Alta Rehab At Oak Brook
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Brook, Illinois.
- Location
- 2013 Midwest Road, Oak Brook, Illinois 60521
- CMS Provider Number
- 145458
- Inspections on file
- 46
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Alta Rehab At Oak Brook during CMS and state inspections, most recent first.
A resident with severely impaired cognition had her pubic hair shaved by CNAs after a family member allegedly requested this care, but the designated Healthcare Power of Attorney (HCPOA) was not informed or asked for consent. The resident later indicated she did not want to be shaved, and the HCPOA reported never authorizing this care and stated she would personally trim hair if needed. One family member denied ever requesting shaving, while staff reported that this family member had requested it on multiple occasions. Facility leadership acknowledged that staff were expected to consult the HCPOA for special care requests outside typical services, but this did not occur, resulting in care being provided without appropriate authorization.
A resident with significant mobility impairments and a history of fractures was transported in a wheelchair with only one footrest, leaving one leg unsupported. During transport, the unsupported leg was caught under the wheelchair, causing an acute fracture. Staff proceeded with transport despite being unable to locate the missing footrest, directly leading to the injury.
A resident with severe cognitive impairment and multiple comorbidities was dropped from a mechanical lift during a transfer when only one staff member assisted and the sling was not properly applied, resulting in a fractured ankle and hospitalization.
A resident's representative was not given accurate information about the process for authorizing an electronic monitoring device in the resident's room. Facility staff, including the DON and RN Supervisor, miscommunicated the facility's policy by stating cameras were not allowed, despite the admission contract permitting them if legal steps were followed. This resulted in miscommunication and lack of informed consent regarding the resident's rights.
A resident with multiple medical conditions and significant skin wounds did not have a grievance regarding poor wound care properly identified, documented, or addressed according to facility policy. The resident's spouse reported concerns about wound management to the Social Service Director, but these concerns were not communicated to administration or recorded in the grievance log, resulting in a lack of investigation or resolution.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
Surveyors found that the facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
The facility failed to provide adequate ADL care for residents needing assistance with toileting, repositioning, and bathing. Residents with severe cognitive impairments were left in soiled incontinence briefs and not repositioned as required, leading to potential skin breakdown. Staff interviews and grievances highlighted systemic issues with delayed response times and inadequate assistance, contributing to the deficiency.
A resident with multiple diagnoses was not promptly assessed for injury after an incident with a mechanical lift. Despite complaints of severe pain, the facility failed to document vital signs, range of motion, or pain level, and did not notify the physician or family. The resident was later diagnosed with a deep vein thrombosis after being sent to the emergency department.
The facility failed to provide timely care for two residents with indwelling urinary catheters. One resident experienced a leaking catheter that was not changed promptly, resulting in prolonged exposure to wetness and a pressure ulcer. Another resident's catheter was not changed monthly as ordered by the physician, despite a history of UTIs. The facility's policies on catheter care were not followed, leading to inadequate care.
A resident with severe cognitive impairment and multiple diagnoses was transferred using a mechanical lift by a CNA without the required two-person assistance, leading to the resident sliding out of the lift and sustaining a skin tear. The facility's policy mandates two caregivers for such transfers, but the CNA did not follow this protocol, resulting in the incident.
A resident with hypertension and chronic back pain did not receive prescribed antihypertensive and pain medications at an LTC facility. Despite the medications being delivered, they were not administered, leading to elevated blood pressure and the resident leaving against medical advice. The facility's policy requires documentation of medication administration, which was not followed.
The facility failed to provide adequate feeding assistance to a male resident with cervical spine myelopathy, despite a physician's order for one-to-one feeding. The dietary card did not reflect this requirement, leading to the resident eating without assistance. Additionally, a female resident experienced significant delays in receiving incontinent care, resulting in her being left in a urine-soaked brief. Staff acknowledged the oversight and delay in care.
The facility failed to resolve resident grievances and provide adequate care, as evidenced by three residents experiencing inadequate incontinence care, delayed call light responses, and missed showers. Despite grievances being filed and discussed in Resident Council meetings, the facility did not address these issues within the required timeframe, leading to deficiencies in care.
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in care. A resident was found in a wet incontinence brief that had not been changed for several hours, and her care plan lacked specific interventions for her needs. Another resident was observed with a soaked incontinence brief and stool caked on her skin, and her care plan did not include necessary interventions for feeding assistance or communication strategies. A third resident was left sitting in the dining room for an extended period without being checked for incontinence, resulting in a pressure ulcer. The facility's failure to provide detailed and individualized care plans resulted in inadequate care and unmet needs.
