Alden Lakeland Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 820 West Lawrence, Chicago, Illinois 60640
- CMS Provider Number
- 145450
- Inspections on file
- 51
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Alden Lakeland Rehab & Hcc during CMS and state inspections, most recent first.
The deficiency involves multiple failures in safe respiratory care for residents with tracheostomies, including one resident on high-flow O2 via trach collar who was cognitively impaired and required continuous pulse oximetry but was not adequately monitored, later found with a dislodged trach and pronounced dead after staff attempts at reinsertion and CPR. An LPN caring for this resident reported no trach or respiratory training and did not know the ordered O2 settings, while HR records showed required competency evaluations for two LPNs were not completed. Surveyors observed several trach residents without complete bedside reinsertion supplies or functional pulse oximeters, and one nurse misidentified an Airvo high-flow device as a ventilator and found it turned off. Another resident with a trach had multiple missed physician-ordered trach care, inner cannula changes, and suctioning, and was later hospitalized with pneumonitis, leukocytosis, and tracheal cultures consistent with pneumonia and sepsis. The facility also failed to conduct an incident report, investigation, or required State reporting for the trach-related death, despite policies requiring reporting of accidents and deaths with potential injury.
A resident with multiple comorbidities was admitted with intact skin but quickly developed sacral MASD that was documented by nursing staff and care planned for barrier cream, yet no corresponding treatment was recorded on the TAR for an extended period. Physician orders for zinc oxide and a wound consult were not obtained until many days after MASD was first noted, and the wound APN did not assess the resident until more than two weeks after the consult order. By that time, the sacral area had progressed to a large open wound, later confirmed by culture to be infected, and the resident was ultimately hospitalized for sepsis and sacral pressure ulcer evaluation, while a family member reported not being informed of the wound’s development.
The facility failed to ensure that each resident had individual, accessible call lights, resulting in residents in three-bed rooms sharing a single call light string that was sometimes hidden behind furniture and out of reach. Several cognitively intact residents with conditions such as spinal stenosis, COPD, diabetes, chronic kidney disease, dementia, history of falls, and heart failure reported that only two call lights were available for three beds, and that less mobile residents could not readily access the call system and sometimes had to walk to the nurse’s station. Staff, including CNAs, an LPN, and a social worker, were unaware of residents’ mobility limitations and complaints about call light access, while leadership (the DON, maintenance director, and administrator) acknowledged that policy requires every resident to have their own call light within reach at all times.
Two residents experienced multiple fall incidents during Hoyer lift transfers when staff failed to follow the facility’s mechanical lift policy, including required pre‑use checks of slings for rips, tears, or abnormal wear and proper positioning close to the receiving surface. One resident with multiple comorbidities and a left BKA was transferred in cramped room conditions that forced staff to conduct Hoyer transfers in or near the hallway; the lift tilted and struck the resident’s head in one incident and, in another, a sling strap broke, causing a fall and head impact on the lift frame. Another resident was being transferred from bed to wheelchair when a Hoyer sling strap tore while he was suspended above the chair, resulting in a fall documented in a facility investigation as caused by a torn sling harness. Staff interviews also revealed that some Hoyer lifts on the unit did not work properly and that room dimensions did not accommodate safe use of the shower bed with the lift, contributing to unsafe transfer practices.
Two residents did not receive scheduled medications as ordered, and the missed doses were not properly documented. One resident’s MAR showed blank entries for scheduled doses of baclofen and pregabalin, which staff confirmed indicate the medications were not administered, despite facility expectations that missed or refused doses be documented with progress notes and notifications. Another resident’s MAR showed a missing scheduled dose of gabapentin ordered every eight hours for polyneuropathy, with no documented explanation. Staff, including an LPN and the DON, verified that blank MAR boxes represent missed doses, contrary to facility policy requiring medications to be administered per physician orders.
A resident with a tracheostomy on high-flow O2 died after the trach became dislodged, and facility documentation of the event was inaccurate, incomplete, and inconsistent. An LPN noted the resident manipulating trach oxygen tubing but did not document any intervention to prevent dislodgement. Later, an RT documented reinserting the trach, stating the resident had a pulse and labored breathing while CPR was charted as occurring, and 911 times in the notes conflicted with EMS records. Paramedics reported finding the resident pulseless and apneic, with staff attempting trach reinsertion, and noted significant facial and tongue swelling that prevented intubation. The RT gave multiple, changing accounts about swelling and trach reinsertion and admitted omitting key clinical details, while a nurse consultant stated that the LPN had not actually performed CPR despite charting that she had. These discrepancies show the facility failed to maintain accurate, complete medical records for the incident.
A resident with intact cognition and multiple chronic conditions reported that another resident had been verbally abusive for about a year, including repeated racial slurs, derogatory name-calling, false accusations, and offensive gestures at the doorway of the resident’s room. Several staff, including an RN, an LPN, and CNAs, confirmed hearing the abusive language and described the aggressor as having a history of verbally abusive behavior toward multiple residents. The resident became socially isolated, stopped attending activities, and began eating meals in the room to avoid the aggressor. Although staff notified social services and the administrator, the abuse coordinator did not initiate a new investigation or report the repeated allegations to the state agency, assumed they were related to a prior incident, and did not interview the involved residents. The abuse risk assessment and care plan were not updated to reflect the ongoing verbal abuse, and there was no documented protective action such as relocating the aggressor away from the affected resident, despite facility policies requiring immediate reporting, investigation, protection, and documentation of abuse concerns.
The facility failed to follow its abuse policy by not timely reporting an initial verbal abuse incident and by not reporting a subsequent allegation of ongoing verbal abuse between two residents. A cognitively intact resident with multiple comorbidities reported that another cognitively intact resident repeatedly used racial slurs and offensive gestures toward her over an extended period. Staff, including an RN, LPN, and Social Services, were aware of a serious verbal abuse episode that led to the aggressor’s hospital transfer, but the Administrator, serving as abuse coordinator, did not submit the required report to the state agency within the 2‑hour window and instead reported it more than 24 hours later. When a new allegation of continued verbal abuse was reported to the RN and Social Services and brought to the Administrator’s attention, the Administrator assumed it related to the prior incident, did not interview the involved residents, did not submit a new report to the state agency, and the resident was not informed of any investigation or its outcome, contrary to the facility’s Abuse Prevention Program requirements.
Two residents who were dependent on staff for toileting hygiene and bed mobility were left soiled or wet for extended periods after bowel and bladder incontinence. One cognitively intact resident with cauda equina syndrome and osteoarthritis remained in feces for about three hours despite repeated call light activation and staff passing the room without providing care, causing pain, itching, burning, and emotional distress. Another moderately cognitively impaired resident with spinal stenosis, a sacral pressure ulcer, and a gastrostomy remained wet for about two hours after an LPN turned off the call light and left, relying on a returning CNA to finally provide incontinence care. Staff reported working short with only two CNAs for approximately forty residents and noted that a primary CNA had been sent out to a medical appointment, leaving coverage gaps.
Two residents experienced prolonged periods in soiled briefs and delayed incontinence care after using call lights and verbally requesting assistance, while multiple residents and staff reported chronic understaffing of nurses and CNAs. On one unit, a resident who reported a bowel movement waited about three hours before a CNA returned with supplies and provided care, after another CNA had turned off the call light and left without assisting. Another resident who stated she was wet and had been wet a long time remained so for about two hours after an LPN turned off the call light, left to handle an admission, and only verbally relayed the need to an unidentified aide. Staff interviews and schedules showed that units, including a vent unit with many bedbound, total-assist residents, were operating with fewer nurses and CNAs than expected, and that on a prior holiday one nurse was responsible for an entire floor and another nurse covered both a vent unit and an adjacent unit when multiple nurses called off and no replacements were found. Residents consistently reported long waits for help with bowel movements and other ADLs, and staff described ongoing staffing shortages and increased workloads.
The facility failed to ensure proper respiratory care by not maintaining correct oxygen settings, not labeling and storing respiratory equipment appropriately, and providing oxygen without a physician order. One resident on continuous oxygen for COPD and chronic respiratory failure had a nebulizer mask left unlabeled and uncovered at the bedside. Another resident with chronic respiratory failure and heart disease was observed with a nasal cannula in place while the wall oxygen flow meter was turned off, and an undated, unbagged nasal cannula attached to a portable tank was present. A third resident with multiple respiratory diagnoses was found using oxygen via concentrator without any corresponding physician order or care plan. Facility leadership and policies confirmed that oxygen should be administered only with a physician order (except in emergencies), at the prescribed LPM setting, and that nasal cannulas and nebulizer equipment must be dated and stored in clean bags to prevent contamination.
A resident with a history of joint replacement and long-term anticoagulant use did not receive their scheduled blood thinner medication for four days due to delays in pharmacy delivery. Despite available procedures for obtaining missing medications, staff did not ensure the medication was administered as ordered by the physician, as confirmed by documentation and staff interviews.
A resident with a history of vascular disease and prior pulmonary embolism experienced significant leg swelling and pain, but staff failed to promptly schedule diagnostic tests, follow up on abnormal results, and notify the physician of a positive DVT finding. The physician was not informed of the resident's worsening pain or the abnormal duplex scan until several days later, delaying appropriate treatment.
A resident with unilateral leg swelling and pain underwent diagnostic testing that revealed deep venous thrombosis, but staff failed to notify both the physician and the resident's family of the abnormal results. The physician was incorrectly told the test was negative and only discovered the positive result upon personal review, contrary to facility policy requiring prompt notification of changes in condition.
A resident with complex medical needs missed multiple off-site imaging appointments due to the facility’s failure to arrange timely transportation and coordinate with dialysis schedules. Staff cited issues with the facility’s ride-hailing service, last-minute escort cancellations, and lack of communication as contributing factors, resulting in delayed diagnostic care.
A facility failed to report and investigate a sexual abuse allegation after a family member observed a male resident in a female resident's room and reported inappropriate touching. Both residents had severe dementia, and the incident was not documented or reported to authorities as required by facility policy. Staff did not follow up with the reporting family member, and the administrator did not consider the event an abuse allegation.
A resident with an indwelling urinary catheter and complex medical needs did not receive documented catheter care or timely catheter changes as ordered by the physician and required by facility policy. The resident was later hospitalized with a catheter-associated UTI, and staff confirmed that proper catheter care and drainage bag management were not performed or documented.
A resident requiring enhanced barrier precautions for multiple infection risks, including MDRO and C. auris, was placed in a room with another resident who had a history of C. auris and other resistant organisms, but not the same active infections. Staff interviews and facility policy confirmed that residents should be cohorted based on the same organism, which was not followed in this case, resulting in a failure to maintain proper infection control.
A resident with cancer missed two chemotherapy appointments due to the facility's failure to arrange proper transportation and escort services. The resident, who requires a stretcher for transport, was not provided with an escort, leading to a missed appointment. The facility's inaction caused stress and concern for the resident and their family about the progression of the cancer.
The facility failed to provide prescribed wound care and proper pressure ulcer management for several residents. One resident was hospitalized for sepsis due to worsening heel wounds, as heel protectors were not applied as ordered. Additionally, the facility did not date wound care dressings, leading to missed treatments, and set a low air mattress at an incorrect setting for another resident, increasing the risk of pressure ulcers.
A facility failed to conduct a fingerprint-based criminal history check for a CNA, V28, as required by their policy, potentially affecting residents on the 3rd floor Vent Unit. Interviews revealed that V28's work eligibility was 'Not Yet Determined' due to incomplete fingerprinting, and staff were unclear about the process. The facility's policies on abuse prevention and background checks were not followed, allowing V28 to work without verifying her eligibility.
