St Anthony's Nsg & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Island, Illinois.
- Location
- 767 30th Street, Rock Island, Illinois 61201
- CMS Provider Number
- 145387
- Inspections on file
- 44
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at St Anthony's Nsg & Rehab Ctr during CMS and state inspections, most recent first.
The facility failed to ensure reasonable access to and privacy in telephone communication when it removed landlines and relied on shared unit cell phones that were often unanswered or inaccessible. At times there was no receptionist to answer ringing phones, and a unit landline was nonfunctional while the unit cell phone sat unattended in the nurse’s station. The ADON and administrator stated that each floor had one cell phone for both staff and resident use and that nurses were supposed to carry it, but they could not explain staff absences from the reception desk. Family members of two residents reported repeated problems reaching staff by phone, including unanswered calls, and an RN stated that the phone system was problematic and that residents could see staff text messages and other communications about other residents when using the shared cell phone.
A resident at moderate risk for skin impairment, who was severely cognitively impaired and dependent on staff for all care, did not have pressure-relieving interventions, repositioning schedules, or pressure ulcer care documented in the care plan, despite facility policies requiring comprehensive prevention and early intervention. The resident developed a facility-acquired coccyx pressure ulcer that progressed from a stage 3 wound with tunneling to an unstageable/stage 4 ulcer with visible bone and osteomyelitis, as documented by wound notes and a wound physician’s debridement and bone scraping. Nursing staff were unable to locate an initial wound assessment or clear onset date, and subsequent documentation described copious drainage, bone particles in the wound bed, and the need for IV antibiotics and debridement.
The facility lacked a full-time DON for several months, leaving an LPN in an assistant role to manage nursing needs without clear departmental leadership, which contributed to poor communication and documentation. In one case, a resident’s SLP notes continued to reference a G-tube and restricted oral intake, while nursing notes showed the G-tube had been pulled out and enteral feedings discontinued, and the SLP reported not being informed of this change. In another case, a dependent resident developed an in-house Stage 3 coccyx pressure ulcer with tunneling and osteomyelitis, but the wound nurse, an LPN, could not locate the initial wound assessment and dated the onset based on when she took over the position rather than when the ulcer actually developed.
The facility operated for several months without a DON, leaving an ADON who is an LPN to manage nursing needs and contributing to poor communication between nursing and therapy. The Administrator acknowledged ongoing communication problems, including no defined process for sharing therapy recommendations and no nursing access to therapy documentation. In this context, a resident’s G-tube was pulled out, enteral feeding orders were discontinued, and only site care was provided, yet speech therapy records continued to reflect that a feeding tube was in place with recommendations for puree diet and therapeutic feedings with the SLP only. The SLP later reported believing the tube remained in place and not being informed of its removal, illustrating the communication breakdown surrounding the resident’s G-tube management.
Surveyors found that resident rooms were maintained at unsafe, uncomfortable temperatures, with readings as low as the mid-50s despite residents wearing multiple layers of clothing, coats, and hats and reporting feeling cold. Temperature logs showed occupied rooms ranging from the mid-50s to upper-60s over several days. The building was heated by two steam boilers, but only one was operational, and the structure’s age, high ceilings, old windows, and multiple elevators allowed significant cold air infiltration, contributing to the facility’s inability to maintain adequate room temperatures.
A resident with multiple respiratory and cardiac conditions was admitted with physician orders for Albuterol nebulizer treatments every six hours. Facility records and interviews confirmed that the ordered nebulizer treatments were not transcribed or administered, and the resident reported not receiving the medication during their stay.
A resident with severe cognitive impairment and multiple risk factors for pressure injuries was not properly assessed for skin breakdown. Staff failed to document and stage superficial open areas found on the buttocks, and a stage 2 pressure injury later developed on the shoulder. Required wound assessments and documentation were not completed according to facility policy.
A resident with a history of a Stage IV sacral pressure ulcer was admitted without a timely skin assessment or initiation of wound care orders. The resident received no wound treatment for several days, and the care plan was not updated to address the worsening wound or the resident's non-compliance. The wound deteriorated significantly, developing necrosis and infection, and required multiple debridements.
The facility failed to document that staff received education on the benefits and risks of the COVID-19 vaccine. A review of consent forms showed three staff members were vaccinated, but there was no evidence of education provided, as required by the facility's policy. This oversight could impact all 82 residents.
