Wentworth Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 201 West 69th Street, Chicago, Illinois 60621
- CMS Provider Number
- 145429
- Inspections on file
- 34
- Latest survey
- December 6, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Wentworth Rehab & Hcc during CMS and state inspections, most recent first.
A resident at moderate risk for pressure ulcers, with significant mobility and incontinence issues, developed a new sacral pressure ulcer that was not identified, reported, or treated by staff as required. CNAs observed the wound but failed to notify nursing staff, and there was no documentation or intervention until the issue was discovered by a surveyor. Facility policies for skin assessment and reporting were not followed, resulting in delayed care.
Three residents with cognitive impairments were not properly informed of their monthly personal fund amounts and did not consistently receive their trust fund disbursements. Facility staff were unclear about representative payee responsibilities and failed to notify residents about the management of their funds, resulting in confusion and lack of access to entitled monies.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
A resident with multiple medical conditions, including a stage 4 pressure ulcer and severe malnutrition, did not have initial wound measurements documented by the LPN upon admission, leaving no baseline for the wound care team. Additionally, required weekly weights were missed, with only two weights recorded instead of the policy-mandated weekly monitoring, hindering proper nutritional assessment and intervention.
A resident with diabetes and multiple comorbidities did not receive appropriate blood glucose monitoring or consistent diabetes medication administration upon admission. Despite physician orders for blood sugar checks and insulin, only one blood sugar reading was documented in the first week, while diabetes medications were administered without monitoring. Nursing staff confirmed that blood glucose checks should have been performed according to orders, highlighting a lapse in following care protocols.
The facility failed to accurately assess fall risks and implement preventive interventions for two residents, resulting in multiple falls and injuries. One resident with Alzheimer's disease experienced several falls, including one causing a head injury requiring staples, without updates to their care plan. Another resident with dementia and hemiplegia had an inaccurately scored fall risk assessment and inadequate supervision, leading to a head laceration. The facility did not adhere to its fall management policy, resulting in deficiencies in fall prevention practices.
A facility failed to develop a comprehensive care plan for a resident involved in an alleged abusive relationship with a CNA. Despite the resident's admission 5.5 months prior, the care plan did not include a risk for abuse. The ADON confirmed the omission and was unsure if abuse should be included in care plans, contrary to the facility's policy requiring a person-centered care plan within 7 days of the MDS completion.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident's care plan for fall risk and behavioral health pass program had expired target dates, and the ADON confirmed they were not reviewed as required. Another resident experienced a fall with a head injury, but the care plan was not updated with preventive interventions. The facility's policies require care plan revisions based on changes in condition and quarterly reviews, which were not followed.
A resident with a history of aggression became physically and verbally aggressive in the dining room. Despite staff attempts to deescalate, the resident grabbed a broom and swung it at a social worker. A housekeeper, untrained in CPI, intervened physically, resulting in the resident falling. This violated the facility's abuse policy, as the housekeeper acted outside his scope of duty.
A resident with multiple health issues experienced significant weight loss due to the facility's failure to implement and revise care plan interventions for nutritional support. Observations showed the resident struggling to eat without staff assistance, and documentation of food intake was inconsistent. The care plan lacked necessary updates, and staff interviews highlighted the need for 1:1 assistance and proper positioning during meals.
A resident with hemiplegia and dementia was observed struggling to eat independently due to the lack of a plate guard, which was documented as necessary in her care plan. Despite the resident's need for adaptive equipment and supervision during meals, staff did not provide the required assistance or ensure cleanliness, and the dietary supervisor confirmed that the necessary equipment was on order but not yet available.
A facility failed to maintain accurate and complete medical records for a resident, as required by its policy and professional standards. The resident's community survival assessment was not documented in the electronic health record before the surveyor's request, and there was a discrepancy between a handwritten assessment and the electronic record. The Director of Behavioral Health admitted the electronic assessment was inaccurate, leading to a handwritten version. The electronic assessment conflicted with the physician's orders, and the assessment was overdue, violating the facility's policy for annual or significant change assessments.
The facility did not follow fall prevention interventions for residents with dementia at risk for falls. Observations revealed several residents wearing smooth-bottomed socks instead of non-skid footwear, contrary to their care plans. The Memory Care Director and a CNA confirmed the oversight. Records showed these residents were assessed as fall risks, requiring proper footwear, as per the facility's Fall Management Program.
The facility failed to maintain the community shower room on the fourth floor East-Wing in a sanitary condition due to a drain/sewer back-up. A wet towel was found covering black liquid oozing from the drain, and the issue was not documented in the maintenance logbook until prompted by a surveyor. The Maintenance Director later attempted to clear the drain, highlighting a lapse in maintenance request procedures.
A facility failed to effectively control a bed bug infestation on the third floor, affecting multiple residents. Despite reports of bed bugs in beds and on curtains, the facility only treated rooms with sightings, allowing the problem to persist. Staff confirmed the issue, noting corporate approval was needed for treatments, limiting the number of rooms addressed. The facility's protocol was not fully implemented, as room changes were undocumented.
A resident with a suspicious breast mass refused a STAT mammogram and ultrasound due to fear, and the LTC facility failed to document or reschedule the appointment promptly. Staff interviews revealed confusion and lack of communication regarding the rescheduling, and the facility lacked a documentation policy, leading to a deficiency in meeting the resident's medical needs.
