The Haven Of Bement.
Inspection history, citations, penalties and survey trends for this long-term care facility in Bement, Illinois.
- Location
- 601 North Morgan, Bement, Illinois 61813
- CMS Provider Number
- 145948
- Inspections on file
- 30
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at The Haven Of Bement. during CMS and state inspections, most recent first.
Two residents were not protected from abuse by their roommates. A non-verbal, quadriplegic resident who was totally dependent for ADLs reported through yes/no responses that an ambulatory roommate with multiple psychiatric and substance use diagnoses punched him in the stomach on three occasions when upset, causing pain and fear. In a separate situation, a resident with moderate cognitive impairment and depression reported being yelled at, cursed at, and called derogatory names by a cognitively intact roommate with dementia and other psychiatric conditions; staff had previously heard a loud verbal altercation between the two and noted that the victimized resident was very upset. Although the facility’s abuse policy defines and prohibits physical and verbal abuse, the Administrator initially treated the reported verbal aggression as a grievance rather than potential abuse, and the facility failed to prevent or adequately recognize these abusive interactions between residents.
QAA committee meetings were not held at the required quarterly frequency, and the DON was not documented as attending two meetings. Survey review found long gaps between documented QA meetings, and the Administrator confirmed the meetings were not timely for 2025. The facility policy required the QAA committee to meet at least quarterly and include the DON among attendees.
Antibiotic Stewardship Program Not Properly Implemented: The facility failed to develop and implement an antibiotic stewardship program with protocols for appropriate ABX use, monitoring of outcomes, resistance, and adverse events, and use of standardized criteria to assess infections. Review of the antibiotic use logs showed they did not document resident symptoms, onset or resolution of infection signs, whether standardized criteria were used to justify ABX use, or whether response to treatment was monitored. The logs also did not show if empiric ABX therapy was changed or if residents had adverse events after ABX use.
The facility failed to timely investigate and report multiple allegations of resident-to-resident verbal abuse to the state agency. A cognitively impaired resident reported being yelled and cursed at by a roommate and expressed fear of this resident. A CNA and a psychotherapist/LCSW separately reported verbal altercations between the two residents to the Administrator and other staff, but no investigation was initiated, no staff interviews were conducted, and the required notification to the Department of Public Health was not made at the time of the initial reports. These actions were inconsistent with the facility’s abuse prevention policy, which requires immediate reporting and accurate, timely investigative reports for all abuse allegations.
The facility failed to investigate and respond appropriately to repeated allegations of verbal abuse between two roommates, one with moderate cognitive impairment and one cognitively intact. A resident reported being yelled at, cursed at, and called derogatory names by her roommate and expressed fear of further incidents. Staff, including a CNA and a psychotherapist/LCSW, had previously reported verbal altercations to the Administrator/Abuse Prevention Coordinator, but the Administrator treated the matter as a grievance, did not document it, did not initiate an abuse investigation, did not interview involved staff or residents, and did not promptly separate the residents. These actions were inconsistent with the facility’s Abuse Prevention Policy, which requires documentation, investigation, and protective measures, including separation of residents when abuse is alleged.
The facility failed to maintain complete and accurate medical records when staff did not document multiple incidents and allegations of verbal abuse between two roommates. One resident reported being yelled at and called offensive names by her roommate and expressed fear of further retaliation, while a CNA and a psychotherapist/LCSW both observed or learned of loud, upsetting verbal altercations and reported them to the Administrator/Abuse Prevention Coordinator and nursing staff. Despite these reports and the separation of the roommates, there was no timely documentation of the abuse allegations, staff notifications, or resident monitoring in either resident’s chart, and only late backdated social service notes were entered, contrary to facility policies requiring documentation of all incidents, allegations of abuse, and changes in condition.
A facility failed to provide timely toileting assistance for four residents who were unable to toilet independently. One resident with MS, urinary conditions, reduced mobility, and complete dependence for toileting hygiene reported waiting well over 30 minutes after using the call light for a bedpan or urinal and sometimes having toileting accidents while waiting. An LPN reported complaints about delays on evening and night shifts, and three other residents also reported accidents while waiting for staff to respond. The facility policy stated call lights should be answered as soon as possible.
A resident was involuntarily discharged for being a threat to another resident’s personal safety, but the EMR lacked a physician note documenting the basis for the discharge, the specific needs that could not be met in the facility, the attempts made by the facility to meet those needs, and the services available at the receiving facility. The Administrator and DON/Regional Consultant confirmed that no such physician documentation existed in the record, and the Administrator acknowledged not being aware of all requirements for an involuntary discharge.
A resident with multiple psychiatric and substance use diagnoses received an emergency involuntary discharge notice that lacked required information about appeal rights and advocacy agencies. The notice did not include the mailing and email address of the entity to receive an appeal, nor instructions on obtaining, completing, and submitting an appeal form. It also omitted the name, mailing address, email address, and phone number of the State LTC Ombudsman and the agency responsible for protection and advocacy of individuals with mental illness. The Administrator and DON later confirmed that these required elements were missing and that the Administrator was unaware of all requirements for an involuntary discharge notice.
A resident with intact cognition, ADL assistance needs, and wheelchair use for mobility fell after trying to self-transfer to the bathroom. The incident review found the bed wheels were not locked, and the resident also had no skid socks on when found on the floor.
Failure to use PPE for a resident on droplet precautions for MRSA in a trach. A resident with lung cancer, COPD, and trach status had a sputum culture showing MRSA, with orders and care plan directing contact/droplet precautions and PPE use. A housekeeping director entered the room to answer a call light, removed the resident’s thermal cup, and left without hand hygiene, gloves, or a gown; she wore only a surgical mask already used elsewhere in the facility.
A resident reported that personal ear buds went missing after the room was deep cleaned and, using a phone tracking function, identified their location at an address associated with two CNAs. The resident reported the suspected theft to the Administrator, expressed a desire to press charges, and stated that no police officer spoke with the resident and that the Administrator later said no charges would be pressed. The resident had to purchase replacement ear buds with personal funds while waiting for the facility to replace them and requested reimbursement. The resident reported feeling upset and angry about the theft and the delay in replacement, and surveyors determined the facility failed to protect the resident from misappropriation of property and to replace the misappropriated item in a reasonable time frame, resulting in psychosocial harm.
A resident experienced an 8% weight loss over a short stay, with documented rapid early weight loss and frequent meal intake of less than 50%, yet staff did not recognize or act on this as significant. Despite policies requiring monitoring of nutrition, identification of weight loss, and notification of the physician, RD, and family, the LPN, NP, RD, and primary care physician all confirmed they were not informed of the resident’s weight loss or poor intake, and the family was also not notified. A therapist reported the resident’s decline in ability to eat and need for assistance, but no further assessment or interventions were initiated. Concurrently, the resident’s potassium levels trended downward while in the facility, and the resident was later hospitalized with hypokalemia attributed by the hospitalist to severe malnutrition and dehydration due to lack of adequate food and fluids.
The facility lacked an effective process to verify the identity and CNA certification of agency staff, allowing an uncertified individual to work an entire CNA shift under another person’s name obtained through a staffing agency. The individual used the other CNA’s identity to access the EMR and provide direct care, while the administrator relied solely on the agency profile and did not independently confirm credentials on the state registry. Subsequent review showed the worker was not listed as a CNA on the Health Care Workers Registry and was only eligible for non‑CNA roles, affecting all 39 residents in the facility.
An uncertified individual worked an entire CNA shift under another CNA’s identity after being supplied through an agency, using the other CNA’s profile to access the EMR and provide resident care. The administrator acknowledged relying on the agency profile, did not verify the individual’s CNA status on the HCWR, and did not report the false identity and uncertified caregiving to the state agency. The scheduled CNA later confirmed not having accepted the shift, while another CNA reported that the uncertified worker was on duty for most of the day and engaged in a yelling altercation in front of residents in common and resident areas, affecting all 39 residents in the facility.