The facility failed to provide timely care and assistance to three residents, including delayed response to call lights, inadequate incontinence care, and lack of feeding assistance. One resident was left in a wet brief for hours, another was found soaked in urine and without feeding help, and a third had a pressure ulcer with no dressing. Documentation showed inconsistencies in providing scheduled showers and hair shampooing.
A resident at high risk for pressure ulcers experienced delayed wound care due to the facility's failure to promptly report and assess a new sacral wound. The wound care nurse discovered the wound had progressed to a stage 4 ulcer with muscle and bone exposure. Despite the CNA reporting the wound in February, the wound care coordinator was only notified on February 27, 2024, with no prior documentation of care initiation. The facility's policy for immediate reporting and assessment was not followed, leading to the wound's deterioration.
The facility failed to maintain food safety and sanitation standards, risking foodborne illnesses. Observations revealed grease-covered vent covers, a dirty meat slicer, and expired food items in refrigerators. The dietary manager admitted to not maintaining sanitizing logs and using the same sanitizer for different purposes without proper documentation. Additionally, the manager did not perform hand hygiene before checking food temperatures, and the facility lacked a policy for kitchen staff hygiene.
The facility failed to ensure call lights were within reach for two residents, one with right-sided hemiplegia and another who was cognitively intact but required assistance. Despite care plans and facility policy, staff left call lights out of reach, confirmed by interviews with staff and the DON.
The facility failed to reassess a resident with a hand wound for an appropriate-fitting device and did not implement skin prevention interventions for a resident with a scratching behavior. Additionally, an LPN did not follow proper procedures for checking blood glucose levels, using the first drop of blood instead of the second. These deficiencies affected two residents with complex medical histories, including dementia and diabetes.
A resident with multiple health conditions experienced a decline in range of motion due to the facility's failure to provide appropriate restorative care. The resident's care plan lacked a hand splint, and assessments were not properly documented or followed. Restorative services were inconsistently provided, contributing to the resident's contracted hand and inability to extend fingers.
The facility failed to act on pharmacy MRRs and provide documentation for two residents, leading to delayed or missing physician responses to medication recommendations. One resident, with multiple diagnoses including dementia and a history of falls, had several pharmacy recommendations for medication adjustments that were not timely addressed. Another resident, with depression and bipolar disorder, also experienced delays in addressing pharmacy recommendations for antipsychotic use. The facility's inability to provide complete MRR documentation indicates a systemic issue in medication management.
A resident with type 2 diabetes was administered 25 units of Humalog insulin by an LPN without priming the insulin pen, contrary to the facility's procedure. The LPN, another LPN, and the DON all acknowledged the requirement to prime the pen with two units of insulin to ensure proper function. The resident had a physician's order for daily insulin administration.
A resident requiring new dentures did not receive necessary dental services due to a lack of follow-up by the facility. Despite requests from the resident's family and notes from a dental hygienist, no dentist evaluated the resident. The facility's dental program, which should have provided free services to Medicaid recipients, was not effectively communicated or utilized, leading to the resident remaining on a mechanical soft diet due to ill-fitting dentures.
A facility failed to obtain an appropriate arbitration agreement from a resident with dementia, who was severely cognitively impaired. Despite the facility's policy requiring agreements to be obtained from a representative in such cases, the resident signed the agreement. Staff interviews confirmed the resident's inability to make decisions, highlighting a lapse in following the facility's policy on resident rights.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents who were observed residing on a lower-level floor below ground. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms.
The facility failed to implement pressure injury prevention strategies for a resident with advanced dementia, who was observed without the prescribed off-loading boots while in bed, despite a physician's order. This contributed to a deficiency in pressure injury prevention and treatment.
