Alpine Fireside Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 3650 North Alpine Road, Rockford, Illinois 61114
- CMS Provider Number
- 146066
- Inspections on file
- 28
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Alpine Fireside Health Center during CMS and state inspections, most recent first.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
A cognitively intact resident reported that cash she kept in her purse, stored in a dresser drawer, went missing after her son brought her money for a hair appointment. The son confirmed he placed the cash in her purse in the resident’s room, where additional smaller bills were already present, and later learned from the resident that all the money was gone. An incident report documented the missing funds and a room search that did not locate the money, demonstrating the facility’s failure to protect the resident from misappropriation of her belongings.
A resident reported that $90 was missing from her room after her son had given her the money, and the facility’s incident report noted that staff interviews and video review were conducted, with no concerns identified. However, hallway surveillance showed four CNAs entering the resident’s room when the resident was not present, and the CNA supervisor who reviewed the footage did not assess or report whether the resident was in the room at those times. The social service designee interviewed staff using only broad, general questions and did not specifically ask the CNAs why they entered the room in the resident’s absence, and one CNA had no written statement on file. As a result, the allegation of misappropriation was not promptly and thoroughly investigated as required by facility policy.
A resident with severe dementia, multiple comorbidities, and a history of combative behavior during care was found with a black eye, swollen lip, and additional bruising of unknown origin after staff provided incontinence and clothing care while short-staffed and without assistance. Despite a recent care plan meeting noting increased agitation, identified behavioral interventions, and a PRN haloperidol order, staff did not administer the PRN medication, did not consistently follow the care plan to stop and re-approach when the resident became agitated, and did not ensure two-person assistance during care as practiced by other CNAs. The resident’s injuries were discovered after the shift in which a CNA reported significant combativeness but no observed bruising, and the facility was unable to determine how the injuries occurred, demonstrating a failure to provide appropriate dementia-focused care and supervision to prevent injury.
A resident with dementia, cognitive impairment, high fall risk, and documented behaviors of restlessness, anxiety, and sleep disturbance was care planned for 1:1 supervision when anxious and attempting to stand, and had a history of removing alarms and not staying seated. On a night when the resident was awake all shift, restless, and kept at the nurse’s station due to behaviors and attempts to get out of bed, an LPN left the resident alone at the nurse’s station to go on break, while a CNA was seated around the corner and could not see the resident. Within minutes, staff heard the alarm and screaming and found the resident on the floor by the nurse’s station, resulting in a right hip fracture and right knee fracture, despite facility policy requiring fall risk assessment and implementation of interventions for residents at risk for falls.
Surveyors found that the facility failed to provide required bed-hold notices to two residents who were transferred to the hospital and did not return, and failed to notify the ombudsman of transfers or discharges for three residents, including one with a planned discharge and another who later died in the hospital. Record review showed no bed-hold documentation in the EMR at the time of transfer or during hospitalization, and no evidence of ombudsman notification for any of the affected residents. The DON, social services staff, and admissions liaison each reported they were not providing ombudsman notifications, and bed-hold information was only given at admission. The facility’s bed-hold policy did not specify when notices must be provided, and there was no policy for ombudsman notification.
A resident with multiple medical conditions, including bowel and bladder incontinence and difficulty walking, was observed with a large wet area on her pants and a strong urine odor after being up in a wheelchair for several hours. When a CNA transferred the resident to the toilet, the resident was found wearing both a thick disposable incontinence pad and an incontinence brief, both saturated with urine. Staff later stated that incontinence care should occur at least every two hours and as needed, that only one brief should be used at a time, and that heavy wetters should be checked more frequently. This situation did not follow the resident’s care plan, which required keeping her clean, dry, and changed as needed, nor the facility’s ADL policy requiring necessary services to maintain personal hygiene.