A resident sustained a burn from a vape pen due to unsupervised smoking, contrary to the facility's policy requiring supervision. Additionally, the facility failed to conduct quarterly smoking assessments for several residents, only performing them annually. This oversight in policy adherence contributed to the incident and lack of monitoring of residents' smoking habits.
A resident was subjected to inappropriate conduct by a staff member, a Registered Nurse, who sent the resident an explicit photo and messages. The resident, who is cognitively intact, reported the incident, and the staff member admitted to sending the photo, citing a lack of friends outside of work. The facility's investigation confirmed the misconduct, leading to the staff member's termination.
A resident with Dementia was prescribed Quetiapine/Seroquel without appropriate indication, as required by facility policy. Despite the medication, the resident's behavior of constant yelling was not reduced, and the dosage was acknowledged to be higher than usual. Observations confirmed the resident's frequent calls for help, indicating insufficient use of non-pharmacological interventions.
A resident received twice the prescribed dosage of Seroquel for a month due to a transcription error by a nurse. The hospice physician had ordered 50mg three times daily, but the resident was given 100mg three times daily. The error was discovered through a review of the MAR, and no adverse effects were noted.
An LPN failed to change gloves during wound care for a resident with a pressure ulcer, violating infection control protocols. The LPN removed a soiled dressing, cleansed the wound, applied barrier cream, and placed a new dressing without changing gloves or performing hand hygiene. The DON confirmed the expectation for glove change and hand hygiene after removing soiled dressings.
The facility did not have the survey binder with State Agency survey results readily available for residents to review. During an annual survey, the binder could not be located, and Resident Council members were unaware of its existence or their right to review it. The administrator confirmed the binder was not accessible, impacting all 82 residents.
A facility failed to change a resident's indwelling catheter monthly as ordered and did not consistently monitor urinary output, leading to a urinary tract infection. The resident, with a neurogenic bladder, had no documented catheter changes during their stay, and sporadic urinary output records. This resulted in the resident being hospitalized with a UTI, hypoxia, and pneumonia.
A resident's family reported a missing ring, a valuable heirloom, to an LPN, who informed the AIT. Despite facility policy requiring immediate reporting of such incidents, the AIT did not notify the state agency or local authorities, citing no follow-up from the family.
The facility did not follow its abuse prevention policy by failing to conduct a background check on a contracted maintenance consultant with a known criminal history. The Operations Manager, aware of the consultant's criminal past, did not pursue necessary checks, citing the consultant's status as a contractor. This oversight potentially affects all 89 residents in the facility.
A CNA's unprofessional conduct, including loud arguments and inappropriate language in front of residents, led to a deficiency in maintaining a respectful and dignified environment. Despite resident complaints and documented incidents, the behavior persisted, causing discomfort and insecurity among residents.
The facility failed to maintain an effective pest management program, affecting all 80 residents. Multiple reports from residents and staff indicated the presence of large roaches in various areas, including shower rooms and hallways. A facility-wide tour confirmed these sightings. The facility's pest control efforts were inadequate, with terminated agreements and incomplete documentation from pest control companies, leading to ongoing pest issues.
The facility failed to provide consistent care and treatment for several residents, including improper wound care and mishandling of scabies treatment. One resident did not receive consistent wound care and repositioning, while another received incorrect doses of Ivermectin for suspected scabies. Additionally, a resident's scabies test was delayed, and another resident's wound care was not consistently provided. These deficiencies highlight a lack of adherence to treatment plans and necessary assessments.
A facility failed to implement isolation precautions for a resident suspected of having scabies. Despite a physician's order for strict contact precaution isolation, there was no signage or PPE in the resident's room. The resident, who had new bites, was observed outside their room, and the DON confirmed the resident was on contact precautions without a confirmed diagnosis.
A resident reported being treated roughly by a CNA, but the facility failed to follow its abuse policy by not suspending the accused CNA during the investigation. Instead, the CNA was moved to another floor, and the investigation remained incomplete. The resident's report was met with skepticism due to perceived inconsistencies and a report of the resident's confusion.
