not disposed of despite being past their expiration dates. This oversight was acknowledged by the LPN, who was unaware that medical supplies had expiration dates. Furthermore, medications were found at residents' bedsides without proper orders or safety assessments, as seen with residents R357, R359, R63, R64, and R304. These medications included nasal sprays, creams, and wound cleansers, which were accessible to residents without supervision or proper documentation. The facility's policies on medication storage and controlled substance accountability were not adhered to, as evidenced by the lack of proper labeling, storage, and disposal of medications. The Director of Nursing and other staff members were unable to provide clear answers or demonstrate knowledge of the facility's expectations regarding medication management. This lack of compliance with established protocols poses a risk of medication errors and potential harm to residents, as medications were not securely stored or properly monitored.
Infection Control Lapses in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control practices for residents under Transmission Based Precautions (TBP) and during the transportation of dirty linen. This deficiency was observed in four residents who were part of a sample of 28. For instance, a resident diagnosed with enterocolitis due to Clostridium difficile was placed under contact isolation. However, a family member and an occupational therapist entered the resident's room without wearing the required personal protective equipment (PPE) and did not follow proper hand hygiene protocols. The family member was not instructed on the necessary precautions, and the occupational therapist used alcohol-based hand sanitizer instead of washing hands with soap and water, which is ineffective against C. difficile. Another resident with a Foley catheter and wounds was under Enhanced Barrier Precautions (EBP) due to the risk of Methicillin Resistant Staphylococcus Aureus (MRSA). Despite this, a certified nurse assistant (CNA) entered the resident's room without a gown because the isolation bin was not stocked with gowns. The CNA handled the urinary catheter bag, which was improperly placed on the ground, without wearing the appropriate PPE. The Director of Nursing (DON) and other staff members acknowledged the need for proper PPE and hand hygiene but failed to ensure compliance. Additionally, there were lapses in the handling and transportation of soiled linen. A CNA performed incontinent care on a resident without changing gloves or performing hand hygiene afterward. The CNA also transported soiled briefs and linen to the soiled utility room without placing them in a garbage bag. Another incident involved a CNA who did not change gloves or wash hands during the process of changing a resident's wet brief and pants. These actions were contrary to the facility's policies on handling soiled linen and hand hygiene, which require proper disposal and hand hygiene to prevent the spread of infection.
Failure to Implement Resident's DNR Status
Penalty
Summary
The facility failed to honor a resident's right to have their chosen Advanced Directives status of Do Not Resuscitate (DNR) implemented. This deficiency was identified for one resident, who was admitted with multiple diagnoses including encephalopathy, frontotemporal neurocognitive disorder, convulsions, type 2 diabetes, hypertension, anxiety, and dementia. The resident's family members confirmed that the resident had made the decision for a DNR status prior to experiencing cognitive changes, and this was documented in the Power of Attorney (POA) paperwork provided to the facility. However, the facility did not have a physician's order for the resident's DNR status, and the Director of Nursing stated that without a POLST or physician's DNR order, the resident is assumed to be a full code. The Assistant Director of Nursing acknowledged that physician orders are required for code status on admission and that the resident's code status, as part of the POA, should have been followed. Despite the POA forms being scanned into the Electronic Medical Record, the physician orders did not contain directives regarding the resident's resuscitation status. The facility's policy on Communication of Code Status emphasizes the importance of adhering to residents' rights to formulate Advanced Directives and implementing procedures to communicate a resident's code status to necessary individuals, which was not followed in this case.
Deficiencies in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide adequate ADL care to two residents, resulting in deficiencies in personal hygiene and toileting assistance. One resident, who was admitted with multiple diagnoses including a fracture, anxiety, and cognitive impairment, required substantial assistance with personal hygiene. Despite this, the resident was observed over several days with a crusted substance on her eyelid, indicating that her face had not been washed. The CNAs responsible for her care admitted to not washing her face, and the Director of Nursing acknowledged that ADLs should be performed daily, with a visual assessment to determine residents' needs. Another resident, diagnosed with Parkinson's disease and other conditions, was dependent on staff for toileting hygiene. During an observation, a CNA assisted the resident with toileting but failed to wipe the resident after a bowel movement or offer handwashing. The CNA later acknowledged the importance of assisting residents with wiping and handwashing. The Director of Nursing confirmed that CNAs are expected to ensure residents' hygiene is maintained and to encourage handwashing to prevent contamination. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain hygiene.
Failure to Apply Assistive Devices as Ordered
Penalty
Summary
The facility failed to ensure the proper application of anti-contracture devices and a Controlled Ankle Movement (CAM) Boot as ordered for two residents. Resident R160, diagnosed with Parkinsonism, weakness, and dementia, had a physician's order for hand rolls to reduce the risk of contractures. However, observations over several days showed that R160's right hand was consistently in a fist form without the prescribed splint. Interviews with staff revealed that there was no restorative program in place, and makeshift solutions like rolled-up washcloths were used instead of the ordered hand rolls. Resident R354, admitted with a displaced bimalleolar fracture and other mobility issues, had a physician's order for a CAM boot to be worn at all times except during range of motion exercises and bathing. Despite this, the CAM boot was observed off while the resident was in bed, contrary to the physician's order. Interviews with CNAs and the Occupational Therapist indicated a misunderstanding of the order, with staff believing the boot was only necessary when the resident was in a chair. The Director of Nursing confirmed that the boot should be on at all times, except during specific activities as per the order.