A resident with dementia, sepsis, UTI, and two stage 4 sacral pressure injuries, assessed as high risk for skin breakdown, did not receive ordered pressure-relieving interventions. Surveyors observed that the resident was placed in bed on a low air loss mattress with the pump turned off and left off while the resident remained in bed, despite staff recognizing air mattresses as a key pressure injury prevention measure. Waffle boots ordered for use while the resident was in bed were found on the floor next to a recliner instead of on the resident’s feet, indicating the facility did not follow the care plan, physician orders, or its own wound care policy.
A resident with dementia, depression, dysphagia, UTI, a prior ankle fracture, and a documented history of multiple falls was assessed as high fall risk and care planned for chair/bed alarms and staff oversight with transfers. Despite this, a CNA observed the resident self-transferring from a wheelchair to the toilet while the chair alarm sounded, told the resident not to get up alone, then turned off the alarm, closed the door, and left the resident alone in the bathroom. Another CNA later confirmed the resident should not be left alone in the bathroom and does not always remember to use the call light, indicating staff did not follow the fall-prevention care plan and facility policy.
Surveyors observed that an LPN did not follow physician orders and facility policy for medication administration, resulting in a 10.71% medication error rate during a medication pass. One resident with multiple chronic conditions received an incorrect dose of calcium/vitamin D and a delayed dose of a phosphorus/potassium/sodium supplement, while another resident with neurological and cardiac diagnoses received a scheduled acetaminophen dose outside the facility’s 60-minute administration window. The facility’s policy requires medications to be given as prescribed and within 60 minutes of the scheduled time, which was not met in these cases.
Two residents developed multiple facility-acquired pressure ulcers, including wounds that progressed from stage 2 to unstageable, due to failures in early identification, timely intervention, and consistent use of pressure reduction devices. Staff did not consistently follow infection control protocols during dressing changes, and pressure-relieving interventions were not always implemented as required.
A nurse failed to wear a gown while performing a wound vac dressing change for a resident on contact isolation for MRSA, despite facility policies and physician orders requiring both gown and gloves for such care. The resident confirmed the omission, and the DON stated that both gown and gloves are necessary for close contact care to prevent infection.
A resident with a history of falls and medical conditions, including a right hip fracture, fell during a transfer due to the CNA's failure to use a gait belt. The resident sustained a hematoma and bruising. The facility's policy requires a Fall Risk Assessment and interventions, which were not followed in this instance.
A resident with cognitive impairment sustained second-degree burns after spilling hot coffee served at unsafe temperatures. The CNA, unfamiliar with the resident's condition, provided coffee without supervision. The facility lacked clear policies on safe coffee temperatures and monitoring procedures.
The facility failed to maintain sanitary food preparation practices, as the Dietary Manager had an uncovered open wound while preparing food and used an improper method to sanitize the food thermometer. The thermometer was dipped into a sanitation bucket without verifying the correct chemical concentration, potentially compromising food safety.
A facility failed to notify a resident's physician when blood glucose levels exceeded the set parameters. The resident, with type II diabetes and dependent on staff for most activities, had orders for blood glucose checks twice daily, with instructions to call the doctor if levels were above 250. Despite multiple high readings, there was no documentation of physician notification. The facility's policy required notifying the physician of condition changes, but the administrator confirmed no such documentation was found.
The facility failed to conduct weekly assessments of pressure wounds for two residents, leading to irregular intervals between assessments. One resident with a Stage 3 pressure injury on the hip had assessments ranging from 9 to 24 days apart, while another resident with multiple stage II pressure injuries had assessments 9 to 16 days apart. The Wound Care Nurse acknowledged the lapses, and the facility's policy requiring regular monitoring was not consistently followed.
The facility failed to prevent cross-contamination during incontinence care for a resident with dementia, did not implement enhanced barrier precautions for a resident with a catheter and wound, and allowed an LPN to touch medications with bare hands, violating infection control and medication administration policies.