The facility failed to administer medications as ordered and did not document reasons for missed doses, affecting five residents. Interviews revealed that a resident was not given medications due to various reasons like computer issues or unavailability. The MARs showed multiple missing entries without explanations, contrary to the facility's policy requiring documentation of medication administration.
A resident with a history of falls and multiple medical conditions fell and fractured her finger due to the facility's failure to ensure her call light was within reach and her bed was in a low position. Staff admitted to not checking on the resident or ensuring necessary safety interventions were in place.
The facility failed to store food in accordance with professional standards, with expired food items found in the fridge and freezer, and opened food items without proper labeling. Additionally, a cook was observed preparing fortified pudding without using measuring utensils, deviating from the recommended recipe. These deficiencies have the potential to affect all 180 residents.
The facility failed to provide adequate staffing on the second floor, affecting all residents residing there. On multiple occasions between October 2023 and December 2023, the second floor had fewer aides than required, despite efforts by the Staffing Coordinator to cover call-offs and holidays. This led to the facility triggering with CMS for excessively low weekend staffing.
The facility failed to administer prescribed medications in a timely manner due to a nurse arriving late for her shift, affecting twelve residents. The facility's eMAR indicated the delay, and the protocol for such situations was not properly followed.
The facility failed to properly clean and disinfect multi-use blood pressure cuffs and pulse oximeters between resident use, did not follow proper hand hygiene protocols during peri-care, and did not post a required contact isolation precaution sign for a resident with specific diagnoses.
The facility failed to ensure that call light devices were within reach for two residents, placing them at risk of not being able to call for help. One resident with limited arm movement due to strokes and another with a right arm contracture were unable to reach their call lights. The facility's LPN acknowledged the importance of accessible call lights, and the facility's policy mandates that call lights be within reach at all times.
The facility failed to refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. One resident was diagnosed with bipolar disorder, and another had major depressive disorder, psychosis, and schizophrenia. Due to staff turnover and vacancies, the necessary screenings were not conducted as required.
The facility failed to provide regular showers to a resident with multiple medical conditions, including stage four and stage three pressure ulcers, dementia, and Alzheimer's disease. Documentation showed the resident did not receive a shower for two weeks, despite requiring substantial assistance with personal hygiene.
A facility failed to document catheter changes for a resident with multiple diagnoses, including stage four pressure ulcer and dementia. Despite protocols requiring weekly catheter changes, there was no documentation of any changes from admission in March 2024 until the end of May 2024. The resident's care plan also lacked information about the catheter and necessary care to prevent infections.
A resident did not receive prescribed medications due to the facility's failure to respond to pharmacy notifications about insurance issues, resulting in the unavailability of the medications. The nursing staff documented the administration of these medications despite their absence.
The facility failed to discard expired medications for two residents, as observed on medication carts managed by LPNs on the 3rd and 4th floors. Despite weekly audits and policies requiring immediate removal of expired medications, the expired medications were not discarded, posing a potential risk to resident safety.
A resident returning from the hospital was not provided a meal, resulting in hunger. The resident, with multiple medical conditions, was found struggling to get dressed and locate her call light. Staff failed to check on her or offer food after her return, despite knowing snacks were available.
A facility failed to implement effective fall prevention measures and supervision for three residents, resulting in falls and injuries. One resident, with dementia and hemiplegia, sustained a fall causing a laceration requiring sutures. Another resident, with vascular dementia, had inadequate floor mat placement, and a third resident experienced an unwitnessed fall due to insufficient supervision. Staff were not fully aware of or able to locate fall prevention interventions, highlighting a lack of proper documentation and communication.
The facility failed to revise care plans with appropriate interventions for three residents at risk for falls. One resident was sent to the hospital post-fall without preventive measures added. Another resident, with cognitive impairments, had floor mats added but lacked supervision. A third resident had a floor mat placed on one side of the bed, despite the risk of falling from either side. These actions did not adequately address fall prevention.
Failure to Prevent, Identify, and Report New Pressure Ulcer
Penalty
Summary
A resident with multiple medical conditions, including hemiplegia, heart failure, and incontinence, was assessed as being at moderate risk for developing pressure ulcers. The resident required substantial assistance for bed mobility and was unable to reposition independently. Despite being identified as at risk, the facility failed to prevent, identify, report, and treat a new pressure ulcer that developed on the resident's sacrum. During a surveyor's observation, an open skin area approximately 2 by 2 inches with a red wound base was found on the resident's sacrum, covered only with barrier cream and without a proper dressing. Certified Nursing Assistant (CNA) staff observed the open wound during routine care but did not report it to the nursing staff as required by facility policy. The CNA initially claimed to have reported the wound but later admitted to assuming someone else had done so and ultimately did not notify the nurse. Licensed Practical Nurses (LPNs) and the Assistant Director of Nursing (ADON) were unaware of the wound prior to the surveyor's observation, and there was no documentation of the wound in the resident's electronic health record, progress notes, or skin assessments prior to the surveyor's findings. The wound care team and physician were not notified until after the surveyor brought the wound to the facility's attention. Facility records, including the resident's care plan and turning/repositioning program, indicated that staff were to check the resident's skin daily and report abnormalities. However, documentation from CNAs on shower/bath reports repeatedly indicated no new skin issues, and there was no record of the pressure ulcer in the days leading up to the survey. The facility's policy required prompt identification and reporting of skin alterations, but this process was not followed, resulting in a delay in assessment and treatment of the resident's pressure ulcer.
