The Haven On The River
Inspection history, citations, penalties and survey trends for this long-term care facility in Grayville, Illinois.
- Location
- 320 South 2nd Street, Grayville, Illinois 62844
- CMS Provider Number
- 146119
- Inspections on file
- 33
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at The Haven On The River during CMS and state inspections, most recent first.
A resident with recent knee replacement surgery and chronic right knee pain had an active PRN oxycodone order and a care plan directing staff to administer analgesia as ordered, yet the facility repeatedly failed to ensure the medication was available. Due to missing or misdirected prescriptions, incomplete DEA information, pharmacy delays, and staff not securing one‑time emergency doses at key points, the resident went periods without oxycodone despite reporting significant pain and requesting it frequently. Nursing notes and interviews document that the resident became upset, restless, and anxious when pain medication was unavailable, at times refused other treatments due to pain, and was instead given PRN Tylenol while staff awaited pharmacy fulfillment, demonstrating a pattern of inadequate pain management access.
A resident with an infected knee prosthesis and recent knee surgery had physician orders for PRN oxycodone and scheduled IV vancomycin, but the facility failed to consistently have oxycodone available and did not administer vancomycin within the required time window. On admission and afterward, pharmacy had not received or could not process valid oxycodone prescriptions, an incomplete DEA number prevented emergency dosing, and staff delayed requesting one-time doses from the emergency kit, resulting in periods where no ordered narcotic was available and only Tylenol was offered. Later, the resident again ran out of oxycodone despite refill requests, leaving gaps in availability between documented doses. For vancomycin, multiple doses scheduled twice daily were administered several hours late over several days, even though pharmacy instructions required administration within a 30‑minute window and contact for retiming if late. The resident complained about late antibiotic administration, the pharmacist confirmed that late dosing could affect trough accuracy, and the facility’s own policy required medications to be given in accordance with orders and within the allowed administration window.
A resident with an infected knee prosthesis and multiple comorbidities was ordered IV vancomycin twice daily with strict timing requirements, including administration within a 30‑minute window and pharmacy notification if doses were more than 30 minutes late. The MAR and audit reports showed that multiple morning and evening doses were administered several hours after the scheduled times, and original orders lacked documented administration times. The resident reported that his IV antibiotic was not given when due and voiced concerns to staff about late doses. A pharmacist confirmed that late administration could affect vancomycin trough levels and emphasized the need for strict timing, while leadership staff acknowledged that doses had been given late and that documentation may not have been completed at the time of administration. These practices did not comply with the facility’s own medication administration policy requiring adherence to practitioner orders and timely administration and documentation.
A resident with dementia, anxiety, depression, and Alzheimer’s disease received multiple PRN and routine Ativan orders with inconsistent and clinically questionable indications, such as nausea related to depression and comfort related to Alzheimer’s. The MAR showed repeated PRN Ativan administrations with progress notes documenting symptoms or reasons for use on only a small fraction of doses, while nursing staff stated they did not believe separate notes were necessary and could not recall the resident’s symptoms at the time of administration. A pharmacy review form requesting action on the PRN psychotropic order, including compliance with the 14‑day CMS guideline and documentation of indication and duration, was left entirely incomplete by the prescriber. Family members reported that Ativan had previously caused an opposite, aggressive reaction at home, stated they had stopped it before admission, and said they repeatedly requested that it not be given, yet Ativan was reordered and administered several times, and they were not informed when it was discontinued and restarted. Staff, including an RN and an LPN, reported that the resident became more aggressive and violent after receiving Ativan, but the facility did not ensure appropriate review, documentation, or response to these concerns.
The facility failed to maintain hot water temperatures within its own stated safe range of 100–110°F in multiple resident rooms and shower areas, resulting in consistently lukewarm or cold water at sinks and showers used for personal care. Surveyors measured water temperatures as low as the mid-60s°F at some sinks and showers, even after running the water for several minutes, and staff were observed relocating a resident to another shower room because the water was not warm enough. Several alert and oriented residents reported that the water in their sinks was too cold or not consistently warm for handwashing. The Maintenance Director acknowledged that he only checked faucet temperatures, not showers, and the Administrator confirmed that facility policy requires all resident sinks, showers, and tubs to remain within the 100–110°F range.
A resident with CHF, COPD, CKD, diabetes, dysphagia, and an indwelling catheter experienced poor oral intake, low urine output, and episodes of non‑responsiveness, yet staff did not complete ordered CBC, CMP, and TSH labs, did not timely act on a UA/culture later showing significant infection, and did not develop care plan focus areas for diabetes or catheter care. Despite physician orders for daily accuchecks, several blood glucose checks were not documented, and when the resident’s family reported blood sugars in the 60s and observed shaking and dyspnea, an RN gave instant glucose to the family to administer without first checking the resident’s glucose and did not assess the resident until after 911 was called. EMS found the resident hypoxic with cloudy, blood‑tinged minimal catheter output, and the resident was hospitalized with acute renal failure and hyperkalemia requiring emergent dialysis, after which he was transferred to another hospital and then hospice, where he died.
The facility failed to maintain adequate nursing staff and timely call-light response, resulting in multiple alert residents waiting 30–60 minutes for assistance, including while incontinent and lying in urine. On one evening, only two CNAs and an agency nurse unfamiliar with the facility were on duty, with one CNA taking residents outside to smoke while multiple call lights on a hall went unanswered and a resident yelled for help. Time records confirmed a period when only one CNA and one nurse were present to care for 45 residents. Several CNAs and an RN reported chronic short staffing due to call-ins and lack of agency CNA coverage, stating that some resident care needs were not completed, particularly on more demanding halls and night shifts, despite a written policy requiring adequate staffing ratios and relief coverage.
The facility failed to respond promptly to call lights, leading multiple residents who were incontinent and dependent for toileting and repositioning to wait 30–60 minutes or more for assistance, often while lying in urine. Cognitively intact or moderately impaired residents with complex conditions such as COPD, CHF, diabetes, Parkinson’s disease, hemiplegia, and chronic pain reported frequent evening delays and described being cold and soaked while waiting. Surveyors observed only one CNA covering a hall of 26 residents while taking residents outside to smoke, leaving multiple call lights unanswered and a resident yelling for help, as the DON and an agency nurse unfamiliar with the building managed the floor. The facility’s own call light policy required responding to residents’ requests and needs, but staff actions and staffing patterns did not ensure timely responses or dignified care.