The facility failed to timely implement dietary recommendations for five residents on feeding tubes, as the Clinical Support Nurse missed an email from the dietitian. This resulted in delays of up to 29 days in adjusting tube feeding regimens, potentially affecting residents' health. The facility lacked a specific policy for handling dietary recommendations, relying on the expectation that recommendations would be promptly transcribed and carried out.
A resident, who is cognitively intact, was taken to a dental appointment wearing only a gown, jacket, and hat, despite cold weather. The resident reported feeling embarrassed and humiliated, and the facility's policy on maintaining self-esteem and privacy was not followed. The CNA claimed the resident preferred to wear a gown, but the resident denied this, highlighting a communication failure.
A resident was not administered prescribed antibiotics, vancomycin and metronidazole, upon readmission to the facility, leading to the development of sepsis. The facility's medication records only showed administration of cefepime, and the necessary orders were not transcribed into the system. The oversight was confirmed by the DON and the Clinical Support Nurse, who missed the transcription during a quality assurance audit. The attending physician and consultant pharmacist affirmed the necessity of the antibiotics, and the facility's Administrator failed to recognize the severity of the situation.
Two residents in an LTC facility experienced significant medication errors. One resident developed sepsis after not receiving prescribed antibiotics, while another received an incorrect dosage of micafungin. The errors were not caught during quality assurance audits, indicating a failure in the facility's medication verification process.
The facility failed to ensure agency staff had the necessary competency and training, potentially affecting all 162 residents. An agency RN admitted to working shifts but could not confirm details of their work, including the transcription of critical medication orders. The facility relies on agency staff without a formal procedure for training or competency evaluation, and there was no evidence that the agency RN was aware of or reviewed available resources.
The facility's assessment failed to accurately document staffing needs, particularly for the ventilator unit, and did not identify respiratory therapists as necessary staff. The Director of Respiratory oversees the program, ensuring a staffing ratio of one therapist per 16 airways, but the facility's assessment lacked a detailed staffing breakdown, relying on a general assessment tool without a specific policy.
The facility failed to maintain an effective infection control program, with foley catheter tubing found on the floor for two residents and inadequate tracking of infections. The infection preventionist did not document infections not treated with anti-infective medications, contrary to facility policy. The Director of Nursing and a Registered Nurse Consultant acknowledged these deficiencies, noting incomplete infection control logs and lack of infection mapping.
The facility failed to provide adequate oral care to residents on the ventilator unit, as observed in a resident with secretions on their lips and teeth. Despite claims of care being provided, documentation was lacking, and staff did not follow the facility's oral care policy. The DON and Medical Director acknowledged the risk of infections due to poor oral hygiene.
The facility failed to change a resident's nebulizer tubing weekly as per policy, potentially affecting respiratory care. The resident, who is cognitively impaired and ventilator-dependent, had tubing dated over a week old. This was confirmed by an LPN, and the resident was later diagnosed with a UTI, pneumonia, and sepsis.
The facility failed to respond to call lights in a timely manner, affecting multiple residents who reported waiting up to an hour for assistance, particularly during afternoon and night shifts. Staff interviews confirmed the importance of prompt responses to prevent potential harm, yet ongoing issues were documented in meeting minutes and grievance forms.
The facility failed to implement effective infection control measures, including the absence of Enhanced Barrier Precaution signage and improper PPE use during high-contact care. Residents with MDROs were not cohorted correctly, and a scabies case was mishandled, lacking proper notification and care planning.
A facility failed to notify a cognitively impaired resident's representative of room changes, as required by policy. The resident, with severe cognitive impairment, was moved twice without documented notification. Interviews with staff revealed confusion over who was responsible for informing the family, resulting in a deficiency in resident rights.
A facility failed to obtain a physician's order and develop a comprehensive care plan for a resident's use of a resting hand splint. The resident, who is cognitively impaired with functional limitations, was observed using the splint without a physician's order, contrary to facility policy. Staff acknowledged the absence of a necessary order and care plan, which could lead to improper application and care.
A resident with epilepsy and Parkinson's disease was found with a 5-6 cm laceration on the upper lip. The injury was discovered by an LPN during rounds, but the facility failed to report it to the State within the required two-hour timeframe. Despite staff interviews, the cause of the injury remained unknown.
Two residents with stage 4 pressure ulcers were found on low air loss mattresses set incorrectly for their weights, potentially compromising pressure ulcer prevention and treatment. The settings were not aligned with the residents' weights, as confirmed by the Wound Care Coordinator, who emphasized the importance of weight-based settings for effective pressure redistribution.
A resident with health issues left a facility unsupervised, traveling over 35 miles away and requiring emergency assistance to return. The resident's care plan required supervision and oxygen, which were not provided. Additionally, medications and sharp objects were left accessible to residents, and a treatment cart was found unlocked, breaching safety protocols.
The facility failed to provide necessary grooming care, including shaving and nail trimming, to several residents who rely on staff assistance for ADLs. Observations revealed residents with unkempt facial hair and long, dirty fingernails, despite facility policies requiring such care on shower days and as needed. Staff acknowledged the importance of these tasks but did not ensure they were consistently performed.
The facility failed to ensure proper settings and functioning of low air loss mattresses for several residents, leading to potential pressure ulcer risks. A resident was observed with a malfunctioning mattress and without required heel boots, despite having severe cognitive impairment and multiple medical conditions. Other residents had mattresses set to incorrect weights, indicating a lack of staff training and awareness.
The facility failed to ensure proper infection control practices, as observed in multiple instances involving resident care and food service. An LPN handled wound care supplies without sanitizing hands, and a CNA performed ADL care without donning required PPE, despite EBP signs. Additionally, a Dietary Aide plated meals without hand hygiene due to a broken sink, risking cross-contamination.
The facility failed to maintain functional call light systems for several residents, leading to anxiety and lack of assistance. A resident's call light was inoperative, requiring the use of a personal phone for help. Another resident's call light activated but did not illuminate outside the room, and a third resident's call light was disconnected. No alternative signaling devices were provided, and staff confirmed the issues.
A resident with multiple health conditions was left alone in a shower room without access to a call light, which was located four feet away and lacked a string. The resident had to use a personal phone to call for help after being left unattended for an hour. Staff confirmed that the call light should have been accessible and that residents unable to reach it should not be left alone.
A facility failed to complete a timely PASRR for a resident with a change in psychiatric diagnosis. The resident had schizoaffective disorder, among other conditions, but the PASRR was delayed by over a year. The facility's policy mandates screenings upon changes in status, which was not followed.
The facility failed to provide daily activity programming as per residents' care plans, affecting three residents. A resident with severe cognitive impairment did not receive the specified activities, such as jazz music and spiritual programs, and had an outdated activity calendar. Two other residents, both cognitively intact, reported a lack of activities, including their preferred ones like bingo. Observations confirmed no activities were provided during surveyor visits, and documentation showed no one-on-one activities for these residents in recent months.
A resident with bilateral hand contractures was found without the necessary splints or hand rolls on two occasions, despite physician orders and care plans requiring their use. The Restorative Aide was absent on one day and unable to locate the splints upon return. The DON suggested the splints might cause pain, indicating a preference for hand rolls. The facility's policies emphasize the importance of using adaptive devices to prevent further contractures, but these were not followed, resulting in a deficiency.
A resident with a mechanically altered diet order was served thin liquids instead of nectar thick liquids and did not receive the prescribed nutritional supplement ice cream at lunch. Despite clear documentation on the meal ticket, dietary staff failed to provide the correct items, potentially compromising the resident's safety and nutritional needs.
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in oxygen therapy and tracheostomy management. One resident's humidifier bottle was empty for several days, another had an open nebulizer port, and a third lacked a backup tracheostomy apparatus at the bedside. These issues were contrary to facility policies and posed risks to the residents' safety.
The facility failed to label and discard medications properly for two residents. A surveyor observed a Fluticasone canister without an open or use-by date and an Albuterol inhaler with a worn label lacking these dates. An LPN confirmed the need for proper labeling, and the DON emphasized discarding expired or worn-label medications. The facility's policy requires medications to be stored and labeled per legal requirements, with damaged or outdated containers removed and disposed of.
A facility failed to provide a thermometer for a resident's personal refrigerator, affecting one resident with multiple health conditions. The resident's refrigerator lacked a temperature log, and there was confusion among staff about who was responsible for monitoring and logging temperatures. The Administrator clarified that housekeeping should log and check temperatures daily, as per facility policy.
A facility failed to obtain guardianship for a resident with severe cognitive impairment and a persistent vegetative state, leaving the resident without a representative to consent to services. Despite the resident's inability to make decisions, the facility did not secure a guardian, resulting in medical decisions being made by the medical director without a legal representative. The deficiency was highlighted when the resident was hospitalized, and no family or representative was notified.
Failure to Provide Safe Tracheostomy Respiratory Care and Monitoring
Penalty
Summary
The deficiency involves multiple failures in providing safe and appropriate respiratory care, particularly for residents with tracheostomies, including one resident who died after a tracheostomy dislodgement. One resident with toxic encephalopathy, respiratory failure with tracheostomy collar, and hemiplegia had a physician order for high-flow O2 at 20 L/min via trach collar and continuous pulse oximetry. On the day of the incident, an LPN observed this resident with oxygen tubing connected to the trach tubing on the resident’s finger but documented no intervention to prevent dislodgement, despite the resident’s impaired cognition and care plan indicating the resident rarely or never understood redirection. Later that afternoon, a respiratory therapist found the trach tube dislodged and attempted reinsertion, while CPR was documented as starting within about a minute of that time and 911 was called shortly thereafter. Paramedic documentation states the crew arrived to find the resident unresponsive, pulseless, and apneic, with staff attempting to reinsert the trach, and noted facial and tongue swelling that prevented intubation; the resident was pronounced dead. The facility did not complete an incident report or investigation for this death and did not report it to the State agency, with the nurse consultant characterizing it as a medical case despite the facility’s own policy requiring reporting of accidents or incidents with injury or potential for injury, including deaths due to accidents. The report also identifies failures in staff competency and training related to tracheostomy and respiratory care. The LPN assigned to the deceased resident stated she did not know the resident’s oxygen requirements, was unfamiliar with ABG and FiO2 changes, and reported receiving no respiratory or trach-specific training at the facility. Human resources records for this LPN and another LPN showed that required nursing skills competency evaluations, including orientation elements such as nursing procedures and multiple specific competencies (e.g., hand hygiene, IV piggyback, PPE, policy review), were not completed; the forms were only signed and dated by the nurses without documented evaluation. The DON confirmed there were no trach care or respiratory care trainings and described onboarding evaluation as a process to identify training needs, but no trach-specific competencies were documented. Staff interviews indicated that RT coverage for trach residents had been reduced, and that nurses, rather than RTs, were responsible for some trach patients, with RTs not performing CPR. Additional deficiencies were found in assessment, monitoring, and equipment readiness for residents with tracheostomies. The facility lacked an initial assessment process specific to trach residents to determine acuity and levels of care, as acknowledged by the DON. For the deceased resident, the care plan and orders required continuous pulse oximetry and oxygen saturation monitoring, yet there was no oxygen saturation documentation on the day of death in the vital sign history, and the MAR showed only a single oxygen saturation entry for that day with no vital signs documented in clinical notes. Observations on the respiratory unit showed multiple residents with trachs lacking required bedside equipment per the facility’s “Reinsertion of Tracheostomy Tube with Accidental Extubation” policy, including missing spare trach tubes, sterile 4x4s, tape, and nonfunctional or disconnected pulse oximeters. Staff acknowledged defective or disconnected pulse oximeters and incomplete supply setups, and in one case a nurse believed an Airvo high-flow device was a ventilator and found it turned off while the resident was ordered to receive high-flow O2. The report further documents failure to follow physician orders for trach care and suctioning for another resident, who was initially admitted without infection and later developed respiratory infection and pneumonia. This resident had orders for trach care, inner cannula changes, and suctioning at specified frequencies, but the treatment administration record showed multiple missed entries for trach care, inner cannula cleaning and changing, and scheduled suctioning across several days. The infection preventionist and a physician stated that trach care, suctioning, and inner cannula changes are intended to clear mucus, maintain airway patency, limit bacterial growth, and reduce infection risk, and that missed care increases the risk of infection. This resident was subsequently sent to the hospital for difficulty breathing and infection, with hospital records noting tachycardia, tachypnea, leukocytosis, chest x-ray with superimposed pneumonitis, and tracheal cultures positive for organisms associated with pneumonia and sepsis. These documented omissions in ordered trach care and suctioning, combined with the lack of respiratory assessments and incomplete documentation, formed part of the cited deficiency. The surveyors determined that these failures constituted an immediate jeopardy beginning when the trach-dependent resident was pronounced dead after being found unresponsive, pulseless, and apneic following trach dislodgement. The facility’s own leadership acknowledged that residents at risk of trach dislodgement should not be left alone and that trach dislodgement can result in low oxygen, confusion, altered mental status, or death, yet there was no trach-specific acuity assessment, no documented respiratory assessments, and incomplete monitoring for the affected residents. The combination of inadequate monitoring, lack of staff competency evaluation and training, failure to maintain functional and complete emergency trach equipment at the bedside, failure to follow physician orders for trach care and suctioning, and failure to report and investigate the death related to trach dislodgement formed the basis of the cited respiratory care deficiency for multiple trach-dependent residents. The nursing home is disputing this citation, but the report documents that eight of eleven reviewed residents with tracheostomies were affected by one or more of these failures, including the resident who died after trach dislodgement, several residents lacking required trach reinsertion equipment or functional monitoring devices, and one resident who developed respiratory infection and pneumonia in the context of missed trach care and suctioning orders. The survey findings are based on interviews with staff and family, review of clinical records, physician orders, hospital records, death certificate, and direct observations of residents and equipment on the respiratory unit.
