Allure Of Pinecrest
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Morris, Illinois.
- Location
- 414 South Wesley Avenue, Mount Morris, Illinois 61054
- CMS Provider Number
- 145024
- Inspections on file
- 31
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Allure Of Pinecrest during CMS and state inspections, most recent first.
A resident with a history of major CVA and g-tube dependence was hospitalized after the DON, lacking documented certification or competency and without consulting the physician, replaced a 16 Fr g-tube with a 20 Fr urinary catheter at the request of the family. The DON stated this procedure was not normally done at the facility, there was no facility policy for changing g-tubes, and her experience came only from prior hands-on training without documentation. Following the change, the resident experienced g-tube leakage, fever, and vomiting; hospital evaluation found the urinary catheter had migrated into the proximal jejunum, causing partial bowel obstruction and substantial leakage, with imaging and labs confirming malposition and pancreatitis. The facility’s feeding tube policy required use of tubes intended for enteral feeding and specified conditions, settings, and personnel for tube replacement.
A resident with dysphagia and a history of major CVA required enteral feeding via a g-tube that was temporarily replaced in the hospital with a Foley catheter used as a feeding tube, with instructions to monitor external markings and secure the tube. After readmission, the DON, without physician consultation or facility policy guidance, replaced the 16 Fr catheter with a 20 Fr catheter, did not measure or mark the external length, and relied only on aspirating gastric contents to verify placement. Multiple LPNs reported no training on urinary catheters used as g-tubes, checked placement only by aspiration or auscultation, and did not use external measurements or anchoring devices; one LPN observed the tube flush against the abdomen with formula leaking over the resident and bed. Facility policies referenced feeding tubes, including coude urinary catheters, but did not define how to verify location or when and by whom such tubes could be replaced, and the care plan was not updated with specific interventions for the temporary catheter g-tube. The resident was ultimately sent to the hospital for a leaking g-tube and was found to have the urinary catheter g-tube migrated into the jejunum, causing partial small bowel obstruction, substantial leakage, and pancreatitis.
A resident who was nonverbal, incontinent, and dependent on staff for all care was subjected to verbal abuse when an LPN, assisting a CNA with incontinence care, used profanity and disparaging remarks within the resident’s hearing, including comments about the situation "getting old" and comparing the resident to a child. The CNA reported feeling the language was inappropriate, and the Social Service Director and Administrator were informed. The LPN admitted to using curse words during care and acknowledged that such comments were not appropriate to say in front of the resident, contrary to the facility’s abuse policy defining verbal abuse as disparaging or derogatory communication within a resident’s hearing.
A CNA reported that an LPN used profanity and made demeaning remarks toward a resident while providing incontinence care in the presence of the resident’s family member. The Administrator was informed of the incident by another staff member and confirmed with the resident’s son that the LPN’s behavior was inappropriate. Despite this, the Administrator treated the matter only as a grievance and did not report the allegation to the state agency as required by the facility’s abuse, neglect, and exploitation policy, which mandates timely reporting of all alleged violations.
A CNA reported that an LPN made loud, inappropriate, and profane comments to a resident during incontinence care while the resident’s son was present in the room. The Administrator was informed by the Social Service Director that the LPN had used curse words and spoken inappropriately, and the son confirmed the inappropriate behavior and requested staff education. Instead of initiating an abuse investigation as required by the facility’s Abuse, Neglect, and Exploitation Policy, the Administrator treated the matter as a grievance and completed a grievance form, and no abuse investigation was conducted.
The facility failed to ensure that elopement interventions were properly implemented for three residents assessed as at risk for elopement and did not have the elopement alert system active on resident wing exit doors. One resident with dementia and a history of falls left the building through a wing door in the early morning, after the delayed egress alarm sounded and the door opened, and was found outside in the dark on a sloped sidewalk without a walker, wearing non-skidless socks and clothing not appropriate for the cold temperature, and without an elopement alert bracelet on her body. Two additional residents on a non-secured unit, both with documented elopement risk and one with prior behavior of going to the front door and wanting to leave, had their elopement alert bracelets attached to their wheelchairs instead of being worn, after one resident cut off the band and the other complained it was bothersome.
A cognitively impaired resident with vascular dementia, severe cognitive impairment, and documented wandering and exit-seeking behaviors was able to leave the building unsupervised. The resident, who wore a wanderguard and was known to wander persistently to multiple doors and resist redirection, exited through a unit door whose alarm was later found disengaged and not sounding. Staff working nearby reported hearing no alarm, despite describing the alarms as typically loud, and the resident was only discovered outside when an activity aide arriving early for her shift heard tapping on a window and brought the resident back inside. This occurred despite facility policies requiring functional door locks/alarms, vigilant response to alarms, and adequate supervision for residents at risk of elopement.
A resident with a PEG tube for dysphagia had the tube dislodged and was sent to the ED, but the facility failed to document the incident, the resident’s departure, or related clinical details in the medical record. A CNA reported finding the tube on the floor, obtaining normal VS, and preparing the resident for transport after notifying an RN. The RN reported managing multiple emergencies and acknowledged that documentation may not have been completed. Staff interviews indicated that an order for transfer, progress notes, and documentation of physician and family notification should have been present, in contrast to facility policy requiring complete, accurate, and timely documentation of resident care and events.
A resident with a history of atrial fibrillation and a stage four pressure ulcer had a critically high INR while on warfarin therapy. The facility did not notify the wound care provider of this abnormal lab result before wound debridement was performed, resulting in significant bleeding that required cauterization. Staff interviews confirmed that the wound care team was unaware of the lab value prior to the procedure, contrary to facility policy requiring notification of changes affecting treatment.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
Staff failed to prepare pureed pork to a pudding-like consistency for several residents on pureed diets, resulting in a product that was lumpy, stringy, and required chewing. Both the cook and Food Service Director acknowledged the texture was not appropriate and did not meet the facility's policy for pureed foods.