A resident at high risk for falls, dependent on staff for transfers, experienced an unwitnessed fall that was not documented or properly assessed by staff. Despite reports of pain and visible leg abnormalities from family and staff, the nurse on duty did not assess the resident or notify the physician or family. The resident was later sent to the hospital, where fractures were diagnosed, revealing a delay in care due to lack of timely assessment and reporting.
A resident with a history of falls and mobility issues was not properly assessed or treated for pain after a fall that resulted in hip and femur fractures. Despite orders for PRN pain medications, the resident did not receive pain relief, and staff failed to document or address pain complaints, leading to delayed recognition and treatment of serious injuries.
A resident who was dependent on staff for transfers due to lower extremity impairment was injured when a CNA, acting alone and contrary to facility policy, attempted to use a sit-to-stand lift for toileting. The resident slipped from the lift and sustained a head laceration requiring staples. Facility policy required two staff for such transfers, but this was not followed, leading to the incident.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not provide surveyors with requested MARs showing medication administration times for two residents, after being instructed by the COO to withhold these records due to an ongoing internal QA investigation that began when the residents reported late medication administration.
Multiple residents with significant medical and mobility needs reported frequent and prolonged delays in receiving care, particularly during evening, night, and weekend shifts, due to insufficient staffing. Staff interviews and assignment records confirmed that the facility often operated with fewer CNAs and nurses than needed, resulting in missed or delayed care tasks such as toileting and showering. Facility leadership maintained that staffing was adequate, despite evidence to the contrary and the absence of a formal staffing policy.
A resident with chronic kidney disease and neuromuscular bladder dysfunction did not have their indwelling urinary catheter changed as ordered by the physician, with no documented catheter change for over two months. Multiple staff interviews confirmed the catheter was not changed within the required timeframe, despite clear orders and care plan interventions.
A resident with multiple medical and psychiatric diagnoses had an MDS annual assessment inaccurately coded, with the PASRR section marked as 'No' for serious mental illness despite active diagnoses of bipolar disorder, psychotic disorder, and schizophrenia. The LPN responsible at the time was not involved in the original assessment, and the administrator confirmed the absence of a specific policy for MDS accuracy, relying instead on the RAI Manual.
A resident with a stage 3 pressure ulcer did not receive wound care according to the most recent physician's orders due to the facility's failure to update the Treatment Administration Record and Physician Order Sheet. Nursing staff continued to provide the previous daily treatment regimen instead of the updated protocol, resulting in care not being delivered as ordered.
A resident with lower extremity impairment and multiple chronic conditions did not receive required range of motion (ROM) services. Despite documented dependence for self-care and mobility, there were no physician orders or restorative nursing interventions for ROM, and staff confirmed that no ROM care was provided or documented.
A resident with severe cognitive impairment and a history of Alzheimer's Disease experienced significant weight loss due to the facility's failure to consistently monitor and document meal intakes and weekly weights as ordered. Despite being at risk for malnutrition and requiring full staff assistance for eating, there were repeated gaps in meal intake records and no documentation of meal refusals, contributing to inadequate assessment and intervention for the resident's nutritional needs.
Two residents with pressure ulcers, both on enhanced barrier precautions, received wound care from an LPN who wore gloves but failed to don a gown as required by facility policy. Despite clear signage and staff awareness of the precautions, the proper use of personal protective equipment was not followed during high-contact care activities.
A facility failed to maintain adequate staffing levels, impacting resident care. A resident reported inconsistent care and missed showers due to staffing shortages, while another was observed not being repositioned as required. Staff interviews revealed systemic staffing issues, particularly after 2 P.M. and on weekends, with discrepancies in the staffing schedule and resident grievances about call bell response times.
The facility failed to provide adequate care for two residents, one of whom did not receive consistent repositioning, and another who experienced delays in call light responses and missed scheduled showers due to staffing shortages. The administration acknowledged staffing challenges, which affected the ability to meet residents' care needs.
A resident with chronic heart failure did not receive a prescribed Furosemide injection due to unavailability in the medication cart and emergency kit. The LPN failed to notify the physician or communicate the issue to the day shift, leading to a significant medication error. The facility's policy requires using the emergency kit and notifying the physician when medications are unavailable, which was not followed in this instance.