Failure to Inform and Distribute Resident Personal Funds
Penalty
Summary
The facility failed to properly inform residents of their monthly personal funds amounts and did not distribute personal fund monies as required. Three residents were affected by this deficiency. One resident, who had moderately impaired cognition, was unaware of why she was not receiving her monthly trust fund disbursement and had not authorized her nephew to manage her finances. The facility did not notify her that her monthly trust fund money was being given to her nephew, and there was confusion regarding who was the authorized representative payee for her Social Security and pension funds. Another resident, with severely impaired cognition, reported not receiving her trust fund money and was unaware of the amount she should receive. The facility staff stated that this resident's family was the representative payee, but the resident was not informed about this arrangement. A third resident, also with moderately impaired cognition, stated he had not received any trust fund money and expressed a desire to receive it. There was further confusion regarding the power of attorney and who was authorized to receive and manage his personal funds. Facility staff interviews and record reviews revealed inconsistent practices in the management and distribution of residents' personal funds. Staff were unclear about the proper procedures for handling Social Security and pension disbursements, and residents were not consistently informed about their personal fund accounts or monthly disbursements. The facility's own policy required uniform guidelines for the protection of personal funds, but these were not followed, resulting in residents not receiving or being informed about their entitled funds.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Document Wound Measurements and Monitor Weekly Weights
Penalty
Summary
The facility failed to follow its own policies regarding the documentation of wound measurements and the monitoring of weights for a resident admitted with multiple complex medical conditions, including a stage 4 sacral pressure ulcer and severe protein-calorie malnutrition. Upon admission, the wound nurse measured the resident's wound but did not document the measurements, resulting in the absence of baseline data for the wound care team and physician to assess wound progression. The wound nurse practitioner confirmed that no initial wound measurements were available prior to his assessment several days after admission, which hindered the ability to monitor wound improvement or deterioration. Additionally, the facility did not adhere to its policy of obtaining a baseline weight upon admission and conducting weekly weights for the first four weeks. The resident's weights were only recorded on two occasions, missing several required weekly weigh-ins. Both the dietitian and assistant director of nursing acknowledged that these missed weights prevented accurate monitoring of the resident's nutritional status and timely intervention. The physician order sheet and facility policy both specified the need for weekly weights, which was not followed in this case.
Failure to Monitor Blood Glucose and Ensure Continuity of Diabetes Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including type 2 diabetes mellitus, was not provided with appropriate blood glucose monitoring and continuity of diabetes medication administration upon admission. The resident was admitted with orders for blood glucose monitoring and several diabetes medications, including insulin and oral agents. Despite these orders, there was only one documented blood sugar reading on the day of admission, with no further monitoring recorded until a week later. During this period, the resident received diabetes medications, including insulin and oral agents, without concurrent blood glucose monitoring as ordered. Interviews with nursing staff and facility leadership confirmed that blood glucose monitoring should have been performed according to physician orders, especially for residents receiving insulin. Staff acknowledged that monitoring is necessary to safely administer insulin and oral diabetes medications and to detect abnormal blood sugar levels that require intervention. The Director of Nursing and Assistant Director of Nursing both stated that the expectation is to follow physician orders for blood glucose checks and that such monitoring is critical for diabetic residents, particularly those on insulin therapy. Record review showed that the resident was administered diabetes medications, including Lantus Insulin Glargine and Empagliflozin, before blood glucose monitoring was initiated. Additionally, an ordered insulin (Semglee) was not administered due to a delay in pharmacy supply. The lack of blood glucose monitoring and incomplete medication administration represented a failure to provide appropriate care and management for the resident's diabetes as ordered and as required by facility policy.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure accurate fall risk assessments and implement preventive interventions for two residents, leading to multiple falls and injuries. Resident 5, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced several falls, including one resulting in an intracranial hemorrhage and traumatic head injury requiring staples. Despite being identified as at risk for falls, the resident's care plan was not updated following a significant fall incident, and interventions were not revised to prevent further falls. Resident 2, with a history of dementia and hemiplegia, also experienced multiple falls, including one that resulted in a head laceration requiring sutures. The resident's fall risk assessment was inaccurately scored, failing to account for hypotension and impaired memory, which would have indicated a higher risk. The care plan included interventions such as call light placement and regular rounding, but these were not effectively implemented, as evidenced by the call light being out of reach during an observation. The facility's management of falls policy requires comprehensive assessments and timely updates to care plans to address fall risks. However, the facility did not adhere to these protocols, resulting in inadequate supervision and failure to prevent accidents. The lack of appropriate interventions and supervision contributed to the residents' injuries and highlighted deficiencies in the facility's fall prevention practices.