Failure to Provide Timely MASD Treatment and Wound Management Leading to Infected Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate preventive treatment for sacral moisture-associated skin damage (MASD) and to prevent worsening of a wound for one resident. The resident, an older adult with diagnoses including cerebral infarction, anoxic brain damage, morbid obesity, and diabetes mellitus, was admitted with intact skin and no wounds on 01/13/2026. On 01/14/2026, a wound nurse documented intact skin with MASD on the sacrum, and the care plan dated 01/27/2026 indicated the need for barrier cream to areas exposed to moisture/incontinence. However, the January 2026 treatment administration record (TAR) contained no documentation of any sacral MASD treatment. For eighteen days there were no documented physician orders or TAR entries for MASD treatment. On 01/31/2026, a registered nurse notified the physician of MASD to the sacrum and left buttock, and the physician ordered zinc oxide cream every shift with each incontinent care and a wound care consult. The wound APN did not see the resident until 02/17/2026, seventeen days after the wound consult was ordered. At the first wound APN evaluation, the sacral area had progressed from intact skin to a wound measuring 10 cm by 15 cm by 0.1 cm, and the APN documented that the sacral MASD had worsened. A culture and sensitivity was ordered to rule out localized infection and to refer to an infectious disease specialist. Dakins solution was added as a new treatment on 02/17/2026. The resident was transferred to the hospital on 02/18/2026 with an elevated temperature and an elevated white blood cell count of 18.5, and clinical notes from 02/19/2026 state the resident was admitted for sepsis and sacral region pressure ulcer evaluation. On 02/20/2026, the facility received culture and sensitivity results confirming a positive wound infection. The resident’s family member reported that the facility did not communicate the wound status and that he first learned from the hospital that the resident had a golf ball–size pressure ulcer about a month after admission. Staff interviews indicated that there should have been an earlier order for zinc oxide cream for MASD and that wound staff were expected to address skin concerns as early as possible to prevent wound issues.
Failure to Ensure Individual, Accessible Call Lights for All Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that each resident had access to an individual, functioning call light in their rooms and bathrooms/bathing areas, as required by facility policy. Multiple cognitively intact residents with significant medical conditions, including spinal stenosis, intervertebral disc degeneration, diabetes, COPD, anoxic brain damage, chronic kidney disease, dementia, history of falls, hypertension, and heart failure, reported sharing a single call light string between beds in three-bed rooms. In one room, a single yellow call light string was attached to a wall switch between two beds and was hidden behind a nightstand, requiring residents to kneel and retrieve it to use it. One resident stated they rarely used the call light because they were independent and walked to the nurse’s station, but reported that their roommate, who was less ambulatory and used a cane, could not reach the call light and would like access to it in case of an emergency. Another resident reported that only two call lights were available in their three-bed room, requiring residents in beds B and C to share a call light string, and that the residents in those beds were less mobile and needed access to the call light. Additional observations and interviews showed that residents in other three-bed rooms also shared call lights, and that at least one resident’s call light string was not within reach and the resident was unable to answer surveyor questions. Another resident reported sharing a call light with their roommate and stated that a call light would be useful because they sometimes could not get to the nurse’s station. CNAs, an LPN, and a social worker stated they were not aware that one resident had difficulty moving around the room due to multiple wheelchairs or that the resident had complained about having only one call light. The DON stated that every resident was expected to have their own call light regardless of mobility status, and the maintenance director stated they were not aware that only one yellow string was attached to the call light switch for two residents in three-bed rooms. The administrator confirmed the expectation that call lights be within reach for each resident at all times, consistent with the facility’s written policy requiring call lights to be placed within resident reach at all times.
Failure to Ensure Safe Hoyer Lift Transfers and Equipment Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe mechanical lift transfer procedures and to check lift equipment in accordance with its own policy for residents who required Hoyer lift transfers. For one resident with diabetes mellitus, foot ulcer, anxiety, depression, and a left below-knee amputation, staff used a Hoyer lift in connection with showering and transfers despite room space limitations that prevented the shower bed from fitting inside the room. The resident reported two separate incidents involving the Hoyer lift: during a Christmas transfer from shower to bed, the lift tilted forward and the handle where the sling was attached struck his head, and staff told him he was unconscious for several seconds; in a later incident, again after a shower, the sling strap attached to the lift broke while transferring him from a shower table to a Geri chair, causing him to fall to the floor and be sent to the hospital. Clinical notes documented that the lift fell and hit the resident’s forehead with a brief unresponsiveness, and that on another date the sling strap broke and the resident’s head hit the frame of the lift during transfer from the Hoyer to the bed. Staff interviews and observations further showed that the Hoyer lifts and slings were not consistently maintained or inspected as required. A registered nurse stated that some Hoyer lifts on the unit did not work properly and that their functioning was inconsistent, with one of two lifts on the floor not working at the time of inspection. Measurements taken with the maintenance director showed that the shower table dimensions exceeded the available space at the side of the resident’s bed, leaving insufficient room to maneuver the shower bed into the room, resulting in transfers being performed in or near the hallway and doorway area. A certified nursing assistant who assisted with both incidents stated that the resident, who weighed approximately 385 lbs, was transferred via Hoyer lift from the hallway near the door to the bed, and that the resident fell at the entrance of the room when the sling broke. A second resident reported being dropped when a Hoyer sling tore during a transfer from bed to wheelchair on an upper floor. The resident stated that as staff began to lower him, the lower strap tore free from the sling, causing him to land on the wheelchair and then be lowered to the floor, after which x‑rays were obtained and he was sent to the hospital and later returned to a different floor. The fall investigation for this incident documented that two CNAs were transferring the resident via Hoyer lift when the sling strap ripped and tore apart while the resident was hovering above the wheelchair, with the root cause identified as a torn sling harness. Facility policy for total mechanical lift use required staff to check the sling for rips, tears, or abnormal wear prior to use and to remove any damaged sling from circulation and notify the DON, and also required positioning as close as possible to the receiving surface; however, the repeated incidents of sling tearing and equipment malfunction during transfers showed that these procedures were not followed for the affected residents.
Missed and Undocumented Scheduled Medication Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders and documented appropriately for two residents. Review of one resident’s medication administration record (MAR) for 2/1/2026 to 2/28/2026 showed that scheduled doses of baclofen 5 mg and pregabalin 10 mg, ordered for administration on 2/25/2026 at 2:00 PM, were not documented as given. Two LPNs separately confirmed that an empty box on the electronic MAR at a scheduled date and time indicates the medication was not administered or was refused, and that when a medication is given, the system displays a check mark in the box. Both LPNs verified that the baclofen and pregabalin administration boxes for that resident on 2/25/2026 at 2:00 PM were blank, and one LPN stated that if a medication is not given or is refused, the physician and family should be notified and a progress note entered. For another resident, review of the MAR for 3/1/2026 to 3/31/2026 showed a missing 6:00 AM dose of gabapentin 300 mg on 3/16/2026, ordered as one capsule by mouth every eight hours for polyneuropathy, with an active order date of 1/6/2026. An LPN explained that an empty box on the MAR can also mean the nurse is waiting for the pharmacy to deliver a reordered medication, but no documentation was cited in the report to explain the missed dose. The DON stated that a green check mark with nurse initials appears in the electronic record when a medication is administered, and that a blank box for a scheduled medication indicates a missed dose, which should be investigated and documented in progress notes. The DON verified that the baclofen and pregabalin doses for the first resident on 2/25/2026 at 2:00 PM were missed, and facility policy dated 9/2020 requires drugs to be administered in accordance with written physician orders.
Inaccurate and Conflicting Documentation After Dislodged Tracheostomy and Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation regarding a resident who expired following a dislodged tracheostomy. The resident had toxic encephalopathy, respiratory failure with a tracheostomy collar, and hemiplegia/hemiparesis after a cerebral infarction, and had been admitted with an order for high-flow oxygen at 20 L/min via trach collar after an ICU stay and tracheotomy. On the day of the incident, an LPN documented at 3:30 PM that the resident was observed with oxygen tubing connected to the tracheostomy tubing in his finger, but no interventions were documented to prevent trach dislodgement. Later, the respiratory therapist (RT) documented that at approximately 4:45 PM he reinserted the tracheostomy, that the resident had a pulse and labored breathing, and that CPR was initiated at 4:46 PM, 911 was called at 4:47 PM, and paramedics arrived at 4:55 PM. These facility records conflicted with the paramedic report and with staff interviews. The 911 report documented dispatch at 4:47:24 PM and arrival at 5:52:37 PM, and stated that the crew found the resident unresponsive, pulseless, and apneic, with staff attempting to reinsert a dislodged trach, and that CPR was initiated by the crew upon arrival. The paramedics noted facial and tongue swelling that prevented intubation, and documented multiple rounds of epinephrine with persistent asystole/PEA until resuscitation was terminated in the field; the death certificate listed time of death as 5:31 PM. The DON stated that CPR is to be performed only when there is no pulse, consistent with facility policy and AHA guidelines, yet the RT’s note indicated the resident had a pulse and labored breathing at the same time CPR was documented as being performed. Further inconsistencies arose in staff accounts and documentation of the resident’s condition and the sequence of events. Initially, the RT stated the resident had vital signs after trach reinsertion, denied facial swelling or subcutaneous emphysema, and admitted he did not document vital signs or appearance because he forgot. Later, after being informed of paramedic findings and family-provided photos showing substantial facial and body swelling, the RT changed his statement multiple times, acknowledging swelling, difficulty reinserting the trach, and uncertainty whether the tube was fully inserted. The DON stated that the LPN was the first to know the trach was dislodged, while the RT claimed he was first to see it dislodged. A nurse consultant stated that the LPN did not actually perform CPR despite documentation indicating she had, and remarked that “it is not always true what they chart.” These conflicting notes, omissions, and changing statements demonstrate that the facility failed to accurately and completely document the incident and the resident’s status surrounding the dislodged tracheostomy and subsequent death.