Failure to Ensure Continuous Availability of Ordered Post‑Surgical Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered pain medication was consistently available for a resident following recent right knee replacement surgery and related complications. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, aftercare following knee joint prosthesis, fracture of the right patella, depression, anxiety, heart failure, and seizures. The MDS documented that the resident was cognitively intact, had recent knee replacement surgery, and experienced frequent pain rated as high as 8/10, affecting sleep, therapy, and daily activities. The care plan identified chronic pain related to the right knee prosthesis and directed staff to administer analgesia per orders, including giving it 30 minutes before treatments or care. Another care plan focus addressed the resident’s frustration and anxiety about possibly going without medications, noting that an earlier incident had occurred when an orthopedic prescription was sent to the wrong pharmacy. From admission onward, there were repeated problems obtaining and maintaining the resident’s ordered oxycodone. On the night of admission, staff contacted the pharmacy for access to oxycodone from the emergency medication system, but the pharmacy reported it had not received the prescription. The DON documented calls to the pharmacy and the discharging hospital, learning that the order would need to come from the surgeon the next day. The resident complained of discomfort, refused PRN Tylenol stating it would not help compared to oxycodone, and ultimately requested transfer to the hospital when no oxycodone was available. Progress notes show that the pharmacy reported never receiving the script, no prescription was found in the admission paperwork, and the on‑call MD did not complete a verbal order despite multiple attempts. The resident became very upset, refused IV antibiotics due to pain, and was transported to the hospital. When he returned, staff again found no oxycodone script in the return paperwork, and the ADON documented that the resident was angry and demanding his pills. The ADON faxed the hospital script to the pharmacy but did not request a one‑time dose from the emergency supply because the resident was calling her names; the pharmacy then reported the script was incomplete due to a missing DEA number, preventing a one‑time dose. The resident’s MAR shows an oxycodone order starting on 3/27 and discontinued on 3/29, with a new order starting 3/31 and subsequent administrations documented into April. However, progress notes and staff interviews reveal multiple gaps when oxycodone was not available despite an active PRN order. On one occasion, all six tablets stocked in the emergency dispensing system were used, a refill request was submitted, and the pharmacy advised that the refill would be delivered the next morning; during this period, the resident was offered and accepted PRN Tylenol as an alternative. On another occasion, narcotic counts showed no oxycodone in the narcotic box, and chart review confirmed delays in refill and lack of restocking of the emergency dispensing system. The resident repeatedly requested pain medication, reported inability to walk due to pain, and was instead given Tylenol when oxycodone was unavailable. Staff, including the ADON and LPN, acknowledged that the resident had run out of oxycodone more than once, that it could take a while to get refills, and that the resident’s use of two tablets per dose contributed to running out quickly. The DON stated she was unsure if the pharmacy was available 24/7, and the NP stated she did not understand why the resident was running out, as she ordered a seven‑day supply each time and had observed an ongoing issue with ensuring pain medication availability. The facility’s own pain management policy stated its purpose was to deliver safe, individualized pain care and promote resident comfort, but the documented events show that the resident’s ordered pain medication was not consistently available, resulting in uncontrolled pain, restlessness, and anxiety. The deficiency is further illustrated by the resident’s own statements and staff observations. The resident reported that he went two to three days without pain medication upon admission and that the facility ran out of his pain medication every weekend, causing him to move less because of pain. Progress notes describe him as demanding his oxycodone, becoming red‑faced, shaking, and using profanity when it was not available, and refusing non‑opioid alternatives at times. Staff documented that he was frequently observed ambulating and participating in activities without obvious distress, and one LPN noted behavior suggestive of medication‑seeking; however, the same records confirm that when oxycodone was not available, staff could not administer it as ordered and instead relied on Tylenol and non‑pharmacologic measures. The NP explicitly stated that not getting pain medications as ordered could slow healing and contribute to anxiety and poor sleep. Overall, the facility did not ensure that the resident’s prescribed oxycodone was continuously available for administration as ordered, leading to periods of uncontrolled post‑surgical pain and associated restlessness and anxiety. The facility’s own documentation shows that the resident’s concern about going without medications was known and care‑planned, yet the underlying issue of ensuring timely, uninterrupted access to his ordered pain medication was not resolved. Pharmacy communication problems (scripts not received, incomplete DEA number, prior fill at another pharmacy, delays in restocking the emergency dispensing system), lack of timely physician orders or corrections, and staff decisions not to pursue one‑time emergency doses at certain points all contributed to repeated lapses in availability of oxycodone. These lapses occurred despite an active PRN order, ongoing pain assessments showing pain scores up to 10/10, and a care plan directing administration of analgesia per orders. As a result, the resident experienced episodes where his pain was not controlled and he became restless, anxious, and at times refused other treatments due to pain.
Failure to Ensure Availability of Ordered Pain Medication and Timely IV Antibiotic Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered pain medication was consistently available and that IV antibiotics were administered within the prescribed time parameters for one cognitively intact resident with complex medical needs. The resident was admitted with an infected right knee prosthesis, recent knee replacement surgery, fracture of the right patella, depression, anxiety, heart failure, and seizures, and had a care plan intervention to receive analgesia as ordered, including prior to treatments. The resident’s MDS documented frequent pain with intensities up to 8/10, and physician orders included oxycodone 5 mg, two tablets every four hours as needed for pain, along with pain monitoring every shift. Despite these orders, the resident reported going 2–3 days without pain medication upon admission and stated that pain medications ran out on weekends, limiting his movement due to pain. On admission and in the days immediately following, multiple nursing notes document that oxycodone was not available because the pharmacy had not received or processed a valid prescription. On the night of admission, staff contacted the pharmacy for emergency access to oxycodone, but the pharmacy reported no script on file. The DON documented that the pharmacy had not received the prescription, and the house supervisor at the discharging hospital indicated the order would need to come from the surgeon the next day. The resident complained of pain, refused PRN Tylenol, and ultimately requested transfer to the hospital due to lack of pain medication; EMS transported him when a prescription still could not be obtained. When the resident returned from the hospital, the ADON faxed the oxycodone prescription but did not immediately request a one-time emergency dose because the resident was speaking to her in a hostile manner and she chose to wait until the pharmacy processed the order. The pharmacy later reported the hospital script was incomplete due to a missing DEA number, preventing issuance of a one-time dose. Progress notes show the resident continued to demand oxycodone, became angry when it was not available, and that his oxycodone did not arrive until the morning of 3/30. Subsequently, the resident experienced additional episodes where oxycodone was not available as ordered. Documentation on 4/9 shows that all six tablets previously stocked in the emergency dispensing system had been used, a refill request had been submitted, but the medication had not yet been received; the resident was offered and accepted Extra Strength Tylenol as an alternative. On 4/12, nursing notes document that no oxycodone was available in the narcotic box despite prior refill attempts and pharmacy contact, and the resident again received Tylenol instead. The MAR and staff interviews indicate that from the morning dose on 4/12 until the evening dose on 4/13, oxycodone was not available for administration. The ADON acknowledged the resident had run out of oxycodone more than once and could not explain why it was not available, while other staff confirmed that residents had complained about running out of narcotics and that refills could take a while. The nurse practitioner stated she ordered a seven-day supply each time and had noticed an issue with ensuring pain medication availability. The deficiency also includes failure to administer IV vancomycin within the ordered time window. The resident had an order for vancomycin 1.5 g twice daily with explicit pharmacy instructions that it be administered within a 30-minute window of the scheduled time and that if given more than 30 minutes late, nursing should call the pharmacy for retiming orders to avoid inaccurate trough levels and dosing. The medication administration audit shows that multiple morning doses scheduled for 6:30 AM were given several hours late on consecutive days, and several evening doses scheduled for 6:00 PM were also administered significantly past the ordered time. The resident voiced concerns to staff that his vancomycin was being given later than due, including a report that a dose was given at approximately 2:30 PM, and requested that the nurse call the pharmacy. The pharmacist confirmed that late administration could affect trough accuracy and reiterated the requirement for administration within a 30-minute window and for pharmacy contact if doses were more than 30 minutes late. The RN and DON later acknowledged that vancomycin had been administered late at times, particularly when an RN was not working, and the pharmacist emphasized the importance of timely administration for appropriate drug clearance and dosing. The facility’s own medication administration policy states that drugs are to be administered in accordance with practitioner orders and that medications shall be administered within one hour before or after the scheduled time unless otherwise ordered, and that medications must be recorded on the MAR promptly after administration. Despite this policy, the documented record shows repeated unavailability of ordered oxycodone and repeated late administration of vancomycin outside the specified time parameters for this resident.