Failure to Develop Comprehensive Care Plan for Abuse Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R4) who was involved in an alleged abusive relationship with a Certified Nursing Assistant (V7). The State Agency received allegations of this intimate relationship, which was considered abuse. Despite R4 being admitted to the facility approximately 5.5 months prior, the comprehensive care plan received on 2/26/25 did not include a risk for abuse. During a surveyor's inquiry, the Assistant Director of Nursing (V3) confirmed that R4's care plan did not address the risk of abuse, and V3 was unsure if abuse should be included in care plans. The facility's policy from 11/2017 requires the interdisciplinary team to develop a person-centered comprehensive care plan within 7 days of the completion of the required comprehensive MDS, which should describe services to maintain the resident's well-being and identify responsible professional services.
Failure to Update Care Plans for Fall Risk and Behavioral Health
Penalty
Summary
The facility failed to follow its policy procedures and did not review or revise comprehensive care plans for two residents, leading to deficiencies in care. For one resident, the care plan for fall risk and behavioral health pass program had expired target dates, and the Assistant Director of Nursing (ADON) acknowledged that the care plans were not reviewed or revised as required. The ADON confirmed that the fall care plan should have been reviewed every three months, but it was not updated within the specified timeframe. Another resident experienced a fall resulting in a head injury, but the care plan was not updated to include preventive interventions or revisions following the incident. The ADON confirmed that the care plan was not updated to reflect the fall incident. The facility's policies require that care plans be revised based on changes in the resident's condition and at least quarterly, but these procedures were not followed, resulting in the deficiencies noted by the surveyor.
Untrained Staff Involvement in Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident who exhibited aggressive behavior. The resident, who has a history of difficulty managing anger and frustration, was involved in an incident where she became verbally and physically aggressive, throwing food and other items. During this episode, a housekeeper, who was not trained in Crisis Prevention Interventions (CPI), attempted to intervene physically, resulting in the resident falling to the floor. The incident began when the resident entered the dining room, cursing and throwing her food on the floor. Despite attempts by staff to deescalate the situation, the resident continued to act out, eventually grabbing a broom and swinging it at a social worker, breaking his glasses. The housekeeper, who was called to clean the floor, attempted to take the broom from the resident, leading to both the resident and the housekeeper ending up on the floor. The housekeeper's actions were outside his scope of duty, as he was not trained to handle aggressive residents and should not have physically engaged with the resident. The facility's abuse policy clearly states that residents should be protected from physical abuse, which includes controlling behavior through corporal punishment. The housekeeper's involvement in the physical altercation with the resident was a violation of this policy, even though the resident did not sustain any injuries.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to implement and revise the care plan interventions necessary for a resident's nutritional support, leading to significant unplanned weight loss. The resident, a [AGE] year-old individual with multiple diagnoses including chronic obstructive pulmonary disease, dementia, and muscle weakness, was observed struggling to eat without adequate assistance from staff. Despite the resident's evident difficulty in maintaining a comfortable eating position and using utensils, no staff intervened to assist during meal times. The resident's weight log indicated a significant weight loss from 138 pounds in August to 119 pounds in October, with no hospitalizations to account for this change. The Clinical Nutrition Manager noted that the resident required setup assistance and encouragement during meals, yet documentation of the resident's food intake and assistance needs was inconsistent and incomplete. The resident's care plan did not include an assessment for the use of finger foods, which could have facilitated easier eating. Interviews with staff, including a Nurse Practitioner and a CNA, highlighted the need for 1:1 assistance and proper positioning during meals, which were not consistently provided. The facility's policy on comprehensive care plans emphasized the need for person-centered care, yet the resident's care plan lacked necessary updates and interventions to address the resident's nutritional needs effectively.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide special eating equipment and appropriate assistance for a resident, identified as R3, who has a history of hemiplegia and hemiparesis following a cerebral infarction, dementia, and generalized muscle weakness. Observations on November 6, 2024, revealed that R3 was having difficulty using a spoon to eat independently in the dining room, often dropping food and resorting to using her left hand to grab food directly. Despite the resident's documented need for a plate guard to assist with eating, no such adaptive equipment was provided during the observed meal times. Additionally, staff did not offer assistance or ensure the resident's hands were clean before eating. Further investigation on November 7, 2024, showed that R3 was being fed by an LPN while lying in bed, again without the use of a plate guard as indicated on her dietary slip. The dietary supervisor confirmed that plate guards were on order but had not yet been received. R3's care plan and assessments documented the need for adaptive equipment and supervision during meals, yet these were not consistently provided. The facility's policy emphasizes the importance of providing appropriate treatment and services to maintain or improve residents' abilities, which was not adhered to in this case.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as required by its policy and accepted professional standards. During a review of the resident's electronic health record, it was found that the most recent community survival assessment was not documented in the electronic health record prior to the surveyor's request. The assessment, which was completed on a previous date, was not signed until the day of the surveyor's inquiry. Additionally, there was a discrepancy between a handwritten assessment provided by the facility and the electronic assessment in the resident's record, with conflicting information regarding the resident's pass privileges. The Director of Behavioral Health acknowledged that the electronic assessment was completed inaccurately and instructed the Behavioral Health Counselor to complete a new form, resulting in a handwritten assessment. The electronic assessment indicated that the resident could not have unsupervised pass privileges, which conflicted with the physician's orders allowing unrestricted independent passes. Furthermore, the community survival skills assessment was past due, as it was completed more than a year after the previous assessment. The facility's policy requires comprehensive assessments to be conducted annually or upon significant change, but this was not adhered to in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for residents with dementia who are at risk for falls. During an observation on the fourth floor, several residents were seen wearing smooth-bottomed socks instead of the required non-skid socks or shoes. Specifically, one resident was observed walking in the hallway and near the nursing station with red smooth-bottomed socks, while three other residents were seen in the day room with similar footwear. The Memory Care Director confirmed that these residents were supposed to wear non-skid socks, and a CNA acknowledged the need to change their socks. The records for the affected residents indicated that they were all assessed to be at risk for falls due to various factors such as poor safety awareness, impaired cognition, unsteady gait, and use of assistive devices. Their care plans specifically stated the need for proper, well-maintained, and non-skid footwear as a preventive measure against falls. The facility's Fall Management Program also emphasized the importance of using standard fall safety precautions for all residents. Despite these documented interventions, the facility did not ensure that the residents were wearing the appropriate footwear, thereby failing to adhere to the established fall prevention strategies.