The facility failed to ensure fall interventions were in place for two residents with a history of falls. One resident was found with a disconnected pad alarm and no floor mats, while another was found without a pad or clip alarm. The facility's policies on fall prevention were not consistently implemented.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Protect Resident From Misappropriation of Money
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from misappropriation of her money. The resident reported that her son brought her $90 in cash, which she placed in her purse along with additional money she believed totaled about $20, and stored the purse in the bottom drawer of her dresser. When she went to retrieve the money on the morning of 1/08/2026 to pay for a scheduled hair appointment, she discovered that all of the money was missing. The resident stated she had kept the money in her purse in the dresser drawer in her room. The resident’s son confirmed that he brought $90 in cash at his mother’s request so she could get a haircut and perm, and that he placed the money in her purse in the bottom dresser drawer in her room, where there was already a $10 bill and a couple of $5 bills. He estimated the total loss to be about $120. The facility’s incident report documented that the resident reported approximately $110 missing and that a room search was conducted but the money was not located. The facility’s policy defines misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the investigation and interviews established that the resident’s money went missing while under the facility’s care and was not recovered or replaced.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of misappropriation of a resident’s money. One resident reported that money was missing from her room after her son had provided her with $90. The facility’s incident report documented that staff from various departments and shifts were interviewed and that surveillance cameras were reviewed between the time the money was reportedly provided and the time the loss was reported. The report stated that all staff entering the room were assigned to the resident, their entry times were considered appropriate for their responsibilities, and no questionable behavior or concerns were identified during staff interviews. Further review of surveillance video from the resident’s hallway over a multi-day period showed four CNAs entering the resident’s room when the resident was not present. The CNA supervisor, who initially reviewed the video, stated she had focused only on who went in and out of rooms and did not consider whether the resident was in the room at the time. She did not relay to the social service designee that these CNAs entered the room while the resident was absent. The social service designee, who conducted staff interviews, reported she only asked general questions and did not ask the CNAs why they were in the room when the resident was not there. Typewritten interview forms for three of the CNAs showed only broad questions about inappropriate interactions, resident mood changes, and coworker stress, all answered negatively, and there was no documentation of specific questioning about their presence in the room during the time the money went missing. No written statement was provided for the fourth CNA. This investigation process did not align with the facility’s policy requiring all reports of theft or misappropriation of resident property to be promptly and thoroughly investigated.
Failure to Protect Combative Dementia Resident From Injury During Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dementia and known aggressive behaviors was cared for in a manner that prevented injury. The resident had multiple diagnoses including vascular dementia, major depressive disorder, cerebrovascular disease, chronic kidney disease, COPD, and benign prostatic hypertrophy, and was described as severely cognitively impaired, unable to communicate effectively, and often nonsensical in speech. On observation, the resident was noted to have a yellow, green, and purple bruise under the right eye, a small red spot with faint bruising on the chin, and a recently healed area on the upper lip. The resident’s wife reported that she had visited him two days before the facility notified her that he had facial bruising and a swollen lip, and the facility’s incident report categorized the injuries as a bruise of unknown origin. In the days leading up to the discovery of the injuries, staff and hospice documentation indicated that the resident had increasing agitation and combative behaviors during care, associated with his progressing dementia. A care plan meeting with the family and hospice nurse occurred shortly before the incident, during which staff discussed the resident’s overall decline, increased agitation, and strategies for staff approaches, including non-pharmacological interventions and medication changes. The care plan identified a problem of physical behaviors toward others, with interventions such as administering medications, attempting to refocus behaviors, and stopping care and re-approaching when the resident became agitated. The resident had a PRN haloperidol order entered shortly before the incident, but the medication administration record showed it had not been used. On the night shift prior to the discovery of the bruising, a CNA reported that the resident was very combative during incontinence and clothing changes, and that she completed care alone because the unit was short-staffed, despite the resident’s known behaviors. She described difficulty removing a soiled shirt while the resident’s arms were moving all over and stated she informed the nurse only that the resident was combative, without reporting any injury or bruising. Another CNA, who had put the resident to bed earlier without bruising present and later found him with a black eye and cut lip, stated she always used a second staff member when providing care to him and had advised the night CNA not to change him alone due to his behaviors. The night RN acknowledged being told the resident was combative but did not administer any medication to address behaviors. The facility’s dementia training policy emphasized the need for specialized, person-centered care and ongoing staff training, but staff interviews and the sequence of events showed that the resident’s known aggression and dementia-related behaviors were not consistently managed in a way that prevented injury, resulting in unexplained facial bruising and other bruises of unknown origin.