Failure to Administer IV Vancomycin as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure that IV vancomycin was administered as ordered for a resident being treated for an infection of a right knee prosthesis. The resident was admitted with multiple diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, aftercare following knee joint prosthesis, fracture of the right patella, depression, anxiety, heart failure, and seizures, and was cognitively intact per the MDS. The care plan identified an active infection of the right knee prosthesis with an intervention to administer antibiotics per physician orders. The physician’s vancomycin order, as reflected on the Order Summary Report, specified vancomycin 1000 mg (1.5 g) twice daily with instructions from the pharmacy that doses must be given within a 30‑minute window and that if a dose was more than 30 minutes late, the pharmacy should be called for retiming to avoid inaccurate trough levels and dosing. The Medication Administration Record for the initial treatment period documented vancomycin 1000 mg (1.5 g) twice daily for infection, but did not include administration times. The Medication Administration Audit Report later showed that vancomycin was scheduled for 6:30 AM and 6:00 PM, yet multiple doses were administered significantly late. Morning doses were given several hours after the scheduled time on multiple consecutive days, and evening doses were also administered hours late on several occasions. These late administrations occurred despite the pharmacy’s explicit instruction that the medication must be administered within a 30‑minute window and that late doses required contacting the pharmacy for retiming orders. The resident reported to surveyors that he did not receive his IV antibiotics the way he should when he first moved to the facility and later approached the nurses’ station to voice concerns that his IV vancomycin was given later than the due time, stating he knew when it was supposed to be administered. A pharmacist, when contacted as documented in the progress note, stated that if the reported late administration time was accurate, the vancomycin trough would be off, leading to incorrect dosing, and reiterated that the medication must be administered within a 30‑minute window with pharmacy notification if given more than 30 minutes late. The ADON stated she was not aware of the antibiotics being administered at incorrect times and believed no doses were missed, while the DON acknowledged that the antibiotic had been administered late at times when no RN was working and suggested that some doses might have been given on time but not documented at the time of administration. The facility’s Medication Administration Policy required drugs to be administered in accordance with practitioner orders and within one hour before or after the scheduled time unless otherwise ordered, and to be recorded promptly after administration, which was not followed in this case.
Failure to Manage and Document PRN Psychotropic (Ativan) Use and Respond to Family Concerns
Penalty
Summary
The deficiency involves the facility’s failure to appropriately manage and document the use of the psychotropic medication Ativan for one resident with dementia, anxiety, depression, and Alzheimer’s disease. The resident’s diagnoses included unspecified dementia with agitation, generalized anxiety disorder, Alzheimer’s disease, and depression. The resident’s care plan identified multiple behavior-related focus areas, including anxiousness, restlessness, destructiveness, potential physical aggression, delusional thinking, hallucinations, delirium, and acute confusion, with interventions that included administering psychotropic medications as ordered and monitoring for effects and effectiveness every shift. The Minimum Data Set documented that the resident was not cognitively intact, had frequent depressive symptoms, and exhibited behaviors such as hitting, scratching self, pacing, rummaging, public sexual acts, and public disrobing, and that the resident was on high-risk drug classes including an antipsychotic and an antidepressant. The facility’s records showed multiple Ativan orders with inconsistent and clinically questionable indications and inadequate documentation. An initial PRN Ativan order for 0.5 mg every 12 hours was entered with an indication of nausea related to depression, followed by a second PRN order for the same dose every 12 hours for comfort related to Alzheimer’s disease, and later a routine order every 12 hours for anxiety, aggression, and agitation related to generalized anxiety disorder. The nurse practitioner later stated that the first indication (nausea related to depression) was something she had only seen in hospice and not related to depression, and that neither the first nor second indication (comfort related to Alzheimer’s) was appropriate. The February MAR showed that the resident received PRN Ativan multiple times under these orders, but progress notes documented the symptoms or reasons for administration on only 1 of 7 PRN doses under the first order and 1 of 4 PRN doses under the second order. Nursing staff, including the DON and an LPN, stated they did not believe it was necessary to write a progress note each time a PRN medication was administered and believed the diagnosis on the MAR was sufficient, and one LPN could not recall the resident’s symptoms at the time she administered Ativan. The facility also failed to respond appropriately to a pharmacy review and to family concerns regarding Ativan use. A pharmacist’s medication review form for the PRN Ativan order requested that the prescriber choose among options to discontinue, add a stop date per CMS 14-day PRN psychotropic guidelines, or extend the order with a specified duration, indication, and rationale. None of these options were selected, and the prescriber response section was left blank, with no indication that the prescriber acknowledged or signed the review. The administrator acknowledged that PRN psychotropic medications should be reviewed within 14 days and either reordered or discontinued and was unsure why this review was missed. The resident’s power of attorney and another family member reported that Ativan had previously caused an idiosyncratic, opposite reaction at home, that they had stopped it before admission, and that they requested on multiple occasions that Ativan not be administered. They stated they were not informed when Ativan was discontinued and then reordered, and one family member denied giving verbal consent for Ativan use. Nursing staff, including an RN and an LPN, reported that each time the resident received Ativan he became more aggressive, violent, and agitated, and one RN stated she had voiced concerns to the DON. Despite these reports and the family’s requests, Ativan was reordered and administered multiple times, with inadequate documentation of indications and without clear evidence of prescriber review or acknowledgment of the pharmacist’s recommendations.