Failure to Protect Resident From Ongoing Verbal Abuse and to Follow Abuse Reporting Policy
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from ongoing verbal abuse by another resident and to follow its abuse prevention and reporting policies. One resident (R1), who had intact cognition with a BIMS score of 15 and multiple medical diagnoses including spinal stenosis, type 2 diabetes, morbid obesity, and chronic pain conditions, reported that another resident (R3) had been verbally abusive for about a year. R1 stated that R3 repeatedly called R1 racial slurs including the n-word, used other derogatory names such as "stupid pedophile," "nasty," and "disgusting," and made false accusations that R1 was misusing the system, not caring for R1’s children, and pretending to be sick to obtain state funding. R1 reported that R3 would wheel to the doorway of R1’s room, sit in front of the door, scream and curse at R1, and make offensive finger gestures. R1 said these behaviors were ongoing and continuous, and that R1 had informed multiple staff members over the course of the year but felt the facility was not doing anything to stop R3’s verbal abuse. Multiple staff interviews corroborated that R3 had a history of verbally abusive behavior, including racial slurs directed at R1 and other residents. An RN (V4) stated that on one occasion in the dining room, R3 rolled up to R1 and called R1 the n-word, which V4 heard, and that V4 reported this to a supervisor. V4 also documented in R1’s progress note on 2/2/2026 that R1 verbalized concerns about another resident making false accusations and continuing to approach R1 despite R1’s discomfort, and V4 reported this to social services and the DON. An LPN (V12) reported hearing R3 call R1 the n-word at the nurse’s station and noted that R1 had become more socially isolated and now ate in the room instead of the dining room. CNAs (V16 and V9) and another resident (R6, a former roommate of R3 with impaired cognition) described R3 as verbally abusive, yelling, cursing, using racial slurs, and calling others names on a daily basis. The Social Services Director (V14) acknowledged that R3 had a history of verbal abuse as part of R3’s diagnosis, that R1 had reported being called the n-word, and that staff had reported R3 sitting in front of R1’s room in a wheelchair. The facility failed to follow its abuse policy and abuse prevention program requirements for reporting, investigating, protecting residents, and care planning. The Administrator (V1), who is the abuse coordinator, stated awareness only of an incident from 10/10/2025 involving racial comments by R3 toward R1, which was reported to the state agency the following day rather than on the day of occurrence, and could not explain the delay. V1 stated that when a nurse raised concerns again on 2/2/2026 about R3 calling R1 racially derogatory names, V1 assumed it referred to the prior incident, did not initiate a new investigation, did not interview R1 or R3 about the new allegations, and did not report the new allegation to the state agency. V14 also admitted speaking with R1 about R3’s name-calling a few weeks before the survey but did not document the conversation in R1’s progress notes. Despite R1’s repeated reports and staff awareness of R3’s ongoing behaviors, there was no documentation of a new investigation, no evidence of protective measures such as relocating R3 away from R1’s room or unit, and no update to R1’s care plan to address the risk or occurrence of verbal abuse. R1’s abuse risk assessment had not been updated since admission, and R1’s care plan contained no focus on verbal abuse or risk for abuse, even though R1 reported feeling safe only in R1’s room, avoiding common areas, no longer attending activities or dining in the dining room, and isolating to avoid contact with R3. The facility’s written policies required immediate reporting of suspected abuse to supervisors or the administrator, timely reporting to the state agency, protection of residents involved in possible abuse incidents, removal from contact of an alleged abuser during investigations, assessment of residents with behaviors that could cause conflict, and documentation and review of residents’ concerns through the grievance process. The abuse policy defined verbal abuse as disparaging or derogatory oral, written, or gestured language and mental abuse as harassment or humiliation that could cause fear or shame. Despite these requirements, the facility did not consistently report or investigate repeated allegations of verbal abuse by R3 toward R1, did not ensure R3 was removed from contact with R1 or relocated to another floor, and did not document or address R1’s expressed concerns and behavioral changes such as social withdrawal and eating in the room. R1 stated that after the October 2025 incident, no one followed up with R1 about what happened or the outcome of any investigation, and that staff responses focused on telling R1 to ignore or avoid R3 rather than implementing protective interventions in accordance with facility policy.
Failure to Timely Report and Investigate Repeated Verbal Abuse Allegations
Penalty
Summary
The facility failed to follow its abuse policy by not timely reporting allegations of verbal abuse to the state agency and by not reporting a subsequent allegation at all for two cognitively intact residents. One resident (R1), with multiple medical conditions including spinal stenosis, type 2 diabetes mellitus, morbid obesity, chronic venous insufficiency with a non‑pressure ulcer, lumbar radiculopathy, and other comorbidities, had a BIMS score of 15 indicating intact cognition. Another resident (R3), with end‑stage renal disease on dialysis, cerebral palsy, chronic kidney disease, sequelae of cerebral infarction, major depressive disorder, PTSD, ADHD, and other diagnoses, also had a BIMS score of 15. R1 reported that R3 had been verbally abusive for almost a year, including calling R1 the n‑word and other racial slurs, and stated that the facility was not preventing this behavior. On 10/10/2025, staff, including an RN (V4) and an LPN (V12), observed or were informed that R3 was verbally aggressive, yelling racial slurs at R1 and others passing R3’s room. The Social Services Director (V14) documented in R3’s progress note that R3 was being verbally abusive and making racial slurs toward another resident and completed a petition for involuntary/judicial admission citing increased agitation, aggression, and racial comments. R3 was sent to the hospital and returned the same day. The Administrator (V1), who is the facility’s abuse coordinator, acknowledged that the incident occurred on 10/10/2025 but reported it to the state agency on 10/11/2025 at 9:09 PM, more than 24 hours after the occurrence, despite the facility’s Abuse Prevention Program requiring that reports of suspected abuse be filed no later than 2 hours from suspicion. The facility’s incident report to the state agency characterized the event as R3 being verbally impolite to R1. V1 stated being unsure why the report was not submitted on the date of the incident. On 2/2/2026, R1 again reported ongoing verbal abuse by R3 to the RN (V4), including continued use of the n‑word, racial name‑calling, and offensive gestures while R3 sat in front of R1’s room. V4 documented R1’s concerns in R1’s progress note and reported them to Social Services and the Director of Nursing, and also went to the Administrator’s office to notify V1. V4 stated that V1 responded that V1 was aware of the issues and was already investigating. V14 reported that about a week before the survey (on or around 2/2/2026), a staff nurse informed V14 that R1 said R3 was verbally abusing R1 again; V14 spoke with R1 but was unsure if this was reported to V1 and had no documentation of this interaction. V1 acknowledged that a nurse spoke with V1 about R3 calling R1 racially derogatory names but assumed the nurse was referring to the prior October incident, did not speak with R1 or R3 about the new allegation, and did not report the new allegation to the state agency. R1 stated that no one followed up after the October incident, that R1 was not informed of any investigation conclusions, and that R1 did not deny the October incident occurred. Review of state reportables from 10/1/2025 to 2/10/2026 showed only the single verbal abuse report from October, confirming that the February allegation was never reported, contrary to the facility’s Abuse Prevention Program requirements for immediate reporting, documentation, and resident notification. The facility’s Abuse Prevention Program (for Illinois facilities) specifies that employees must immediately report any observed, heard about, or suspected incident to a supervisor or the Administrator, that an initial report of an accusation should be completed immediately, and that a written report must be sent to the state agency no later than 2 hours from suspicion. It also requires that the Administrator inform the resident that a report has been made and that an investigation has started, and later notify the resident of the conclusion of the investigation. In this case, the October 10 verbal abuse incident involving racial slurs was not reported to the state agency within the required 2‑hour timeframe, and the subsequent February allegation of ongoing verbal abuse was not reported at all. Additionally, R1 reported not being informed about the investigation or its conclusion and not being asked if R1 felt safe, despite the policy requiring resident notification and follow‑up. These actions and inactions by the Administrator and other staff led to the identified deficiency in timely reporting and handling of abuse allegations.
Failure to Provide Timely Incontinence and ADL Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely ADL and incontinence care to residents who were dependent on staff assistance. One resident with diagnoses including lack of coordination, cauda equina syndrome, osteoarthritis, and major depressive disorder was cognitively intact and care planned as dependent for toileting hygiene and bed mobility. On the morning in question, this resident reported having a bowel movement after breakfast and stated they had just turned on the call light. A strong fecal odor was noted in the room. Despite the call light sounding, the assigned LPN remained at the medication cart nearby and a CNA walked past the room multiple times over a 14‑minute period without entering. The resident’s assigned CNA had been sent out of the facility around 8:30 a.m. to accompany another resident to a medical appointment, and coverage was to be provided by other CNAs on the unit. At 10:00 a.m., a covering CNA entered the resident’s room only to turn off the call light and then left without providing care. When the surveyor re-entered the room at 10:15 a.m., the resident was crying and reported that the CNA had said they were busy and would return in a few minutes, which did not occur. Continuous surveillance from 9:00 a.m. to 11:50 a.m. showed that the CNA did not return. The resident reactivated the call light at 11:45 a.m., and another CNA responded at 11:50 a.m., returning with supplies and initiating incontinence care around noon, resulting in the resident remaining soiled with feces for approximately three hours while reporting itching, burning, pain, humiliation, and feeling “like a dog” lying in feces. A second resident, with medical conditions including spinal stenosis, weakness, a gastrostomy, a sacral pressure ulcer, and polyosteoarthritis, was moderately cognitively impaired and care planned as dependent for toileting hygiene and bed mobility. During the same surveillance period, this resident was heard calling out for help and reported being wet for a long time. The surveyor activated the call light, which the LPN answered by entering the room, turning off the call light, and then leaving to return to the nursing station. The LPN later stated that the resident needed to be cleaned up and that she had told one of the aides but did not recall which one, noting she was occupied with an admission. The resident remained wet until a CNA who had been out on a medical escort returned to the unit and, at the surveyor’s request, provided incontinence care, resulting in the resident being left wet for approximately two hours. Staff interviews referenced ongoing staffing issues and working short, with only two CNAs on the floor for about forty residents and the reassignment of a primary CNA to an outside appointment.