Failure to Obtain HCPOA Consent for Atypical Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Healthcare Power of Attorney (HCPOA) before providing atypical personal care. The resident’s MDS documented severely impaired cognition, and the HCPOA (V4) later filed a grievance stating that the resident’s pubic hair had been shaved by a CNA without permission. During an examination with the DON (V2) and restorative staff (V17), the resident’s pubic area appeared recently shaved with approximately 1/4 inch hair regrowth. When asked, the resident indicated awareness that her pubic area had been shaved and indicated she did not want to have been shaved. Staff interviews revealed that a CNA (V5) reported a family member (V7) requested that the resident’s pubic hair be shaved so the resident would be “nice and clean,” and another CNA (V11) confirmed it was clear to them that V7 made this request. V5 stated she obtained razors and shaved the resident’s pubic area while V7 was out of the room. An LPN (V12) also stated that V7 had previously asked her to shave the resident’s pubic hair. V7, however, denied ever asking staff to shave the resident’s pubic hair and stated she knew only the HCPOA (V4) could make such care decisions. V4 stated she had never given permission for staff to shave the resident’s pubic hair and that, if trimming were needed, she would do it herself. Facility leadership (V2 and V14) stated staff were expected to check with the HCPOA before providing any special care requests outside typical services, consistent with the facility’s Resident Rights policy, but this did not occur in this case.
Failure to Provide Proper Foot Support During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, spastic hemiplegia, paraplegia, prior femur fractures, diabetes, and dementia, was transported in a wheelchair without proper foot support. The resident required extensive assistance with activities of daily living and was dependent on staff for lower body mobility and transfers. During transport from the therapy room to the resident's room, only one footrest was attached to the wheelchair, leaving the resident's left leg unsupported. As a result of the missing footrest, the resident's left leg was abruptly placed on the floor and became caught under the wheelchair, leading to an acute nondisplaced fracture of the proximal left tibia. Staff reported that they were unable to locate the second footrest but proceeded with the transport regardless, which directly resulted in the injury. The incident was confirmed through staff interviews, medical record review, and diagnostic imaging.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, atrial fibrillation, congestive heart failure, and pain, who was admitted to hospice care, was transferred using a mechanical lift by only one staff member. The resident's care plan required two staff members to assist with mechanical lift transfers, and the facility's policy also mandated two caregivers for such transfers. During the transfer, the staff member did not properly apply the sling, resulting in the resident being dropped from the lift. As a result of this improper transfer, the resident sustained a displaced fracture to the distal tibia and fibula and required hospital evaluation and treatment. Documentation in the electronic medical record, progress notes, and incident report confirmed that the transfer was performed by a single staff member and that the sling was not adequately secured, directly leading to the resident's fall and injury.
Failure to Provide Accurate Information on Electronic Monitoring Rights
Penalty
Summary
The facility failed to provide accurate information to a resident's representative regarding the authorization and process for installing an electronic monitoring device in the resident's room, resulting in miscommunication and lack of informed consent related to resident rights. The resident in question was admitted with multiple diagnoses, including muscle wasting, COPD, acute bronchitis, and COVID-19, and was noted to be alert and oriented to person and place, but with moderate impairment in decision-making and episodes of confusion. The resident's daughter, who held Power of Attorney, requested to install a video surveillance camera in the resident's room and was initially told by the RN Supervisor, based on information from the DON, that cameras were not allowed in resident rooms according to facility policy. The admission contract, however, stated that video cameras are prohibited in resident rooms unless the resident or representative follows steps outlined under Illinois law, which includes notifying the facility and obtaining necessary consents. The admission assistant discussed this policy with the resident and the daughter, and the contract was signed, with the daughter acknowledging that cameras could be allowed if procedures were followed. Despite this, the RN Supervisor continued to inform the family that cameras were not permitted, based on the DON's interpretation of the policy, which overlooked the exception allowing cameras if legal steps were followed. The DON later admitted that she had focused only on the prohibition statement in the contract and did not notice the clause allowing cameras under certain conditions. There was no direct communication between the DON and the resident's representative regarding the request, and the family was not provided with accurate or complete information about the process for authorizing electronic monitoring, leading to confusion and a lack of informed consent regarding the resident's rights.
Failure to Identify and Address Grievance Regarding Wound Care
Penalty
Summary
The facility failed to identify, document, and address a grievance in accordance with its policy for a resident who was admitted following a fall and had multiple complex medical conditions, including dementia, repeated falls, ataxia, diabetes, COPD, cirrhosis, malnutrition, and depression. Upon admission, the resident had several skin impairments, including a left elbow skin tear, a deep tissue injury to the sacrum, and a bruise to the left hip, as well as multiple bruises and scabbing on various parts of the body. Facility-acquired skin tears were later documented on the shoulders, right forearm, and head. On one occasion, the Wound Care Nurse observed significant bloody drainage from a right forearm wound but did not notify the physician or Nurse Practitioner despite the change in wound status. The resident's spouse voiced concerns to the Social Service Director about poor wound care, specifically mentioning dried blood leaking through the resident's shirt and subsequently requested a transfer to another facility. The Social Service Director acknowledged not reporting this grievance to the Administrator or Assistant DON. There was no documentation in the facility's grievance records that the spouse's concerns were reported, investigated, or resolved. Both the Administrator and Assistant DON confirmed they had not received any report of a grievance related to the resident's wound care. The facility's grievance policy requires prompt resolution of all grievances related to care and treatment, but this process was not followed in this case.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, were not provided in the report.