Failure to Maintain Safe Hot Water Temperatures for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequately heated water for showers and personal care to all eight residents reviewed for environmental conditions. Surveyors verified thermometer accuracy and then documented multiple instances where hot water temperatures at resident sinks and in shower rooms were significantly below the facility’s stated safe range of 100–110°F. On several occasions, water at resident bathroom sinks did not exceed temperatures ranging from approximately 63°F to 96°F even after running for several minutes, and shower water temperatures in the North Hall shower rooms were recorded between 66°F and 85°F. Residents who were alert and oriented reported that the water in their sinks was too cold to wash their hands or was sometimes not warm, and a CNA was observed moving a resident from one shower room to another because the water was not warm enough. The Maintenance Director stated he only checks water temperatures at faucets and not in showers, relying on a loop system that he believed should keep temperatures consistent, and reported that temperatures appear fine when he checks them early in the morning before showers are given. The Administrator stated his expectation, consistent with the facility’s Water Temperature Safety Guideline, is that water temperatures in resident sinks, showers, and tubs remain between 100–110°F and be checked per protocol. The facility’s written guideline specifies that this temperature range is intended to help prevent resident burns and reduce the risk of bacteria growth by keeping water at safe temperatures, yet the documented observations show that resident care areas, including individual bathrooms and shower rooms, did not consistently meet these parameters during the survey.
Failure to Obtain Ordered Labs and Monitor Decline Leading to Acute Renal Failure
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders, obtain and act on ordered laboratory tests, and adequately assess and monitor a cognitively intact resident with multiple serious comorbidities, including acute on chronic heart failure, COPD, acute kidney failure, CKD stage IIIa, and insulin‑dependent type 2 diabetes. The resident was admitted with dysphagia, poor intake, and an indwelling catheter, and the MDS documented substantial/maximal assistance for toileting and use of an indwelling catheter. The care plan included psycho‑social and delirium focus areas, with an intervention to report abnormal lab results to the MD, and a nutritional problem related to dysphagia with instructions to monitor and record intake every meal; however, there were no care plan focus areas for diabetes mellitus or the indwelling catheter. On 12/28, nursing documentation showed the resident was not taking food or thickened liquids, was non‑verbal, and had a firm bladder; a Foley catheter was inserted with 450 ml of clear yellow urine obtained, and the MD was notified. Later on 12/28, the MD ordered Megace, CBC, CMP, TSH, UA and urine culture, protein supplements, and nutrition and psychiatry consults. The order summary reflected one‑time orders for CBC, CMP, TSH, and UA with culture starting 12/29, as well as an order for morning accuchecks for diabetes and, later, an order to record catheter output every shift starting 01/07. The DON later stated the CBC, CMP, and TSH were never completed because the nurse entered them on the wrong flowsheet so they did not populate to the EMAR, and the facility did not discover this until after the incident. The DON also acknowledged that the UA was completed but the results, which ultimately showed >100,000 CFU/mL Pseudomonas fluorescens and >100,000 CFU/mL Enterococcus faecalis, were not available in the chart until they were printed weeks later; the Administrator stated the lab was supposed to deliver results and that nurses should have followed up. Staff interviews showed that, despite the presence of an indwelling catheter and poor intake, the facility’s practice was not to monitor intake or output unless there was a specific physician order, and the Administrator and DON confirmed they did not routinely monitor outputs with a catheter unless ordered. From 01/07 through 01/11, the treatment record documented catheter outputs that nephrology later characterized as not good outputs and potential indicators of renal problems or poor intake, with several shifts showing low volumes and some shifts with no output recorded. CNAs and nurses reported the resident was not drinking well, was a poor eater, had very little urine in the catheter bag, complained of needing to urinate, and had shortness of breath at times. The MAR showed ordered morning accuchecks for diabetes, but there were no documented blood glucose checks on several days, including 01/11. On 01/11, the family member, using a continuous glucose monitor, reported blood sugars in the 60s throughout the day and found the resident shaking and struggling to breathe. The Assistant DON gave the family member a tube of instant glucose to administer, did not check the resident’s blood sugar at that time, and later stated she did not know why she allowed the family member to give it. The family member reported the nurse “threw” the glucose and spoon at her without instructions and did not enter the room until after 911 was called. EMS documented that the nurse said she had not called 911 and saw no reason to send the resident out, that the nurse refused to assist EMS in the room, that the resident’s SpO2 was 89% and improved with 3 L O2, and that the catheter drainage was cloudy with specks of blood and minimal output. The resident was transported to the hospital, where he was diagnosed with acute renal failure and hyperkalemia requiring emergent dialysis, and was later transferred to another hospital for higher‑level nephrology care and ultimately to hospice, where he died. The surveyors determined that the facility failed to obtain ordered labs, failed to follow up on UA and culture results, and failed to notify the physician of the resident’s decline, resulting in delayed medical treatment and constituting Immediate Jeopardy beginning 12/28.