Sanitation Deficiency in Community Shower Room
Penalty
Summary
The facility failed to maintain the large community shower room on the fourth floor East-Wing in a sanitary condition, as evidenced by a drain/sewer back-up. This issue was observed when a wet towel was found covering black liquid oozing from the drain. The Assistant Director of Nursing acknowledged the problem and mentioned that maintenance would be notified. However, the Maintenance logbook did not initially document the clogged drain issue. The Maintenance Director later confirmed being informed about the problem and attempted to clear the drain using a wire. The maintenance logbook was updated only after the surveyor's inquiry, indicating a lapse in the facility's maintenance request procedures.
Inadequate Pest Control Measures Lead to Persistent Bed Bug Infestation
Penalty
Summary
The facility failed to provide effective pest control for residents on the third floor, as evidenced by multiple reports of bed bug infestations affecting seven residents in a sample of ten. Residents reported bed bugs crawling on them, their beds, and privacy curtains, leading to multiple room changes. The facility's pest control measures were inadequate, as they only treated rooms where bed bugs were sighted, rather than conducting a comprehensive treatment of the affected area. This approach allowed the bed bug problem to persist since at least January 2024, with residents experiencing repeated infestations and embarrassment due to the need for room changes. Interviews with staff, including the administrator and a licensed practical nurse, confirmed the ongoing bed bug issue on the third floor. The administrator noted that corporate approval was required for extermination treatments, which limited the number of rooms treated at any given time. The pest control invoices reviewed indicated sporadic treatments of individual rooms, rather than a coordinated effort to address the infestation comprehensively. Additionally, the facility's bed bug protocol was not effectively implemented, as room changes were not documented in residents' clinical records, and the pest control contractor's inspections were limited to rooms with reported sightings.
Failure to Address Resident's Refusal for Critical Medical Appointment
Penalty
Summary
The facility failed to address a resident's refusal to attend a scheduled mammogram and ultrasound appointment, which was ordered on a STAT basis due to a highly suspicious mass found in a previous ultrasound. The resident, who has intact cognitive function, refused to attend the appointment out of fear that her breast would be removed. Despite this refusal, there was no documentation of any further attempts to reschedule the appointment until a later date, and the facility's records lacked evidence of timely communication with the physician regarding the resident's refusal. Interviews with facility staff revealed a lack of clarity and communication regarding the rescheduling of the appointment. The Clinical Director of Behavioral Health Services and the Licensed Practical Nurse were unsure if the appointment had been rescheduled, and the nurse practitioner was informed of the refusal but did not document it. The Director of Nursing was unaware of the STAT order and acknowledged that the documentation was late, indicating a failure in the facility's process for handling such critical appointments. The facility's documentation practices were found to be lacking, as there was no policy for documentation, and the nurse responsible for rescheduling the appointment did not document her actions. The resident's rights document indicated that the facility must make reasonable arrangements to meet the resident's needs and choices, which was not adhered to in this case. The deficiency highlights a failure in ensuring timely and appropriate care for the resident, as well as a breakdown in communication and documentation processes within the facility.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to administer medications as ordered by the physician and did not document the reasons for not administering these medications. This deficiency affected five residents who were reviewed for medication administration. During interviews, one resident reported that the nurse did not provide medications on several occasions, citing reasons such as computer issues, unavailability of medication, or inability to find keys. The Medication Administration Records (MAR) for these residents showed multiple missing entries without any chart codes or explanations for the missed doses. The Director of Nursing and Licensed Practical Nurses confirmed that MAR should not be left blank and that chart codes should be used to indicate reasons for missed medications, such as resident refusal or absence from the facility. However, the MARs for the residents in question had several blank entries, indicating that the medications were not given. The facility's policy requires medications to be administered according to the physician's written orders, but this was not adhered to, leading to the deficiency.