Prolonged Incontinence and Delayed ADL Care Due to Insufficient Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ ADL and incontinence care needs in a timely manner, resulting in prolonged periods in soiled briefs and unmet requests for assistance. On multiple occasions, residents and family members reported that staffing was inadequate and that residents waited a long time, sometimes hours, for incontinence care. One family member stated that on a holiday evening there was only one nurse covering approximately fifty residents on a floor after another nurse called off, and that there had been several times when the resident’s under brief was entirely wet and soiled with feces stuck to her body. This family member reported that staffing issues were ongoing and ultimately moved the resident to another facility. On one survey day, a resident on the third floor was observed with a strong fecal odor in the room shortly after activating the call light and reporting a bowel movement after breakfast. The resident stated that staffing was terrible and that he often waited a long time, sometimes hours, to be changed and cleaned up. The surveyor observed that a CNA entered the room, turned off the call light, exited without providing care, and the resident turned the call light back on. Surveillance of the room from 9:00 AM to 11:50 AM showed that incontinence care was not initiated until approximately 11:50 AM, meaning the resident remained soiled with feces for about three hours. The CNA later stated she had told the resident she would return but forgot because she was very busy with her assigned residents and that there were only two CNAs on the floor for approximately forty or more residents. Another resident was heard yelling for help, stating she was wet and had been wet for a long time. The surveyor turned on the call light, and an LPN entered, turned off the light, left the room, and returned to the nursing station. When asked later, the resident reported she was still wet and that the staff member had said she would be back. The LPN stated the resident needed to be cleaned up and that she had told one of the aides but could not recall which one, explaining she had an admission coming and needed to get report, and that staffing had been an issue for a while. The resident did not receive incontinence care until a CNA who had been off the unit escorting another resident to a medical appointment returned and was asked by the surveyor to provide care, resulting in the resident remaining wet for about two hours. Staff interviews and staffing records showed that on the day of survey the vent unit had only one nurse and two CNAs instead of the expected two nurses and three CNAs, and CNAs reported that most residents on that unit were bedbound and total assist, making it difficult to care for everyone properly when short staffed. Residents on the third floor and other units reported that there were not enough CNAs or nurses, that they had to wait a long time for assistance, and that short staffing was common, especially on weekends and holidays. The nurse scheduler described expected staffing levels for each floor and shift and confirmed that on a prior holiday three nurses had called off and replacements could not be found, resulting in only one nurse on the second floor for a 7:00 AM–7:00 PM shift and one nurse covering both the vent unit and the west unit for part of a shift. A nurse who worked that day stated she was the only nurse on the second floor, that there were normally two nurses, that she notified the former DON, and that she resigned shortly afterward due to unsafe staffing. The administrator acknowledged being notified of nurse call-offs on the holiday and stated that attempts to contact the DON, ADONs, staff nurses, and an agency did not result in additional coverage, and that staff worked short that day. The acting DON, who assumed the role after these events, stated that residents should not wait three hours for assistance, that the second floor should have two nurses, and that the vent unit and west unit each needed their own nurse to provide adequate care. Multiple staff members and residents reported ongoing staffing issues, including insufficient CNAs and nurses, increased workloads, delayed response to call lights, and delays in changing residents after bowel movements. The facility did not have a staffing policy, despite a facility assessment statement indicating that extra and relief staffing would be provided by sister facilities and corporate employees, and federal regulations require sufficient nursing staff with appropriate competencies and skill sets to meet residents’ needs on a 24-hour basis.
Failure to Ensure Proper Oxygen Orders, Settings, and Equipment Handling
Penalty
Summary
The deficiency involves failures in providing safe and appropriate respiratory care, including incorrect oxygen settings, unlabeled and improperly stored respiratory equipment, and use of oxygen without a physician order. One resident with COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and pulmonary hypertension had care plan interventions directing staff to administer oxygen as ordered. The physician order allowed oxygen via nasal cannula at 1–5 L/min continuous. During observation, this resident was on 3 L/min via nasal cannula with the wall flow meter set at 3 L/min, and the nebulizer mask was found lying on a bedside table, unlabeled and not stored in a bag. Another resident with primary pulmonary hypertension, acute and chronic respiratory failure with hypoxia, and chronic systolic congestive heart failure had a care plan indicating PRN oxygen therapy related to chronic respiratory failure and interventions to administer oxygen per MD orders. This resident was observed in bed with a nasal cannula in place while the wall oxygen flow meter was turned off. An oxygen tank with a nasal cannula attached was on the wheelchair, undated and without a storage bag. The resident reported using oxygen sometimes as needed and stated the prescribed amount was 2 L, but when the surveyor checked, the flow meter was set at zero and the resident reported not feeling any oxygen until the nurse turned the flow meter to 2 L. A third resident with diagnoses including pleural effusion, chronic pulmonary edema, pneumonia, acute metabolic acidosis, and acute and chronic respiratory failure with hypoxia was admitted without any physician order for oxygen in the electronic medical record and without a care plan addressing oxygen use. Despite this, the resident’s oxygen concentrator was observed running at 1 L/min via nasal cannula, and the resident stated they had been using oxygen since admission. The acting DON/nurse consultant stated that there should be a physician order and care plan for oxygen, that oxygen should only be given without an order in an emergency, and that nasal cannulas and nebulizer masks should be stored in clean bags and dated when changed, consistent with facility policies on oxygen therapy and equipment storage and change schedules.
Failure to Administer Prescribed Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of joint replacement surgery, use of an artificial hip joint, polyosteoarthritis, and long-term anticoagulant therapy did not receive their prescribed blood thinner medication, Rivaroxaban, for four days. The resident, who was cognitively intact, reported missing the medication and expressed concern about the risk of blood clots. Documentation in the Medication Administration Report confirmed that the medication was not administered on four specific days, with notes indicating the facility was waiting for pharmacy delivery. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, revealed that procedures existed for obtaining medications not immediately available, such as retrieving them from a medication dispensing machine or requesting a rush delivery. Despite these procedures, the resident's medication was not provided as ordered by the physician, and the facility's policies require medications to be administered according to physician orders. The failure to ensure timely administration of the blood thinner directly affected the resident.
Failure to Timely Communicate and Act on Diagnostic Results for DVT
Penalty
Summary
The facility failed to follow its own policies and procedures regarding timely diagnostic testing, follow-up on diagnostic results, and physician notification for a resident experiencing a change in condition. The resident, who had a history of obesity, cellulitis, peripheral vascular disease, and prior pulmonary embolism, presented with unilateral leg swelling, warmth, and increased pain. Despite these symptoms, there was a delay in scheduling and performing the ordered venous and arterial doppler studies, with the tests being conducted three days after the initial order. After the diagnostic tests were completed, the results of the venous duplex scan, which confirmed deep vein thrombosis (DVT), were not promptly communicated to the physician. The physician was not notified of the abnormal findings or the resident's escalating pain, which increased to a rating of 8/10. The physician only became aware of the positive DVT result during a subsequent visit, seven days after the initial symptoms were noted, and initiated appropriate anticoagulant therapy at that time. Interviews with facility staff revealed that required documentation, such as the SBAR communication form, was missing for the period in question, and there was no record of the change in condition being communicated via the facility's established communication systems. Staff acknowledged that the expected process for reporting and following up on diagnostic results was not followed, and the physician confirmed that he was not informed of the abnormal results or the resident's increased pain until several days later.
Failure to Notify Physician and Family of Abnormal Diagnostic Results
Penalty
Summary
The facility failed to follow its policy and procedures regarding notification of a change in condition for a resident who developed unilateral leg swelling, pain, and abnormal diagnostic test results. Despite the resident's symptoms and subsequent orders for venous and arterial doppler studies, the facility did not notify the resident's emergency contacts or family about the change in condition or the abnormal findings. Documentation shows that family notification was excluded at multiple points, even though the facility's policy requires notifying the responsible party of all changes in condition. Additionally, the facility failed to accurately communicate abnormal diagnostic results to the physician. The physician was incorrectly informed that the venous doppler was negative for clots, when in fact it was positive for deep venous thrombosis. The physician only became aware of the true results upon personal review of the report days later. Staff interviews confirmed that abnormal results should be reported to providers, especially when positive, but this did not occur in this case.
Failure to Arrange Timely Transportation for Medically Necessary Appointments
Penalty
Summary
The facility failed to provide appropriate transportation arrangements for a resident requiring a CT scan, resulting in multiple missed appointments and a delay in treatment. The resident, who has a complex medical history including traumatic brain injuries and end stage renal disease requiring dialysis, was dependent on the facility to coordinate transportation due to her use of a wheelchair. Documentation and staff interviews revealed that the transportation coordinator encountered issues with the facility’s ride-hailing service card, which was unavailable for a period, necessitating reliance on insurance-based transportation that required advance notice. Additionally, there were scheduling conflicts with the resident’s dialysis treatments, and a lack of available escorts further contributed to missed appointments. Staff interviews indicated that the transportation coordinator was not always aware of all scheduled appointments and did not consistently arrange transportation in advance. On one occasion, an escort canceled last minute, and the appointment was not rescheduled in a timely manner. There was also confusion and lack of communication among staff regarding the resident’s appointment times and the ability to adjust dialysis schedules to accommodate external medical appointments. The resident missed several appointments due to these coordination failures, including one where transportation was not set up and another where the dialysis schedule could not be changed. Facility records and staff statements confirmed that the resident’s appointments for necessary imaging studies were repeatedly missed or rescheduled due to transportation and scheduling issues. The facility’s own policy stated that it would assist residents in arranging transportation as needed, but this was not consistently followed. As a result, the resident experienced delays in receiving diagnostic imaging required for ongoing neurosurgical care.
Failure to Report and Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of sexual abuse involving a resident with severe cognitive impairment. A family member observed a male resident in a female resident's room and reported witnessing inappropriate touching of the female resident's inner thigh. The family member immediately notified staff at the nurse's station, but no one followed up with her for further details about her observation. The nurse who responded to the report did not observe any distress or inappropriate behavior and did not document the incident, only redirecting the male resident due to wandering. The social services director and administrator were made aware of the allegation through internal communication, not directly from the family member. Both residents involved had diagnoses of dementia and were severely cognitively impaired according to their most recent BIMS scores. The female resident was unable to recall the incident, and the male resident denied any inappropriate behavior. Despite the facility's policy requiring immediate reporting and investigation of abuse allegations, no report was made to the state agency, and the incident was not documented in the facility's reported incidents log. Interviews with staff and review of records revealed that the facility did not consider the event an abuse allegation and therefore did not initiate the required reporting or investigation procedures. The administrator stated that he did not believe anything inappropriate occurred based on his interviews and the information provided by staff. The facility's failure to report and investigate the allegation was contrary to its own abuse policy, which mandates prompt reporting and investigation of all abuse allegations, including those not witnessed by staff.
Failure to Provide Ordered Catheter Care and Timely Drainage Bag Emptying
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including anoxic brain damage, quadriplegia, chronic respiratory failure, and an indwelling urinary catheter, did not receive appropriate catheter care as ordered by the physician and outlined in the facility's protocol. The resident's physician orders specified that the catheter should be changed monthly and that daily catheter care should be provided. However, a review of the treatment administration record for a three-month period showed no documentation that catheter changes or daily catheter care were performed. The resident was observed with a urinary catheter and a drainage bag containing 1100 milliliters of urine, and staff interviews confirmed that catheter care and timely emptying of the drainage bag are necessary to prevent complications. Further, the resident was admitted to the hospital with a diagnosis of catheter-associated urinary tract infection (CAUTI) during the review period. Staff interviews revealed that failure to provide catheter care and timely emptying of the drainage bag could lead to urinary tract infections. The facility's policy requires daily catheter care and emptying of drainage bags at least once per shift, but there was no evidence that these procedures were followed for this resident, as confirmed by both record review and staff statements.
Failure to Cohort Residents with Infectious Risks According to Policy
Penalty
Summary
The facility failed to prevent the risk of communicable disease transmission by inappropriately cohorting a resident with multiple infection risks, including a multidrug-resistant organism (MDRO) and Candida auris (C. auris), in a room with another resident who did not have the same infectious agents. Observations and staff interviews confirmed that a resident requiring enhanced barrier precautions (EBP) due to tube feeding, tracheostomy, indwelling catheter, ventilator, wounds, and a history of MDRO was placed in a room with another resident who had a history of C. auris and other resistant organisms, but not the same active infections. Facility policy and CDC guidance require cohorting residents with the same organism to prevent cross-transmission, which was not followed in this instance. Staff interviews revealed that the standard practice is to cohort residents based on the specific organism and mechanism of transfer, and to avoid rooming residents with different infectious agents together. Despite this, the resident with multiple infection risks was placed in a room with another resident with a history of C. auris due to a lack of available rooms with piped-in oxygen. Both residents were on ventilators and under EBP, but the facility's actions did not align with their own infection prevention and control policy or CDC recommendations, resulting in a failure to maintain appropriate infection control practices.