Failure to Maintain Adequate Nursing Staff and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely response to call lights. Multiple alert and oriented residents reported waiting 30 minutes to an hour for assistance, particularly on evening and night shifts. One resident stated she intentionally activated her call light to see which staff were working and waited over 30 minutes before the administrator answered her light, noting this type of delay happens frequently in the evenings when there is often only one CNA per hall. Another resident reported waiting over half an hour on several nights for staff to answer her call light, including an occasion when her bed was soaked and she was freezing from lying in urine. A third resident stated she had to wait 30–45 minutes for staff to respond when she needed to be changed and had to lie in urine during the wait, and that this occurs often on both day and evening shifts. A fourth resident reported being on her call light for over 30 minutes after an incontinent episode and ultimately called the nurses’ station before the DON came to assist her, stating that evening call light response can take 30–45 minutes or up to an hour. Surveyor observations on one evening documented that only two CNAs were initially working the floor, with an agency nurse on duty who had never been at the facility before. One CNA was observed taking residents outside to smoke on the North Hall, leaving no other CNA on that hall. During this time, four call lights were observed going off in separate rooms on the North Hall and remained unanswered for an extended period. The DON directed the CNA to obtain vital signs equipment and assess a sick resident in the dining room while the call lights continued to sound. The CNA then answered the phone and reported that a resident was calling for help. A resident’s voice was later heard yelling for help from the North Hall while the same call lights remained on. It was not until approximately 7:21 p.m. that the CNA entered one of the rooms, followed by the administrator entering another room, and call lights in the affected rooms were gradually turned off. Another CNA arrived later in the evening to assist. Time clock records and staff interviews further demonstrated staffing shortages. Punch records showed that from just before midnight until 1:42 a.m. on one date, only one CNA and one agency nurse were in the building to care for 45 residents. Multiple CNAs and an RN stated the facility did not have enough staff to adequately care for all residents, describing frequent call-ins, no-shows, and the lack of agency CNAs to cover open shifts. Staff reported that when they worked short, some resident care needs were not completed and that on some nights there was only one CNA on the North Hall and one CNA on the South or memory care unit with one nurse. One CNA confirmed being called in at 1:40 a.m. because only one CNA and one nurse were on duty. Another CNA stated that North Hall was more demanding and that, although the schedule called for multiple CNAs, call-ins often left the facility short without coverage. Despite this, the administrator stated he felt call lights were answered timely and that the facility had enough staff, although he also stated he did not think a single CNA on a hall should be taking residents out to smoke and leaving no staff on the hallway, and he was not aware of the period when only one CNA and one nurse were working overnight. The facility’s undated staffing policy stated that it is the policy of the facility to provide an adequate number of staff to meet resident needs and to maintain adequate staffing ratios, including scheduling relief staff during vacations, holidays, and relief periods. However, the documented resident reports of prolonged call light response times, observations of unanswered call lights and residents calling out for help, verified periods with only one CNA and one nurse on duty for the entire facility, and staff statements that resident care needs sometimes could not be completed due to insufficient staffing, all occurred despite this written policy.
Failure to Respond Timely to Call Lights Resulting in Prolonged Incontinence and Loss of Dignity
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely care and dignified treatment by not responding promptly to call lights, particularly on the North Hall. Multiple cognitively intact or moderately impaired residents who were dependent on staff for toileting and repositioning reported extended delays, often 30–60 minutes, before staff responded to their requests for assistance. These delays occurred despite care plan interventions that emphasized keeping call lights within reach and encouraging residents to use them for help, as well as documentation that several residents were incontinent and required extensive or total assistance with ADLs and toileting. One resident with chronic respiratory failure, type 2 diabetes, morbid obesity, chronic kidney and heart disease, and a history of moisture-associated skin damage reported that on an evening shift she waited over 30 minutes for her call light to be answered, and that such delays of 30 minutes to an hour happened frequently, especially in the evenings. This resident was bedbound, dependent on staff for toileting and repositioning, always incontinent of bowel, and at risk for impaired skin integrity, yet she reported that often only one CNA was assigned to her hall and one CNA to the other hall. Another resident with Parkinson’s disease, COPD, panic disorder, and fibromyalgia, who required assistance with ADLs and was occasionally incontinent, stated she had to wait over an hour on an evening shift for her call light to be answered while lying in a soaked bed and feeling cold from being in her urine. She reported that when still in her wheelchair, she would sometimes wheel into the hall to look for staff because of the delays. A third resident with permanent atrial fibrillation, chronic respiratory failure, type 2 diabetes, unsteadiness on feet, and chronic pain, who was always incontinent and dependent for toileting hygiene, stated she had her call light on several times one night and had to wait 30–45 minutes each time for staff to respond, during which she lay in urine while waiting to be changed. A fourth resident with hemiplegia, type 2 diabetes, COPD, morbid obesity, neurocognitive disorder with Lewy bodies, dementia with behavioral disturbance, Parkinson’s disease, and multiple other comorbidities, who was always incontinent and dependent for toileting and transfers, reported being on her call light for over 30 minutes one night, even calling the nurses’ station for help, while waiting to be changed after an incontinent episode. She stated that such delays in the evening occurred often and that it could take 30–45 minutes, sometimes an hour, for call lights to be answered. Surveyor observations and staff interviews corroborated these reports of delayed responses. On one evening, the DON stated that only two CNAs were working the floor, one CNA had called in, another had not shown up or called, and an agency nurse unfamiliar with the facility was the nurse on duty. The DON also stated another CNA was coming in later to help. During this time, the CNA assigned to the North Hall was observed taking residents outside to smoke, leaving no other CNA visible on that hall. Multiple call lights were observed activated in four separate rooms on the North Hall for an extended period while the CNA was outside and then occupied with other tasks, including taking vital signs on a resident in the dining room and answering the phone. An unknown resident was heard yelling for help from the North Hall while call lights continued to sound. The Administrator later stated he felt staff answered call lights in a timely manner but acknowledged that if only one CNA was on a hall, that CNA should not be taking residents out to smoke and leaving no staff on the hallway. The facility’s policy on answering call lights stated that the purpose of the procedure was to respond to residents’ requests and needs, but the observed and reported delays demonstrated a failure to follow this policy.
Failure to Provide Timely Post-Fall Assessment and Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall. The resident, who was at high risk for falls and dependent on staff for all transfers, was found on the floor in her room after an unwitnessed fall. There was no documentation in the progress notes of the fall or a post-fall evaluation on the date of the incident, despite facility policy requiring such documentation. Staff did not perform or document a timely assessment, and the fall was not reported to the physician or the resident's family as required. Following the fall, the resident exhibited signs of pain and swelling in her leg, which were noticed by family members and reported to staff. Multiple staff interviews revealed that the resident's pain was reported to the nurse on duty, but no action was taken to assess or address the resident's condition. The nurse involved did not assess the resident after the fall, nor did she notify the family or physician, and the resident continued to display symptoms over the following days. The resident was eventually sent to the hospital at the request of her family, where she was diagnosed with fractures in her left femur and right hip. The lack of timely assessment, monitoring, and reporting after the fall resulted in a delay in treatment for the resident's injuries. The facility's failure to follow its own fall guidelines and professional standards of care led to the deficiency cited in the report.