Failure to Ensure Safe Environment for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accidents and hazards for a resident, resulting in the resident falling and sustaining a fracture of the second left finger. The resident, who has a history of falls and multiple medical conditions including end-stage renal disease, hemiplegia, and type 2 diabetes, was observed sitting at the edge of her bed in incontinence underwear, struggling to get dressed and find her call light. The resident reported that she had not been checked on by staff since returning from the hospital that morning and was very hungry. The call light was found to be out of reach, and the resident's bed was not in a low position, which is a necessary intervention for fall risk residents. The Certified Nursing Assistant (CNA) who assisted the resident back to bed after her return from the hospital admitted to not checking on the resident again or ensuring the call light was within reach. The CNA also confirmed that the resident's bed could not be lowered, which is contrary to the facility's policy for fall risk residents. The Assistant Director of Nursing (ADON) acknowledged that the resident had multiple falls in the past year and should have had interventions such as a low bed, floor mats, and a call light within reach. The Licensed Practical Nurse (LPN) also admitted to not checking on the resident after her initial assessment and not ensuring the bed was in a low position or the call light was accessible. The Maintenance Director confirmed that the bed model used for the resident could not be adjusted for height and did not have half rails to assist the resident in getting in and out of bed. The Assistant Administrator swapped the resident's bed with her roommate's bed, which could be lowered, after the surveyor's observation. The Nurse Practitioner emphasized the importance of having floor mats, a call light within reach, and a bed in a low position for the resident due to her high risk of falls and fractures. The facility's policy on fall management was not followed, leading to the resident's fall and subsequent injury.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and sanitation. During a kitchen observation, a cook was seen without a hair net while preparing food, and expired food items were found in the main fridge and freezer. Specifically, the surveyor observed expired potato salad, chicken base, magic cup, Worcestershire sauce, mayonnaise cole-slaw dressing, and grits. Additionally, there were opened food items without proper labeling, such as vanilla ice-cream in a damaged container and an opened red-hot bottle without an open or expiration date. The facility's policy requires that all food products with pre-printed manufacturer date labels be discarded by the noted date, and any opened food should be labeled with the date and time it was placed in the refrigerator. The failure to adhere to these policies was evident during the surveyor's inspection. Furthermore, the facility did not follow the recommended portion size for the menu and failed to utilize measuring utensils when mixing ingredients. A cook was observed preparing fortified pudding by mixing ingredients without using any measuring utensils, relying instead on visual estimation. This practice deviated from the US Foods Management System production recipe for fortified pudding, which specifies precise measurements for ingredients. The dietary manager confirmed that all staff should follow protocol when preparing meals and mixing ingredients, and that expired foods should be discarded immediately. The failure to follow these protocols has the potential to affect all 180 residents in the facility.
Inadequate Staffing on Second Floor
Penalty
Summary
The facility failed to provide adequate staffing for one out of four floors, specifically the second floor, which affects all residents residing there. On multiple occasions, the second floor was understaffed, with fewer aides than required. For instance, on several Sundays and Saturdays between October 2023 and December 2023, the second floor had only three or four aides instead of the required six for various shifts. This pattern of understaffing was confirmed through interviews and record reviews, including statements from the Staffing Coordinator, who acknowledged the staffing issues and the efforts made to cover call-offs and holidays. The deficiency was highlighted by the facility triggering with CMS for excessively low weekend staffing. The Staffing Coordinator detailed the usual staffing levels, which include five nurses per shift and a varying number of aides based on floor acuity and census. Despite these efforts, the second floor, which has the highest acuity, consistently fell short of the required staffing levels, leading to the identified deficiency. The report does not mention any specific residents' medical history or conditions at the time of the deficiency but emphasizes the overall impact on the second floor residents due to inadequate staffing.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer residents' prescribed medications in a timely manner according to physician orders. On 05/28/2024, a registered nurse (V3) arrived late for her shift, starting at approximately 8:20 AM instead of the scheduled 7:00 AM. Consequently, V3 began administering medications at around 9:00 AM, which was beyond the acceptable time frame for timely medication administration. The facility's electronic medication administration record (eMAR) indicated that medications for twelve residents were administered late, as the eMAR turned red to signify the delay. The facility's policy mandates that medications should be administered within one hour of the prescribed time, which was not adhered to in this instance. The Assistant Director of Nursing (V23) confirmed that the protocol for such situations involves the unit supervisor or another nurse from the previous shift administering medications until the scheduled nurse arrives. However, it was unclear who was responsible for administering medications on the first floor until V3 arrived. The medication administration audit report and time clock punches corroborated that V3 and another nurse (V22) were late in administering medications to the affected residents. This lapse in protocol and timely medication administration affected twelve residents in the facility.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that multi-use blood pressure cuff devices and pulse oximeters were properly cleaned and disinfected between resident use. Observations revealed that staff members did not clean or disinfect these devices after using them on multiple residents, including R12, R20, R27, R29, R83, R98, R124, R126, R159, and R161. This failure was noted during medication administration observations on different floors of the facility. Staff members placed the used devices back on the medication cart without cleaning them, which was confirmed by the Assistant Director of Nursing (ADON) and Infection Preventionist, who acknowledged the potential for the spread of germs and infections due to this oversight. The facility also failed to ensure that staff followed proper hand hygiene protocols while performing peri-care. During an observation, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after cleaning a resident's peri-area and before applying a new brief. The CNA admitted that she was not informed about the necessity of changing gloves after such procedures. The facility's policy on perineal care and hand hygiene clearly states the importance of removing gloves and washing hands to prevent infection and odor. Additionally, the facility did not post a contact isolation precaution sign for a resident identified as having a physician order for contact isolation precautions. The resident, who had diagnoses including chronic osteomyelitis, pressure ulcers, urinary tract infection, sepsis, and pericarditis, was observed without the required contact isolation sign outside his room. Staff members provided conflicting information about the resident's isolation status, and it was noted that sometimes staff did not wear gowns when entering the resident's room. The facility's infection prevention and control manual mandates the use of appropriate personal protective equipment (PPE) and the posting of a CDC contact precaution sign for residents on contact isolation.