Failure to Ensure Resident's Chemotherapy Appointments
Penalty
Summary
The facility failed to ensure that a resident diagnosed with cancer received two scheduled chemotherapy treatments, leading to stress and worry for the resident about the potential progression of their cancer. The resident, who is cognitively intact and has a diagnosis of malignant neoplasm of the lung, quadriplegia, and other conditions, missed the first chemotherapy appointment due to a failure in setting up transportation. The second missed appointment occurred because the resident was picked up too early and, without an escort, had to be returned to the facility. The transportation personnel indicated that the first appointment did not appear on their report due to a missing end date in the order, and the second appointment required an escort due to the resident's need for a stretcher. The resident expressed concern about the missed appointments, emphasizing the importance of consistent chemotherapy treatments every six weeks. The resident's family also voiced concerns about the facility's passive approach to rescheduling these critical appointments. The facility's policy states that it will assist residents in arranging transportation as needed, but in this case, the policy was not effectively implemented, resulting in the resident missing essential cancer treatments. The surveyor's findings highlight the facility's failure to coordinate and ensure the resident's access to necessary medical care.
Deficiencies in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to provide prescribed wound care as ordered by the physician for several residents, leading to significant deficiencies in pressure ulcer management. For instance, the facility did not date wound care dressings, which is against standard practice, and there was no policy in place to justify this omission. This lack of documentation led to missed wound care treatments for residents, as evidenced by the Treatment Administration Records (TAR) showing missing signatures for wound care on specific dates. The absence of proper documentation and adherence to physician orders resulted in the worsening of wounds and increased risk of infection. One resident, identified as R1, suffered from multiple pressure ulcers, including on the sacral region and both heels. The facility failed to apply heel protectors as ordered, and the resident was observed lying flat without any pressure-relieving devices in place. This oversight contributed to the deterioration of R1's heel wound, ultimately leading to hospitalization for sepsis. The facility's failure to follow wound care protocols and physician orders, such as offloading heels and documenting wound assessments, directly impacted the resident's health. Additionally, the facility did not set the low air mattress at the appropriate setting for another resident, R10, whose mattress was set at a weight significantly higher than the resident's actual weight. This improper setting could lead to the mattress being too firm, thereby increasing the risk of pressure ulcers. The facility's lack of adherence to proper wound care protocols and equipment settings highlights significant deficiencies in their pressure ulcer prevention and treatment practices.
Failure to Conduct Fingerprint-Based Background Check for CNA
Penalty
Summary
The facility failed to adhere to its policy of conducting a fingerprint-based criminal history records check for a Certified Nursing Assistant (CNA), identified as V28, which is a crucial step in preventing abuse at the facility. This oversight was discovered during an interview and record review, revealing that V28's work eligibility was marked as 'Not Yet Determined' due to the absence of a completed fingerprinting process. The CNA was assigned to the 3rd floor Vent Unit, which had a daily census of 33 residents, potentially affecting all residents on that floor. Interviews with various staff members, including the Business Office Manager/HR Manager (V24), the Administrator/Abuse Coordinator (V1), and the Senior Business Office Manager (V27), highlighted a lack of clarity and communication regarding the fingerprinting process. V24 admitted that V28's work eligibility was not determined because the fingerprinting had not been completed, and V1 was unaware of the 'Not Yet Determined' status. V27 confirmed that the absence of a 'FEE_APP' in the IDPH portal indicated that V28 had not been fingerprinted, and thus, her eligibility to work at the facility was uncertain. The facility's policies, including the abuse prevention program and the fingerprint-based criminal history records check, were not followed as required. The policy mandates that all new hires undergo a background check and fingerprinting to ensure they do not have a history of abuse, neglect, or other criminal activities. Despite these policies, V28 was hired and allowed to work without completing the necessary fingerprinting process, which is a critical step in safeguarding residents from potential abuse.
Delayed Implementation of Dietary Recommendations for Tube Feeding
Penalty
Summary
The facility failed to ensure that dietary recommendations for residents on feeding tubes were ordered and carried out in a timely manner for five residents. The dietitian, identified as V8, made specific recommendations for adjustments to the tube feeding regimens of these residents, which were documented in the General Notes Report. These recommendations included changes in the type of formula, infusion rates, and water flushes. However, these recommendations were not promptly converted into orders by the Clinical Support Nurse, V22, leading to delays in implementation. The Director of Nursing, V2, and the Clinical Support Nurse, V22, acknowledged the process for handling dietary recommendations. V22 was responsible for reviewing the dietitian's recommendations and writing the corresponding orders within 24 hours. However, an email containing these recommendations, sent on January 16, 2025, was missed by V22, resulting in a delay of up to 29 days for some residents before the orders were placed. This oversight affected residents with various medical conditions, including diabetes, dysphagia, and those requiring dialysis, potentially impacting their nutritional status and health. The facility did not have a specific policy for handling dietary recommendations, but the expectation was that once a recommendation was agreed upon by the physician, it should be transcribed and carried out. The delay in implementing these recommendations was acknowledged by V22 and V2, who admitted that the oversight could lead to potential weight loss and other health issues for the affected residents. The deficiency was identified during a survey, highlighting the need for timely and accurate processing of dietary recommendations to ensure quality care for residents.
Resident Not Properly Dressed for Appointment
Penalty
Summary
The facility failed to ensure that a resident, who is cognitively intact with a BIMS score of 15, was properly dressed for a dental appointment outside the facility. The resident, who has medical conditions including hemiplegia, hemiparesis, and cognitive communication deficit, reported being taken to the appointment wearing only a gown, a jacket, and a hat, despite the cold weather. The resident expressed feelings of embarrassment and humiliation, stating that the staff did not know about the appointment until the last minute, which led to the inadequate preparation. The transportation personnel reported that the resident's CNA claimed the resident did not want to get dressed and preferred to wear a gown. However, the resident refuted this, stating he would never choose to wear a gown outside the facility. The incident was further corroborated by the resident's sister, who was upset upon seeing the resident at the appointment. The facility's policy on dressing and grooming emphasizes maintaining the resident's self-esteem, privacy, and confidentiality, which was not upheld in this instance.
Failure to Administer Prescribed Antibiotics Leads to Resident's Sepsis
Penalty
Summary
The facility failed to ensure a resident, identified as R1, was free from neglect by not administering necessary antibiotics to treat R1's infections. R1 was discharged from the hospital with instructions to continue antibiotics, including vancomycin, metronidazole, and cefepime. However, the facility's medication administration records showed that R1 only received cefepime, and there was no documentation of vancomycin or metronidazole being administered. The orders for these antibiotics were not transcribed into the facility's physician orders, and the Director of Nursing confirmed the oversight. The Consultant Pharmacist and the attending physician both affirmed that the antibiotics were necessary to treat the bacteria identified in R1's cultures. The lack of administration of vancomycin and metronidazole contributed to R1 developing sepsis, as confirmed by the attending physician. The Clinical Support Nurse, responsible for quality assurance audits, admitted to missing the transcription of the antibiotic orders into R1's medical record. The facility's Administrator, who is also the abuse prevention coordinator, was unable to provide a clear definition of neglect and did not recognize sepsis as a life-threatening condition. The Agency Registered Nurse, who was responsible for transcribing the orders, could not provide a consistent explanation for the missing orders. The facility's policy affirms the right of residents to be free from neglect, which includes the failure to provide necessary medical services, as occurred in this case.
Significant Medication Errors Lead to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, which contributed to a resident developing sepsis and requiring hospitalization. The first resident, R1, was discharged from the hospital with instructions to continue antibiotics, including vancomycin, metronidazole, and cefepime. However, the facility's medication administration records showed that R1 only received cefepime, and there was no documentation of vancomycin or metronidazole being administered. The Director of Nursing confirmed that these medications were not transcribed into the facility's records, and the consultant pharmacist verified that the pharmacy was not made aware of the orders for vancomycin and metronidazole. The attending physician confirmed that the lack of these antibiotics could have contributed to R1 developing sepsis. Another resident, R3, was affected by a medication error involving the incorrect dosage of micafungin. R3's hospital discharge paperwork indicated an order for 100 mg of micafungin every 24 hours, but the facility's records showed that R3 received only 50 mg. The Director of Nursing confirmed the error and could not provide a reason for the discrepancy. The Clinical Support Nurse, responsible for quality assurance audits, admitted to missing the error during the audit process. The facility's policy on re-admissions requires that medications for residents readmitted to the facility are verified and initiated on a timely basis. However, the failure to accurately transcribe and administer the correct medications for both R1 and R3 indicates a breakdown in this process. The errors were not caught during the quality assurance audits, leading to significant medication errors that affected the residents' health outcomes.
Inadequate Training and Competency Evaluation for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff had the necessary competency, training, and skills to care for its residents, which could potentially affect all 162 residents residing in the facility. An agency registered nurse, identified as V20, admitted to working shifts at the facility but could not confirm specific dates or details of their work, including the transcription of critical medication orders for a resident readmitted on a particular date. V20 acknowledged transcribing orders and contacting a nurse practitioner but failed to document orders for metronidazole and vancomycin in the electronic health record. V20's explanation for the missing orders was inconsistent, and they could not provide further information about the incident. The Director of Nursing, V2, confirmed that the facility relies on agency staff to fill staffing needs and does not have a formal procedure for training or evaluating the competency of agency nurses before they start their shifts. V2 stated that the agency did not have training documents for V20, and the facility lacked documentation proving V20's competency in completing admissions. Although a resource binder was available for agency staff, there was no evidence that V20 was aware of or had reviewed its contents. The facility's job description for staff nurses requires knowledge of nursing practices and procedures, including admission processes, but the facility assessment tool's training and competencies tab was not provided during the survey.
Inaccurate Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. The assessment did not include specific staffing information, such as the number of staff needed per shift or unit, and did not identify respiratory therapists as necessary staff members for the facility's population. Additionally, the assessment failed to mention the ventilator unit, which houses 36 residents, and did not identify the contracts for staffing respiratory therapists. Interviews and record reviews revealed that the Director of Respiratory, a registered respiratory therapist, oversees the respiratory therapy program and stated that the facility contracts with a medical staffing agency to staff the ventilator unit. The staffing needs for the ventilator unit are determined by the Director of Respiratory, with a staffing ratio of one respiratory therapist to every 16 airways, ensuring at least two respiratory therapists are on site at all times. Despite these arrangements, the facility's administrator stated that the facility assessment is completed yearly and does not require a breakdown of staffing needs, relying instead on a facility assessment tool without a specific policy for completing the assessment.
Inadequate Infection Control and Foley Catheter Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of foley catheter tubing and inadequate infection tracking and surveillance. Observations revealed that foley catheter tubing for two residents was found lying on the floor, which was acknowledged by a Resident Care Coordinator as a potential source of infection. The facility's policies on catheter care did not provide specific instructions on preventing catheter tubing from touching the floor, contributing to this oversight. Additionally, the facility's infection preventionist, who was responsible for tracking infections, did not adequately document or track infections that were not treated with anti-infective medications. This included failing to track pathogens, symptoms, and mapping of infections, which are essential components of an effective infection control program. The infection preventionist believed that only infections treated with anti-infective medications needed to be tracked, which was contrary to the facility's policy and best practices. The Director of Nursing and a Registered Nurse Consultant acknowledged the deficiencies in the infection control program, noting that the previous assistant director of nursing had been responsible for these tasks before leaving the facility. The Registered Nurse Consultant, who was overseeing the infection preventionist's work, confirmed that the infection control logs were incomplete and that mapping of infections had not been conducted. This lack of comprehensive infection tracking and surveillance could potentially lead to outbreaks within the facility, as noted by the Director of Nursing.