Two residents experienced significant unplanned weight loss and poor meal intake without required notification to their physician, RD, or family, in violation of facility policy. One resident with diabetes and coordination issues lost 8% of body weight over a short stay, with many meals documented as less than 50% consumed and some intake undocumented; an LPN acknowledged not notifying the physician or family, and the NP, RD, physician, and family all confirmed they were not informed. Another resident with multiple acute conditions, including fractures, acute anemia, AKI on CKD, and A-fib, lost 19% of body weight over several weeks, yet the NP, physician, and family member each reported they had not been notified of this weight loss. The DON confirmed both residents had significant weight loss and that required notifications to the physician, RD, and family were not made.
Staff failed to report a verbal altercation and threats between CNAs that occurred in resident care areas and in front of multiple residents, including in a resident’s room and the cafeteria. One CNA yelled, made racially derogatory comments, and threatened coworkers following a dispute over which staff member was responsible for a resident who had not been cared for since early morning. Law enforcement was called, and during the investigation the administrator learned that the CNA involved in the altercations was not listed as a CNA on the registry, despite having worked a full shift in that role. The administrator knew of the incident but did not report either the staff altercation or the use of an unqualified individual as a CNA to proper authorities.
A resident discovered personal ear buds missing after a deep cleaning of their room and, using a phone tracking function, identified the device at an address shared by two CNAs. The resident reported the suspected theft to staff, and the facility documented that local police were notified; however, the resident later stated they never spoke with law enforcement and still wished to press charges. The Administrator reported having called the local police, but the local sheriff’s office had no record of any call, dispatch, or report from the facility. This sequence of events shows the facility failed to timely and effectively report the misappropriation of the resident’s property to law enforcement, contrary to its abuse prevention policy.
Two residents experienced harm due to the facility's failure to maintain transport equipment, properly secure a resident during van transport, and implement individualized fall interventions. One resident suffered significant injuries after falling from a wheelchair in a van with a faulty seatbelt, while another experienced multiple unwitnessed falls without root cause analysis or appropriate care plan updates. Staff did not consistently follow protocols for safe transfers or use required equipment.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, resulting in missed RN coverage on two days and limiting the ability to provide services such as IV medication administration for all residents.
A resident with a urinary catheter experienced a catheter-associated urinary tract infection (CAUTI) due to the facility's failure to monitor and report changes in urine characteristics. Despite symptoms such as hematuria and mucus in the urine, the facility delayed notifying the physician and implementing Enhanced Barrier Precautions (EBP). The resident's urine culture results, indicating resistance to the prescribed antibiotic, were not reported promptly, leading to delayed treatment and hospitalization.
The facility failed to provide adequate CNA staffing, resulting in delayed response to call lights and missed showers for residents. Observations and staff interviews confirmed that only two CNAs were working during certain shifts, despite the need for more staff due to resident acuity. The administrator acknowledged the staffing issues, which were confirmed by the facility's schedules.
The facility failed to staff a full-time DON, potentially affecting all 32 residents. Observations over three days showed no DON present, and the nurse schedule lacked documentation of a full-time DON. The administrator confirmed the absence of a full-time DON since December 2023.
The facility did not document registry verifications of nurse aide competency for five newly hired nurse aides before they began working, potentially affecting all 32 residents. The checks were delayed until after the aides had started, despite being hired in October and November. The administrator confirmed the lack of documentation proving checks were done before employment.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, with the Dietary Manager lacking necessary qualifications and the dietician working only one day per month. This led to unsanitary food storage and unplanned resident diets, potentially affecting all 32 residents.
The facility failed to maintain sanitary conditions in the kitchen's walk-in cooler, affecting all 32 residents. Surveyors observed the cooler's flooring soiled with decomposed food debris and spilled liquids. The Dietary Manager could not identify the source of the liquids, and the condition remained unchanged over several days. The food in the cooler is available for all residents, indicating a potential widespread impact.
The facility failed to effectively monitor resident infections and develop a comprehensive water management plan to mitigate Legionella risk. Infection logs showed multiple UTIs and E. Coli infections without documented corrective actions beyond hand hygiene training. The Maintenance Director was unaware of the Legionella plan and had not completed a required risk assessment, leaving potential risk areas unaddressed.
The facility failed to implement its antibiotic stewardship policy, as evidenced by incomplete documentation and lack of evaluation of clinical data for appropriate antibiotic use. A resident was treated with an antibiotic for pneumonitis, which is not an infection, without documented symptoms. The Infection Preventionist was unfamiliar with the stewardship program and had not used assessment tools to determine infection criteria, potentially affecting all 32 residents.
The facility failed to document and follow up on grievances regarding missing personal items for several residents. Despite the facility's Grievance Policy requiring investigation and reporting of findings, there was no documented follow-up or resolution for grievances reported during resident council meetings. Staff members were informed, but the facility did not maintain proper records or adhere to its grievance policy, leading to the deficiency.
The facility failed to serve pureed diets as planned, affecting three residents who did not receive pureed bread and sugar cookies with their meals. Observations showed the absence of these items, and the Dietary Manager confirmed that pudding was served instead due to staff not preparing the cookies.
The facility failed to provide scheduled showers and personal hygiene care for three residents who depend on staff assistance. One resident did not receive a shower for 13 days, another went 12 days without a shower due to staffing issues, and a third was observed with unremoved facial hair despite scheduled grooming. These deficiencies indicate non-compliance with the facility's policies and residents' care plans.
A facility failed to safely perform a mechanical lift transfer for a resident. The CNA did not use the leg strap on the sit-to-stand lift, contrary to the facility's policy. The resident, who has impaired range of motion and requires assistance for transfers, was not documented to use a mechanical lift or leg strap in their care plan. The Director of Rehab stated that the leg strap should be used for all residents during transfers.
The facility failed to provide adequate respiratory care for two residents. One resident with a tracheostomy did not have their oxygen mask replaced weekly, and a replacement tracheostomy was not kept at the bedside. Another resident with COPD received oxygen at a higher rate than prescribed. These actions indicate non-compliance with facility policies and physician orders.
Two residents experienced significant medication errors due to the facility's failure to ensure medications were available and administered as ordered. One resident missed doses of Losartan due to unavailability, with no physician notification. Another resident missed insulin doses, with no documentation of physician notification, and Novolog was unavailable on one occasion.
The facility failed to offer and document pneumococcal vaccinations for three residents, leading to a deficiency in immunization practices. Despite guidelines and facility policy, a resident with chronic conditions was not documented as being offered the vaccine, and two other residents had outdated vaccination records without further offers or documentation. The Infection Preventionist/MDS Coordinator admitted to not managing the vaccinations due to uncertainty about the schedule.
A resident's medications were found crushed in the garbage, and an LPN reported the incident to the administrator, who failed to respond or initiate an investigation as required by facility policy. No report was made to the Department of Public Health regarding the suspected misappropriation.
A resident's crushed medications were found discarded in the garbage by an LPN, who promptly reported the incident to the administrator. The administrator failed to follow up, conduct interviews, or initiate any investigation or documentation, in violation of the facility's abuse prevention policy.
A resident with epilepsy did not receive scheduled seizure medications when an agency nurse was unable to administer them due to a missing PEG tube adapter, resulting in the medications being found discarded. The incident was reported verbally to the administrator and during shift change, but no follow-up, documentation, or required reporting was completed by the administrator or staff, contrary to facility policy.
A resident with multiple diagnoses experienced a significant increase in Risperdal dosage, leading to lethargy and inability to eat. Despite facility policy, the RN did not notify medical providers of the change in condition. The CNA reported concerns, but no action was taken until the NP was informed two days later, resulting in a medication adjustment and hospital evaluation.