Failure to Maintain Safe Environment and Adequate 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. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. 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 Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for residents requiring assistance with toileting, repositioning, and bathing. This deficiency was observed in all 16 residents reviewed for ADL care. Residents with severe cognitive impairments and physical limitations were left without necessary assistance, leading to prolonged periods in soiled incontinence briefs and lack of repositioning, which are critical for preventing skin breakdown and maintaining dignity. One resident, diagnosed with Alzheimer's disease and other cognitive impairments, was observed sitting in a wheelchair for over three hours without having her incontinence brief checked or changed, despite being incontinent of bowel and bladder. Another resident, dependent on staff for transfers and toileting, was left in a wheelchair for over two hours without repositioning or incontinence care. Similar neglect was noted for other residents, including one with a pressure injury related to immobility, who was not toileted or repositioned for extended periods. The facility's incontinence care policy mandates checking and changing incontinence briefs every two hours, yet staff interviews revealed that this protocol was not consistently followed. Multiple grievances from residents and their families highlighted ongoing issues with delayed response times to call lights, inadequate assistance with toileting, and missed showers. These grievances, along with resident council meeting minutes, underscored systemic problems in staffing and resource availability, such as the need for additional mechanical lifts, contributing to the deficiency in care.
Failure to Assess Resident After Mechanical Lift Incident
Penalty
Summary
The facility failed to promptly assess a resident for injury following an incident during a transfer with a mechanical lift. The resident, who had multiple diagnoses including drug-induced polyneuropathy, sepsis, and atrial fibrillation, was cognitively intact and dependent on staff for all activities of daily living, including transfers. During a transfer using a sit-to-stand lift, the resident let go of the machine handles, resulting in an abrasion and redness on the left arm. Despite the resident's complaints of severe pain, the facility did not document a comprehensive assessment, including vital signs, range of motion, or pain level, nor did they notify the resident's physician or family. The incident report and subsequent documentation by facility staff, including a CNA, LPN, and WCN, lacked detailed assessments of the resident's condition following the incident. The LPN and WCN did not assess or document the resident's pain level or range of motion, and the incident report did not include vital signs or a detailed description of the injury. The facility's Director of Nursing acknowledged the lack of documentation and assessment, stating that the resident should have been assessed for pain and other vital signs following the incident. The resident was later seen by a Nurse Practitioner who noted swelling, erythema, and severe pain in the left arm, leading to orders for a Doppler ultrasound and X-ray. The resident's spouse requested a quicker evaluation, resulting in the resident being sent to the emergency department. Hospital records confirmed a diagnosis of left upper extremity deep vein thrombosis. The facility's policy on accidents and incidents requires prompt investigation and documentation, which was not adhered to in this case.
Deficiencies in Catheter Management for Two Residents
Penalty
Summary
The facility failed to ensure timely care for residents with indwelling urinary catheters, leading to deficiencies in catheter management for two residents. One resident, R2, experienced a leaking catheter that was not addressed promptly. Despite reporting the issue to multiple staff members, the catheter was not changed until several days later, resulting in the resident lying in a wet bed with a significant pressure ulcer. The facility documentation shows that the catheter was noted to be leaking on January 31, 2025, but it was not replaced until February 2, 2025. This delay in care was acknowledged by the Director of Nursing, who had instructed staff to change the catheter, but the instructions were not followed in a timely manner. Another resident, R4, had an indwelling urinary catheter that was not changed monthly as per the physician's documented orders. The resident had a history of multiple urinary tract infections (UTIs) and was hospitalized due to a UTI and altered mental status. The physician had repeatedly documented the need for monthly catheter changes, but the facility failed to provide documentation that these changes were carried out as ordered. The physician expressed that it was his expectation for the catheter to be changed monthly, which was communicated to the nursing staff. The facility's policies on equipment replacement and urinary catheter care were not adhered to, contributing to the deficiencies observed. The policies outlined conditions under which catheters should be changed, including physician orders, but these were not followed in the cases of R2 and R4. The lack of timely catheter changes and adherence to physician orders resulted in inadequate care for the residents, as evidenced by the documented events and interviews with staff and family members.