Inadequate Oral Care for Ventilator Unit Residents
Penalty
Summary
The facility failed to ensure that oral care was provided to residents on the ventilator unit in accordance with professional standards and facility policy. This deficiency was observed in the case of a resident who was dependent on staff for oral care. The resident was found with thick, beige secretions on their lips and teeth, indicating a lack of proper oral hygiene. Despite a Certified Nursing Assistant claiming to have provided oral care earlier, the Licensed Practical Nurse noted the need for immediate attention and attempted to clean the resident's mouth using a dry washcloth, which is not in line with the facility's oral care policy. Further investigation revealed that other residents on the ventilator unit also did not receive adequate oral care. Documentation showed that oral care was not consistently provided twice daily as required, and in some cases, there was no documentation to confirm that oral care was provided at all. The facility's policy for oral care of unconscious residents was not followed, as staff did not use the appropriate equipment and procedures outlined in the policy. The Director of Nursing and the Medical Director both acknowledged the importance of proper oral care to prevent infections such as pneumonia, yet the facility's practices did not align with these standards.
Failure to Change Nebulizer Tubing Timely
Penalty
Summary
The facility failed to adhere to its policy regarding the timely change of nebulizer tubing, which has the potential to affect the respiratory care of a resident. The resident, identified as R12, is cognitively impaired, unable to speak, and dependent on staff for daily activities, while also utilizing a ventilator. During an observation, it was noted that the nebulizer tubing attached to R12's tracheostomy site was dated 1/15/2025, indicating it had not been changed in accordance with the facility's policy of weekly changes. This oversight was confirmed by the Resident Care Coordinator, a Licensed Practical Nurse, who acknowledged the tubing should be changed weekly to prevent infection. Subsequently, R12 was diagnosed with a urinary tract infection, pneumonia, and sepsis, as documented in the resident's progress notes.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to adhere to its policy of ensuring that call lights are answered promptly, affecting five residents out of seven reviewed. Residents reported that their call lights often went unanswered for extended periods, sometimes up to an hour, particularly during the afternoon and night shifts. This delay in response left residents in uncomfortable and potentially harmful situations, such as sitting on soiled linens for too long. Interviews with staff, including a CNA and the Social Worker Director, confirmed that call lights should be answered promptly to prevent potential harm to residents, such as falls or medical emergencies. The Director of Nursing stated that the expectation is for staff to respond to call lights within 2 to 3 minutes to meet residents' needs. However, the facility's failure to meet this standard was documented in Resident Council Meeting Minutes and Grievance/Concern Forms, which highlighted ongoing issues with call light response times. The deficiency was further supported by the Minimum Data Set of one resident, which showed dependency on staff for toileting and transfers, emphasizing the critical need for timely assistance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precaution (EBP) signage on the doors of residents with specific medical needs and the improper use of personal protective equipment (PPE) during high-contact care activities. Several residents, including those with enteral feedings, urinary catheters, and tracheostomies, were not properly identified with EBP signage, leading to staff uncertainty about the necessary precautions. This oversight was observed during interactions with multiple residents, where staff did not wear isolation gowns while performing tasks that required direct contact, such as checking gastrostomy tube sites and providing hygiene care. Additionally, the facility failed to appropriately cohort a resident with a multidrug-resistant organism (MDRO) with another resident who had no history of such infections. This misplacement occurred due to a lack of communication and verification of the resident's infection status before room changes were made. The Infection Control Preventionist later identified the mismatch and took steps to rectify the situation, but the initial failure to adhere to cohorting guidelines posed a risk of infection transmission. The facility also did not follow its policy regarding the management of a resident with suspected or confirmed scabies. The resident's linens and clothing were not promptly laundered, and the roommate's physician was not contacted for prophylactic treatment. Furthermore, the local health department and the Illinois Department of Public Health were not informed of the scabies case, and a comprehensive care plan was not developed for the affected resident. These lapses in protocol could have led to cross-contamination and reinfection, as noted by staff observations and interviews.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to adhere to its policy of notifying the resident's representative prior to changing the room of a cognitively impaired resident, identified as R5. R5, who has severe cognitive impairment due to conditions such as Hemiplegia and Hemiparesis following a cerebral infarction, was moved twice within two days without documented notification to their representative. The facility's policy mandates that residents or their representatives be informed of room changes, but there was no documentation in R5's records indicating that this notification occurred. Interviews with various staff members, including the Director of Nursing, Admissions Director, Infection Control Preventionist, and several nurses, revealed a lack of clarity and communication regarding who was responsible for notifying R5's family about the room changes. Each staff member either assumed another was responsible or could not recall if the notification was made. This lack of documentation and communication led to the deficiency in honoring the resident's right to be informed about room changes.
Failure to Obtain Physician's Order and Develop Care Plan for Splint Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of a resting hand splint for a resident, identified as R1, who is cognitively severely impaired and has functional limitations in all extremities. Despite the facility's policy requiring a physician's order for splint use, R1's Physician Order Sheet did not include an order for the splint. Observations confirmed that R1 was using a right-hand resting splint, and interviews with staff, including the Restorative Nurse and the Director of Nursing, acknowledged the absence of a necessary physician's order, which is a potential risk for injury. Additionally, the facility did not develop a comprehensive care plan for R1's splint use. The care plan completion document for R1 did not mention the use of a resting hand splint, contrary to the facility's policy that mandates individualized, person-centered care plans. The MDS/Care Plan Coordinator and other staff confirmed that the care plan should include specific goals and interventions for splint use, but this was not done for R1. The lack of a care plan could lead to improper application and care of the splint, as noted by the staff.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy of reporting injuries of unknown origin within the required timeframe, affecting one resident. The incident involved a resident who was found with a laceration on the upper lip, which was approximately 5-6 cm in length. The injury was discovered during rounds by a Licensed Practice Nurse (LPN) and was reported to the Director of Nursing (DON) and Assistant Director of Nursing (ADON). However, the initial report to the State was submitted more than two hours after the injury was noted, which is against the facility's policy that requires immediate reporting, no later than two hours, for injuries of unknown source. The resident involved had a medical history that included epilepsy and Parkinson's disease, and cognitive assessments indicated memory problems. The injury was considered serious enough to warrant a visit to the emergency room. Despite interviews with staff, the cause of the injury remained unknown. The facility's policy mandates that serious incidents or accidents causing physical harm be reported to the State Department of Public Health immediately, which was not adhered to in this case.
Improper Low Air Loss Mattress Settings for Residents with Pressure Injuries
Penalty
Summary
The facility failed to ensure that low air loss mattresses were set to the recommended settings based on the residents' weights, affecting two residents with pressure injuries. One resident, who weighed 247 pounds, was found lying on a low air loss mattress set at 340 pounds, which was not appropriate for their weight. The setting was later adjusted to 280 pounds, which was deemed the closest appropriate setting by the Wound Care Coordinator. Another resident, weighing 197.4 pounds, was found on a mattress set at 280 pounds, which was also not aligned with their weight. The Wound Care Coordinator confirmed that the mattress settings should be based on the resident's weight to prevent the worsening of pressure wounds. Both residents had documented diagnoses of stage 4 pressure ulcers in the sacral region and were at risk of pressure ulcers or injuries. The facility's failure to adjust the mattress settings according to the residents' weights could potentially compromise the effectiveness of the pressure redistribution support intended to prevent and treat pressure ulcers. The low air loss mattress manual specifies that the pressure should be adjusted according to the patient's weight and comfort to ensure proper pressure area care.
Resident Left Unsupervised and Safety Protocols Breached
Penalty
Summary
The facility failed to ensure that a resident, who required supervision, did not leave the facility unsupervised. This resulted in the resident leaving the facility, boarding a bus, and ending up over 35 miles away, unable to return without assistance from emergency services. The resident, who had a history of acute respiratory failure, asthma, and other health issues, was found to have left the facility without the necessary supervision and without the required oxygen supply. The resident's medical records indicated that they should have been accompanied when leaving the facility, but this order was not followed. The incident was identified as an immediate jeopardy situation, beginning when an LPN gave the resident a pass without ensuring supervision. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan and physician orders. The resident's social service assessment noted periods of forgetfulness and anxiety, which further emphasized the need for supervision. Despite these documented needs, the resident was allowed to leave the facility alone, leading to a situation where they became disoriented and required emergency assistance. Additionally, the facility failed to maintain a safe environment by leaving medication and sharp objects accessible to residents. Medications were left unattended on a bedside table, and a disposable razor was found in a resident's room, contrary to facility policy. An unlocked treatment cart was also observed, posing a potential hazard to residents. These oversights indicate a failure to adhere to established safety protocols, increasing the risk of accidental harm to residents.
Deficiency in Resident Grooming Care
Penalty
Summary
The facility failed to provide adequate grooming care, specifically shaving and nail care, to five residents who depend on staff assistance for their Activities of Daily Living (ADL). Residents R86 and R102 were observed with ungroomed facial hair, and both expressed that they had to request shaving services from the staff. R86, a cognitively intact resident with a history of hemiplegia and other health issues, had not been shaved since June 30th despite needing assistance. Similarly, R102, who is alert and oriented, also reported having to ask for shaving, which was only done if staff had time. Additionally, residents R10, R65, and R99 were observed with long, unkempt fingernails, some with substances underneath. R10, who is cognitively intact and has multiple health conditions, stated that despite requesting nail care, it was not provided. R65 was observed with long nails and unkempt facial hair, and it was noted that the resident might have been digging in their diaper, leading to dirty nails. R99, who also has a BIMS score indicating cognitive intactness, reported having to repeatedly ask for nail trimming, which was not done over several days of observation. The facility's policies and care plans indicate that grooming tasks such as shaving and nail care should be performed on shower days and as needed. However, the observations and resident reports suggest that these tasks were not consistently carried out, affecting the dignity and personal hygiene of the residents. Staff members, including LPNs and the Director of Nursing, acknowledged the importance of these grooming tasks but did not ensure they were completed as required.