A resident with a history of aggression physically abused another resident who is unable to defend themselves due to severe disabilities. The incident occurred in the dining room, where the aggressive resident slapped the vulnerable resident multiple times, despite the facility's abuse prevention policy and the aggressive resident's care plan aimed at preventing harm.
A facility failed to document a resident-to-resident physical abuse incident in a victim's medical record. Two residents were involved in an altercation where one slapped the other multiple times. The incident was not recorded in the victim's medical record, only in the aggressor's, as reported by a Registered Nurse.
Failure to Protect Residents From Physical and Verbal Abuse by Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and physical abuse by another resident. One resident with cerebral vascular accident, quadriplegia, contractures, anxiety, and total dependence for all ADLs, who is non-verbal but cognitively intact and communicates by yes/no head movements, reported being punched in the stomach by his ambulatory roommate on three separate occasions. Nursing progress notes document that this dependent resident had decreased appetite and an upset stomach in the days preceding disclosure. On one occasion, a CNA brought the resident to a nurse because the resident was afraid to return to his room due to his roommate, and during further evaluation the resident accused the roommate of assaulting him. The medical record documents that the non-verbal resident indicated his roommate hit him in the stomach with a closed fist on three occasions when the roommate was upset about facility issues such as smoking or leaving the building. The resident reported that the punches hurt and made him feel bad, and that he was afraid of his roommate. The facility’s investigative report and a police incident report confirm that the resident communicated fear of reprisal if the roommate remained in the facility and that the roommate had a prior history of leaving the facility and threatening violence toward staff if they tried to stop him. The roommate’s diagnoses included personality disorder, bipolar disorder, schizoaffective disorder, major recurrent depression, anxiety, stimulant abuse, and cannabis use, and he was ambulatory and made attempts to leave the building without notifying staff. These circumstances show that the facility did not prevent repeated physical abuse of a highly dependent, non-verbal resident by another resident. The deficiency also includes the facility’s failure to recognize and respond to verbal abuse between roommates as potential abuse. One resident with moderate cognitive impairment and major depressive disorder in remission reported feeling fearful of her former roommate, who was cognitively intact and diagnosed with dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The fearful resident stated that her roommate yelled, cursed, and repeatedly used an expletive toward her about a week prior and that this behavior scared her. A CNA reported that about a week before a later reported incident, staff heard the cognitively intact roommate loudly yelling at the other resident, that the fearful resident was very upset, and that both residents were verbally arguing back and forth before the CNA intervened to de-escalate the situation and then reported it to the Administrator and nurse. A psychotherapist/LCSW later reported hearing the same verbally aggressive resident call her roommate a derogatory name, after which the residents were separated. The Administrator/Abuse Prevention Coordinator stated that when this verbal altercation was reported, it was viewed as more of a grievance and was not entered on the grievance log, and acknowledged it should have been handled as a potential abuse issue. The facility’s own Abuse Prevention Policy affirms residents’ rights to be free from abuse and defines verbal abuse as the use of disparaging and derogatory language, including saying things to frighten a resident. Despite this policy, the facility did not initially treat the reported verbal aggression and the fearful resident’s statements as potential abuse, contributing to the failure to protect residents from verbal abuse by another resident.
QAA Committee Meetings Not Held Quarterly and DON Not Documented as Attending
Penalty
Summary
The facility failed to ensure that Quality Assurance (QA) meetings were held quarterly and failed to ensure the Director of Nursing (DON) attended the QA meetings. The report states this deficiency affected all 36 residents residing in the facility. Survey review found that the Quarterly Quality Assurance Committee Signature Sheet documented a QA meeting on 3/12/2025 for fourth quarter 2024, then the next documented meeting was on 7/17/2025 for first quarter 2025, which was four months and 5 days later. The next documented meeting was on 12/30/2025 for second quarter 2025, which was five months and 13 days after the prior meeting. The signature sheet for the 12/30/2025 meeting did not document that the DON/Infection Preventionist attended. The signature sheet for the 01/28/2026 meeting also did not document that the DON/Infection Preventionist attended. On 03/12/2026 at 12:20 pm, the Administrator reviewed the quarterly signature sheets and confirmed that QA quarterly meetings were not conducted in a timely manner for 2025, as required, and that the previous DON did not attend the 12/30/2025 or 1/28/2026 meetings. The facility policy titled GENERAL QAPI Program, dated September 2022, states the QAA Committee meets at least quarterly and lists the Administrator, DON, Medical Director or designee, Infection Preventionist, Social Service Director, Business Office Manager, Housekeeping Director, and MDS Coordinator as attendees. The facility 671 form dated 3/12/2026 documents that 36 residents reside in the facility.
Antibiotic Stewardship Program Not Properly Implemented
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. Survey review found that the antibiotic use and stewardship logs provided by the Regional Nurse Consultant documented resident infections occurring between January 2025 and March 2026, and the Administrator stated there was no additional information related to the facility’s antibiotic stewardship or infection control program beyond those records. Review of the logs on 3/13/2026 showed they did not document what symptoms residents experienced that signified a potential infection, the onset of signs and symptoms, the resolution of symptoms, whether nationally recognized and standardized criteria were used to justify and guide antibiotic use, or whether response to treatment was monitored to determine if the antibiotic was effective and still indicated or if adjustments were needed. The logs also did not document when or if antibiotic therapy was changed after being initially prescribed empirically by a medical provider, and they did not show whether residents experienced adverse events after antibiotic use. The facility’s Antibiotic Stewardship Program Guideline, dated 4/29/2025, stated the purpose of the program was to improve anti-microbial stewardship practices and monitor outcomes and anti-microbial use. The facility’s Medicare and Medicaid application documented that 36 residents resided in the facility.
Failure to Timely Report and Investigate Resident-to-Resident Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s repeated failure to timely report allegations of resident-to-resident verbal abuse to the Illinois Department of Public Health (IDPH) as required by its abuse prevention policy. One resident (R18) had a BIMS score of 12/15, indicating moderate cognitive impairment, and another resident (R15) had a BIMS score of 15/15, indicating no cognitive impairment. R18 reported that approximately one week prior to the survey, R15 yelled, cussed, and repeatedly used the f*** expletive toward her, causing R18 to feel afraid and fearful of retaliation. R18 stated she had been R15’s roommate and was moved to a separate room after this incident, and she described R15 as regularly using offensive language and a confrontational tone. Staff interviews revealed that facility leadership was aware of at least one verbal altercation between these two residents before the surveyor’s notification, but no investigation or required external reporting was initiated at that time. The Social Service Director (V10) stated that on the day before the survey, the psychotherapist/LCSW (V7) reported that R15 and R18 had a verbal altercation, and V10 directed V7 to report this to the Administrator/Abuse Prevention Coordinator (V1). V1 later confirmed that V7 had reported that R15 called R18 a derogatory name (“d*****s”) on that date, but V1 did not initiate an investigation, did not interview residents or staff, and did not notify IDPH at that time, despite acknowledging that the allegation should have been investigated and reported. Further, a CNA (V9) reported that about a week prior to the LCSW’s report, there had been another incident in which R15 yelled at R18, with both residents eventually arguing back and forth. V9 stated that R18 was initially very upset and that V9 intervened to de-escalate the situation, then immediately reported the incident to the Administrator and that another CNA reported it to a nurse. V9 stated that no one interviewed her about the incident and that the residents were not moved to separate rooms until several days later. The facility’s undated Abuse Prevention Policy requires accurate and timely investigative reports and mandates that when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation is made, the Administrator or designee must immediately notify the Department of Public Health’s regional office. Despite these policy requirements and multiple staff reports of verbal altercations, the facility did not timely investigate or report the allegations of verbal abuse involving R15 and R18 to IDPH until after the surveyor brought the issue to the Administrator’s attention.