Failure to Provide Required 1:1 Supervision for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure fall prevention interventions were in place for a resident with a known history of falls and behavioral symptoms. The resident had Alzheimer’s disease and dementia, was cognitively impaired, alert only to self, had poor safety awareness and impaired decision-making, and required frequent redirection. The care plan dated 12/12/25 identified that the resident did not stay in a chair, removed alarms, and needed 1:1 staff supervision throughout the day when experiencing increased anxiety, restlessness, and yelling. A fall risk assessment and Minimum Data Set documented that the resident was at high risk for falls due to abnormal gait or balance, medications that could impair balance, conditions affecting ambulation, and cognitive impairment with poor decision-making. In the hours leading up to the fall, progress notes documented significant behavioral issues and sleep disturbance. On 12/22/25 at 11:01 PM, the resident was noted as disruptive, crying, yelling/screaming, having sleeping problems, feeling angry/anxious, and feeling restless/anxious. A subsequent progress note on 12/23/25 at 4:44 AM recorded that the resident was awake all shift. Staff interviews confirmed that on the night of the fall, the resident had been “up and busy all night,” not sleeping, and was kept at the nurse’s station due to these behaviors and attempts to get out of bed. The DON and the nurse practitioner both stated that, per the care plan, the resident should have 1:1 care when exhibiting such anxious, restless, and standing behaviors. Despite these identified risks and care plan directives, the resident was left unsupervised at the nurse’s station. The LPN reported that she had the resident sitting with her at the nurse’s station because of the resident’s behaviors, then left the nurse’s station to go on break, leaving the resident there alone and only informing a CNA who was seated around the corner at the beginning of another hall and could not see the resident. Within minutes, staff heard the resident’s alarm and screaming and found the resident on the floor on her right side by the nurse’s station, with no nurse present. The progress note and emergency department documentation show that the resident sustained a right intertrochanteric hip fracture and a right patellar fracture, requiring hospital admission and surgical repair. The facility’s fall policy states that on admission and readmission, a fall risk assessment will be completed and interventions implemented for residents at risk for falls, but the required 1:1 supervision intervention was not in place at the time of the fall.
Failure to Provide Bed-Hold Notices and Notify Ombudsman of Transfers and Discharges
Penalty
Summary
Surveyors identified that the facility failed to provide required bed-hold notices to two residents and failed to notify the ombudsman of transfers and discharges for three residents. One resident was transferred from the facility to the hospital and did not return, instead being discharged to another placement with family; another resident was transferred to the hospital and later expired there; and a third resident had a planned discharge from the facility. For the two residents who were transferred to the hospital, there was no documentation in the electronic medical record that a bed-hold notice was provided to them or their representatives at the time of transfer or during hospitalization. Staff interviews confirmed that nursing did not send out bed-hold notices on transfer and that no additional bed-hold notices were sent after admission because residents received a copy in their admission contract. The facility’s bed-hold policy described the bed-hold policy itself but did not specify when a copy of the notice should be provided to residents or their representatives. The survey also found that the facility did not notify the ombudsman of resident transfers and discharges for three reviewed residents. Record review showed no documentation that the ombudsman was notified of the transfer or discharge for the resident who went to the hospital and then to another placement, the resident who had a planned discharge, or the resident who was transferred to the hospital and later died there. The ombudsman stated that facilities should be notifying the ombudsman program of resident discharges and that this facility had not been doing so. The social services staff member reported she had not been notifying the ombudsman of transfers or discharges because she was unaware this was required, and the DON stated that nursing did not notify the ombudsman and she was unsure if anyone else did. The admissions liaison confirmed she did not send anything to the ombudsman. The administrator acknowledged that bed-hold notices were given on admission only and that there was no facility policy for ombudsman notification, and the facility was unable to provide a policy addressing ombudsman notifications.