The facility did not provide required Advance Beneficiary Notice (ABN) forms to three residents whose Medicare Part A coverage ended, even though they were given Notice of Medicare Non-Coverage (NOMNC) forms and transitioned to private pay or personal insurance. Staff interviews revealed a lack of awareness and implementation of the ABN process, despite facility policy requiring its use.
A dependent resident with multiple diagnoses was found with a saturated incontinence brief and pad, and staff could not confirm when incontinence care was last provided. The resident, who relies on staff for toileting and hygiene, did not refuse care. Facility policy and staff interviews indicated that incontinence care should be performed at least every two hours and that pads should not be used with briefs, but these standards were not followed.
The facility did not follow physician orders for two residents: one did not have a prescribed anticoagulant held prior to scheduled surgery despite pre-op instructions being faxed and received, resulting in surgery rescheduling; another with spinal fractures was observed multiple times out of bed without the ordered back brace, despite staff awareness of the order.
Two residents at risk for falls were not safely transferred according to facility policy. One was moved without a gait belt by a CNA, while another, unable to bear weight, was lifted by two CNAs using improper techniques and without required alarms in place. Both cases involved residents with documented fall risks and prior incidents, and staff interviews confirmed that proper procedures were not followed.
Two residents with dementia did not consistently receive individualized, non-pharmacological interventions as outlined in their care plans and the facility's dementia care policy. Staff were observed physically guiding residents who were resistive to care, rather than using recommended approaches such as providing choices, involving them in activities, or allowing time for response.
A resident with multiple cognitive and psychiatric diagnoses was prescribed quetiapine and furosemide, and the pharmacist recommended a CMP lab be completed and repeated every six months. Although the provider signed off on the recommendation, the lab order was not entered or completed as required, and the omission was not addressed until the following month, contrary to facility policy.
A deficiency was found when a blue pill bottle in the memory care unit medication cart had a legible resident name but an illegible medication name and dispensed date. An LPN could not identify the medication, and the ADON confirmed that labels must be legible and replaced if not. Facility policy requires all medication labels to be clear and replaced by the pharmacy if they become illegible.
Staff did not wear gowns, as required, while providing incontinence care to a resident on enhanced barrier precautions due to a feeding tube. Although gloves were used, both CNAs also touched the resident's tube feeding equipment without full PPE, contrary to facility policy and posted instructions.
A wound care nurse failed to wear a gown while providing care to two residents on enhanced barrier precautions, despite the facility's policy requiring both gloves and gowns for wound care. One resident had skin cancer on the left ear, and the other had a wound on the right great toe. The infection control preventionist confirmed the requirement for gowns during such care.
The facility failed to monitor weights and complete lab work for two residents with CHF, leading to one resident's readmission to the hospital due to fluid overload. Despite physician orders, weights and labs were not conducted as required, impeding effective management of the residents' conditions.
The facility failed to maintain resident dignity, as evidenced by a CNA's rude behavior towards two residents, leading one to avoid seeking assistance. Additionally, staff were observed using cell phones during work hours, contrary to facility policy. The ADON acknowledged multiple complaints about the CNA's attitude, and the administrator confirmed the prohibition of cell phone use by staff.
A resident with moderate cognitive impairment reported feeling scared and disrespected when a CNA forcibly removed a blanket from her lap and insisted she go to the dining room despite being in her pajamas. Staff interviews corroborated the resident's account, revealing the CNA's history of rude behavior. The CNA was suspended and later terminated her own employment.
A resident with multiple health conditions, including Parkinson's Disease, recurrent pneumonia, and dementia, was admitted with a comfort-focused treatment plan. Despite signs of distress such as clamminess, increased respirations, and elevated vital signs, the night shift nurse and nurse practitioner chose to keep the resident comfortable on-site per the power of attorney's wishes. Throughout the day, the resident exhibited symptoms like coughing, low oxygen levels, and difficulty obtaining vital signs. The nurse practitioner did not provide clear orders for oxygen or manual blood pressure monitoring. The resident's condition deteriorated, leading to a critical incident where the resident was found unresponsive and subsequently passed away. The lack of timely and appropriate interventions and inadequate monitoring contributed to the outcome.
A resident experienced an 11.41% weight loss over six months due to the facility's failure to provide prescribed nutritional supplements. Despite orders for a health shake and pudding, the resident did not receive these items during a meal observation. The dietary staff admitted to not providing the supplements, contributing to the resident's significant weight loss.
The facility failed to ensure that PRN psychotropic medications had a specified duration for five residents. Physician orders for these residents did not contain a stop date or duration for the medications prescribed. The Director of Nursing confirmed that PRN psychotropic medications should have a duration or stop date, as per the facility's policy.
The facility failed to assess and implement interventions for a resident's known contracture in her left hand. Despite the resident's history of stroke and functional limitations, there was no documentation or updated care plan addressing her condition. Staff interviews revealed a lack of awareness and documentation, and the facility's policy on preventing decline in range of motion was not followed.
A resident experienced multiple unsafe transfers with a sit-to-stand lift, resulting in being lowered to the floor. Staff failed to use two-person assistance and did not apply necessary safety straps, despite the resident's known difficulties with standing during transfers.
A facility failed to ensure a resident's head remained elevated above 30 degrees while a tube feeding was infusing. The resident, who had dysphagia and a gastrostomy, was observed with their head of bed lowered below 30 degrees during incontinence care, contrary to their care plan and facility policy. The tube feeding was not paused, increasing the risk of complications.