A resident with a history of mental health issues and substance use eloped from the facility unsupervised and returned exhibiting signs of intoxication. The facility failed to document the incident, notify the physician, or implement necessary interventions to prevent future elopements, despite staff awareness of the resident's tendencies.
Failure to Ensure Reasonable Access to and Privacy in Telephone Communication
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when it eliminated landlines and relied on shared cell phones that were often unanswered or inaccessible. A paramedic reported that dispatch could not reach anyone at the facility’s cell phone after landlines were removed. On one survey day, there was no receptionist at the front desk for over 20 minutes while the phone rang unanswered, and a housekeeper confirmed there was no receptionist that day and that the previous day’s receptionist did not arrive until midday. On the second floor, the landline was nonfunctional and the unit cell phone was left inside the nurse’s station while a CNA sat outside in the hallway area. The ADON stated each floor had one cell phone for staff and resident use, that nurses were supposed to carry the phones, and that a receptionist should be present from 8:00 AM to 8:00 PM to transfer calls, but could not explain the absence of a receptionist that morning. The Administrator stated that there was always supposed to be someone at the reception desk during daytime hours to answer calls and transfer them to the unit cell phones, and confirmed that after 8:00 PM there was no one to answer the phone and callers only reached a recording with options to leave messages for various departments. He also confirmed that police, paramedics, and fire stations did not have the unit cell phone numbers and could not call them directly after hours. Family members of two residents reported repeated problems reaching staff by phone, including calls that went unanswered at night and during the day, and stated that staff did not answer the unit cell phones. An RN reported that the phone system was a problem, that families complained about calls not being answered, and that the single shared cell phone on each floor was used for staff texting with physicians and other communications that residents could see when they used the phone, exposing information about other residents. The facility’s Resident Rights policy stated that residents were to be treated with dignity, respect, and fairness while safeguarding their rights, safety, and access to services.
Failure to Prevent and Properly Manage Facility-Acquired Pressure Ulcer With Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to implement and document appropriate pressure ulcer prevention and management for a resident identified as being at moderate risk for skin impairment. The facility’s own policies required comprehensive skin assessments, risk evaluations, pressure-relieving interventions, timely reassessment with any change in condition, and prompt notification of the nurse supervisor, medical provider, and wound nurse when new wounds or deterioration occurred. Despite Braden assessments indicating moderate risk, the resident’s care plan did not include pressure-relieving interventions, repositioning schedules, or documentation of pressure ulcer care. The resident was severely cognitively impaired and dependent on staff for all care, yet there was no initial assessment documented for when the coccyx pressure ulcer developed, and the wound nurse later stated she could not locate this initial assessment and had only documented that the pressure ulcer developed in July when she assumed her role. Over time, the resident developed a facility-acquired coccyx pressure ulcer that progressed from a stage 3 pressure injury with tunneling to an unstageable/stage 4 wound with osteomyelitis. Wound documentation on one date described a stage 3 full-thickness coccyx ulcer with a 2.2 cm tunnel and noted that the wound was acquired in-house with an unknown onset. A subsequent wound evaluation by a wound physician documented mechanical debridement of the coccyx wound, bone scraping to confirm osteomyelitis, copious bright red bleeding requiring direct pressure and calcium alginate with blood-stop granules, and instructions to keep the resident supine with direct pressure to the wound bed. Later nursing notes described bone particles visible in the wound bed and copious serosanguineous drainage. The resident ultimately required IV vancomycin for wound infection and debridement, and the wound nurse confirmed that the coccyx ulcer was a facility-acquired stage 3 pressure ulcer and that the resident grimaced or pulled away during dressing changes and debridements.
Lack of DON Oversight Leading to Communication and Documentation Failures
Penalty
Summary
The facility failed to ensure the nursing department was directed by a qualified full-time Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported the facility had been without a DON for several months, and the Assistant Director of Nursing, an LPN, stated the former DON left approximately eight months prior and the position had not been replaced. The Administrator also stated there were communication issues between departments, that nursing staff did not have access to therapy documentation, and that there was no defined process for communicating therapy recommendations. For one resident with a history of a gastrostomy tube (G-tube), speech therapy documentation over a two‑month period indicated the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). Nursing progress notes documented that the resident had pulled out the G-tube and that enteral feeding orders were discontinued, with only G-tube site care continued. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube remained in place and had not been informed that the resident had pulled out the G-tube and that it was not reinserted. In a separate case, wound documentation for another resident showed an in-house acquired Stage 3 pressure ulcer to the coccyx with tunneling and subsequent bone debridement and treatment, including involvement of a wound doctor and infectious disease due to osteomyelitis and kidney failure considerations. The wound nurse, an LPN, confirmed the pressure ulcer developed at the facility and that the resident was dependent on staff for all care, but was unable to locate the initial assessment from when the pressure ulcer developed, stating she documented the pressure ulcer as developing in July only because that was when she assumed the wound nurse role. These findings demonstrate missing leadership and oversight in the nursing department, as well as gaps in communication and documentation related to resident care and assessments.
