Alden Estates Of Shorewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Shorewood, Illinois.
- Location
- 710 W Black Road, Shorewood, Illinois 60404
- CMS Provider Number
- 146153
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Alden Estates Of Shorewood during CMS and state inspections, most recent first.
Staff failed to follow established infection prevention practices during incontinence care, medication administration, and care of a resident on enhanced barrier precautions. In multiple instances, CNAs handled urine- and blood-soiled linens, applied briefs and creams, adjusted bed controls, dressed residents, and exited rooms without changing gloves or performing hand hygiene as required by facility policy. Soiled linens were placed on the floor, and a resident remained on a urine-soiled mattress during care. Nurses administered insulin and other medications, checked vital signs, and managed a central IV line without performing hand hygiene before or after care, and one nurse did not don the required gown when providing high-contact care to a resident under EBP. These actions were inconsistent with the facility’s hand hygiene policy and posted EBP instructions.
A resident with multiple serious cardiac and renal diagnoses had conflicting information regarding code status across the EMR, orders, and care plan. The face sheet, EMR dashboard, and active physician orders all listed the resident as No CPR/DNAR, but the active care plan documented that the resident had not chosen any advance directives and was full code. No signed POLST or advance directive documents were uploaded in the EMR or available in the designated black folder at the nursing station, despite facility policy requiring this for residents with DNR status. A nurse reported she would follow the DNR order and withhold emergency interventions, while the resident, who was alert and decision-capable, stated he wanted to be resuscitated and confirmed he wished to be full code, demonstrating a failure to align documentation and orders with the resident’s expressed treatment preferences.
A resident with a history of falls, unsteady gait, and recent hospitalization-related weakness was care planned as a fall risk requiring assistance with ADLs. During a transfer from a chair to a wheelchair, a CNA, assisting the newly admitted resident for the first time, held the resident’s hand while the resident stood and transferred but did not apply a gait belt, despite having one in her pocket and acknowledging that CNAs are supposed to use it for transfers. The DON later confirmed that staff are required to use a gait belt with weight-bearing residents needing hands-on assistance, in accordance with the facility’s gait belt policy.
A resident with COPD, chronic respiratory failure with hypoxia, and a recent pneumonia hospitalization had physician orders and a care plan for continuous O2 at 2 L/min via nasal cannula. The resident was observed in a wheelchair with a nasal cannula connected to a portable O2 tank, and when the POA questioned whether O2 was infusing, staff found the portable tank empty despite being set at 2 L/min. Staff interviews revealed uncertainty about who transferred the resident from bed to wheelchair and who switched her from the concentrator to the portable tank, while the DON and CNAs stated that only nurses are responsible for connecting O2 equipment and that CNAs may only assist with transfers and adjust the cannula. Facility policy required RNs or LPNs to provide compressed O2 per MD orders, but the resident remained on an empty portable tank while ordered to be on continuous O2.
A resident receiving high-risk opioid therapy for neoplasm-related pain had a 12 mcg/hr fentanyl patch ordered to be applied and removed every 72 hours per the MAR and physician order. Staff documented application of a patch and a subsequent due removal but instead entered a code on the MAR that should have been supported by a progress note, which was missing. Another 12 mcg/hr fentanyl patch was later applied to the resident’s arm with no documentation that the original patch was removed. The DON confirmed the order was not followed and that documentation of removal was absent, and an NP reported that two fentanyl patches were found on the resident upon arrival to the ER. The resident had multiple serious diagnoses, including malignant neoplasms, neoplasm-related pain, pulmonary embolism, morbid obesity, and protein-calorie malnutrition.
A resident with a history of anemia and cancer diagnoses received Ribociclib chemotherapy during a period when it was ordered to be held, due to staff failing to update and follow new physician orders after an oncology appointment. The responsible LPN did not enter all the new orders, and the medication was administered despite clear instructions to pause treatment, contrary to facility policy.