The facility failed to ensure staff wore isolation gowns when providing high contact care to a resident on enhanced barrier precautions. Despite a sign indicating the need for gloves and gowns, two CNAs did not wear isolation gowns while providing incontinence care to a resident with a gastrostomy. The DON confirmed that high contact care activities require the use of gloves and gowns, as per the facility's Enhanced Barrier Precautions policy.
Unqualified G-tube Replacement with Urinary Catheter Leading to Complications
Penalty
Summary
The facility failed to ensure that care was provided by qualified staff according to a resident's written plan of care when the DON replaced a gastrostomy tube (g-tube) without documented training, competency, or adherence to facility policy. The DON reported that a nurse approached her stating the family wanted the g-tube changed, and she proceeded with the change as a "routine procedure" under what she described as a standing order, without contacting the resident's physician. She replaced the resident's existing 16 French g-tube with a 20 French urinary catheter, stating the stoma had stretched and that the larger size would make feeding easier. The DON acknowledged that changing g-tubes was not normally done at this facility, that there was no facility policy or procedure for changing g-tubes, and that she had no certification for this procedure, only hands-on training from a previous employer, which could not provide any documentation of competencies. The resident had a history of a major cerebrovascular accident with right-sided hemiparesis and aphasia and was admitted to the hospital from the facility for a leaking g-tube, fever, and an episode of vomiting. The resident’s son, who is the power of attorney, reported that the facility had changed the g-tube and placed a 20 French urinary catheter, and that it had been leaking since that time. Hospital evaluation found the g-tube displaced into the proximal jejunum, with labs showing an elevated lipase consistent with pancreatitis and a CT scan confirming the tube’s position. A procedure note documented that the balloon of the old g-tube (a urinary catheter placed through the gastrostomy stoma) was deflated and that the catheter had migrated into the jejunum, with only the tip visible at the skin site, causing partial bowel obstruction and substantial leakage from the stoma. The facility’s written policy on feeding tubes specified that only tubes designed for enteral feeding would be used except under extenuating circumstances and for the shortest time possible, and that directions would be provided regarding when and by whom tubes could be replaced, including when replacement must occur in another setting.
Improper Management of Temporary Urinary Catheter G-Tube Leading to Malposition and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to properly monitor and manage a temporary urinary catheter used as a gastrostomy tube (g-tube), lack of clear policies and procedures for this type of device, and inadequate staff training and competency, which led to a resident’s hospitalization. The resident had a history of major cerebrovascular accident with right-sided hemiparesis and aphasia and required tube feeding for dysphagia. After the resident’s original surgically placed g-tube was pulled out, the hospital replaced it with a 16 French coude Foley catheter to be used as a temporary feeding tube and provided written instructions to check the external guide mark at the skin, ensure it did not change, and secure the tube with tape or an anchoring device. The hospital also instructed that the resident follow up with surgery within 1–2 weeks for placement of a longer-term g-tube. Upon return to the facility, the DON later replaced the 16 French urinary catheter g-tube with a 20 French urinary catheter at the request of the resident’s family, without contacting the physician and without any facility policy or procedure governing such a replacement. The DON stated she relied on experience from a previous employer, had no certification, and did not mark or measure the external length of the tube at the skin level, only recalling that approximately 12 inches of tubing extended from the abdomen. She reported that staff checked tube placement by aspirating gastric contents before medications, flushes, or feedings, but did not monitor tube placement by checking external markings or measurements. The facility’s physician orders directed staff to check tube placement before formula, medications, and flushing, but did not include orders to check external tube measurements. The facility’s feeding tube policies referenced use of coude urinary catheters under extenuating circumstances and stated that licensed nurses would monitor that the tube was in the right location and that the enteral retention device would be checked daily, but did not define how to verify correct location or specify conditions and personnel for tube replacement in this situation. Multiple nurses, including LPNs, reported they had no education or training on urinary catheters used as g-tubes and described checking placement only by aspirating gastric contents or listening to the stomach, with no knowledge of how to determine if the tube had migrated in or out. One LPN stated that the day the resident was sent to the hospital, it was the first time she had seen a urinary catheter used as a g-tube, she had received no education, and she observed the catheter flush against the resident’s stomach with tube feeding leaking over the abdomen and bed, and no tape or anchoring device in place. Progress notes documented continuous leaking from the g-tube with most of the feeding coming out around the stoma, unsuccessful attempts to control leakage by adding fluid to the balloon, and subsequent transfer to the emergency room. Hospital records showed that the urinary catheter used as a g-tube had migrated into the proximal jejunum, with only the tip visible at the skin, causing partial small bowel obstruction, substantial leakage from the stoma, and pancreatitis. The resident’s care plan noted tube feeding for dysphagia and an emergency room transfer for g-tube malfunction but was not updated with specific interventions for the urinary catheter g-tube. The facility administrator and DON confirmed there were no specific policies or staff in-services on urinary catheter g-tubes or their replacement, and the physician stated that nurses should monitor external g-tube placement and that such tube changes are typically done in the emergency room by a physician.
Verbal Abuse Toward Dependent, Nonverbal Resident During Incontinence Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a nurse used disparaging and profane language within the resident’s hearing during incontinence care. The resident was described by staff as alert to self only, nonverbal, incontinent of bowel and bladder, dependent on staff for all care, and frequently crying out. On the day of the incident, the resident’s son was present in the room, seated in a corner, when a CNA requested assistance from an LPN to change the resident, who had been incontinent of stool. Upon entering the room, the LPN made statements including, according to the CNA, “this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked,” directed toward the resident. The CNA reported feeling the LPN’s comments were inappropriate and not the way she would speak even to her own child, and stated it was not appropriate to talk to residents in that manner. The Social Service Director reported that the CNA came to her and relayed that the LPN had said something about leaving the resident naked and used profanity while providing care, which made her uncomfortable. The Administrator stated she was informed that the LPN had been inappropriate and used curse words while caring for the resident and confirmed that the resident’s son also reported the LPN’s behavior as inappropriate. The LPN acknowledged using curse words during care, recalling saying “what the h*ll did you do now” after finding that the resident had torn up her incontinence brief and spread it around the room, and admitted that what she said was not right to say in front of the resident. The facility’s Abuse, Neglect, and Exploitation policy defines verbal abuse as oral, written, or gestured communication that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability, which was not followed in this incident.