Lack of DON Oversight and Poor Nursing–Therapy Communication on G-Tube Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure the nursing department was directed by a qualified Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported that the facility had been without a DON for several months and acknowledged communication issues between departments, including the absence of a defined process for communicating therapy recommendations and the lack of nursing staff access to therapy documentation. The Assistant Director of Nursing, an LPN, stated that the former DON had left approximately eight months earlier and that the position had not been replaced, leaving her to manage nursing needs to the best of her ability. For one resident reviewed for G-tube management, speech therapy documentation over a period of time recorded that the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). However, nursing progress notes documented that the resident had pulled out her G-tube, that enteral feeding orders were discontinued by a nurse practitioner, and that G-tube site care was initiated. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube was still in place and had not been informed that the G-tube had been removed and not replaced, demonstrating a breakdown in communication about the resident’s G-tube status and care needs.
Failure to Maintain Safe and Comfortable Resident Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures at a comfortable, safe level for multiple residents during a period of substandard indoor temperatures. Surveyors measured room temperatures for three residents on the second floor, finding readings between 59.9 and 62.4 degrees using an infrared thermometer. One resident was observed in a wheelchair wearing multiple layers of clothing and a knitted hat and stated he was cold and that his room had been cold for the past week. Another resident was seated in an easy chair wearing multiple layers of clothing, a coat, and a hat and also stated he was cold. A third resident was seated on his bed in multiple layers of clothing and stated it was cool in his room. Facility temperature logs for occupied rooms over several days documented random room temperatures ranging from 54 to 68 degrees. The facility’s heating system consisted of two steam boilers, with only one boiler functioning at the time of the survey. The Administrator stated that the working boiler had the capacity to heat the entire building but acknowledged the facility had been having trouble maintaining air temperatures inside the building for about a week due to sub-zero wind chills. The Maintenance Director reported that the building is over 100 years old, with high ceilings, large old windows, and multiple elevators that allow cold air to enter without restriction, and that one boiler was shut down due to the need for major repairs. He stated that he had taken temperatures in all resident rooms twice daily and that resident room temperatures had ranged from 54 to 68 degrees. These conditions occurred despite the facility’s policy on emergency procedures for heat loss, which directs staff to quickly assess loss of heating and determine if remediation is possible or if partial or full evacuation is necessary.
Failure to Administer Physician-Ordered Nebulizer Treatments
Penalty
Summary
A resident with a history of acute respiratory failure with hypoxia, pneumonia, COPD with acute exacerbation, chronic systolic heart failure, atrial fibrillation, and hypertension was admitted to the facility with hospital discharge orders for Albuterol nebulizer treatments every six hours. The facility's Medication Administration Policy requires accurate administration of all medications as ordered. Review of the resident's medical record, order summary, and medication administration records showed no documentation that the prescribed nebulizer treatments were administered. The resident reported not receiving any nebulizer treatments during their stay and stated that they requested discharge due to not receiving necessary medication. The facility nurse practitioner confirmed that the nebulizer treatment orders were neither transcribed nor administered as ordered.
Failure to Identify and Assess Pressure Injuries in High-Risk Resident
Penalty
Summary
The facility failed to identify and properly assess pressure injuries in a resident who was admitted with severe cognitive impairment, was dependent on staff for all care, and was at high risk for pressure injuries due to conditions such as severe protein-calorie malnutrition, anemia, Alzheimer's Disease, and incontinence. Upon admission, the resident had no open wounds, but was always incontinent and required frequent repositioning and assistance with mobility. Despite these risk factors, the facility did not document any open wounds at admission. On 6/4/25, nursing progress notes indicated the presence of two small superficial open areas on the resident's buttocks, but there was no documentation of measurements, staging, or a thorough assessment of these wounds. Later, on 6/24/25, a new stage 2 pressure injury was identified on the resident's right shoulder, with measurements recorded. Interviews with staff confirmed that skin checks should have been performed regularly and that wounds should have been identified and documented before advancing to stage 2. The facility's own policy required detailed documentation of wound type, stage, location, size, and other characteristics, which was not followed in this case.