Failure to Follow Transfer Protocols with Mechanical Lift
Penalty
Summary
The facility failed to ensure that a resident was transferred with the assistance of two people while using a mechanical lift, as required by the facility's policy. This deficiency was observed during the transfer of a resident who has severe cognitive impairment and multiple diagnoses, including dementia and agitation. The resident requires substantial assistance for various activities, including transfers, and is dependent on staff for these tasks. The care plan for the resident clearly states that transfers should be conducted with a total body mechanical lift and two-person assistance. On a specific occasion, a CNA attempted to transfer the resident alone, resulting in the resident sliding out of the mechanical lift and sustaining a skin tear on the left lower extremity. The incident occurred because the CNA did not request assistance from another staff member, contrary to the facility's guidelines. The Director of Nursing confirmed that the CNA was aware of the protocol but failed to adhere to it, leading to the resident's fall and injury.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer prescribed antihypertensive and pain medications to a resident with multiple diagnoses, including hypertension and chronic back pain, following a recent back surgery. The resident was admitted to the facility and had physician orders for Gabapentin and Losartan Potassium-HCTZ, which were not administered as scheduled. The medications were delivered to the facility, but the nursing staff did not administer them, leading to the resident's elevated blood pressure and subsequent distress. On the morning of the resident's discharge, the resident expressed frustration over not receiving her medications, which was documented by an LPN. The resident's blood pressure was recorded as high, and the attending physician was notified. The physician ordered alternate medications to be administered immediately, but there is no documentation in the EMAR that these alternate medications were given. The resident eventually left the facility against medical advice. The Director of Nursing confirmed that the medications were delivered but not administered, and the facility's policy requires that the MAR be used during medication administration. The attending physician emphasized the significance of the medications, noting that their omission could lead to significant results. The failure to administer the medications as prescribed and document their administration constitutes a significant medication error.
Failure to Provide Adequate ADL Assistance and Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate feeding assistance to a male resident with cervical spine myelopathy, who was admitted with a physician's order for one-to-one feeding due to his arm weakness. Despite the order being in place since mid-October, the dietary card did not reflect this requirement, leading to the resident having to eat without assistance, which he described as akin to eating like a dog. The oversight was confirmed by multiple staff members, including CNAs and the Dietary Manager, who acknowledged the absence of the one-to-one feeding instruction on the dietary card. The Director of Nursing also confirmed that the staff should have adhered to the physician's order for feeding assistance. Additionally, the facility failed to provide timely incontinent care to a female resident who was dependent on assistance for toileting hygiene and repositioning in bed. The resident reported significant delays in receiving care, including a delay from 3:00 AM to 4:45 AM for a brief change. Observations confirmed that the resident was left in a urine-soaked brief with stained linens. The staff, including the Wound Care Nurse and the assigned CNA, acknowledged the delay in providing care. The Director of Nursing stated that incontinent care should have been offered without delay when requested by the resident.