The facility failed to manage medications properly, with residents found with medications at their bedside without physician orders. One resident had an inhaler from home, another had eye drops without an order, and a third had pain relief cream and ointment. Additionally, a resident was left with a medication cup containing pills, and another had eye drops and cream not prescribed to them. The facility's policy requires orders for bedside medications, which was not followed.
The facility failed to justify the necessity of antibiotics for four residents, as they did not meet the criteria for prescription. The Director of Nursing/Infection Preventionist admitted that the McGeer tool was not completed for tracking antibiotic use, leading to unnecessary prescriptions. The facility's policy to optimize antibiotic use was not adhered to, resulting in deficiencies.
The facility failed to conduct performance evaluations for five CNAs, affecting all 79 residents. The Business Office Manager, V9, admitted to not completing the evaluations, which were supposed to be done after corporate rate changes. The Director of Nursing clarified that V9 was not responsible for these evaluations, which should have been conducted by the CNA supervisor. A review of personnel files showed that none of the five CNAs had received annual performance reviews for several years, contrary to the facility's policy.
A resident's PICC line transparent sterile dressing was not changed as ordered by the physician due to a lack of available supplies in the facility. The Director of Nursing and registered nurses confirmed that the dressing changes were not performed or documented as required, leading to a deficiency in providing appropriate PICC line care.
Failure to Follow Hand Hygiene, PPE, and Linen-Handling Practices
Penalty
Summary
The deficiency involves multiple failures to follow the facility’s infection prevention and control practices, particularly related to hand hygiene, glove use, handling of soiled linens, and adherence to enhanced barrier precautions. One resident with chronic kidney disease, knee pain, hypertension, and muscle weakness was found lying in bed on an incontinence pad and linens soiled with urine and blood, with additional bed linens on the floor. A CNA, already wearing gloves, removed the soiled incontinence pad and placed it on the floor, then continued to cover the resident with clean linens, adjust the bed controls, and hand the resident the call light while wearing the same soiled gloves. The CNA then placed the soiled linens and pad into a plastic bag taken from the resident’s trash bin, contrary to the DON’s expectation that staff remove gloves, perform hand hygiene between dirty and clean tasks, and avoid placing linens on the floor. Another resident with stage 4 chronic kidney disease, type 2 diabetes mellitus, severe morbid obesity, and polyneuropathy required extensive assistance with personal hygiene and toileting. During incontinence care, a CNA wore gloves while wiping urine from the resident’s buttocks and groin and tucking a soiled bedsheet under the resident, then applied a clean brief and cream to the buttocks without changing gloves. After removing one soiled glove, the CNA took a clean glove from her pocket and another from the bathroom, donned them without performing hand hygiene, and continued to apply cream to the groin, remove the soiled bedsheet, and finish securing the brief. The CNA then put on the resident’s socks and shorts while the resident remained on a urine-soiled mattress, placed a mechanical lift sling under the resident, removed gloves, and handled the trash bag with soiled linens and exited the room without performing hand hygiene, contrary to the facility’s hand hygiene policy and the DON’s stated expectations. Additional deficiencies were observed during medication administration and care of a resident on enhanced barrier precautions. A nurse administered insulin to one resident and then prepared and administered two types of insulin to another resident without performing hand hygiene before or after either medication pass. For a resident on enhanced barrier precautions with a central IV line, a nurse checked vital signs without gloves and without hand hygiene before or after, then prepared and administered oral and IV medications wearing only gloves and without performing hand hygiene. This was inconsistent with the facility’s hand hygiene policy, which requires alcohol-based hand rub before resident contact, between soiled and clean body sites, and after glove removal, and with the EBP posting on the resident’s door, which instructed staff to clean hands upon entering and leaving the room and to wear gown and gloves for high-contact care involving devices such as central lines.