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely ADL care, specifically incontinence care, to a resident who required assistance. The resident was admitted with diagnoses including anorexia, polyarthritis, excoriation disorder, difficulty walking, and paranoid schizophrenia, and had a care plan effective September 20, 2025, indicating she was at risk for skin breakdown related to bowel and bladder incontinence and directing staff to ensure she was kept clean and dry and changed as needed. On December 8, 2025, at 11:20 AM, a CNA (V9) used a mechanical stand lift to transfer the resident, revealing a large wet circle on the back of the resident’s pants and a strong urine odor. When the CNA placed the resident on the toilet and removed her incontinence brief, the resident was found to be wearing both a thick disposable incontinence pad and an incontinence brief, both saturated with urine; the CNA stated the resident had been up in her wheelchair since about 8:00 AM and that the extra pad and brief were used because the resident was a heavy wetter. Another CNA (V12) later stated that incontinence care should be provided at least every two hours and as needed, that residents should only wear one incontinence brief at a time, and that heavy wetters should be checked and changed more frequently. The facility’s ADL policy states that residents unable to carry out ADLs will receive necessary services to maintain good grooming and personal hygiene, but the observed condition of the resident’s saturated incontinence products and clothing demonstrated that timely incontinence care was not provided in accordance with the care plan and policy.
Failure to Implement Ordered Pressure-Relieving Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pressure-relieving interventions were in place for a resident with existing pressure injuries and a high risk for further skin breakdown. The resident was admitted with diagnoses including sepsis, UTI, dementia, and a sacral pressure injury, and an assessment identified her as high risk for pressure injuries. Physician orders directed the use of waffle boots while in bed, and the care plan included encouraging the resident to float her heels and use an air mattress. Weekly wound assessments documented two stage 4 pressure injuries to the sacrum and indicated the use of a low air loss mattress. On the observed day, CNAs transferred the resident to bed with a sacral dressing in place and a pump attached to the bed, but the pump was not turned on and the resident’s feet were placed directly on the mattress. Over 30 minutes later, the air mattress pump remained off until a CNA attempted to turn it on, then shut it off again after hearing a loud noise, stating she did not know what was wrong and would notify maintenance. An hour later, the air mattress was still off while the resident was asleep in bed. Additionally, waffle boots ordered for use while in bed were observed on the floor beside the resident’s recliner rather than on the resident. Staff interviews described pressure injury prevention interventions such as repositioning, air mattresses, and elevating feet, and the facility’s wound care policy stated that evidence-based treatments would be provided in accordance with current standards of practice and physician orders.
Failure to Supervise High Fall-Risk Resident During Bathroom Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall-prevention interventions for a resident with a high risk of falls and a history of multiple falls. The resident, admitted in June 2024, had diagnoses including depression, dysphagia, major depressive disorder, UTI, dementia, and a nondisplaced fracture of the lateral malleolus, and had fallen five times in the prior four months. A fall risk assessment identified the resident as at risk for falls, and the care plan effective October 30, 2025, documented that the resident was at risk for falls, sometimes self-transferred, and required chair and bed alarms to alert staff of unplanned movement, as well as oversight and assistance with transfers. On December 8, 2025, a surveyor observed the resident transferring independently from a wheelchair to the toilet while the chair alarm was sounding; a CNA entered, told the resident she was not supposed to get up alone, then turned off the alarm, closed the bedroom door, and left the resident alone in the bathroom. The next day, another CNA stated that this resident should not be left alone in the bathroom and that the resident does not always remember to use the call light. The facility’s fall prevention policy required interventions for residents assessed at risk for falls to be implemented and documented in the plan of care. These observations, interviews, and record reviews show that staff did not follow the resident’s care plan and the facility’s fall prevention policy by leaving a high fall-risk resident unattended in the bathroom after silencing the chair alarm, despite the resident’s documented history of falls, cognitive impairment, and need for supervised transfers.