Failure to Initiate Admission Skin Assessment and Wound Care Orders
Penalty
Summary
The facility failed to initiate a skin assessment upon admission, did not implement admission wound care orders, and did not develop an appropriate wound care plan for a resident with a known sacral pressure wound. Upon transfer from another facility, the resident had a history of a Stage IV sacral pressure ulcer, with documentation from the previous facility indicating the wound was being treated and managed. However, after admission, no skin assessment was completed within the required timeframe, and wound care orders were not initiated until several days later, resulting in a lapse in treatment. During the period without wound care, the resident received no wound treatment, and there was no documentation of a skin assessment until a wound physician evaluated the resident days after admission. The wound had significantly deteriorated by the time it was assessed, with the presence of thick, adherent black necrotic tissue (eschar) and an increase in wound size. The care plan was not updated or revised to reflect the worsening condition, changes in treatment, or the development of infection, despite multiple debridements and ongoing wound management needs. Interviews with facility staff confirmed that the required admission skin assessment was not completed, and the initial care plan did not address the resident's non-compliance with wound care interventions or include necessary pressure relief equipment. The resident's medical history included multiple comorbidities such as diabetes, paraplegia, and neurogenic bladder, which increased the risk for skin breakdown. The lack of timely assessment, failure to implement wound care orders, and inadequate care planning contributed to the progression of the resident's pressure ulcer to a severe, necrotic state.
Lack of Documentation for COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document that staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccination. This deficiency was identified during a review of employee COVID-19 consent forms, which showed that three staff members received the COVID-19 vaccination, but there was no documentation indicating they or any other staff received the necessary education. The facility's policy, last revised on 10/14/24, mandates that educational materials about the benefits, risks, and availability of vaccines be provided to all employees. However, the Assistant Director of Nursing and Infection Preventionist confirmed the absence of such documentation, which has the potential to affect all 82 residents in the facility.
Failure to Prevent Smoking-Related Injury and Conduct Assessments
Penalty
Summary
The facility failed to prevent a resident from sustaining a smoking or vape-related burn and did not complete quarterly Smoking Assessment Evaluations for several residents. One resident, identified as R46, sustained a burn on his right forearm, which he attributed to his vape pen. Despite the facility's policy requiring smoking to be supervised and assessments to be conducted quarterly, R46 was able to smoke unsupervised, leading to the injury. The resident's care plan noted his non-compliance with the smoking policy, as he would leave the unit unattended to smoke at undesignated times. Additionally, the facility did not complete the required quarterly smoking assessments for residents R33, R46, R51, and R79. The facility's policy mandates that these assessments be conducted upon admission, quarterly, and with any change in condition. However, the facility was only conducting these assessments annually, as confirmed by the administrator. This lack of adherence to the policy contributed to the oversight in monitoring the residents' smoking habits and ensuring their safety.
Resident Subjected to Inappropriate Conduct by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. A cognitively intact resident, identified as R33, reported receiving an inappropriate nude photo and messages from a staff member, V8, who is a Registered Nurse. The incident was documented in a facility-reported incident report, where R33 showed a staff member a picture of a woman's naked vagina and messages sent from V8's phone number. The messages were inappropriate and included a reference to a 'holocaust victim.' R33 expressed that while he was not overly upset, the messages were inappropriate and should not have occurred. Upon investigation, V8 initially denied sending the explicit photo but later admitted to sending it to R33, acknowledging it was inappropriate. V8 stated she sent the photo because she does not have many friends outside of work. The facility's investigation concluded that V8 was guilty of sending the explicit photo, and she was subsequently terminated from her position. The report highlights a failure in the facility's responsibility to ensure residents are free from abuse, as outlined in their Abuse and Neglect Prevention policy.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to provide an appropriate indication for the use of an antipsychotic medication for a resident diagnosed with Dementia. The resident, identified as R21, was prescribed Quetiapine/Seroquel, an antipsychotic medication, initially at a dose of 100mg twice daily, which was later increased to 100mg three times daily. The facility's policy on psychotropic medications requires that such drugs are only administered when necessary to treat a specific condition, with documented clinical justification. However, the report indicates that the use of Seroquel did not effectively reduce the resident's behavior of constant yelling, which was the primary behavior being addressed. The resident's care plan noted behaviors such as verbal aggression, yelling out exaggerated claims, and attention-seeking actions, but these behaviors were not sufficiently managed by the medication. The Director of Nursing acknowledged that the medication had not reduced the resident's yelling behavior and that the dosage was higher than usual. Observations over two days confirmed the resident's frequent calls for help, indicating that the non-pharmacological interventions were not effectively utilized or documented as required by the facility's policy.