Failure to Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the state agency as required by its Abuse, Neglect, and Exploitation Policy. During an interview on 4/9/26 at 2:16 PM, a CNA (V6) stated that she requested assistance from an LPN (V7) to change Resident 1 (R1), who was incontinent of stool. V6 reported that when they entered R1’s room, V7, apparently unaware that R1’s son (V13) was present in the corner of the room, spoke loudly and inappropriately to R1, saying, “this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked.” V6 stated that V7’s comments were inappropriate, that she would not speak that way to her own child, and that it was not appropriate to talk to residents in that manner. V6 also indicated she spoke to someone about the incident that same day, though she was unsure who. In a subsequent interview on 4/9/26 at 2:52 PM, the Administrator (V1) reported that another staff member (V8) had informed her that V7 was inappropriate and used curse words while providing care to R1. V1 stated she then spoke with R1’s son, who confirmed that V7 had been inappropriate and asked that the nurses be educated. V1 acknowledged that, based on her perception that R1’s son did not seem very concerned, she treated the matter as a grievance and did not report the allegation to the state agency. This action was inconsistent with the facility’s written Abuse, Neglect, and Exploitation Policy dated 2025, which requires reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediate but no later than 2 hours for allegations involving abuse, and no later than 24 hours for other events that do not involve abuse or serious bodily injury.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident. A CNA (V6) reported that she and an LPN (V7) entered the resident’s room together to provide incontinence care after the resident had been incontinent of stool. V6 stated that V7, unaware that the resident’s son (V13) was in the room, spoke loudly and said, “this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked.” V6 described these comments as inappropriate and stated that she would not say such things to her own child, and that it was not appropriate to talk to residents that way. V6 reported that she spoke to someone about the incident that same day but could not recall to whom she reported it. The Administrator (V1) stated that the Social Service Director (V8) reported to her that V7 had been inappropriate and used curse words while providing care to the resident. V1 then spoke with the resident’s son (V13), who told her that V7 was inappropriate and asked that the nurses be educated. V1 stated that because V13 did not seem very concerned, she completed a grievance form instead of initiating an abuse investigation. The grievance form documented that V8 spoke with the family member about a comment made to the resident, “oh you wet yourself again,” and that the family member viewed it as an inappropriate comment. Despite the facility’s Abuse, Neglect, and Exploitation Policy requiring an immediate investigation when there is suspicion or reports of abuse, including identifying and interviewing all involved persons, no abuse investigation was conducted in response to this allegation of verbal abuse.
Failure to Implement Elopement Interventions and Alert Systems for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that assessed elopement interventions were in place for three residents identified as at risk for elopement and to ensure that the elopement alert system was implemented at exit doors in resident areas. One resident with dementia, repeated falls, bipolar disorder, and identified as at risk for elopement and falls, exited through a resident wing door in the early morning hours. Staff reported last seeing this resident asleep in bed shortly before the incident. The resident’s elopement alert bracelet, which had been ordered as an intervention following an earlier elopement in the facility, was not on the resident’s body but was instead on the resident’s walker in the room. When the resident pushed on the wing 3 exit door, the door alarm sounded and then opened after 15 seconds, allowing the resident to leave the building. Staff interviews and observations showed that the resident was found outside in the dark on a sloped sidewalk approximately 50 feet from the wing 3 door, without a walker, wearing non-skidless socks and clothing that was not temperature appropriate for the 44-degree Fahrenheit weather. The resident appeared confused, asked where her room was, and stated it was dark outside. Nursing staff described the resident as sometimes confused and noted that on the day of the incident the resident was particularly confused due to a urinary tract infection. The elopement alert bracelet, which is normally placed on the ankle, had been placed on the resident’s wrist because it was too tight on the ankle, but at the time of the incident it was not on the resident at all. The facility’s elopement alert system was only active on the front door and solarium doors, not on the resident wing exit doors, which only had delayed egress alarms that allowed doors to open after being pushed. Additional deficiencies were identified for two other residents on the facility’s elopement risk list who resided on a non-secured unit. Both residents had documented elopement risk assessments and care plans indicating risk for elopement, including attempting to leave the facility without a responsible escort and impaired safety awareness. However, their elopement alert bracelets were observed attached to the handles of their wheelchairs rather than on their bodies. One resident had a history of going to the front door and wanting to leave, and the other had talked about leaving and had previously cut off her elopement alert band from her leg. Staff reported that the bracelets were moved to the wheelchairs because one resident complained the bracelet bothered her and the other had removed it, resulting in elopement devices not being worn as intended for residents assessed as at risk for elopement.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from leaving the building unsupervised despite known elopement risk and wandering behaviors. The resident had vascular dementia with behavioral disturbance, severe cognitive impairment, and a documented history of restlessness, pacing, intrusive behavior in peers’ rooms, calling out for parents, and repeated attempts to exit the facility. An elopement/wandering assessment identified behaviors such as attempting to leave without a responsible escort, pacing and roaming, and becoming agitated while looking for family, with a plan to use a wanderguard device. Nursing notes prior to the incident documented that the resident had been combative, agitated, exit seeking, going into other rooms, and difficult to redirect, with frequent checks maintained. On the day of the elopement, the resident, who was identified as an elopement risk, exited the facility through door #4 without staff knowledge. The door alarm did activate, but staff did not hear it due to environmental noise at the nurses’ station. The resident was later found outside by the door, tapping on the window to be let back in, and was brought back into the building by an activity aide who arrived early for her shift and heard the tapping. Staff interviews indicated that the resident frequently wandered, persistently went to multiple doors, twisted knobs, pushed on doors, and tried to get out, and that she did not take redirection well. Following the incident, staff interviews revealed that door #4 on the memory care unit was found disengaged and unlocked, and no one reported hearing an alarm at the time the resident exited. A CNA reported that when she checked the doors after the resident was returned, door #4 was disengaged and could be opened without the alarm sounding. Housekeepers working in nearby hallways also stated they did not hear any alarm, even though they described the alarms as typically very loud and easily heard from their work areas. Maintenance staff explained that the door system required the alarm to be engaged for it to sound when pushed, and that if it was disengaged, the door could be opened without triggering an alarm. The facility’s elopement and wandering policy stated that the facility is equipped with door locks/alarms to help avoid elopements, that alarms are not a replacement for necessary supervision, that staff must be vigilant in responding to alarms, and that adequate supervision will be provided to help prevent accidents or elopements, which did not occur in this case.