Failure to Investigate and Timely Separate Residents After Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond appropriately to repeated allegations of resident-to-resident verbal abuse, and to timely separate the alleged perpetrator from the alleged victim. Two cognitively assessed residents shared a room for over two months; one resident had a BIMS score of 12/15 indicating moderate cognitive impairment, and the other had a BIMS score of 15/15 indicating no cognitive impairment. The resident with moderate cognitive impairment reported that her roommate repeatedly yelled, cursed, and used explicit language toward her, stated she was afraid of her roommate, and declined to provide the roommate’s name out of fear of retaliation. She reported that the roommate regularly used offensive language and a confrontational tone and that she was scared of further verbal abuse. Multiple staff members were aware of verbal altercations between the two residents prior to the surveyor’s interview, but the facility did not initiate or document an abuse investigation as required by its Abuse Prevention Policy. The Administrator/Abuse Prevention Coordinator acknowledged that a psychotherapist/LCSW had reported a verbal altercation in which one resident called the other a derogatory name, but the Administrator considered it a grievance rather than potential abuse, did not log it as a grievance, and did not document anything in either resident’s chart. The Social Service Director stated that she directed the psychotherapist/LCSW to report the incident to the Administrator, which occurred, but no internal investigation steps were taken at that time. Additionally, a CNA reported that about a week before the psychotherapist’s report, she and other agency staff heard one resident yelling at the other, observed the alleged victim to be upset, and immediately reported the incident to the Administrator after calming the situation. Despite this earlier report, the Administrator did not interview the CNA or other staff, did not interview the residents regarding the incident, did not initiate an internal investigation, and did not report the allegation to the state survey agency. The facility’s own Abuse Prevention Policy requires that all incidents and allegations involving abuse be documented, investigated, and that residents who allegedly abuse others be immediately evaluated and separated as necessary to ensure safety. These steps were not taken in a timely or documented manner in response to the repeated verbal abuse allegations between these two residents.
Failure to Document Resident-to-Resident Verbal Abuse Incidents in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to allegations of resident-to-resident verbal abuse. One resident (R18) reported that her former roommate (R15) yelled, cursed, and repeatedly used offensive language toward her about a week prior, causing her to feel afraid and reluctant to identify the roommate for fear of retaliation. A CNA (V9) corroborated that sometime the previous week, R15 was loudly yelling at R18, that R18 was visibly upset, and that the two residents were arguing back and forth. The CNA stated that an agency staff member notified an unidentified nurse, and that the CNA notified the Administrator/Abuse Prevention Coordinator (V1) the same day after calming the residents. Despite these reports, there was no contemporaneous documentation of the verbal abuse allegations or related monitoring in either R15’s or R18’s medical records. The facility’s initial report to the Illinois Department of Public Health (IDPH), dated 3/10/26 and written by V1, shows that V9 had reported an incident from approximately one week earlier and that a psychotherapist/LCSW (V7) reported on 3/9/26 hearing R15 call R18 a derogatory name, after which the residents were moved to separate rooms. The IDPH report also records that R18 described feeling fearful of R15, citing the earlier name-calling incident that she had been too afraid to report at the time, and that R18 stated R15 regularly used offensive language and a confrontational tone. V1 acknowledged that when V7 reported hearing R15 call R18 a derogatory name, V1 viewed it more as a grievance, did not enter it on the grievance log, did not treat it as a potential abuse issue, and did not document anything in either resident’s chart. Review of the electronic medical records for R15 and R18 confirmed that neither social services (V10, Social Service Director; V7, LCSW/Psychotherapist) nor nursing staff documented the abuse allegations or any monitoring on the dates the incidents were reported by staff or surveyors. Late social service notes for both residents were created on 3/12/26, backdated to 3/9/26, indicating that the Administrator and an NP were notified that one resident called the other a name and to monitor for further behaviors or anxiety, but these notes did not capture the earlier incident reported by the CNA or the subsequent allegations reported on 3/9/26 and 3/10/26. These omissions occurred despite facility policies requiring that all incidents, allegations, or suspicions of abuse, and all incidents, accidents, or changes in condition, be documented in the resident’s medical record.
Delayed Response to Call Lights for Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for four residents who were unable to toilet independently. One resident had multiple diagnoses including Multiple Sclerosis, obstructive and reflux uropathy, prostatic hyperplasia with lower urinary symptoms, muscle wasting and atrophy, unsteadiness on feet, reduced mobility, abnormal gait and mobility, and major depressive disorder. That resident’s assessment documented cognitive intactness, bilateral impairment in upper and lower extremity range of motion, complete dependence on staff for toileting hygiene, and no behaviors, delusions, or hallucinations. The care plan directed staff to check frequently and assist with toileting as needed, and also noted moisture associated skin damage to the coccyx and predisposition to skin impairment related to incontinence. During interview, the resident reported using a bedpan and urinal while in bed, activating the call light for assistance, and sometimes waiting well over 30 minutes for staff to respond, with occasional toileting accidents while waiting. An LPN reported receiving complaints from the resident about evening and night staff delays in responding to the call light and stated those shifts had less direct care staff than daytime. Three other residents also reported having toileting accidents while waiting for staff to respond to call lights. The facility’s call light policy stated staff are to answer a resident’s call light as soon as possible.
Lack of Required Physician Documentation for Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a physician documented the required elements in the medical record to support an involuntary discharge of a resident. For one resident (R44) reviewed for discharge, the comprehensive electronic medical record did not contain a physician note documenting the basis for the discharge, the specific needs the resident had that could not be met in the facility, the attempts the facility made to meet those needs, and the services available at the receiving facility to meet those needs. An involuntary discharge notice dated 1/30/26 stated that the resident was being discharged due to being a threat to the personal safety of another resident (R23), but this notice was not supported by the required physician documentation in the medical record. During an interview on 3/12/26, the Administrator, with the DON/Regional Consultant present, confirmed that there was no physician note in the resident’s record addressing the basis for the discharge or the other required elements, and confirmed that the resident had been discharged and would not be returning. As of 3/13/26, the Administrator had not provided any evidence of such a physician note and stated that this was her first involuntary discharge and she was not aware of all of the requirements.
Incomplete Involuntary Discharge Notice Lacking Advocacy and Appeal Information
Penalty
Summary
The facility failed to include required information regarding advocacy agencies and appeal rights in an emergency involuntary discharge notice for one resident. The resident was admitted with multiple psychiatric and substance use diagnoses, including Personality Disorder, Bipolar Disorder, Schizoaffective Disorder, Major Recurrent Depression, Anxiety, Stimulant Abuse, and Cannabis Use. Review of the resident’s emergency involuntary discharge notice dated 1/30/26 showed it did not contain the mailing and email address of the entity that would receive an appeal of the discharge, nor information on how to obtain, complete, and submit an appeal form. The notice also omitted the name, mailing address, email address, and phone number of the State LTC Ombudsman, as well as the mailing address, email address, and phone number of an agency responsible for protection and advocacy of individuals with mental illness. During an interview, the Administrator, with the DON/Regional Consultant present, confirmed that the required information was not included in the involuntary discharge notice and acknowledged that this was the Administrator’s first involuntary discharge and that she was not aware of all the requirements. The resident had already been discharged and was not expected to return.
Unsecured Bed Wheels During Resident Fall
Penalty
Summary
A resident with diagnoses of lumbago with sciatica on the right side, pain in the right hip, and cellulitis of the lower right limb was found on the floor after attempting to self-transfer to the bathroom. The resident’s MDS documented intact cognition, assistance with activities of daily living, and wheelchair use for mobility. The incident report states that the resident had no skid socks on and was returned to bed by mechanical lift after the fall. The incident investigation identified that the wheels on the resident’s bed were not locked. The interdisciplinary team documented the root cause as the unlocked bed wheels, and the facility administrator stated that the resident was trying to self-transfer when the bed rolled because the wheels were not locked. The facility policy on Fall Guidelines states the intent is to provide an environment free from hazards under facility control and appropriate supervision to each resident.