Medication Administration Errors Exceed Acceptable Error Rate
Penalty
Summary
Surveyors identified a medication administration deficiency in which the facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 10.71% (3 errors out of 28 opportunities) during a medication pass observation. For one resident (R30), who had multiple diagnoses including dementia, alcohol-induced persisting dementia, hypertensive heart and chronic kidney disease with heart failure, moderate protein malnutrition, Alzheimer's disease, major depressive disorder, delusional disorder, hypokalemia, and anorexia, the Medication Record for December 1–31, 2025 showed an order for phosphorus/potassium/sodium one packet by mouth four times daily at 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM, and calcium 600 mg with vitamin D3 20 mcg daily. On December 8, 2025 at 10:34 AM, an LPN (V11) administered calcium 600 mg with vitamin D3 10 mcg instead of the ordered 20 mcg dose and also administered the resident’s 8:00 AM dose of phosphorus/potassium/sodium at 10:34 AM, outside the facility’s stated 60-minute window from the scheduled time. For another resident (R24), who had diagnoses including traumatic subdural hemorrhage, atrial fibrillation, Alzheimer's disease, anorexia, dementia, anxiety disorder, major depressive disorder, osteoarthritis, delusional disorders, and poly-osteoarthritis, the Medication Record for December 1–31, 2025 showed an order for acetaminophen 325 mg, give 650 mg by mouth three times per day at 8:00 AM, 12:00 PM, and 5:00 PM. On December 8, 2025 at 10:20 AM, the same LPN (V11) administered the resident’s 8:00 AM scheduled dose of acetaminophen, which was not given within 60 minutes of the scheduled administration time. The facility’s undated Medication Administration Policy states that medications are to be administered as prescribed, in accordance with written physician orders and good nursing principles, and within 60 minutes of the scheduled time, which was not followed in these instances.
Failure to Prevent and Identify Pressure Ulcers and Maintain Infection Control
Penalty
Summary
The facility failed to identify and intervene in the early stages of pressure injuries for two residents, resulting in the development and worsening of multiple facility-acquired pressure ulcers. One resident was admitted without a pressure injury to the coccyx, as documented on the admission skin check. However, a wound was later discovered on the coccyx that had already progressed to an unstageable pressure injury by the time it was identified. The wound measured 6.5 cm x 4.5 cm and contained both granulation and slough tissue. Staff interviews confirmed that skin checks were performed during showers and care, but the wound was not detected until it had reached an advanced stage. The resident was noted to have severe cognitive impairment and was dependent on staff for most activities of daily living, including mobility and hygiene, which increased the risk for pressure injuries. Another resident developed several facility-acquired pressure ulcers, including a stage 2 pressure ulcer on the right buttock, an unstageable pressure ulcer on the right great toe (later staged as a 2), a right heel ulcer that progressed from stage 2 to unstageable, and a stage 2 ulcer on the right groin. The right heel ulcer began as a blister, which ruptured and evolved into a wound with necrotic tissue, eventually being classified as unstageable. The resident had diabetes and edema, which contributed to the development of the blister. Documentation and staff interviews indicated that the resident was supposed to have both heels offloaded and be repositioned every two hours, but the resident reported that repositioning was not consistently performed. The care plan included interventions such as pressure relief mattresses, floating heels, and wound care, but these measures were not always implemented in a timely or consistent manner. During wound care observations, staff failed to follow proper infection control protocols. For example, a nurse did not change gloves between removing soiled dressings and applying clean ones, and used her finger to apply ointment directly to the wound. Supplies used during the dressing change were not handled in a manner that would prevent cross-contamination, as items were carried out of the resident's room and placed on common surfaces before being cleaned. Additionally, pressure reduction devices, such as offloading boots, were not reapplied after dressing changes, and soiled items were left in the resident's room. These lapses in infection control and pressure injury prevention contributed to the development and worsening of pressure ulcers in the affected residents.