Significant Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was prescribed an antipsychotic medication. The error involved a resident who was observed frequently calling out for help. The hospice physician had ordered Seroquel 50mg to be administered three times per day. However, due to a transcription error by a nurse, the resident received Seroquel 100mg three times per day, resulting in the resident receiving twice the prescribed dosage from January 27, 2025, to February 27, 2025. The error was discovered when reviewing the Medication Administration Record (MAR), which indicated the incorrect dosage was administered for a month. The Director of Nursing confirmed the error and noted that the nurse responsible for the transcription error had already been terminated for unrelated reasons. Despite the error, no adverse effects were noted at the time of discovery.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for a resident with a pressure ulcer. A Licensed Practical Nurse (LPN) did not change gloves after removing a soiled dressing from the resident's right buttock wound. The LPN proceeded to cleanse the wound, apply barrier cream, and place a new dressing without changing gloves or performing hand hygiene, which is against the standard infection control procedures outlined in clinical nursing guidelines. The resident's electronic medical record indicated a physician's order to cleanse the wound with normal saline, apply barrier cream, and cover with border gauze daily and as needed until healed. During an observation, the LPN confirmed not changing gloves after removing the soiled dressing. The Director of Nursing later confirmed that the expectation was for the LPN to change gloves and perform hand hygiene after removing the soiled dressing, highlighting a lapse in adherence to infection control protocols.
Survey Binder Not Accessible to Residents
Penalty
Summary
The facility failed to make the survey binder, which contains the results of State Agency surveys, readily available and in a conspicuous place for residents to review. This deficiency was identified during the facility's annual survey conducted by the State Agency on February 25 and 26, 2025, when the survey binder could not be located. Interviews with members of the Resident Council revealed that they were unaware of the existence of the survey binder and their entitlement to review the survey results. The facility's administrator confirmed that the binder was not readily available to residents, affecting all 82 residents residing in the facility.
Failure to Change Catheter and Monitor Output Leads to UTI
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency. The resident, who had a neurogenic bladder, was ordered to have their 16 French indwelling catheter changed every month and as needed. However, there was no documentation in the resident's Treatment Administration Records indicating that the catheter was ever changed during their stay at the facility. Additionally, the facility did not consistently monitor the resident's urinary output, as required, with only sporadic entries found in handwritten day sheet notes. This lack of monitoring and catheter care contributed to the resident developing a urinary tract infection, which was treated with antibiotics. The deficiency was further highlighted when the resident was sent to the emergency room due to symptoms of hypoxia, pneumonia, and a urinary tract infection associated with the indwelling catheter. The Director of Nursing confirmed the absence of documentation for catheter changes and was unaware of any issues with the resident's catheter. The resident's doctor emphasized the importance of changing the catheter monthly to prevent infections, which were evident in this case. The failure to adhere to the physician's orders and monitor the resident's condition adequately resulted in the resident's hospitalization for further treatment.
Failure to Report Misappropriation of Resident's Jewelry
Penalty
Summary
The facility failed to report an allegation of misappropriation of jewelry to the state agency or local law enforcement for a resident. The facility's policy mandates that any suspected acts of misappropriation should be reported immediately to the nursing home Administrator/Designee and subsequently to the state agency and local authorities. However, in this case, the Administrator In Training (AIT) did not report the missing ring to the state agency or local authorities after being informed by the Licensed Practical Nurse (LPN) that the resident's family member had reported the ring missing. The incident involved a resident whose family member noticed a missing ring, which was a valuable and irreplaceable family heirloom, on the day the resident was sent to the hospital. The family member reported the missing ring to the LPN, who then notified the AIT, designated as the Abuse Coordinator. Despite this notification, the AIT did not take further action to report the incident to the appropriate authorities, citing a lack of follow-up from the family as the reason for inaction.