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, R14 and R17, which placed them at risk of not being able to call for help if needed. On 05/28/24, the surveyor observed R17 in bed with limited movement in her right arm due to a history of strokes. The call light was placed under her right arm, making it difficult for her to reach it with her left hand. R17 confirmed that she often could not reach her call light due to a lack of strength. Similarly, on the same day, the surveyor observed R14's call light hanging from the right side of his bed's side rail, which he could not reach due to a right arm contracture. R14 confirmed his inability to reach the call light when questioned by the surveyor. The facility's Licensed Practical Nurse (LPN) acknowledged the importance of having call lights within residents' reach to ensure they can call for assistance in emergencies. R17's medical records indicate she is a cognitively intact female with a history of hemiplegia, hemiparesis following cerebral infarction, generalized anxiety disorder, and muscle weakness. R14's records show he is a male with moderately impaired cognition, muscle contracture, and generalized muscle weakness. The facility's policy, dated 9/20, mandates that call lights be placed within residents' reach at all times, which was not adhered to in these cases.
Failure to Refer Residents with Serious Mental Disorders for Review
Penalty
Summary
The facility failed to refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. This deficiency affected two residents, one of whom was diagnosed with bipolar disorder and the other with major depressive disorder, psychosis, and schizophrenia. The first resident, a man diagnosed with bipolar disorder, was admitted to the facility with an initial OBRA screen indicating no reasonable basis for suspecting mental illness. However, he was later diagnosed with bipolar disorder, and the facility did not initiate a new screening as required. The psychosocial coordinator acknowledged that due to staff turnover and vacancies, the necessary screenings might not have been conducted, despite quarterly assessments prompting for changes in resident diagnoses. The second resident had diagnoses including major depressive disorder, psychosis, and schizophrenia, which are considered serious mental illnesses. Despite these diagnoses, the initial PASRR Level I screen indicated no need for a Level II screening. The resident was readmitted to the facility after a hospital stay, and it appears that the necessary diagnoses were not updated in the Maximus system. The psychosocial coordinator confirmed that the facility did not notice the discrepancy between the screening and the resident's records until much later, prompting a new Level I screening. The facility's policy mandates that residents be screened for severe mental illness or developmental disabilities prior to admission and upon any changes in status, which was not adhered to in these cases.
Failure to Provide Regular Showers to Resident
Penalty
Summary
The facility failed to provide showers to a resident who is unable to maintain good personal hygiene. This deficiency affected a [AGE] year-old female resident with multiple medical diagnoses, including stage four pressure ulcer of the sacral region, stage three pressure ulcers of the right heel and other sites, dementia, Alzheimer's disease, high blood pressure, visual disturbance, and wasting syndrome. The resident's Minimum Data Set (MDS) indicated that she was not alert and required substantial/maximal assistance with showers and bathing. The resident's care plan noted a functional performance deficit in activities of daily living (ADL) and required staff assistance with personal hygiene. However, documentation revealed that the resident did not receive a shower for two weeks in May 2024, with the last recorded shower on May 1, 2024, and the next on May 15, 2024. The Assistant Director of Nursing confirmed that residents are supposed to be showered once a week and as needed, and if a shower is not documented, it was not done.
Failure to Document Catheter Changes
Penalty
Summary
The facility failed to document catheter changes for a resident requiring an indwelling catheter. The resident, a [AGE] year-old female with multiple diagnoses including stage four pressure ulcer, dementia, and Alzheimer's disease, was observed with a very dark urine and old, discolored catheter tubing containing dark sediment. Despite the facility's protocol to change catheters weekly and as needed, there was no documentation of any catheter change from the resident's admission in March 2024 until the end of May 2024. Interviews with nursing staff revealed that catheter changes should be documented in progress notes, but a review of the resident's progress notes showed no such documentation. The Assistant Director of Nursing confirmed that nurses are expected to follow physician orders, change visibly dirty catheters, notify the physician, and document the change and the resident's condition. However, the resident's care plan did not include any information about the catheter, its necessity, or the required care to prevent urinary tract infections.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the resident's physician for one resident. On the morning of 05/28/2024, a surveyor observed a registered nurse (V3) unable to locate the resident's medications in the medication carts. The nurse then contacted the facility's contracted pharmacy, which revealed that the resident's medications had not been shipped due to a loss of insurance. The pharmacy had previously notified the facility about the insurance issue via fax on multiple occasions, but the facility had not responded until the surveyor's visit on 05/28/2024. The resident, identified as R83, was admitted with diagnoses including acute chronic systolic heart failure, atrial fibrillation, pulmonary hypertension, and type 2 diabetes mellitus. The resident's physician had prescribed several medications, including Amiodarone, Apixaban, Empagliflozin, and Spironolactone, which were not available in the facility's emergency medication convenience box. The resident's medication administration record indicated that the nursing staff had been documenting the administration of these medications, despite their unavailability. The facility's policy on medication administration requires that medications be administered safely as prescribed and that the physician be notified if an order cannot be followed. However, the facility failed to adhere to this policy, resulting in the resident not receiving the prescribed medications for an extended period. The progress notes documented by the nurse on 05/28/2024 indicated that the issue was being addressed, but the deficiency had already occurred due to the facility's inaction in responding to the pharmacy's notifications and ensuring the resident's medications were available and administered as ordered.