Inconsistent Advance Directive Documentation and Orders for a Resident
Penalty
Summary
The facility failed to ensure that one resident’s advance directive documentation, physician order, and care plan were consistent and accurately reflected the resident’s treatment wishes in the event of a medical emergency. The resident was admitted with multiple significant diagnoses, including acute kidney failure, acute on chronic diastolic congestive heart failure, and ventricular premature depolarization. The face sheet, EMR dashboard, and active order summary all indicated a No CPR/Do Not Attempt Resuscitation (DNAR) status. However, the active care plan stated that the resident had not chosen any advance directives due to personal preference and identified the resident’s code status as full code. Review of the EMR revealed no uploaded advance directive forms or signed POLST to support the DNR order. During interviews, the Social Service Director (SSD) confirmed that, according to facility policy, signed POLST and/or advance directive documents for residents with DNR status should be uploaded into the EMR and an actual signed copy should be kept in a black folder at the nursing station. The SSD found that neither an uploaded document nor a physical copy was available for this resident. A registered nurse, when asked about the resident’s code status, stated she would rely on the EMR dashboard and active orders, which showed DNR, and that no emergency action would be taken if the resident were found unresponsive. The nurse also confirmed there were no supporting advance directive documents in the EMR or black folder and acknowledged the contradiction between the DNR order and the full code care plan. When the SSD directly asked the resident, who was alert and able to make decisions, the resident stated he wanted to be resuscitated and confirmed he wished to be full code, further demonstrating the inconsistency between the resident’s expressed wishes, the orders, and the care plan, contrary to the facility’s advance directive policy and procedure.
Failure to Use Gait Belt During Transfer of High Fall-Risk Resident
Penalty
Summary
The deficiency involves staff failure to follow the facility’s gait belt policy during the transfer of a resident identified as being at risk for falls. The resident had multiple diagnoses, including a history of falling, polyosteoarthritis, other chronic pain, and hypertension. A fall risk assessment documented that the resident was at risk for falls, had an unsteady gait, and had experienced one to two falls in the prior three months. The resident’s fall care plan and ADL care plan, both initiated on the same date as the observation, identified a risk for falls and functional performance deficits due to weakness from a recent hospitalization, with interventions directing staff to assist the resident with ADL tasks as needed. On the morning of the observation, the resident was seated in a chair in their room when a CNA, who stated it was her first time assisting this newly admitted resident, prepared to transfer the resident from the chair to a wheelchair. The CNA positioned the wheelchair close to the resident’s chair and asked the resident to stand. The resident stood while the CNA held the resident’s hand to assist with the transfer. Although the CNA had a gait belt in her pants side pocket and acknowledged that CNAs are supposed to use a gait belt when assisting residents with transfers, she did not place the gait belt around the resident’s waist during this transfer. Later that day, the DON confirmed that CNAs are required to use a gait belt when transferring residents and that the CNA should have used a gait belt with this resident, consistent with the facility’s written policy stating that a gait belt will be used with weight-bearing residents who require hands-on assistance.
Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide ordered continuous oxygen therapy to a resident with multiple respiratory-related diagnoses. The resident had COPD, chronic respiratory failure with hypoxia, and a recent hospitalization for pneumonia, and the physician’s order and care plan required continuous oxygen at 2 L/min via nasal cannula. On observation, the resident was seated in a wheelchair with a nasal cannula connected to a portable oxygen tank, and an oxygen concentrator was also present in the room. When the resident’s POA questioned whether oxygen was infusing, staff checked the portable tank and found the gauge in the red zone, and the RN confirmed the tank was empty despite being set at 2 L/min. The resident reported that an aide had gotten her out of bed to the wheelchair but could not identify who or when, and the RN stated that whoever got the resident up had switched her from the concentrator to the portable tank. Subsequent interviews showed uncertainty among staff about who transferred the resident and who switched the oxygen source. The PTA reported therapy had not gotten the resident up that morning, and the DON stated that interviews with CNAs indicated none of them had transferred the resident and that the resident might have gotten herself up, as her daughter had previously commented that she was getting stronger and able to get out of bed on her own. CNAs and the DON stated that only nurses are responsible for disconnecting oxygen from the floor concentrator and connecting it to a portable tank, and that CNAs only assist with transfers and may adjust or reapply the nasal cannula. Facility policy specified that oxygen via compressed gas must be provided per physician orders by an RN or LPN, with CNAs/rehab aides limited to adjusting or reapplying the cannula or mask. Despite these orders and policies, the resident was found on an empty portable oxygen tank while ordered to be on continuous oxygen.