Failure to Resolve Resident Grievances and Provide Adequate Care
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not establish a grievance policy to resolve grievances promptly. This deficiency was observed in the care of three residents who required assistance with Activities of Daily Living (ADLs). The facility did not provide adequate incontinence care, timely response to call lights, or scheduled showers as per their policy. For instance, one resident was found in a wet incontinence brief and bed sheets, with no record of receiving scheduled showers or hair washing. Another resident, who was dependent on staff for all ADLs, was found with a soaked incontinence brief and stool caked on her skin, despite a grievance being filed by her family weeks earlier. The facility lacked documentation of providing the resident with scheduled showers. Additionally, a third resident was left in a wheelchair without incontinence checks, resulting in a pressure ulcer on her sacrum. A grievance had been filed by the resident's family regarding similar issues, but no resolution was documented. The Resident Council meeting minutes revealed ongoing concerns about call light response times, incontinence care, and the behavior of Certified Nursing Assistants (CNAs), particularly agency CNAs. Despite these grievances being discussed in meetings, the facility did not resolve the issues within the timeframe outlined in their grievance policy. The facility's failure to address these grievances in a timely manner contributed to the deficiency in care provided to the residents.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in care. Resident 1 (R1) was found in a wet incontinence brief that had not been changed since 2:00 AM, despite being dependent on staff for toilet hygiene and other activities of daily living (ADLs). The care plan for R1 lacked specific interventions for her needs, such as the requirement for bed baths due to the absence of a suitable shower chair. Additionally, the care plan did not specify the amount of assistance needed for ADLs, and the green care card in R1's room did not detail her specific care needs. Resident 2 (R2) was observed with a soaked incontinence brief and stool caked on her skin, indicating a lack of timely incontinence care. R2's care plan did not include necessary interventions for her one-to-one feeding assistance, specific transfer methods, or communication strategies for her unclear speech. The care plan also failed to address R2's dietary needs and the assistance required for eating, despite her dependence on staff for all ADLs and her moderate cognitive impairment. Resident 3 (R3) was left sitting in the dining room for an extended period without being checked for incontinence, resulting in a pressure ulcer. R3's care plan did not specify the type of assistive mobility device needed, nor did it address her incontinence issues or communication needs due to her lack of speech. The facility's failure to provide detailed and individualized care plans for these residents resulted in inadequate care and unmet needs, as confirmed by staff interviews and record reviews.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to promptly respond to call lights and provide timely incontinence care, feeding assistance, and showers/bed baths as per their policy for three residents. Resident 1, who was admitted with multiple diagnoses including lymphedema, hypertension, and morbid obesity, was found in a wet incontinence brief that had not been changed since 2:00 AM. The resident's call light was illuminated for over 26 minutes before staff responded. The facility lacked appropriate equipment to provide showers for Resident 1 due to her obesity, and documentation showed inconsistencies in providing scheduled showers and hair shampooing. Resident 2, with diagnoses including metabolic encephalopathy and hemiplegia, was found in a wheelchair with soaked pants and a strong urine odor. The CNA assigned to her care admitted to not checking her incontinence brief since 9:30 AM. Additionally, Resident 2 was observed attempting to feed herself without assistance, despite having an active order for 1:1 feeding assistance. Documentation also showed a lack of hair shampooing during the 30-day review period. Resident 3, who has multiple diagnoses including metabolic encephalopathy and UTI, was observed sitting in the dining room for over two hours without being checked for incontinence. When finally attended to, stool was found in her incontinence brief, and a pressure ulcer was visible on her sacrum without a dressing. The facility's policies on call light response, bathing, and incontinence care were not adhered to, as evidenced by the ongoing issues discussed in Resident Council meetings and concern forms submitted by family members.
Delayed Reporting and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to report, assess, and obtain treatment orders for a resident identified with a new wound before it became unstageable. This resulted in delayed wound care and deterioration of the wound for the resident, who was at high risk for pressure ulcers due to multiple health conditions including encephalopathy, malnutrition, and dementia. The resident required substantial to maximal staff assistance with personal hygiene and bed mobility, and had a history of skin alterations. The wound care nurse discovered the resident's sacral wound had muscle and bone exposed, with significant slough tissue, indicating a stage 4 pressure ulcer. The certified nurse assistant reported noticing a small open area on the resident's sacrum in February, which was reported to the nurse on duty. However, the wound care coordinator was only notified of the wound on February 27, 2024, and found no documentation of the wound's identification or initiation of care prior to this date. The wound physician managing the resident's care noted the resident was at risk for pressure ulcers due to immobility, incontinence, poor nutrition, and dependency on staff for repositioning. The facility's policy required immediate reporting and assessment of new skin alterations, but this was not followed, leading to the wound's deterioration. The resident's care plan included interventions for skin integrity, but the lack of prompt reporting and treatment initiation contributed to the wound becoming unstageable.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, which could lead to foodborne illnesses. During a kitchen tour, it was observed that the vent covers over the stove were covered with grease and lint/dust, and the meat slicer had smears of grease and crust on its base. The dietary manager admitted that testing logs for sanitizing buckets were not maintained, and the same sanitizer used for the three-compartment sink was also used for disinfecting buckets without proper documentation of its concentration or contact time. The facility's policy did not specify the frequency of testing or documentation for the dishwasher, three-compartment sink, or sanitization buckets, nor did it document the disinfecting product used. Additionally, expired food items were found in various refrigerators, including expired orange juice concentrate, milk, applesauce, and sour cream. Some items were not labeled or dated, contrary to the facility's signage that stated items should be discarded after three days or if they lacked information. The dietary manager acknowledged that expired food might be overlooked and served to residents. Furthermore, the dietary manager was observed not performing hand hygiene before conducting food holding temperatures, and the facility did not provide a policy for kitchen staff hand hygiene and head coverings.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were placed within reach, affecting two residents assessed for accommodation of needs. One resident, who had right-sided hemiplegia and other medical conditions, was found with her call light out of reach on multiple occasions. Despite having a care plan that specified the call light should be accessible on her left side, staff repeatedly left the call light behind her bed or chair, making it inaccessible. Interviews with staff confirmed that the call light should be placed within reach of the resident's functional side, yet this was not consistently done. Another resident, who was cognitively intact but required assistance for various activities, also had her call light placed out of reach. The call light was left behind her on the bed while she was in a wheelchair, preventing her from reaching it. The facility's policy stated that call lights should be accessible to residents at all times, but this was not adhered to, as confirmed by the Director of Nursing and other staff members.