Deficiencies in Pressure Ulcer Prevention and Mattress Management
Penalty
Summary
The facility failed to ensure that residents' low air loss (LAL) mattresses were set to the correct weight and functioning properly, and that heel boots were used as required for pressure ulcer prevention. Specifically, three residents had incorrect weight settings on their LAL mattresses, and two residents had malfunctioning mattresses. Additionally, one resident was observed without heel boots, despite a posted sign indicating their necessity. Resident 84 was observed multiple times with a malfunctioning LAL mattress, as indicated by a low pressure alarm that sounded intermittently. Despite being repositioned, the alarm continued to activate, suggesting a persistent issue with the mattress. The resident, who has a history of severe cognitive impairment and multiple medical conditions, including an unstageable pressure ulcer, was also found without heel boots, which are essential for pressure relief and skin protection. Residents 65 and 103 were found with LAL mattresses set to incorrect weight settings, which could compromise the effectiveness of pressure relief. Resident 65's mattress was set to 180 lbs, while their actual weight was 109 lbs, and Resident 103's mattress was set to 340 lbs, despite their weight being 186.2 lbs. Resident 105's mattress was also set incorrectly and was alarming with an error code, indicating a potential malfunction. These discrepancies highlight a lack of staff training and awareness regarding the proper use and maintenance of pressure-relieving devices.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as observed in several instances involving both resident care and food service. A Licensed Practical Nurse (LPN) was seen handling wound care supplies without sanitizing hands and using unclean scissors from their pocket to cut wound dressings, which were then placed on a resident's dresser without sanitizing the surface. This practice was observed during the care of a resident with multiple drug-resistant organism (MDRO) infections, including Candida Auris and Carbapenem-Resistant Acinetobacter Baumannii (CRAB), who required Enhanced Barrier Precautions (EBP). Additionally, a Certified Nursing Assistant (CNA) was observed performing activities of daily living (ADL) care for residents without donning the required personal protective equipment (PPE), such as gowns, despite the presence of EBP signs indicating the need for such precautions. This included care for residents with chronic wounds and indwelling medical devices, which necessitate the use of gowns and gloves to prevent cross-contamination. The CNA's misunderstanding of the EBP requirements was evident, as they incorrectly believed that gowns were only necessary if the resident had an active infection. In the dining area, a Dietary Aide was observed plating meals without performing hand hygiene, despite handling a steam table cart and serving food to residents. The aide admitted to not washing hands due to a broken sink, which was marked as out of order. This lack of hand hygiene before food handling poses a risk of cross-contamination and the spread of germs to residents. The facility's policies on hand hygiene and sanitation were not adhered to, contributing to the deficient practices observed during the survey.
Deficient Call Light Systems in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light systems were operating in good working condition, affecting five residents. Resident R143 reported that their call light was not functioning, causing anxiety and necessitating the use of a personal cell phone to call for assistance. The surveyor observed that the call light system in R143's room was not activated when the string was pulled, and the Registered Nurse confirmed the malfunction. No alternative device was provided to R143 to signal for help while the call light was in disrepair. Residents R61, R114, and R31 also experienced issues with their call light system. R61 stated that staff did not respond when the call string was pulled, and the surveyor observed that the light outside their room did not illuminate when activated. The Licensed Practical Nurse confirmed the issue and acknowledged that staff might miss the call light, leading to a lack of assistance for the residents. No alternative call system was provided to these residents. Resident R67 was observed with a call light string that was not connected to the switch, rendering the system inoperative. The Certified Nursing Assistant confirmed the disconnection and noted that other call lights on the unit were also not working. No alternative call system was provided to R67. The Director of Nursing affirmed that all residents should have a working call light and that bells should be provided when call lights are not functioning.
Inaccessible Call Light in Shower Room
Penalty
Summary
The facility failed to ensure that the call light was accessible and within reach in the 4th floor shower room, potentially affecting all 70 residents residing on that floor. A resident, identified as R21, who has multiple sclerosis, paraplegia, diabetes mellitus type II, hypertension, and anxiety disorder, reported being left in the shower unable to reach the call light. R21, who is cognitively intact with a BIMS score of 15, had to use a personal phone to call a family member for assistance after being left alone for an hour. The call light was located four feet away from the shower, without a string attached, making it inaccessible for residents who cannot stand or walk to reach it. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), confirmed that the call light should have been within reach and that residents unable to reach it should not be left alone. The Building Manager noted that the call light string was previously closer to the shower but was moved due to residents getting tangled. Facility policies and job descriptions emphasize the importance of keeping call lights within easy reach and ensuring residents' safety and satisfaction, which were not adhered to in this instance.
Failure to Timely Complete PASRR for Resident with Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure a timely Preadmission Screening and Resident Review (PASRR) for a resident with a change in psychiatric diagnosis. The resident, identified as R61, had a documented history of chronic obstructive pulmonary disease, heart failure, schizoaffective disorder, unspecified mood disorder, and major depressive disorder. Despite the onset of schizoaffective disorder being recorded on 3/22/2023, a Level I PASRR was not completed until 7/9/2024, over a year later. This delay was noted during a record review, and the Social Services Consultant, V38, could not provide a rationale for the delay. The facility's policy requires PASRR screenings prior to admission and upon changes in status, which was not adhered to in this case.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide daily activity programming and activity programming as identified on the residents' care plans, affecting three residents in a sample of 62. Resident 11, with severe cognitive impairment and multiple diagnoses including encephalopathy and dementia, was observed without the appropriate activity programming as outlined in their care plan. The care plan specified preferences for television, jazz music, and spiritual programs, none of which were provided. The activity calendar in Resident 11's room was outdated, and no records of one-on-one activity participation for July 2024 were available. The Activity Director acknowledged the lack of updated calendars and stated that the facility did not have a policy for activities. Residents 40 and 99, both with a Brief Interview of Mental Status score of 15, also reported a lack of activities. Resident 40, with diagnoses including end-stage renal dialysis and COPD, expressed frustration over the absence of activities and the lack of communication regarding the activity schedule. Resident 99, with a history of hemiplegia and heart disease, reported that no activities had been provided for several months, including their preferred activity, bingo. Observations confirmed the absence of activities on the second floor during the surveyor's visits, and documentation showed no one-on-one activities for Residents 40 and 99 in June and July 2024.
Failure to Apply Adaptive Devices for Resident with Hand Contractures
Penalty
Summary
The facility failed to ensure that an adaptive device, specifically a splint or hand roll, was in place for a resident with bilateral hand contractures. This deficiency was observed during a survey when the resident was found in bed without the necessary splints or hand rolls on two separate occasions. The resident, who was not alert and unable to communicate, has a medical history that includes anoxic brain damage, dystonia, myoclonus, dysphagia, retention of urine, klebsiella pneumoniae, and encephalopathy. The resident's physician order sheet indicated that hand rolls should be applied daily in the morning and removed in the evening, and the care plan required the use of splints due to decreased joint mobility. The Restorative Aide, responsible for applying the splints, was not present on the first day of observation, and upon returning, was unable to locate the resident's splints. The Director of Nursing suggested that the splints might have caused the resident pain, indicating a preference for hand rolls. The facility's policies and job descriptions for restorative care staff emphasize the importance of following physician orders and ensuring adaptive devices are used to prevent further contractures. However, the lack of adherence to these protocols resulted in the resident not receiving the necessary care to maintain or improve their range of motion.
Failure to Provide Correct Diet and Supplements
Penalty
Summary
The facility failed to provide a resident with the correct liquid consistency and nutritional supplement as per the resident's diet order. During observations, it was noted that the resident, who had a mechanically altered diet order, was served thin lemonade instead of the prescribed nectar thick liquids. Additionally, the resident's lunch meal tray was missing the nutritional supplement ice cream, which was part of the standing order for lunch. The resident in question, identified as R69, has a medical history that includes hemiplegia, dysphagia, and other conditions following a cerebral infarction. The resident's diet order specified pureed texture and nectar thick liquids, with a daily nutritional supplement ice cream at lunch. Despite these orders being documented on the meal ticket, the dietary staff failed to adhere to them, resulting in the resident receiving inappropriate meal components. Interviews with facility staff, including the Dietary Supervisor and Director of Nursing, revealed a breakdown in the process of meal preparation and delivery. The dietary aides were responsible for reading the meal tickets and ensuring the correct items were placed on the trays. However, the presence of thin liquids and the absence of the nutritional supplement ice cream indicated a failure in following the established procedures, potentially compromising the resident's safety and nutritional needs.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in oxygen therapy and tracheostomy management. For one resident, the oxygen tubing was not properly dated, and the humidifier bottle was found empty, which the resident reported had been the case for several days. This resident, who was cognitively intact, expressed discomfort due to the dryness caused by the empty humidifier. The facility's policy required the humidifier bottle to be checked every shift and changed weekly or as needed, but this was not adhered to, as confirmed by the LPN and DON. Another resident with a tracheostomy was observed with a nebulizer extender port left open when not in use, which could potentially disrupt the direct flow of oxygen and humidity. The Respiratory Therapy Manager explained that the port should be closed after nebulizer treatments to ensure proper oxygen delivery. This resident had a history of severe cognitive impairment and required continuous oxygen therapy and tracheostomy care, highlighting the importance of proper equipment management. A third resident, also with a tracheostomy connected to a ventilator, did not have a backup tracheostomy apparatus readily available at the bedside. The Respiratory Therapy Manager was unable to locate the backup apparatus initially and had difficulty identifying the correct tracheostomy size. The facility's standard of care required a backup tracheostomy to be kept at the bedside for emergency situations, but this protocol was not followed, posing a risk to the resident's safety in case of accidental decannulation.
Medication Labeling and Disposal Deficiency
Penalty
Summary
The facility failed to properly label and discard medications for two residents, leading to a deficiency. During an observation, a surveyor noted that a canister of Fluticasone 50mcg for one resident lacked an open or use-by date. Additionally, another resident's Albuterol inhaler, ordered nearly a year prior, had a worn label with no open or use-by date. A Licensed Practical Nurse (LPN) confirmed that such medications should be labeled with the date they were opened and their expiration or use-by date. The Director of Nursing (DON) stated that expired medications and those with worn labels should be discarded due to potential contamination and reduced effectiveness. The facility's policy, dated January 2022, mandates that medications be stored and labeled according to legal requirements, and any damaged, soiled, contaminated, or outdated medication containers should be immediately removed and disposed of according to procedure.
Failure to Monitor Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to provide a thermometer for a resident's personal refrigerator, which affected one resident in a sample of 62. The resident, who is cognitively intact with a BIMS score of 15, has multiple diagnoses including cardiomegaly, hypertensive heart disease with heart failure, atrial fibrillation, iron deficiency, and constipation. During an observation, it was noted that the resident's refrigerator was missing a temperature log sheet, and the resident mentioned that housekeeping staff checks the refrigerator twice a week. There was confusion among the staff regarding the responsibility for monitoring and logging the temperatures of residents' personal refrigerators. The Housekeeping Supervisor stated that their department is only responsible for cleaning the refrigerators, while the Dietary Supervisor was unaware of who should be responsible for logging the temperatures. The facility's Administrator clarified that it is the housekeeping department's responsibility to log and check the temperatures daily. The facility's policy requires designated staff to inspect resident refrigerators for outdated foods and monitor temperatures to reduce the risk of foodborne illness.
Failure to Obtain Guardianship for Cognitively Impaired Resident
Penalty
Summary
The facility failed to obtain guardianship for a resident, identified as R4, who was unable to make decisions due to severe cognitive impairment and a persistent vegetative state. R4 was admitted to the facility with multiple diagnoses, including dependence on supplemental oxygen, tracheostomy, dysphagia, and chronic respiratory failure with hypoxia. The resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills, and the care plan noted R4's inability to make decisions. Despite this, the facility did not secure a guardian for R4, leaving the resident without a representative to consent to services. The deficiency was highlighted when R4 was transferred to a hospital for a possible head edema, and it was discovered that no family or representative was notified of the hospitalization. Interviews with facility staff, including a Licensed Practical Nurse (LPN), Social Service Director, and Assistant Director of Nursing, revealed that R4 had no family or friends listed as contacts and was listed as his own representative. The staff acknowledged that a guardian should have been appointed given R4's condition and lack of decision-making capacity. The facility's failure to initiate guardianship proceedings was further confirmed by the Psychosocial Coordinator, who stated that the hospital had to initiate the guardianship process. The facility's policies and job descriptions indicated that the Social Service Director was responsible for pursuing guardianship when necessary, but this was not done for R4. The lack of a guardian for R4 meant that medical decisions were being made by the medical director without a legal representative, which was against the resident's rights as outlined in the facility's policies and state regulations.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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