Failure to Use PPE for Resident on Droplet Precautions
Penalty
Summary
The facility failed to wear PPE while providing care to a resident on droplet precautions for MRSA in the tracheostomy. The resident had diagnoses including malignant neoplasm of the right bronchus or lung, COPD, and tracheostomy status, and a sputum culture showed moderate growth of MRSA. The physician order sheet directed special contact droplet precautions related to MRSA in the trach every shift, and the care plan directed staff to wear gowns, gloves, and masks when providing care, along with other isolation measures. On observation, the resident was in bed with the head elevated and had a tracheostomy with oxygen attached. Signs on the bedroom door indicated infection control droplet precautions and to see a nurse before entering, and PPE was available outside the room. A housekeeping director entered the room to answer the resident’s call light, removed the resident’s thermal cup, and exited without washing hands, using hand sanitizer, or donning gloves or a gown; she wore only a surgical mask she had already been wearing in the facility. The housekeeping director stated she knew she was supposed to wear a gown and gloves in the room, and the infection control preventionist/interim DON confirmed staff should have followed the facility’s infection control protocol and worn PPE in the resident’s room.
Failure to Timely Address Resident’s Reported Theft and Property Loss
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property and did not replace the misappropriated item in a reasonable time frame, resulting in psychosocial harm. The resident reported that a pair of ear buds, which were kept in a specific place in the resident’s room, went missing after the room was deep cleaned, during which a CNA assisted in placing the resident’s belongings on the bedside table. Later that evening, when the resident attempted to use the ear buds, they were no longer there. The resident used the tracking function on a cellular phone and identified the location of the missing ear buds at an address approximately 30 miles away, which the resident associated with a mother and daughter who were both CNAs employed at the facility. The facility’s abuse prevention policy affirms residents’ rights to be free from misappropriation of property and to be kept informed of investigation conclusions. The resident reported the theft to the Administrator and expressed a desire to press charges. The resident stated that no police officer spoke with the resident that night and that the Administrator later told the resident that no charges were being pressed. The resident also reported having to purchase replacement ear buds with personal funds while waiting for the facility to replace them, and later requested reimbursement. The resident stated feeling upset and angry that someone could steal from the resident and other residents in what the resident considers home, and reiterated the desire to press charges more than two months after the incident. The survey findings concluded that the facility failed to replace the misappropriated goods in a reasonable time frame and failed to report the incident to the police as the resident requested, resulting in psychosocial harm to the resident.
Failure to Identify and Address Significant Weight Loss and Poor Intake
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and respond to a resident’s significant weight loss and declining nutritional status. The facility had policies requiring monitoring of weight and nutritional status, identification of recent or rapid weight loss, and notification of the physician, dietitian, and family of significant changes, including possible fluid and electrolyte imbalances. Despite these policies, the resident’s weights from admission to discharge showed a total loss of 14.1 pounds (8%) over 22 days, with early rapid losses documented, but no evidence that this weight loss was identified as significant or that appropriate assessments were completed. During the resident’s stay, meal intake records showed that out of 61 meals served, six had no documented intake percentage, and of the 55 documented meals, 29 reflected less than 50% consumption and 15 reflected less than 25% consumption. A speech therapist observed a sharp decline in the resident’s abilities, including talking less and not feeding herself, and reported this to an LPN, who documented that the therapist had to assist the resident with eating and that the resident seemed to be declining. However, the LPN later stated they did not recall notifying the physician or family of the resident’s decline or weight loss. The registered dietitian confirmed not being informed of the weight loss and did not see the resident in the facility, instead making diet recommendations based only on prior speech therapy notes. Laboratory results showed a downward trend in the resident’s potassium levels while at the facility, from 3.5 mEq/L on one date to 2.6 mEq/L on the day of discharge, compared to a prior hospital potassium level of 4.0 mmol/L. The nurse practitioner and primary care physician both confirmed they were not notified of the resident’s weight loss or poor intake, and both acknowledged that limited meal consumption could lead to weight loss and electrolyte imbalance. The resident’s family also reported not being informed of the weight loss or lack of food consumption. The resident was ultimately sent to the hospital for altered mental status and possible stroke, and the hospitalist documented that the resident was admitted with hypokalemia secondary to severe malnutrition and dehydration, stating that the lack of food and drink at the facility was the cause of the hypokalemia.
Unverified Agency CNA Identity and Certification Leading to Unqualified Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides had appropriate competencies and valid certification, specifically by not having a policy or process to verify the identity and credentials of agency staff working as CNAs. The facility’s CNA job description required a current CNA certification in accordance with Illinois law. However, on one occasion, an individual (V28) worked an entire scheduled CNA shift under another person’s identity (V20) obtained through a contracted staffing agency. The administrator (V1) reported to law enforcement (V29) that V28 was operating under the false name V20 while working as a CNA and that the only documentation V1 had seen was the staffing agency profile for V20. V1 later checked the registry under V28’s real name and discovered that V28 was not listed as a CNA. During the incident, V28 arrived for a scheduled shift that was assigned to V20 and used V20’s name to gain access to the EMR and work as a CNA from 6:00 a.m. until an altercation occurred around 5:00 p.m. Another staff member (V19) reported that V28 had been working that full shift, and V20 later stated that they had not picked up any shifts at the facility. An email from the Health Care Workers Registry confirmed that V28 did not have CNA certification and was not eligible to be employed as a CNA, though eligible to work in a non‑CNA capacity. The facility census at the time was 39 residents, and the lack of a policy to verify agency staff identity and certification resulted in an uncertified individual providing CNA-level care to residents under another person’s credentials.
Uncertified Individual Worked as CNA Under False Identity Without Registry Verification
Penalty
Summary
The deficiency involves the facility’s failure to verify nurse aide certification and ensure that only properly certified CNAs provided resident care. On a specific date, an individual identified as V28 presented to the facility and worked an entire shift as a CNA by using the identity and staffing profile of another CNA, V20, who was scheduled to work that day. The Administrator (V1) stated that the facility uses a contracted agency to supply certified staff and that the profile being used belonged to V20, a CNA. V28 provided V20’s name as their own in order to work, access the electronic medical record, and provide resident care. Subsequent verification with the Health Care Worker Registry (HCWR) confirmed that V28 did not hold CNA certification and therefore was not eligible to be employed as a CNA, although eligible to work in a non‑CNA capacity. The report further documents that V1 did not report the incident of false identity and uncertified personnel providing resident care to the state agency. Interview with V20 confirmed that V20 did not pick up any shifts at the facility, despite the nursing schedule listing V20 to work a 6:00 a.m. to 6:00 p.m. shift on the date in question. Interview with another CNA, V19, indicated that V28 worked from 6:00 a.m. until an altercation occurred around 5:00 p.m., during which V28 was yelling and screaming in front of residents in the cafeteria and in a resident’s room. The facility’s resident roster documented a census of 39 residents, all of whom were affected by the presence of an uncertified individual working as a CNA and providing care under a false identity.