Failure to Use Required PPE During Wound Care for Resident on Contact Isolation
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to wear a gown while performing a wound vac dressing change for a resident who was on contact isolation due to methicillin-resistant Staphylococcus aureus (MRSA) in the nares and a right knee surgical wound. The resident's care plan and physician orders specified the need for contact isolation precautions, including the use of personal protective equipment (PPE) such as gloves and gowns during care. During the observed dressing change, the RN wore gloves but did not don a gown, despite the resident being on isolation for MRSA. Another RN, who entered the room to troubleshoot the wound vac, was observed wearing both a gown and gloves. The resident confirmed that the RN did not wear a gown during the dressing change. The Director of Nursing stated that both gown and gloves are required for close contact care to prevent contamination and infection. Facility policies on infection control, contact precautions, and enhanced barrier precautions all require the use of appropriate PPE, including gowns and gloves, during high-contact resident care activities such as wound care. Documentation showed the resident had a surgical wound with significant tunneling and a wound vac in place, requiring regular dressing changes.
Failure to Use Gait Belt Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident with a history of falls, leading to an accident. The resident, a female with a right hip fracture, hypertension, chronic kidney disease, and congestive heart failure, was observed with a dark purple hematoma on her forehead and bruising around her right eye and side of her face. She reported falling while transferring from her bed to her wheelchair because the Certified Nursing Assistant (CNA) did not use a gait belt during the transfer. The CNA confirmed that she did not use a gait belt, believing the resident was not a fall risk and did not require it. The resident's Minimum Data Set assessment indicated she was cognitively intact but required moderate assistance with transfers due to limited range of motion in one lower extremity. A Fall Risk assessment showed she had a previous fall at home, resulting in a right femur fracture. The facility's Fall Policy requires a Fall Risk Assessment and implementation of interventions for residents at risk, which were not adequately followed in this case, as evidenced by the lack of a gait belt during the transfer.
Resident Sustains Burns Due to Unsafe Coffee Temperature
Penalty
Summary
The facility failed to ensure that a resident's coffee was served at a safe temperature, resulting in the resident sustaining second-degree burns. The incident involved a resident with severe cognitive impairment who required staff supervision or assistance for eating. On the day of the incident, a CNA, who was unfamiliar with the resident's condition, provided her with a cup of coffee in bed without realizing her cognitive limitations. The resident spilled the coffee on herself, leading to significant burns on her thigh and calf. The CNA discovered the burns when he returned to the resident's room and noticed coffee stains on her sheets. Upon further inspection, he found blisters on the resident's thigh and alerted the Director of Nurses (DON), who assessed the burns and provided initial treatment. The resident's condition was further evaluated by a wound care nurse and a nurse practitioner, who confirmed the severity of the burns and recommended further medical evaluation. The facility's dietary manager was responsible for monitoring coffee temperatures, which were found to be between 175-190°F, a range that could cause burns. However, the facility lacked a clear policy on safe coffee temperature limits and monitoring procedures. The dietary manager admitted to not recording coffee temperatures unless an incident occurred, and the facility's policies did not adequately address the safe serving of hot liquids, particularly to residents with cognitive impairments.
Unsanitary Food Preparation Practices
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as evidenced by the actions of the Dietary Manager, who had an open wound on his right inner forearm that was not covered while preparing and serving food. This was observed during the preparation of the lunch meal, where the Dietary Manager was involved in taking food temperatures without covering the wound, which had a small smear that appeared to be blood. The facility's policy requires that open wounds be covered to prevent contamination, but this was not adhered to, potentially compromising the sanitary conditions of food preparation. Additionally, the Dietary Manager used an improper method to sanitize the food thermometer between temperature checks of different food items. Instead of using alcohol wipes, the thermometer was dipped into a sanitation bucket containing quaternary ammonium compound sanitizer, which was not tested for the correct chemical sanitation level before use. The test strip used to check the sanitation level showed a yellow color, indicating an incorrect concentration, contrary to the Dietary Manager's assertion that it was between 150 ppm and 200 ppm. This improper sanitization process further contributed to the unsanitary conditions in food preparation.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician when blood glucose levels were outside the parameters set by the physician's orders. The resident, who had type II diabetes mellitus and was dependent on staff for all activities of daily living except eating, had physician's orders for blood glucose checks twice daily, with instructions to call the doctor if levels were greater than 250 or less than 70. Despite this, there were multiple instances between July and October where the resident's blood glucose levels exceeded 250, yet there was no documentation that the physician or nurse practitioner was notified. The facility's policy required staff to notify the physician of any condition changes and document the condition, interventions, and response in the resident's record. However, the review of the resident's nurse progress notes and communication portal notes showed no evidence of such notifications on several occasions when the blood glucose levels were high. The administrator confirmed that no further documentation was found to show that the physician or nurse practitioner had been updated, and the expectation was for the nurse on duty to call the doctor, not use the communication portal.