Failure to Conduct Background Check on Contracted Employee
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing a background check on a contracted maintenance consultant with a known criminal history. The facility's policy mandates that all prospective healthcare employees undergo a criminal history background check to ensure a safe environment for residents, staff, and visitors. However, the Operations Manager did not pursue the necessary background checks, including fingerprinting, for the maintenance consultant, citing that as a contracted consultant from another company, the facility was not required to perform these checks. This oversight has the potential to affect all 89 residents currently residing in the facility. Interviews and record reviews revealed that the Human Resources personnel, responsible for overseeing employee and consultant background checks, were unaware if the maintenance consultant's background and fingerprint results were completed. The consultant's pre-employment background check authorization indicated a criminal conviction, and the health care worker registry did not list the consultant. Additionally, the consultant's employee file was missing the Fee App or Eligibility to work documentation. Despite being aware of the consultant's criminal history, the Operations Manager did not take further action to ensure compliance with the facility's background check policy.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to a dignified existence and self-determination by not providing an environment of respect and dignity. This deficiency was evident in the behavior of a Certified Nursing Assistant (CNA), identified as V7, who engaged in unprofessional conduct in the presence of residents. Multiple residents reported incidents where V7 was involved in loud arguments and used inappropriate language with other staff members, causing discomfort and a sense of insecurity among the residents. The facility's Resident Council Minutes and Grievance/Complaint Reports documented several instances of V7's disruptive behavior. Residents expressed their concerns during council meetings, highlighting V7's tendency to yell and curse in front of them. Despite these complaints, the behavior persisted, with V7 being involved in multiple altercations, including a physical confrontation with another CNA, V13, in the facility lobby. These incidents were not only disruptive but also violated the facility's policies on maintaining a respectful and safe environment for residents. Interviews with residents further corroborated the reports of V7's inappropriate conduct. Residents described feeling uncomfortable and unsafe due to V7's actions, which included yelling, cursing, and engaging in confrontations with other staff members. The Director of Nursing acknowledged being unaware of the full extent of the incidents until recently, despite previous counseling sessions with V7. The failure to address these issues promptly and effectively contributed to the deficiency in maintaining a respectful and dignified environment for the residents.
Ineffective Pest Management Program
Penalty
Summary
The facility failed to maintain an effective pest management program, which has the potential to affect all 80 residents residing in the facility. Multiple residents and staff members reported sightings of large roaches, some with wings, in various areas of the facility, including shower rooms, soiled linen rooms, hallways, and individual rooms. These reports were corroborated by a facility-wide tour, during which a cockroach with parasites was observed in a hallway. Residents expressed concerns about being bitten by these pests, and staff members noted that the insects were more prevalent at night. The facility's pest control efforts were found to be inadequate. The facility had terminated an agreement with a pest control company in February 2024 due to a significant bill and had not effectively engaged another service provider. Documentation from a second pest control company was incomplete, and the company could not be contacted. A third pest control company had only provided a quote for future services and had not yet performed any pest control activities at the facility. This lack of a consistent and effective pest control program contributed to the ongoing pest issues within the facility.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to implement appropriate care for residents, as evidenced by the lack of wound care and other treatments for several residents. One resident, identified as R1, had multiple wounds that were not treated consistently over several months. The resident's treatment records showed numerous instances where wound care, weighing, and application of barrier cream and extensor brace were not conducted as ordered. Additionally, the resident was observed lying in bed for extended periods without repositioning, despite being at high risk for pressure ulcers. Another resident, R2, was suspected of having scabies, but the treatment and follow-up were mishandled. The resident received incorrect doses of Ivermectin, and there was a delay in administering the correct dose. Furthermore, the resident's records lacked documentation of ongoing skin assessments and the results of a scabies test, which was ordered but not completed in a timely manner. Similarly, R4 also had suspected scabies, but the medication was not administered as ordered, and there was confusion regarding the scabies test. The resident reported new bites and expressed concern about the lack of confirmed diagnosis and treatment. Additionally, R6's records indicated that wound care was not consistently provided for various wounds, including pressure ulcers. The facility's failure to adhere to treatment plans and conduct necessary assessments contributed to the deficiencies identified in the care of these residents.