Failure to Notify Physician and Family of Significant Weight Loss in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians, the dietitian, and family members of significant weight loss and decreased nutritional intake for two residents, contrary to its own policies on change in condition and impaired nutrition/unplanned weight loss. The facility’s policy required staff to monitor and document residents’ weights in a way that allowed month-to-month comparison, identify recent or rapid weight loss, and notify the physician and family of significant weight changes or persistent declines in appetite or intake. The policy also required the physician and staff to review possible causes of weight loss and monitor nutritional status and response to interventions. For one resident (R1), admitted with diabetes mellitus due to underlying condition with diabetic neuropathy and other lack of coordination, weight records showed a decline from 175.2 lbs at admission to 161.1 lbs at discharge over 22 days, a total loss of 14.1 lbs or 8%. During the stay, the resident was served 61 meals; documentation of intake was missing for 6 meals, and of the 55 meals with documentation, 29 meals showed less than 50% consumption and 15 meals showed less than 25% consumption. The LPN who documented in the record stated they did not recall notifying the family or physician of the resident’s decline and confirmed they did not inform them of the weight loss. The NP, RD, and primary care physician each confirmed they had not been notified of the resident’s weight loss, and the family member confirmed they were not informed of the weight loss or lack of food consumption. The DON confirmed the resident had a significant weight loss and that the family, physician, and RD had not been notified. For another resident (R8), admitted with multiple acute conditions including mechanical fall with right lower extremity fractures, severe pain, acute hypotension/shock versus anemia, acute anemia, suspected GI bleed ruled out, acute kidney injury on chronic kidney disease, and atrial fibrillation, serial weights showed a decline from 201.8 lbs near admission to 161.1 lbs over 44 days, a total loss of 36.8 lbs or 19%. Despite this significant weight loss, the NP and the resident’s physician each confirmed they had not been informed of any weight loss. The resident’s family member reported noticing that the resident was losing weight but was unaware of the extent of the loss and stated they had not been notified by staff. The DON confirmed that this resident also had significant weight loss and that the family and physician had not been notified, demonstrating a failure to follow facility policy for physician and family notification of significant changes in condition related to weight and nutrition.
Failure to Report Staff Altercation and Use of Unqualified CNA
Penalty
Summary
The deficiency involves the facility’s failure to timely report to proper authorities an altercation between staff that occurred in the presence of residents, and the discovery that an unqualified individual was working as a CNA. A sheriff’s deputy was dispatched to the facility after receiving 911 calls from two CNAs regarding threats made by one CNA toward another. One CNA reported that the other CNA told her to meet by the time clock so she could beat her, which made her feel uncomfortable and unsafe. This conflict arose after a dispute over which CNA was responsible for a resident who had not been cared for since early that morning. The reporting CNA also described an earlier verbal altercation that same shift between the same aggressive CNA and a different CNA, during which threats were made and had to be de-escalated. The aggressive CNA was reported to have yelled, accused coworkers of disrespect, and made racially derogatory comments. The incident included yelling and screaming by the aggressive CNA in front of residents in the cafeteria and in a resident’s room, with at least one resident later confirming that two CNAs were yelling and having a disagreement in the resident’s room and that one CNA walked out. The administrator acknowledged knowing about the incident but did not report it. During the law enforcement contact, the administrator also stated that, upon checking the registry, it was discovered that the CNA who had been working from early morning until the time of the incident was not actually a CNA. Despite this, there is no indication in the report that the facility reported either the staff altercation in the presence of residents or the fact that an unqualified individual had been working as a CNA to the appropriate authorities.
Failure to Timely Report Misappropriation of Resident Property to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to timely report to local law enforcement the misappropriation of a resident’s personal property. On the evening of 11/6/2025, a resident discovered that their ear buds, which were normally kept in a specific place in their room, were missing after the room had been deep cleaned and a CNA assisted with placing personal belongings on the bedside table. Around 9:00 PM, when the resident attempted to use the ear buds, they realized they were gone and used the tracking function on their cell phone, which showed the ear buds at an address approximately 30 miles away. The resident asked a CNA on shift for her address, and the CNA stated she lived with her mother, who was also a CNA at the facility, and confirmed that the address matched the location where the ear buds were pinged. The resident reported the theft to staff that night. The facility reported the misappropriation of goods to the state agency, and the facility’s incident report documented that the CNA was terminated, local police were notified, and the ear buds would be replaced. However, during a later interview, the resident stated they did not speak to a police officer that night and still wished to press charges, but reported being told by the Administrator that no charges were being pressed. The Administrator stated they called the local police department around 9:30 PM on 11/6/2025 but could not recall whom they spoke with. Subsequently, the local sheriff’s office reported there was no call log, dispatch, or report from the facility on or around that date. The facility’s Abuse Prevention Policy affirms residents’ rights to be free from misappropriation of property and states that residents will be kept informed of investigation conclusions, but the record and interviews show that the facility did not timely or effectively report the misappropriation to law enforcement as required.
Failure to Maintain Safe Transport and Fall Prevention Practices
Penalty
Summary
The facility failed to maintain transport equipment in working order and did not ensure the safe and proper securing of a resident during van transport. One resident, who was cognitively intact but physically dependent and classified as high fall risk, was transported in a facility van with a seatbelt that was not properly attached to the floor anchor. The staff member responsible for securing the resident did not verify the functionality of the seatbelt or the anchor, resulting in the resident falling from the wheelchair during transport. The fall led to significant injuries, including a forehead hematoma, multiple facial lacerations requiring sutures, and bilateral nasal bone fractures. The van's equipment was later found to have stiff, loose, and aged lap belts, with a faulty anchor that contributed to the incident. Additionally, the facility failed to implement and update fall interventions and did not conduct root cause analyses for multiple falls experienced by another resident. This resident, who had significant cognitive and physical impairments and was classified as high fall risk, experienced several unwitnessed falls while attempting self-transfers. Despite repeated incidents, the facility did not document root causes for these falls or update the care plan with appropriate interventions. Staff were observed transferring the resident without required assistance, mechanical lift, or gait belt, and the resident's wheelchair was not adjusted as specified in the care plan. Personal alarms and other interventions were also not in place as directed. The facility's own policy requires individualized interventions, hazard analysis, and root cause identification for all residents at fall risk. However, documentation and investigation of falls were insufficient, lacking necessary details to determine causes and prevent recurrence. The failure to maintain equipment, ensure proper supervision, and follow established protocols directly contributed to the injuries and repeated falls experienced by the residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for eight consecutive hours each day, seven days per week, as required. Staffing postings for a one-week period showed that there was no RN on duty on two separate days. On one of those days, an RN worked the overnight shift but was only present until approximately 7:40 AM, which did not meet the eight-hour requirement. The administrator confirmed these staffing gaps and stated that the absence of an RN prevented the facility from providing certain services, such as administering intravenous medications. At the time of the deficiency, 39 residents were residing in the facility.
Failure to Monitor and Report Urine Changes Leads to CAUTI and Hospitalization
Penalty
Summary
The facility failed to adequately monitor and report changes in urine characteristics for a resident with a urinary catheter, leading to a catheter-associated urinary tract infection (CAUTI) and subsequent hospitalization. The resident, who was cognitively intact and dependent on staff for toileting hygiene, experienced hematuria and mucus in the urine, which were not timely reported to the physician. The facility's policy required notification of the physician for symptoms of infection, but there was a lack of documentation and follow-up on the resident's urine characteristics between May and July 2024. The resident was admitted to the facility with a urinary catheter and later developed symptoms of a UTI, including lower abdominal pain and a blocked catheter. Despite the presence of blood and mucus in the urine, the facility did not implement Enhanced Barrier Precautions (EBP) until months later. The resident's urine culture results, which indicated resistance to the prescribed antibiotic Levaquin, were not reported to a practitioner until three days after they were received, delaying the change in antibiotic treatment. Interviews with facility staff, including the Infection Preventionist and a Nurse Practitioner, confirmed that the urine culture results should have been reported immediately and that routine monitoring of urine characteristics was necessary. The resident was hospitalized twice due to complications from the CAUTI, highlighting the facility's failure to adhere to infection control measures and timely communication with healthcare providers.