Failure to Assess and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident who was at risk for falls and dependent on staff for all transfers was not properly assessed for injury and pain following a fall. The resident, who had a history of muscle weakness, abnormal gait, and prior knee replacements, was found to have sustained a hip and femur fracture. Despite having physician orders for as-needed pain medications, the resident did not receive any pain relief between the dates surrounding the incident, and pain assessments documented minimal or no pain, even though family members and staff observed signs of pain and physical abnormalities in the resident's leg. Family members reported that the resident appeared to be in pain and had visible leg deformities, prompting them to request further evaluation. Staff interviews revealed that pain and injury were reported to a nurse, but there was no evidence that the nurse conducted a thorough assessment, notified the physician or family, or administered pain medication. Documentation in the resident's medical record did not reflect the pain complaints or the fall, and pain assessments were inconsistent with the observations of pain by family and staff. When the resident was eventually sent to the hospital, x-rays confirmed fractures in the left femur and right hip. Hospital records indicated that the resident and her family had reported pain for several days prior to transfer, but the facility's records did not document these complaints or provide appropriate pain management. The facility's fall policy required consistent identification, evaluation, and treatment of residents who fall, which was not followed in this case.
Improper Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and toileting due to lower extremity impairment and other medical conditions, was improperly transferred using a mechanical lift. The resident had a BIMS score indicating cognitive intactness and required two staff members for safe transfer according to facility policy. On the day of the incident, a CNA responded to the resident's call light and, despite knowing the policy, attempted to transfer the resident alone using a sit-to-stand lift. During the transfer, the resident slipped out of the straps and fell, resulting in a head injury and a 1.2 cm laceration that required three staples. The facility's investigation and interviews confirmed that the CNA did not wait for a second staff member before using the mechanical lift, which was against established policy. The resident's emergency room records corroborated the account of the fall and injury. The root cause analysis identified improper use of the mechanical lifting device as the cause of the incident. Facility policy clearly stated that at least two nursing assistants are required for such transfers, but this protocol was not followed in this instance.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Medication Administration Records During Survey
Penalty
Summary
The facility failed to provide requested medical records, specifically the July 2025 Medication Administration Records (MARs) for two residents, which were needed to assist the survey process. The MARs reviewed in the Electronic Health Records did not document the actual time medications were administered. When the surveyor requested MARs with documented and timestamped medication administration times, the Director of Nursing (DON) stated he was instructed by the Chief Operating Officer not to provide these records or allow the surveyor to view them, citing an ongoing internal Quality Assurance investigation. The internal investigation had been initiated after the two residents reported that their medications were being administered outside of the ordered time ranges.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of all residents, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents with complex medical conditions, including diabetes, morbid obesity, chronic obstructive pulmonary disease, chronic pain, and mobility impairments, reported frequent and prolonged delays in receiving assistance, particularly with activities of daily living (ADLs) such as toileting, showering, and repositioning. Residents consistently described long wait times for call light responses, especially during evening, night, and weekend shifts, with some reporting waits of up to two hours. Staff interviews corroborated these accounts, with multiple CNAs and nurses stating that the facility was regularly short-staffed, particularly on night shifts and weekends. Staff reported difficulty completing required rounds and providing timely care, with some stating that showers and other essential care tasks were often missed due to inadequate staffing. Assignment records confirmed that on several occasions, only one nurse and two CNAs were present to care for all 47 residents during overnight shifts, which was below the facility's own assessment of required staffing levels. Despite these findings, facility leadership, including the Administrator and DON, maintained that staffing was adequate, though they acknowledged occasional reliance on agency staff and admitted to shifts with only two CNAs and one nurse. The facility did not have a formal staffing policy in place. The deficiency was identified through direct resident and staff testimony, review of care plans and assignment sheets, and census data, all of which demonstrated a pattern of insufficient staffing that affected the ability to meet residents' care needs.
Failure to Change Indwelling Urinary Catheter per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, benign lipomatous neoplasm of the kidney, and neuromuscular dysfunction of the bladder did not have their indwelling urinary catheter changed according to physician orders. The resident's care plan and physician orders specified that the catheter should be changed once monthly and as needed for infection prevention. However, review of the Treatment Administration Records (TAR) for three consecutive months showed no documentation that the catheter was changed during this period. The last documented catheter change was on 3/28/25, and both the resident and multiple nursing staff confirmed that no catheter change had occurred in the subsequent two months. Interviews with the Medical Doctor, Director of Nursing, and other nursing staff confirmed that the expectation was for the catheter to be changed every thirty days as ordered. Despite this, none of the nurses interviewed recalled changing the catheter for the resident during the required timeframe, and the Director of Nursing was unable to identify any staff who had performed the change. The deficiency was identified when the catheter was finally changed on 6/16/25, more than two months after the previous change, and the physician was notified that this was the first change in over two months.
Inaccurate MDS Assessment Coding for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one resident. The resident, a 71-year-old individual with multiple diagnoses including unspecified atrial fibrillation, type 2 diabetes mellitus, edema, osteoarthritis, obesity, venous insufficiency, and psychiatric/mood disorders, had an MDS annual assessment completed with discrepancies. Specifically, Section A1500 of the MDS, which addresses the Preadmission Screening and Resident Review (PASRR), was marked as 'No' for serious mental illness or intellectual disability, despite the resident having active diagnoses of bipolar disorder, psychotic disorder, and schizophrenia as indicated in Section I of the same assessment. Interviews revealed that the LPN responsible for MDS at the time of the survey was not the one who completed the July MDS and was not employed at the facility during that period. The LPN acknowledged that Section A1500 was not documented appropriately. The facility administrator confirmed there was no specific policy for accurately completing MDS assessments and stated that staff are expected to follow the RAI Manual for guidance.
Failure to Update and Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to provide pressure wound treatment according to the physician's updated orders for one resident with a stage 3 pressure ulcer. The resident, who had diagnoses including chronic kidney disease, polyneuropathy, and peripheral vascular disease, was admitted with a stage 3 pressure injury to the right buttock/ischium. The initial physician's order directed daily wound care with wound cleanser, barrier wipe, calcium alginate, and bordered gauze. However, a new order was issued by the wound care nurse practitioner to change the treatment to cleansing, application of collagen, and covering with bordered gauze three times per week and as needed. Despite the updated order, the Treatment Administration Record (TAR) and Physician Order Sheet (POS) were not updated to reflect the new treatment regimen. Nursing staff continued to provide the previous daily treatment, as observed during wound care, and the documentation showed the outdated treatment was administered. The Director of Nursing acknowledged that the new order had not been entered into the medical record, resulting in the resident not receiving wound care as per the most recent physician's instructions.