Improper Catheter Positioning Risking UTI
Penalty
Summary
The facility failed to maintain proper catheter care for a resident, leading to a potential risk of urinary tract infection (UTI). A male resident with severe cognitive impairment and a diagnosis of urinary retention was observed with an indwelling catheter bag positioned above the bladder level while seated in a wheelchair. This improper positioning caused urine to pool in the catheter tubing. A registered nurse acknowledged that the catheter bag might have been left in this position by a therapist and confirmed that such positioning could lead to a UTI. The Director of Nursing also stated that the catheter bag should be kept below the bladder level to prevent potential UTIs. The facility's policy on indwelling catheter use and removal specifies that the catheter should be secured to facilitate urine flow, prevent kinks, and be positioned below the bladder level.
Failure to Maintain PICC Line Dressing
Penalty
Summary
The facility failed to adhere to its policy on maintaining a Peripherally Inserted Central Catheter (PICC) line for a resident, identified as R62, who was part of a sample of 28 residents reviewed for central line catheter care. R62, a male resident with intact cognition, was admitted with diagnoses including Sepsis, Right Lower Limb Cellulitis, and Osteolysis. On observation, R62 was found with a left upper arm double lumen PICC line that had a dirty, peeling dressing with no date or label. The resident expressed uncertainty about whether the facility had ever changed his PICC line dressing. Further investigation revealed that there was no physician order to change R62's PICC line dressing, and the Medication Administration Record (MAR) lacked documentation of weekly dressing changes. The Registered Nurse (V5) confirmed the absence of an order and documentation for dressing changes. The Director of Nursing (V2) stated that PICC line dressings should be changed weekly and as needed, with proper dating and labeling to prevent central line-associated bloodstream infections (CLABSI). The facility's policy, reviewed and revised shortly before the incident, mandates weekly dressing changes or as needed to minimize infection risks, with physician orders specifying dressing type and change frequency.
Failure to Obtain Consents and Follow Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for psychotropic and antidepressant medications for two residents, R156 and R308, and did not follow pharmacy recommendations. R308, who had multiple diagnoses including major depressive disorder and anxiety, was administered Clonazepam and Mirtazapine without signed consents or documented verbal consents in the electronic medical record. The facility's administrator and director of nursing acknowledged the absence of consents and highlighted the potential risks of administering psychotropic medications without them. Additionally, the facility's policy required that residents and their representatives be educated on the risks and benefits of psychotropic drug use, which was not adhered to in these cases. For R156, who had diagnoses including Alzheimer's Disease and unspecified psychosis, the facility did not have medication consents for Escitalopram and Olanzapine. Furthermore, the facility failed to complete the AIMS test as recommended by the pharmacist until the survey was conducted. The assistant director of nursing confirmed that the AIMS test should have been completed within a day of the pharmacy's recommendation. These oversights indicate a failure to comply with the facility's policy on psychotropic medication management and monitoring.
Lack of Documentation for Falls PIP
Penalty
Summary
The facility failed to provide documentation or evidence of their yearly Performance Improvement Projects (PIP) for falls, which they had identified as a problem-prone area. This deficiency was discovered during a QAPI/QAA task conducted with the surveyor, where the Administrator and Assistant Director of Nursing (ADON) were unable to locate any records of QAPI/QAA meetings or information regarding the facility's PIP. Additionally, there was no tracking or trending data available to demonstrate which interventions were implemented to address the fall PIP or their effectiveness in reducing falls within the facility. The facility's QAPI Feedback policy outlines the importance of collecting feedback from staff, residents, and family members to conduct structured investigations and analyses of problems affecting quality of care, quality of life, and resident safety. However, the lack of documentation and data collection indicates a failure to adhere to this policy. The ADON mentioned having interventions in mind but had not documented them, as she had only recently taken over the QAPI responsibilities. This lack of documentation and systematic data collection potentially affects all 90 residents residing in the facility.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to hold Quality Assessment and Assurance (QAA) meetings on a quarterly basis and did not have the appropriate committee members present at these meetings. During an interview and record review, it was revealed that the Medical Director did not participate in the last QAPI meeting since the Assistant Director of Nursing (ADON) took over two weeks prior. The Administrator provided sign-in sheets for the QAA meetings, with the last meeting held in June 2024. The ADON provided two sign-in sheets dated September 26, 2024, and October 3, 2024, which were not QAA meetings but rather introductory sessions on QAPI for staff. These sign-in sheets did not include the Medical Director's attendance. According to the facility's policy, the QAA committee should include the Director of Nursing and the Medical Director or their designee and meet at least quarterly.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