Failure to Implement Isolation Precautions for Suspected Scabies
Penalty
Summary
The facility failed to implement isolation precautions as ordered for a resident suspected of having scabies. The Scabies Policy requires the use of gloves and gowns when providing direct care to residents suspected or confirmed to have scabies, along with implementing contact precautions. Despite a physician's order placing the resident on strict contact precaution isolation, observations on July 29 revealed the absence of contact precaution signage and personal protective equipment in the resident's room. The resident expressed confusion about the lack of adherence to isolation protocols, noting new bites on various parts of their body. Additionally, the resident was observed at the nurse's station, indicating a breach in isolation protocol. The Director of Nursing confirmed the resident was on contact precautions, although a test to confirm the diagnosis was not obtained.
Failure to Implement Abuse Policy During Investigation
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by the handling of an incident involving a resident who reported being treated roughly by a Certified Nursing Assistant (CNA). The facility's policy mandates that any employee accused of abuse should be immediately removed from the facility to protect the resident during the investigation. However, in this case, the alleged perpetrator, a CNA, was not suspended but merely moved to another floor, despite the resident's report of the CNA grabbing her face and chin. The facility's investigation was still incomplete at the time of the report, and the CNA continued to work in the facility during the investigation period. The incident involved a resident who reported the rough treatment to another CNA during the third shift. The resident's Power of Attorney and physician were notified, and an investigation was initiated. Despite the resident's report and the concern expressed by another CNA, the facility administrator decided not to suspend the accused CNA due to perceived inconsistencies in the resident's story and a report from the resident's granddaughter about the resident's increasing confusion. This decision was made even though the facility's policy clearly states that accused employees should be removed pending the outcome of the investigation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to accurately assess a resident at risk for elopement and did not implement necessary interventions, resulting in the resident eloping from the facility unsupervised. The resident, who had a history of mental health issues and substance use, was found by a city bus driver sleeping on a park bench and was returned to the facility exhibiting signs of intoxication. Despite this incident, there was no documentation of the event in the resident's record, no notification to the physician, and no medications were held as per the facility's policy. The resident's care plan did not reflect his repeated statements about wanting to leave the facility or his risk of elopement. Staff interviews revealed that the resident had previously left the facility with a friend and returned in an impaired state, yet no formal interventions were put in place to prevent future elopements. The resident was able to use the elevator freely, which facilitated his unsupervised departure from the facility. The facility's policies on elopement and drug-free environment were not followed, as evidenced by the lack of documentation and appropriate response to the resident's behavior. Staff members were aware of the resident's tendencies and previous incidents but did not take adequate measures to ensure his safety. The facility's failure to address these issues led to the resident's unsupervised elopement and subsequent return in a compromised state.
Removal Plan
- An elopement binder is kept at the front desk identifying those residents who may pose a risk for attempted elopement or wandering out of the facility.
- All Staff are being re-educated on: Elopement/Elopement risks amongst residents (including wandering), Managing behaviors and effective interventions, Resident Drug Free Environment. This training is being conducted with employees in the building as they report to work until all employees have received the training (including any agency staff on duty). This training has also been uploaded to the nursing staff agency the facility occasionally uses so that all staff coming to the facility will be required to complete the education before their first/next scheduled shift at the facility.
- All current residents are being re-evaluated for elopement risk and care plans updated accordingly with any new interventions. New residents are evaluated upon admission and then re-evaluated as changes are indicated. Interventions and risks are reviewed and revised accordingly minimally at care plan reviews, more often as indicated.
- In order to assure ongoing compliance, the Administrator and/or designee shall conduct an audit of 10 residents per week to assure that all elopement assessments are up-to-date and current care plan interventions in place. Any issues shall be addressed immediately and corrected with findings reviewed at the quarterly QAPI meeting. Behavior Committee meetings to be held one time per month to review residents requiring behavioral monitoring, use of antipsychotics and GDRs being conducted, elopement risks/factors, etc.
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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