Failure to Conduct Weekly Pressure Wound Assessments
Penalty
Summary
The facility failed to conduct weekly assessments of pressure wounds for two residents, R23 and R15, as required by their wound management policy. R23, who had a Stage 3 pressure injury on the right hip, had irregular intervals between wound assessments, ranging from 9 to 24 days, instead of the weekly assessments that were supposed to be conducted. The Wound Care Nurse, V4, acknowledged that assessments were typically done weekly, but there were gaps in the documentation, especially when she was off duty. R15, who had multiple diagnoses including chronic kidney disease and Alzheimer's disease, developed six stage II pressure injuries on her buttocks and coccyx. The assessments for these wounds were not conducted weekly, with intervals ranging from 9 to 16 days between assessments. R15 had been sent to the hospital and returned more deconditioned, which may have contributed to the skin breakdown. The Wound Care Nurse, V4, admitted that the assessments were not done weekly and emphasized the importance of regular monitoring to track wound progress and inform the physician for potential new orders. The facility's policy required regular monitoring and documentation of pressure sores, but the documentation provided showed inconsistencies in following this policy. The Director of Nursing and the Administrator were aware of the situation, and the Administrator confirmed that all available assessments had been provided, indicating a lack of adherence to the facility's wound management policy.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to perform incontinence care properly for a resident with multiple diagnoses, including Alzheimer's disease and dementia, who was dependent on staff for toileting and bathing. During an observation, two CNAs provided incontinence care to the resident but did not follow proper procedures to prevent cross-contamination. They used the same wet wipe for multiple areas and wiped from back to front, contrary to the facility's policy, which requires using a clean wipe for each area and wiping from front to back to prevent infection. Another deficiency was noted with a resident who had an indwelling catheter and a wound on her heel. The facility did not implement enhanced barrier precautions for this resident, as required by their policy for residents with wounds or indwelling medical devices. The CNA responsible for the resident's care was unaware of any isolation requirements, and there were no signs indicating the need for enhanced barrier precautions in the resident's room. Additionally, a medication administration error was observed when an LPN was seen touching medications with her bare hands before placing them into a medication cup. This practice was against the facility's policy, which states that medications should be handled without direct contact to prevent contamination. The DON confirmed that nurses should not touch medications with their hands, highlighting a lapse in adherence to proper medication administration protocols.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure fall interventions were in place for residents with a history of falls. Resident R2, who had a history of eight falls and was at high risk due to an unsteady gait and dementia, was found in bed with her legs off the bed and no floor mats in place. The pad alarm intended to alert staff of unplanned movement was disconnected and turned off. R2's family member confirmed that the alarm was often found turned off, and R2 had recently fallen out of bed again. The Licensed Practical Nurse confirmed that R2 should have had a pad alarm or clip alarm in place and mats on the floor next to her bed. Resident R3, who had a history of three falls and was at risk due to an unsteady gait and amputation of toes, was found seated in a recliner without a pad or clip alarm. The clip alarm was found turned off and hanging off the handle of a wheelchair in R3's room. The Director of Nursing stated that floor mats and position alarms are used as fall interventions for high-risk residents and that CNAs should check to ensure alarms are in place and working. The facility's Fall Policy and Fall Prevention Program policy indicated that interventions should be documented in the Plan of Care, but these were not consistently implemented for R2 and R3.
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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