Failure to Document PEG Tube Dislodgement and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident who was dependent on a percutaneous endoscopic gastrostomy (PEG) tube for nutrition due to dysphagia and cognitive communication deficit. The resident’s face sheet and care plan documented gastrostomy status and the need for tube feeding. Emergency department records show that the resident arrived with a dislodged feeding tube and had a temporary tube placed, with an outpatient procedure planned to replace the PEG. However, the facility’s medical record contained no documentation of the PEG tube being pulled out, no description of the incident, and no indication that the resident left the facility for emergency care. Staff interviews confirmed that the event occurred and that required documentation was omitted. A CNA reported finding the resident in bed with the feeding tube on the floor, minimal blood at the site, and the resident in no apparent distress; she took vital signs, which were normal, and prepared the resident for transport to the emergency room, reporting the incident to an RN. The RN stated she was notified that the PEG tube had been removed, directed the CNA to obtain vital signs, and notified the on-call manager and physician before sending the resident to the emergency room, but acknowledged that due to multiple simultaneous emergencies it would not be surprising if nothing was documented. An LPN stated there should have been an order for hospital transfer, progress notes detailing the event, and documentation of family and physician notification. The DON stated nurses should document why and when a resident leaves, with whom, and in what condition. This lack of documentation was inconsistent with the facility’s policy requiring complete, accurate, and timely documentation of each resident’s experiences and care, to be completed no later than the end of the shift in which the care occurred.
Failure to Notify Wound Care Provider of Critical Lab Value Prior to Procedure
Penalty
Summary
The facility failed to notify the wound care provider of a resident's critically elevated INR lab value prior to performing wound care. The resident, who had a history of a stage four pressure ulcer to the left heel, atrial fibrillation, and a left hip fracture, was receiving warfarin therapy. On the day in question, the resident's INR was reported as 7.8, a value significantly above the therapeutic range, and this result was flagged in the laboratory report. Despite this, there was no documentation in the progress notes that the provider or the resident's family had been notified of the abnormal result. Subsequently, the wound care physician assessed and debrided the resident's left heel wound without knowledge of the elevated INR. During the procedure, the wound bled heavily and required cauterization and pressure bandaging. Interviews with facility staff confirmed that the wound care nurse and physician were not informed of the critical lab value prior to the procedure. The facility's policy required prompt notification of changes that may necessitate an alteration in treatment, but this was not followed in this instance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prepare Pureed Pork to Required Consistency for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed pork served to residents on pureed diets was prepared to the required pudding-like consistency. During meal preparation, the cook measured, weighed, and blended pork with broth for residents requiring pureed diets. Despite multiple attempts to blend the pork, the resulting product was observed to be lumpy and stringy, rather than smooth and pudding-like as required by the facility's policy. The cook acknowledged the difficulty in achieving the correct texture, particularly noting that pork tends to be more difficult to puree. Further observations confirmed that the pureed pork was not fully blended and required chewing, which is inconsistent with the dietary needs of residents on pureed diets. The Food Service Director also agreed that the texture was inappropriate. The facility's policy specifies that pureed foods must be ground, pressed, or strained to a soft, smooth, thick paste similar to thick pudding, which was not achieved in this instance for all residents on pureed diets reviewed.
Failure to Issue Advance Beneficiary Notices for Non-Covered Services
Penalty
Summary
The facility failed to provide required Advance Beneficiary Notice (ABN) forms to residents whose Medicare Part A coverage was ending, as observed in three cases reviewed. In each instance, the residents were given a Notice of Medicare Non-Coverage (NOMNC) form indicating the last covered day of Medicare services, but there was no documentation that the ABN form was provided. Facility records confirmed that while the NOMNC was issued, the ABN was not, even when residents transitioned to private pay or personal insurance after Medicare coverage ended. Interviews with facility staff revealed a lack of understanding and implementation regarding the ABN process. The Social Services Director and Memory Care Coordinator/Social Services were responsible for providing NOMNC forms but did not provide ABN forms, with one staff member unfamiliar with the ABN entirely. The Business Office Manager, who handled financial discussions with residents, also did not provide or document the ABN form. The facility's own policy required the use of the CMS-approved ABN form for Part A items and services, but this was not followed in the reviewed cases.