Failure to Provide Range of Motion Services for Resident with Impairment
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including osteoarthritis, obesity, and lower extremity impairment, did not receive range of motion (ROM) services as required. The resident's Minimum Data Set (MDS) documented significant functional limitations and dependence on staff for activities of daily living, including self-care and mobility. Despite these documented needs, there were no physician orders for ROM or restorative nursing programs, and the care plan interventions focused only on assistance with daily activities, not on maintaining or improving ROM. Interviews with facility staff confirmed that the resident had not received any active or passive ROM services, and there was no documentation in the electronic medical record to indicate that such care was provided. The Director of Nursing acknowledged the absence of restorative CNA services and related charting, while the Director of Therapy stated the resident had only been verbally screened and had not received therapy services. The facility's policy required contacting the physician for treatment orders if none existed, but this was not done prior to the survey findings.
Failure to Monitor and Document Nutrition for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and document the weights and meal intakes for a resident with significant weight loss. The resident, who had diagnoses including early onset Alzheimer's Disease and osteoarthritis, was identified as being at risk for altered nutrition and required at least partial or moderate assistance with eating. Despite physician orders for a regular diet with puree texture, thin liquids, and weekly weights, there were multiple instances in April and May where meal intake documentation was missing, with no indication if meals were refused. The resident's weight showed a significant downward trend, with a loss of over 12% in three months, triggering concern for malnutrition. The registered dietician noted the resident averaged 25-75% meal intake and was refusing some meals, and recommended nutritional supplements and fortified foods to address the weight loss. Observations confirmed the resident required full staff assistance for eating and had severe cognitive deficits. Interviews revealed that the registered dietician was not responsible for ordering weekly weights and assumed the primary care physician had done so. The facility's policy required the multidisciplinary team to monitor and intervene for undesirable weight loss, with specific thresholds for significant and severe weight loss. However, the lack of consistent documentation of meal intake and adherence to weight monitoring orders contributed to the failure to properly assess and address the resident's nutritional status.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for two residents who had pressure ulcers and were on EBP due to their wounds. For both residents, signage was posted on their doors instructing that all staff must clean their hands before entering and leaving the room, and that providers and staff must wear gloves and a gown during high-contact care activities such as wound care. Despite these instructions, a Licensed Practical Nurse (LPN) was observed entering the rooms of both residents to provide wound care while only donning gloves and not a gown. Both residents had significant medical histories, including chronic kidney disease, polyneuropathy, peripheral vascular disease, chronic obstructive pulmonary disease, and traumatic brain injury. Each had a documented pressure ulcer, with one resident having a stage 3 ulcer and the other an unstageable ulcer. The LPN acknowledged that both residents were on enhanced barrier precautions due to their wounds and confirmed that staff are required to don both gown and gloves before providing care. The Director of Nursing also confirmed that the LPN should have worn a gown in addition to gloves during the observed wound care activities.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all residents, as evidenced by the experiences of two residents, R5 and R9. R5, who is cognitively intact and requires extensive assistance with activities of daily living due to multiple health conditions, reported inconsistent care, including delays in call light responses and missed showers due to staffing shortages. R5 noted that the facility was particularly short-staffed on weekends, leading to missed showers and inadequate care. R9, who is severely cognitively impaired and dependent on staff for basic care needs, was observed over two days to remain in the same position in bed without being repositioned, contrary to the care plan that required repositioning every two hours. Despite the Director of Nursing's expectation for regular repositioning, observations indicated that R9 was not receiving the necessary care, highlighting a failure in staff adherence to care protocols. Interviews with staff, including the Director of Nursing and various CNAs, revealed systemic staffing issues, with reports of insufficient staff to cover shifts, particularly after 2 P.M. and on weekends. The facility's staffing policy was unclear, and there were discrepancies in the staffing schedule, leading to inadequate care for residents. The facility's grievance summary also documented resident concerns about call bell response times, further indicating the impact of staffing shortages on resident care.
Deficiency in Resident Care and Staffing Issues
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living for two residents, R5 and R9, as observed during the survey. R5, who is cognitively intact and requires extensive assistance due to reduced mobility and other health conditions, reported inconsistencies in receiving ice water and delays in call light responses, sometimes waiting up to two hours. R5 also mentioned not receiving scheduled showers on weekends due to staffing shortages, which was corroborated by the facility's staffing records showing insufficient CNA coverage on those days. R9, who is severely cognitively impaired and dependent on assistance for daily activities, was observed over two days to remain in the same position on his back without being repositioned every two hours as required. Despite the facility's policy and the Director of Nursing's expectations for regular repositioning, R9 was not turned or repositioned, and staff were unsure of when repositioning occurred. This lack of adherence to care plans and facility policies highlights a deficiency in providing necessary care to maintain residents' health and comfort. The facility's administration acknowledged issues with staffing, noting that corporate decisions had led to reduced staffing levels, impacting the ability to provide consistent care. The Director of Nursing and other staff members admitted to challenges in maintaining adequate staffing, particularly on weekends and during night shifts, which contributed to the failure in meeting residents' care needs. Despite efforts to cover shifts and assist on the floor, the facility's staffing practices were insufficient to ensure compliance with care plans and policies, resulting in the observed deficiencies.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Furosemide (Lasix) injections. The resident, who has a complex medical history including chronic diastolic heart failure and chronic kidney disease, was prescribed Furosemide to be administered intramuscularly twice a week. On one occasion, the medication was not administered because it was not available in the medication cart or the emergency kit. The Licensed Practical Nurse (LPN) on duty did not notify the physician or pass the information to the day shift, resulting in the resident missing a dose of the critical medication. The Director of Nursing (DON) and other nursing staff confirmed that the facility has an emergency medication kit to prevent such occurrences, and it is expected that nurses utilize this resource when medications are not available. However, the LPN did not follow the facility's policy, which requires notifying the attending physician and obtaining alternative orders when a medication is unavailable. The failure to administer the medication and the lack of communication with the physician or pharmacy were identified as significant deficiencies in the facility's medication administration process.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