Inadequate CNA Staffing Leads to Delayed Care
Penalty
Summary
The facility failed to provide sufficient staffing of certified nursing assistants (CNAs) to meet the needs of its residents, affecting four residents directly and potentially impacting all 32 residents in the facility. During a resident council meeting, several residents reported waiting up to an hour for their call lights to be answered and not receiving scheduled showers. Observations revealed that only two CNAs were working during certain shifts, which was insufficient given the number of residents requiring full mechanical lifts for transfers. The facility's staffing records and interviews with staff confirmed that there were instances where only one or two CNAs were available during shifts, despite the facility's assessment indicating a need for more staff based on resident acuity and census. The facility's administrator acknowledged the staffing issues and confirmed the accuracy of the CNA schedules, which showed a pattern of understaffing. The facility's master shower schedule also indicated that residents were not consistently receiving their scheduled showers due to staffing shortages.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to staff a full-time Director of Nursing (DON), which has the potential to affect all 32 residents in the facility. Observations conducted on three consecutive days between 9:15 AM and 4:00 PM revealed the absence of a DON working in the facility. The facility's assessment, reviewed on May 23, 2024, indicated that a full-time DON would be staffed, yet the nurse schedule from November 23, 2024, to December 15, 2024, did not document a full-time DON. The facility administrator confirmed that the facility has been without a full-time DON since December 2023. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated December 11, 2024, documented a resident census of 32.
Failure to Verify Nurse Aide Competency Before Employment
Penalty
Summary
The facility failed to document registry verifications of nurse aide competency for five newly hired nurse aides before they began employment. This oversight potentially affects all 32 residents residing in the facility. The employee files show that the facility did not check the nurse aide registry for competency verification for four nurse aides until December 11, 2024, and for one nurse aide until November 22, 2024, despite their hire dates being in October and November 2024. The facility administrator confirmed that while background checks were completed prior to hiring, there was no documentation to prove that these checks were done before the staff started working in the facility.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 32 residents. During the survey, it was observed that the Dietary Manager, V2, was actively supervising dietary operations without the necessary qualifications. V2 admitted to not being a certified dietary manager, dietician, or having the required educational background or experience to meet the State of Illinois standards for the position. Additionally, the facility's dietician was reported to work only one day per month, which is insufficient to meet the facility's needs as outlined in their Facility Assessment. Throughout the survey, the facility also failed to maintain sanitary food storage areas and did not serve resident diets as planned on facility menus. These deficiencies were observed from December 9 to December 12, 2024. The facility's Long-Term Care Facility Application for Medicare and Medicaid documented that 32 residents reside in the facility, all of whom could potentially be affected by these failures.
Unsanitary Conditions in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen's walk-in cooler, which has the potential to affect all 32 residents residing in the facility. On multiple occasions, surveyors observed the cooler's flooring to be soiled with accumulations of dark-colored decomposed food debris and spilled liquids. The Dietary Manager, who was present during these observations, was unable to identify the source of the liquids. Despite the issue being noted on December 9, 2024, the condition of the cooler remained unchanged during subsequent observations on December 10 and December 12, 2024. The food stored in the cooler is available for all residents to consume, indicating a widespread potential impact on the facility's population.
Inadequate Infection Control and Legionella Management
Penalty
Summary
The facility failed to implement effective surveillance monitoring of resident infections and did not develop a comprehensive water management plan to mitigate the risk of Legionella and other pathogens. The Infection Control Surveillance and Monitoring policy required routine surveillance, monitoring, and analysis of infection data to identify trends and implement corrective measures. However, the facility's infection control logs from February to December 2024 showed multiple instances of urinary tract infections (UTIs) and wound infections with Escherichia Coli (E. Coli), but there was no documentation of tracking infections by resident room location or implementing corrective actions beyond hand hygiene training in March. The Infection Preventionist acknowledged the lack of training and documentation of follow-up education or audits on identified infection control trends. Additionally, the facility's Legionella Management Procedure required a risk assessment of the water system to identify and control potential sources of Legionella bacteria. The Maintenance Director was unaware of the facility's Legionella plan, risk areas, and control measures, and had not received training on Legionella. The Administrator confirmed that the Maintenance Director was responsible for completing the Legionella Risk Assessment, but it had not been done, leaving risk areas and control measures unidentified. The facility's application for Medicare and Medicaid documented a resident census of 32, indicating the potential impact of these deficiencies on all residents.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy effectively, as evidenced by the lack of evaluation of clinical data to ensure infection criteria and appropriate use of antibiotics. The facility's Antibiotic Stewardship Program, dated November 1, 2017, was intended to improve antibiotic use and reduce resistance through core elements such as leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. However, the program included an incomplete checklist for these core elements. Additionally, the facility's policy on the assessment of infections and antimicrobial usage required monthly reviews to determine if criteria were met, including alignment with the Centers for Disease Control and Prevention's standard definitions for infection surveillance. Despite this, the facility's infection control logs from February to December 2024 did not document clinical signs and symptoms for each prescribed antibiotic, indicating a failure to adhere to the policy. A specific instance involved a resident who was treated with one dose of Levaquin, an antibiotic, for pneumonitis, which is not considered an infection. The infection control logs did not document the symptoms that justified this antibiotic use. During a review with the facility's Infection Preventionist, it was confirmed that no assessment tool, such as the McGeer Criteria, was used to determine infection criteria and appropriate antibiotic use. The Infection Preventionist admitted to a lack of familiarity with the facility's antibiotic stewardship program and had not received adequate training on it. This oversight has the potential to affect all 32 residents in the facility, as the program's implementation was not effectively monitored or executed.
Failure to Document and Follow Up on Resident Grievances
Penalty
Summary
The facility failed to document and follow up on grievances for five residents regarding missing personal items. The facility's Grievance Policy requires grievances to be investigated within five working days, with findings and corrective actions reported to the person who filed the grievance. However, the facility did not adhere to this policy. During a resident council meeting, several residents reported missing clothing and blankets, but there was no documented follow-up or resolution. The Resident Council Meeting Minutes repeatedly documented concerns about missing items, but the facility did not maintain proper records of grievances or follow-up actions. Staff members, including the Maintenance Director, Activity Director, and Social Services Director, were informed of the grievances, but there was no documented investigation or resolution. The facility's administrator stated that items are offered to be replaced on a case-by-case basis, as residents sign an admission contract stating the facility is not responsible for lost items. Despite this, the facility's grievance policy was not followed, and there was a lack of documentation and follow-up on the reported grievances, leading to the deficiency.
Failure to Serve Planned Pureed Diets
Penalty
Summary
The facility failed to serve pureed diets as planned on the menu, affecting three residents who were supposed to receive pureed bread and pureed sugar cookies with their meals. On December 9, 2024, observations revealed that no pureed bread was present among the prepared food items in the kitchen or with the meals of residents receiving pureed diets. A Certified Nurse Aide feeding one of the residents was unaware of the absence of pureed bread. On December 10, 2024, residents were observed eating pureed meals without the planned pureed sugar cookies. The Dietary Manager reported that pudding was served instead of pureed cookies because the staff did not prepare the cookies.
Failure to Provide Scheduled Showers and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for residents who are dependent on staff assistance for activities of daily living. Specifically, three residents, identified as R4, R8, and R22, did not receive showers as per their care plans and facility policy. R4, who requires partial/moderate assistance for bathing, did not receive a shower for 13 days, despite being scheduled for showers twice a week. R22, who requires substantial/maximum assistance, went 12 days without a shower due to staffing shortages, as confirmed by the resident. Both residents expressed dissatisfaction with the frequency of showers received. Additionally, R8, who requires assistance with personal hygiene, was observed with facial hair that should have been removed during scheduled shower days. The facility's policy mandates that residents be free of facial hair unless they request otherwise, which was not documented in R8's care plan. The facility's shower schedule and documentation revealed that R8 missed several scheduled showers, and staff confirmed the oversight in grooming. These deficiencies highlight a failure to adhere to the facility's policies and residents' care plans, impacting the residents' personal hygiene and care preferences.