Failure to Remove Fentanyl Patch as Ordered Resulting in Duplicate Opioid Patches
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the facility’s medication administration policy requiring drugs to be given in accordance with written orders. The physician order and MAR for one resident in November 2025 directed that a 12 mcg/hr fentanyl patch be applied transdermally every 72 hours for pain management and removed per schedule. Documentation showed a patch was applied on 11/26/25 at 5:25 PM and was due to be removed 72 hours later on 11/29/25 at 4:19 PM. Instead, a “9” was entered on the MAR on 11/29/25 at 3:22 PM, which should have been accompanied by a progress note, but no such note was found. The resident’s care plan identified them as receiving high-risk opioid medication and directed staff to administer pain strategies and medications per MD order and MAR/TAR. On 11/30/25 at 6:00 AM, another 12 mcg/hr fentanyl patch was documented as applied to the resident’s right arm, with no documentation that the original patch had been removed. The DON later confirmed that the order indicated the patch should have been removed on 11/29/25, that the physician order was not followed, and that there was no progress note or MAR prompt showing removal of the old patch. A nurse practitioner reported that when the resident arrived at the emergency room on 12/1/25, the ER nurse found two 12 mcg/hr fentanyl patches on the resident. The resident’s diagnoses included multiple serious conditions such as neoplasm-related pain, malignant neoplasms of bone and bone marrow, secondary neoplasms, pulmonary embolism, morbid obesity, protein-calorie malnutrition, neuromuscular bladder dysfunction, and pressure-induced deep tissue damage.
Failure to Update and Follow Physician Orders After Oncology Appointment
Penalty
Summary
The facility failed to update and follow all physician orders after a resident's outpatient oncology appointment. The resident, who had diagnoses including iron deficiency anemia, malignant neoplasm of the breast, and secondary malignant neoplasms of the bone and bone marrow, was seen by an oncology nurse practitioner and doctor, who provided written orders to hold the chemotherapy medication Ribociclib for one week and to resume it on a specified date. The physician order sheet included instructions for weekly CBC, daily Letvozole, a specific start date for the next Ribociclib cycle, and an evaluation by radiation oncology. Despite these orders, the medication administration record showed that the resident continued to receive Ribociclib during the period it was supposed to be held. Interviews with facility staff revealed that the nurse responsible for the resident after the appointment did not enter all of the new physician orders into the system, only entering the order for weekly CBC. The nurse acknowledged not entering the order to hold Ribociclib, despite being aware of the written instructions. Another nurse attempted to administer Ribociclib during the hold period and was informed by the resident that it should not be given until the specified date. The facility's policy requires that all medication orders be documented and followed, but this was not done in this case, resulting in the resident receiving chemotherapy against the physician's orders.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management for residents, as evidenced by several observations and interviews. One resident, R10, was found with an Atrovent inhaler from home on her bedside table, despite having no physician's order for its use or for it to be at the bedside. The resident, who has chronic obstructive pulmonary disease and acute respiratory failure, stated that the inhaler is usually kept in her purse, which she could not locate. The facility's policy requires an order for medications to be stored at the bedside, which was not followed in this case. Another resident, R127, was found with eye drops on her bedside table, labeled with her name but without a corresponding physician's order. The resident, diagnosed with glaucoma, was cognitively intact, as indicated by her BIMS score. The Director of Nursing confirmed that no residents should have medications at the bedside without an order. Similarly, R19 had a pain relief cream and vaporizing ointment on her over-bed table, which she used without a physician's order. The LPN assigned to R19 was unaware of any residents being assessed to keep medications at the bedside. Additionally, R57 was found with a medication cup containing seven pills left at his bedside, which he did not take in the presence of a nurse. The LPN admitted to leaving the medications unattended, contrary to the facility's policy that requires nurses to ensure residents take their medications. R65 was found with eye drops and cortisone cream in her room, neither of which had a physician's order. The resident stated that the eye drops were not hers, and a family member suggested they belonged to a previous resident. The facility's failure to adhere to its medication management policies resulted in these deficiencies.