Failure to Provide Timely and Appropriate ADL Assistance for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including major depressive disorder, osteoarthritis, and Alzheimer's disease was not provided with adequate assistance for activities of daily living (ADLs) as required by her care plan. On observation, certified nursing assistants (CNAs) found the resident in bed with both an incontinence pad and an incontinence brief, both saturated with dark urine, and the resident reported being wet. The CNAs were unable to determine when the resident's incontinence brief was last changed, and one CNA stated that the resident should have been gotten up by the night shift earlier in the morning. Facility policy requires that residents unable to perform ADLs receive necessary services to maintain hygiene, and staff interviews confirmed that incontinence care should be provided at least every two hours and that an incontinence pad should not be used together with an incontinence brief. The resident's records indicated she is dependent on staff for toileting and personal hygiene and does not refuse care.
Failure to Implement Physician Orders for Pre-Surgical Medication Hold and Back Brace Use
Penalty
Summary
The facility failed to implement and follow physician orders for two residents, resulting in deficiencies in care. For one resident with dementia, Alzheimer's disease, and atrial fibrillation on anticoagulation therapy, the facility did not hold the prescribed blood-thinning medication as instructed in pre-surgical orders faxed by the resident's surgeon. The pre-op instructions, which required holding the medication for three days prior to scheduled abdominal hernia surgery, were faxed to the facility but not acted upon. The resident continued to receive the medication, leading to the surgery being rescheduled. Documentation and interviews confirmed that the facility received the faxed orders but failed to implement them in a timely manner. Another resident admitted with compression fractures of the spine had a physician order to wear a back brace when out of bed. Despite this order being present in the resident's records, observations on multiple occasions showed the resident seated in a recliner without the back brace. Staff interviews confirmed awareness of the order, but the brace was not applied as required. The facility's procedures for handling consulting physician orders were not followed, resulting in the resident not receiving the prescribed treatment.
Failure to Ensure Safe Transfer Practices and Accident Prevention
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents identified as being at risk for falls and requiring assistance. One resident, with a history of falls, decreased muscular coordination, and the use of assistive devices, was transferred by a CNA without the use of a gait belt, contrary to facility policy. The CNA lifted the resident by the waistband of her pants during transfers from a recliner to a wheelchair and from the wheelchair to the toilet. Another CNA confirmed that a gait belt should be used for all transfers involving this resident. A second resident, admitted with multiple diagnoses including osteoarthritis, osteoporosis, and Alzheimer's disease, had a history of falls and was care planned for sensor alarms and assistance with transfers. During observed transfers, two CNAs used a gait belt but lifted the resident, who was unable to bear weight, by the gait belt and then by holding under her arms and legs. The resident's bed alarm did not sound, and no wheelchair alarm was applied. Documentation showed the resident had experienced skin tears and falls during previous transfers. Staff interviews indicated that the resident was not bearing weight and should have been re-evaluated by nursing and therapy. Facility policy required safe handling and regular review of mobility needs, which was not followed in these instances.
Failure to Provide Individualized Dementia Care and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with dementia, as evidenced by the care of two residents. One resident with diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease, anxiety, major depressive disorder, and a history of falls, was observed to be resistive to care. Despite a care plan instructing staff to use a warm, safe, and inviting approach, emphasizing dignity and patience, staff were observed physically pushing the resident towards the bathroom when he was unwilling to walk, rather than allowing time or using alternative non-pharmacological interventions as outlined in the care plan. Interviews with staff indicated inconsistent application of the care plan, with some staff offering snacks or dancing to encourage movement, while others resorted to physical guidance. Another resident with dementia, anxiety, and restlessness was also observed to be resistive to care, repeatedly attempting to stand and walk. The care plan directed staff to provide choices and use individualized, non-pharmacological approaches, but staff were seen physically guiding the resident back into a chair and telling her to sit down, rather than involving her in activities or walking with her as recommended. The facility's own dementia care policy requires individualized, non-pharmacological interventions to enhance well-being, but observations and interviews revealed that staff did not consistently follow these approaches for residents displaying dementia-related behaviors.
Failure to Address Pharmacist-Identified Medication Review Irregularity
Penalty
Summary
A deficiency occurred when the facility failed to address an irregularity identified by the pharmacist during the monthly medication review for one resident. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling, was receiving quetiapine and furosemide. The pharmacist recommended a Comprehensive Metabolic Panel (CMP) be completed immediately and every six months thereafter, as documented in the Medication Regimen Review (MRR) dated March 11, 2025. Although the physician signed off on this recommendation and a nurse indicated the order was faxed to the lab, there was no evidence that the lab order was actually entered or completed in March. A subsequent MRR in April noted that the CMP lab results were still missing and the order had not been entered. The advanced practice nurse signed off to schedule the lab for the next available day, and staff documented that the order was placed for April 23, 2025. However, review of the order summary confirmed that no CMP lab draw was ordered in March, and the order was not entered until April. The facility's policy requires staff to act upon all pharmacist recommendations according to established procedures, but this was not followed in this instance.
Illegible Medication Label Found in Memory Care Unit
Penalty
Summary
A deficiency was identified when a blue bottle containing white round pills was found in the locked memory care unit medication cart, with the resident's name legible on the label but the medication name and full dispensed date illegible. The LPN present was unable to identify the medication, only stating it was believed to be a hospice medication. The Assistant Director of Nursing confirmed that medication labels should be legible and replaced if not. The facility's policy requires all medication labels to be legible at all times and replaced by the issuing pharmacy if they become illegible, soiled, incomplete, or worn. The failure to maintain a legible medication label was observed for a resident with multiple diagnoses, including heart disease, unsteadiness, convulsions, dementia, Alzheimer's disease, and anxiety disorder.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow required infection prevention protocols for a resident on enhanced barrier precautions. The resident, who had a feeding tube, was identified as needing enhanced barrier precautions, which included the use of gloves and gowns during high-contact care activities such as changing incontinence briefs. On the observed date, two certified nursing assistants entered the resident's room to provide incontinence care. Although they wore gloves, they did not wear gowns as required by the posted signage and facility policy. During the care, both staff members also touched the resident's tube feeding equipment. Interviews with the staff and the infection control nurse confirmed that gloves and gowns should be worn when providing incontinence care to residents on enhanced barrier precautions, especially those with implanted medical devices like feeding tubes. The resident's care plan and the facility's policy both specified the need for appropriate PPE during high-contact care activities to reduce the risk of transmission of multidrug-resistant organisms. The failure to wear gowns during the care activity constituted a breach of the facility's infection control program.