Failure to Use Leg Strap During Mechanical Lift Transfer
Penalty
Summary
The facility failed to perform a mechanical lift transfer safely for a resident reviewed for transfers. The Stand-Up Lift policy requires the use of a leg strap to stabilize the feet during transfers. However, during an observation, a Certified Nursing Assistant transferred a resident to and from the toilet using a mechanical sit-to-stand lift without utilizing the leg strap. The resident has impaired range of motion in both legs and requires partial/moderate assistance for toilet transfers. The resident's care plan indicates transfers with one staff person and a gait belt but does not document the use of a mechanical sit-to-stand lift or the necessity of the leg strap. The Director of Rehab confirmed that the leg strap should be used for all residents during such transfers.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, R23 and R24, as observed during a survey. For R23, who has a tracheostomy due to a total laryngectomy, the facility did not replace the tracheostomy oxygen mask weekly as required, with the mask dated 9/15/24 still in use on 12/09/24. Additionally, R23's tracheostomy was not reinserted promptly after removal, and a replacement tracheostomy was not kept at the bedside as per the facility's policy. The tracheostomy was found lying in a container on the bedside table, and the replacement was locked in an office, contrary to the policy that it should be clearly visible at the head of the bed. For R24, who has a diagnosis of Chronic Obstructive Pulmonary Disease, the facility failed to administer oxygen according to the physician's order. R24 was receiving oxygen at five liters per nasal cannula, exceeding the prescribed range of two to four liters. This discrepancy was confirmed by a registered nurse who acknowledged that the oxygen should have been delivered at two liters per nasal cannula. These failures indicate a lack of adherence to the facility's respiratory care policies and physician orders, potentially compromising the residents' care.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure medications were available and administered as ordered, resulting in significant medication errors for two residents. For one resident, Losartan Potassium was not administered on three separate occasions due to unavailability, and there was no documentation that the physician was notified of these missed doses. The facility had a backup medication system that included Losartan, but it was not utilized, and the nursing notes lacked follow-up communication with the pharmacy or the physician. Another resident did not receive Insulin Glargine and Insulin Lispro as ordered, with several instances of missed doses and unrecorded blood glucose results. The nursing notes indicated that the resident refused to eat or have their blood glucose checked on some occasions, but there was no documentation of physician notification for the missed insulin doses. Additionally, there was an instance where Novolog insulin was unavailable, and the nurse did not report this to the administrator.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations and maintain proper documentation for three residents, leading to a deficiency in immunization practices. The Centers for Disease Control and Prevention guidelines specify that adults aged 19-64 with chronic health conditions should receive the PCV20 or PCV15 followed by PPSV23, and adults over 65 should receive PCV20 or PPSV23 based on their previous vaccination history. However, the facility's policy, which requires offering the vaccine within 30 days of admission and documenting it in the resident's records, was not followed. Resident 18, aged 63 with Type Two Diabetes Mellitus, Interstitial Pulmonary Disease, and nicotine use, did not have documentation of being offered the pneumococcal vaccine, despite the Minimum Data Set indicating a decline. Resident 19, aged 76 with Asthma and Obstructive Sleep Apnea, received Prevnar13 in 2018 but had no further vaccinations or offers documented. Resident 22, aged 73 with Atherosclerotic Heart Disease, received Pneumovax23 in 2021, with no additional offers or vaccinations documented. The Infection Preventionist/MDS Coordinator admitted to not managing pneumococcal vaccinations due to uncertainty about the schedule, resulting in a lack of documentation and adherence to guidelines.
Failure to Report and Investigate Suspected Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication for one resident. A Licensed Practical Nurse (LPN) discovered crushed medications labeled for a resident in the garbage and was informed by an agency nurse that an adapter for the resident's gastrostomy tube was missing. The LPN notified the facility administrator via text message about the incident, as there was no Director of Nursing present at the time. The administrator did not respond to the text and did not initiate any investigation or reporting process regarding the incident. According to the facility's Abuse Prevention Program Policy, the administrator is required to appoint an investigator and report the results to the Department of Public Health within five working days of the incident. However, the administrator confirmed that no report or investigation was conducted following the LPN's notification. The failure to follow policy resulted in the lack of timely reporting and investigation of a potential misappropriation of resident medication.
Failure to Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to investigate a reported incident of misappropriation of a resident's medication. An LPN discovered a resident's crushed medications in the garbage at the start of a night shift and immediately reported the finding to the administrator. However, the administrator did not follow up on the report, did not conduct any interviews, and did not initiate any investigation or documentation regarding the incident. This inaction was contrary to the facility's Abuse Prevention Program Policy, which requires a thorough investigation process for all allegations, including interviews and written reports.
Failure to Administer and Report Missed Seizure Medications
Penalty
Summary
A resident with a diagnosis of intractable focal epilepsy requiring scheduled administration of seizure medications and therapeutic drug monitoring did not receive prescribed doses of Levetiracetam and Carbamazepine. The medications, which were to be administered via PEG tube, were found crushed and discarded in the trash by an LPN at the start of the night shift. The LPN learned from an agency nurse that the PEG tube adapter was missing, which prevented medication administration, and subsequently found a new adapter in the medication cart. The discarded medications were identified by the resident's name on the medication cup, and the incident was verbally reported to the facility administrator and during shift report. Despite being informed of the incident, the administrator did not follow up, interview staff, or initiate any documentation or reporting as required by the facility's policy on medication discrepancies. The policy mandates immediate reporting to the physician, documentation in the medical record, completion of a Medication Discrepancy Report, and review by the medical director and Quality Assurance Committee. No such actions were taken, and the incident was not documented or investigated further, resulting in a failure to ensure the resident was free from significant medication errors.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's change in physical condition, which affected one of the three residents reviewed for nursing care. The facility's policy requires prompt notification of medical providers regarding changes in a resident's condition. The resident in question, diagnosed with Dementia, Covid-19, Heart Failure, Dissociative and Conversion Disorder, Major Depression, and Lewy Body Dementia, experienced a significant increase in Risperdal dosage due to uncontrollable behaviors. Following the dosage increase, the resident became lethargic, slept more than usual, and was unable to stay awake to eat, appearing sedated. Despite these changes, the Registered Nurse responsible for the resident's care over the weekend did not notify any medical providers about the resident's condition. The Certified Nurses Assistant also observed the resident's decline and reported it to the Registered Nurse, but no action was taken. The Nurse Practitioner was not informed of the resident's condition until two days later, at which point the medication was adjusted, and the resident was sent to the hospital for evaluation. This delay in notification and response contributed to the deficiency identified in the report.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. Resident R1, who has a history of physical aggression, was documented to have slapped Resident R2 approximately ten times on the thigh while they were seated next to each other in the dining room. R2, who suffers from quadriplegia, epilepsy, cortical blindness, profound intellectual disabilities, cerebral palsy, and major depressive disorder, is completely dependent on staff for all activities of daily living and is unable to defend themselves due to upper extremity impairment. The incident was witnessed by a unit aide, V2, who reported hearing R2 scream in pain and observed R1 continuing to slap R2 even after the initial altercation began. The facility's abuse prevention policy affirms the right of residents to be free from abuse, yet the incident investigation revealed a failure to prevent R1's aggressive behavior towards R2. R1's care plan had previously documented their physical aggression, including behaviors such as grabbing, biting, and pinching, with a goal to prevent harm to themselves or others. Despite this, the incident occurred, indicating a lapse in the implementation of measures to protect residents from abuse, particularly those who are vulnerable and unable to defend themselves.
Failure to Document Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to document a resident-to-resident physical abuse incident and investigation in a resident's medical record. On June 16, 2024, two residents were involved in an altercation in the dining room where one resident began making noises that agitated the other, leading to the latter slapping the former on the thigh approximately ten times. Despite this incident, the victim's electronic medical record and nursing progress notes for June 2024 did not contain any documentation of the altercation or the fact that the resident was a victim of physical abuse. On June 27, 2024, it was reported that the Registered Nurse only documented the incident in the aggressor's medical record and not in the victim's medical record. This oversight was identified during an interview and record review, affecting one of the three residents reviewed for abuse in the sample.
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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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