Failure to Justify Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to utilize an appropriate standardized tool or system to justify the necessity of antibiotics at the time they were ordered for four residents. Resident 43 was prescribed Nitrofurantoin for a UTI despite not meeting the criteria for antibiotic prescription, as her only symptom was increasing confusion, which was her baseline. Similarly, Resident 65 was given Bactrim for a UTI without presenting any symptoms, and Resident 66 received Nitrofurantoin for a UTI with only increased confusion as a symptom, which was also her baseline. Resident 4 was on Cephalexin and Ciprofloxacin for prophylactic treatment without proper justification. The Director of Nursing/Infection Preventionist (V2) acknowledged that the McGeer tool, which is used for tracking antibiotic use, was not completed for any residents on antibiotics for November 2024. The facility's policy emphasizes optimizing antibiotic use to prevent resistance and adverse effects, but the lack of adherence to this policy led to unnecessary antibiotic prescriptions. The facility's failure to communicate resident assessment information and apply the McGeer criteria contributed to these deficiencies.
Failure to Conduct CNA Performance Evaluations
Penalty
Summary
The facility failed to complete performance review evaluations for five Certified Nursing Assistants (CNAs), affecting all 79 residents. The Business Office Manager, V9, admitted to not conducting the evaluations, which were supposed to be done following corporate rate changes for CNAs. V9, who started in April 2023, was attempting to assist the supervisors by taking on the task of performance evaluations but forgot to complete them. The Director of Nursing, V2, clarified that V9 was not responsible for CNA evaluations, which should have been conducted by the CNA supervisor, V10, or the previous supervisor, V11, who left the facility in October 2024. A review of personnel files revealed that none of the five CNAs had received annual performance reviews for several years. V4, hired in 2021, lacked reviews for 2022, 2023, and 2024. V5, hired in 2021, had no reviews for 2022, 2023, and 2024, with only one review in 2021. V6, employed since 2014, had only one review in 2019, missing evaluations for multiple years. V7, hired in 2022, had no review for 2023, and V8, employed since 2017, lacked reviews from 2018 to 2024. The facility's policy mandates annual performance evaluations from the original hire date or following a position change, to be completed by the employee's department supervisor and reviewed by the Administrator.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to change a resident's PICC line transparent sterile dressing as ordered by the physician. The resident, who was admitted with multiple diagnoses including mechanical complication of an internal right knee prosthesis and infection, had a PICC line in her right arm. The physician's orders required the dressing to be changed within 24 hours of admission and then weekly. However, the treatment administration record (TAR) and medication administration record (MAR) showed no documentation that the dressing was changed as ordered from April 25 through April 30, 2024, and from May 9 through May 14, 2024. Progress notes also lacked documentation of the dressing changes during these periods. Interviews with the Director of Nursing and registered nurses confirmed that the dressing changes were not performed due to a lack of available supplies in the facility, and there was no follow-up to ensure the supplies were delivered and the dressing changes were completed as ordered. The Director of Nursing reviewed the resident's medical records and confirmed that the PICC line dressing was not changed within 24 hours of admission and was not changed for the scheduled weekly change on May 9, 2024. The registered nurses involved stated that they were unable to perform the dressing changes due to the unavailability of supplies and were unsure if or when the supplies were delivered. This lack of adherence to physician orders and failure to document the dressing changes as required led to the deficiency in providing appropriate PICC line care for the resident.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