Failure to Use Required PPE During Wound Care
Penalty
Summary
The facility failed to ensure that staff wore the required personal protective equipment (PPE) for residents on enhanced barrier precautions. Specifically, a wound care nurse provided care to two residents without wearing a gown, which is required under the facility's infection control policy. The first resident had a diagnosis of skin cancer on the left ear, and the nurse provided wound care using gloves but no gown. The second resident had a wound on the right great toe, and again, the nurse used gloves but did not wear a gown. The facility's infection control preventionist confirmed that staff should wear both gloves and gowns when providing wound care to residents with wounds, as per the enhanced barrier precautions policy.
Failure to Monitor Weights and Labs for CHF Residents
Penalty
Summary
The facility failed to obtain necessary weights and complete lab work for residents with congestive heart failure (CHF), specifically affecting two residents, R1 and R5. R1 was discharged from the hospital with instructions to have weekly lab work and weights monitored due to CHF and chronic kidney disease. However, the facility did not document R1's weight upon admission and failed to conduct the required lab work on the specified dates. This oversight contributed to R1's readmission to the hospital with fluid overload and exacerbation of CHF. R1's condition deteriorated over several days, with increasing edema and decreased oxygen saturation levels, which were not adequately monitored due to the lack of timely lab work and weight measurements. Despite physician orders for daily weights and lab tests, these were not performed as required, impeding the physician's ability to manage R1's condition effectively. The facility's failure to adhere to physician orders and monitor R1's condition closely led to a significant decline in R1's health, resulting in emergency hospitalization. Similarly, R5, another resident with CHF, was not weighed daily as ordered by the physician. The facility's records showed multiple instances where R5's weight was not documented, indicating a pattern of non-compliance with physician orders. This lack of monitoring could potentially lead to undetected weight changes, which are critical for managing CHF. The facility's inaction in both cases highlights a deficiency in providing necessary care and services as per physician orders.
Failure to Maintain Resident Dignity and Staff Conduct Issues
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by the behavior of a Certified Nursing Assistant (CNA), identified as V12, towards two residents. One resident, R12, expressed that V12 was short with residents, leading her to avoid asking V12 for assistance, opting instead to manage on her own or wait for another staff member. Another resident, R14, reported that V12 entered her room without knocking and, when questioned about it, refused to discuss the matter and subsequently refused to assist her. Interviews with other staff members, including V16 CNA and V3 CNA, corroborated these claims, describing V12 as rude and having an attitude problem. The Assistant Director of Nursing (ADON), V2, acknowledged receiving multiple complaints about V12's attitude, highlighting that R12's reluctance to seek help from staff was a significant issue. Additionally, the facility was found to be non-compliant with its policy on maintaining resident dignity due to staff using cell phones during work hours. A CNA, V7, was observed using a cell phone at the nursing station, and a resident, R14, noted that staff frequently used their phones, which she found inappropriate. The facility's administrator, V1, confirmed that staff were not permitted to use cell phones while on duty. The facility's policy, dated December 1, 2023, emphasizes the importance of treating residents with respect and dignity, including speaking respectfully and respecting residents' living spaces and personal possessions.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner, as evidenced by an incident involving a CNA and a resident with moderate cognitive impairment. The resident, who had multiple diagnoses including Alzheimer's Disease and chronic kidney disease, reported that a CNA forcibly removed a blanket from her lap and insisted she go to the dining room despite her being in her pajamas and not feeling well. The resident felt scared and disrespected by the CNA's loud and abrasive behavior, which included a comment that the resident 'hadn't seen anything yet' in response to a request for an apology. Interviews with staff corroborated the resident's account, revealing that the CNA had a history of using an abrasive tone and being rude to both staff and residents. Another CNA who entered the room confirmed that the resident was in her nightgown and should not have been taken to the dining room. The RN on duty also reported hearing the CNA make a 'not too smart' comment in the hallway, which could have been overheard by other residents. The facility's investigation led to the immediate suspension of the CNA involved, who subsequently terminated her own employment. The facility's policy on promoting and maintaining resident dignity emphasizes treating each resident with respect and acting upon their preferences, which was not adhered to in this incident.