Failure to Discard Expired Medications
Penalty
Summary
The facility failed to follow its policy to ensure that medications that are outdated are immediately removed or disposed of. This deficiency was observed for two residents out of three reviewed for medication storage and labeling. On the 3rd floor, a surveyor observed an expired budesonide formoterol fumarate dihydrate inhaler for a resident on cart #1, which had an expiration date of 5/13/2024. The LPN managing the cart confirmed that the medication was expired and should have been discarded. Similarly, on the 4th floor, the surveyor found an expired insulin Lispro pen injector and an expired Fluticasone Advair inhaler for another resident on cart #2. The LPN managing this cart also confirmed that these medications were expired and should have been discarded. The Associate Director of Nursing stated that weekly cart audits are conducted to ensure that medications are within their proper expiration dates and to reorder any necessary medications. The facility's policy requires that medications be labeled with the date they are first given and their expiration date, and that expired medications be immediately removed for the safety of the residents. Despite these procedures, the expired medications were not discarded as required, posing a potential risk to the residents' safety.
Failure to Provide Meal to Resident Returning from Hospital
Penalty
Summary
The facility failed to provide a meal to one resident (R85) who had returned from the hospital, resulting in the resident experiencing hunger. R85, a [AGE] year-old individual with multiple medical conditions including end-stage renal disease, hemiplegia, and type 2 diabetes mellitus, was observed in her room at 11:35 am, stating she was very hungry and had not been offered food since her return from the hospital earlier that morning. R85 was found struggling to get dressed and locate her call light, which was out of her reach. The Certified Nursing Assistant (CNA) who assisted the paramedics in transferring R85 to bed did not check on her or offer her food after the initial transfer. The Licensed Practical Nurse (LPN) also failed to check on R85 after the initial assessment and did not ensure the call light was within reach or offer food, despite knowing that breakfast time had ended and snacks were available in the kitchen. The Assistant Director of Nursing (ADON) confirmed that the nursing staff should have asked R85 if she was hungry and provided a meal, even if breakfast was over. The facility's policy on food substitutes and the always available menu, which includes items like grilled cheese and hamburgers, was not followed. This oversight led to R85 experiencing hunger and being unable to communicate her needs due to the call light being out of reach and the lack of staff follow-up after her return from the hospital.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure adequate fall prevention measures and supervision for three residents, leading to a significant incident involving one resident. This resident, diagnosed with dementia and hemiplegia, was at high risk for falls as indicated by their fall risk assessment. Despite this, the facility did not implement effective interventions after previous falls, resulting in the resident sustaining a fall that caused a laceration requiring sutures. The care plan was not adequately updated to prevent further incidents, and staff were not fully aware of the necessary interventions. Another resident, with vascular dementia and a history of falls, was also inadequately protected. The resident's care plan included interventions such as keeping the bed in the lowest position and using floor mats. However, during the survey, it was observed that only one floor mat was in place, despite the bed not being against a wall, which could have prevented falls from either side. The staff's understanding of the resident's fall prevention measures was incomplete, as they failed to mention the use of floor mats. A third resident, with cognitive impairments and a history of falls, was found on the floor after an unwitnessed fall. The care plan included the use of floor mats, but supervision was not mentioned as an intervention. Staff were unable to locate the resident's fall prevention interventions in the communication book, indicating a lack of proper documentation and communication regarding fall prevention strategies. This lack of awareness and implementation of fall prevention measures contributed to the residents' falls and injuries.
Failure to Revise Care Plans for Fall Prevention
Penalty
Summary
The facility failed to revise care plans with appropriate interventions for three residents who were reviewed for falls. For the first resident, the care plan noted a risk for falls and included an intervention to send the resident to the hospital for evaluation and treatment after a fall. However, this intervention did not address the prevention of future falls. The resident had fallen while receiving ADL care and sustained a head injury. The restorative nurse confirmed that sending the resident to the hospital would not prevent additional falls. The second resident's care plan identified risks related to muscle weakness, poor balance, poor safety awareness, and visual impairment. After an unwitnessed fall, the intervention added was the use of floor mats while in bed, but supervision was not included despite the resident's cognitive impairments. The third resident, diagnosed with vascular dementia and unsteadiness, had a care plan intervention to keep the bed in the lowest position and use a floor mat on one side of the bed. However, the resident could fall from either side as neither side of the bed was against the wall, and the intervention did not adequately address the risk of falls.
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.
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