Failure to Monitor and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to assess and monitor a resident (R93) who experienced a change in condition, ultimately resulting in the resident's death. R93, a resident with mild intellectual disabilities, Parkinson's Disease, recurrent pneumonia history, major depressive disorder, dementia, and dysphagia, was admitted to the facility with a comfort-focused treatment plan, including instructions to transfer to the hospital only if comfort could not be achieved on-site. Despite signs of distress, including clamminess, increased respirations, and elevated vital signs, the night shift nurse and nurse practitioner opted to keep R93 comfortable at the facility rather than transfer to the hospital as per the resident's power of attorney's wishes. The failure to adequately assess and respond to R93's deteriorating condition continued throughout the day, with reports of coughing, low oxygen levels, and difficulty obtaining vital signs. Despite these concerning symptoms, the nurse practitioner did not provide clear orders for oxygen or manual blood pressure monitoring. The resident's condition worsened, leading to a critical incident where R93 was found unresponsive, with visible signs of distress, ultimately passing away in the facility. The lack of timely and appropriate interventions, including failure to follow through on physician orders and inadequate monitoring, contributed to the tragic outcome for R93.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for a resident (R64), which contributed to an 11.41% weight loss over six months. R64 was admitted with multiple diagnoses, including Alzheimer's disease, dementia, and generalized anxiety disorder. The resident had orders for a health shake three times per day and pudding with lunch. However, during an observation on May 7, 2024, R64 did not receive the prescribed health shake or pudding cup at lunchtime. The dietary staff admitted to not providing the supplements because R64 was not seated, and another resident nearby tends to grab things. R64's weight records show a significant decline from 147.2 pounds in November 2023 to 130.4 pounds in May 2024. The dietitian confirmed that the health shake and ice cream were ordered to increase R64's caloric intake due to weight loss. The facility's Weight Monitoring Policy emphasizes the importance of implementing and monitoring nutritional interventions to maintain residents' nutritional status. The failure to provide the ordered supplements directly contradicts this policy and contributed to R64's continued weight loss.
Failure to Ensure PRN Psychotropic Medications Had a Specified Duration
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had a specified duration for five residents reviewed for psychotropic medications. Specifically, the physician orders for these residents did not contain a stop date or duration for the medications prescribed. For instance, one resident had orders for Haloperidol Lactate Concentrate and Lorazepam Oral Concentrate without a stop date or duration. Another resident had an order for Lorazepam Concentrate for anxiety, also lacking a stop date or duration. Similar deficiencies were found in the orders for three other residents, all of which were missing the required duration or stop date for their PRN psychotropic medications. The Director of Nursing confirmed that PRN psychotropic medications should have a duration or stop date. The facility's policy on the use of psychotropic medications, implemented in December 2022, states that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration, typically 14 days. If an extension beyond 14 days is needed, the attending physician or prescribing practitioner must document their rationale and indicate the duration for the PRN order. However, this policy was not followed in the cases reviewed, leading to the identified deficiencies.
Failure to Assess and Implement Interventions for Contracture
Penalty
Summary
The facility failed to assess and implement interventions for a known contracture in a resident's left hand. The resident, who had a stroke affecting her left side, was observed with her left hand fingers curled into her palm. Despite the resident mentioning the use of a brace and other devices in the past, her most recent Care Plan contained no documentation of her contracture or range of motion/restorative needs. The Minimum Data Set indicated functional limitations, but there was no follow-up or updated care plan addressing these issues. Interviews with the facility staff, including the Director of Nursing, Assistant Director of Nursing, and Physical Therapy Director, revealed a lack of awareness and documentation regarding the resident's contracture. The Physical Therapy Director confirmed that the resident had not been seen by therapy since 2023, and there were no recent assessments or interventions documented. The facility's policy on the prevention of decline in range of motion was not followed, as there was no systematic approach for assessment, care planning, and preventative care for the resident's contracture.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure a resident was safely transferred with a sit-to-stand lift, resulting in multiple incidents where the resident was lowered to the floor. The first incident occurred when a CNA was transferring the resident to the toilet, and the resident began letting go of the grab bars. The CNA, who was alone and unable to reach the call light for assistance, slowly lowered the resident to the floor. The resident's nurse's notes indicated that the resident frequently bent her knees and needed constant cueing to stay standing during transfers. Despite this, the resident continued to be transferred using the sit-to-stand lift until a physical therapist recommended downgrading to a mechanical sling lift for safety reasons. A second incident occurred when another CNA was transferring the resident in the morning. The resident, who did not want to get up, let go and slid through the sling, landing on the floor because the leg strap was not applied. A Licensed Practical Nurse (LPN) who heard the CNA instructing the resident to put her feet back found the resident with one foot off the base of the lift. Despite attempts to reposition the resident, she was eventually lowered to the ground. Interviews with staff, including the Therapy Director and the Director of Nursing, confirmed that two staff members should always assist with sit-to-stand transfers for safety, and the resident should have been changed to a mechanical sling lift if having trouble with the sit-to-stand lift.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure a resident's head remained elevated above 30 degrees while a tube feeding was infusing. The resident, who had dysphagia, a gastrostomy, and gastro-esophageal reflux disease, was observed with their head of bed lowered below 30 degrees while the tube feeding continued to infuse. This occurred during incontinence care provided by two CNAs, who did not pause the tube feeding during the process. The resident's head of bed was nearly flat, and the tube feeding pump was infusing at 50 milliliters per hour. The resident's care plan and order summary report both indicated that the head of bed should be elevated 30 to 45 degrees at all times while the tube feeding is infusing. Additionally, the facility's policy on the care and treatment of feeding tubes required adherence to current clinical standards of practice to prevent complications. Despite these guidelines, the CNAs did not follow the proper protocol, and the RN confirmed that the tube feeding should be paused when the head of bed is lowered below 30 degrees to prevent the risk of aspiration.
Failure to Use Isolation Gowns During High Contact Care
Penalty
Summary
The facility failed to ensure staff wore isolation gowns when providing high contact care to a resident on enhanced barrier precautions. A resident with a gastrostomy was observed to be incontinent of stool and had their adult incontinence brief changed by two CNAs. Despite a sign on the resident's door indicating the need for gloves and gowns during high contact care, the CNAs did not wear isolation gowns while providing incontinence care. The Director of Nursing confirmed that residents with catheters or implanted medical devices should be on enhanced barrier precautions and that high contact care activities, such as providing incontinence care, require the use of gloves and gowns. The facility's Enhanced Barrier Precautions policy also indicated that gowns and gloves should be used during high contact resident care activities, including providing hygiene and changing briefs.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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