Deficiencies in Wound Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to reassess a resident, R61, for an appropriate-fitting device despite having a hand wound. R61, who had multiple diagnoses including encephalopathy, dementia, and anxiety, was dependent on staff for activities of daily living. Observations revealed that R61 had a contracted left hand with a wound between the first and second fingers, and was using a palm protector device with a finger separator strap, which was not reassessed despite the presence of the wound. The wound care nurse and restorative nurse were unaware of the wound and the inappropriate use of the device, indicating a lack of communication and reassessment. Additionally, R61's care plan included interventions for skin impairment and behaviors such as scratching, but these were not effectively implemented, as evidenced by untrimmed fingernails and the absence of protective gloves. The facility also failed to ensure proper skin prevention interventions for R61, who had a known behavior of scratching. The wound care coordinator noted that R61's plan of care included keeping nails trimmed, applying gloves, and monitoring for scratching, but these measures were not consistently followed. R61 was observed with untrimmed nails and without gloves, contributing to self-inflicted injuries. The facility's policies on pressure injury and skin condition assessment, as well as restorative services, were not adequately followed, leading to the oversight in reassessing the appropriateness of the contracture device and implementing preventive measures. Additionally, the facility failed to adhere to proper procedures for checking blood glucose levels for another resident, R58. An LPN was observed testing R58's blood glucose using the first drop of blood, contrary to the procedure of wiping the first drop and testing the second to avoid alcohol contamination. This was confirmed by the LPN and the Director of Nursing, who stated the expectation to follow the correct procedure. R58 had a history of type 2 diabetes mellitus and was on a physician-ordered regimen for blood glucose monitoring and insulin administration, highlighting the importance of accurate testing procedures.
Failure to Prevent Decrease in Range of Motion for Resident
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident, identified as R36, who was admitted with multiple diagnoses including acute kidney failure, dementia, and poly-osteoarthritis. Upon observation, R36 was found with a contracted left hand and was unable to extend her fingers. The resident reported not having a splint for her hand, and the Certified Nursing Assistant confirmed that a hand splint was not included in her care plan. The Restorative Nurse acknowledged that R36 should have undergone an Occupational Therapy (OT) and Physical Therapy (PT) assessment upon admission to guide her care, but there was no documentation of contractures at that time. The Restorative Aide, responsible for documenting changes, stated that R36 was supposed to receive restorative services three times a week, but these sessions were sometimes missed due to staffing issues. The Director of Rehab Services was unable to access R36's OT and PT assessments, and the Occupational Therapist evaluated R36 during the survey, noting tightness and decreased ability to extend her fingers. The resident's care plan indicated a need for restorative nursing and active range of motion exercises, but there was no completed and signed restorative nurse assessment since February. The facility's policies required services to be provided according to assessment results and care plans, but these were not adequately followed, leading to the resident's decline in range of motion.
Failure to Act on Pharmacy Medication Regimen Reviews
Penalty
Summary
The facility failed to act on the pharmacy Medication Regimen Review (MRR) and provide documentation of monthly MRRs for two residents, R44 and R52, out of a sample of 23. For R44, the pharmacist made several recommendations regarding the resident's medication regimen, including requests for gradual dose reductions (GDR) and stop dates for certain medications. However, these recommendations were not consistently addressed by the physician or prescriber, with some responses delayed by months or not provided at all. Additionally, the facility was unable to provide documentation of MRRs for several months, indicating a lack of consistent review and action on pharmacy recommendations. R44, who has multiple diagnoses including dementia, psychosis, and a history of falls, was on psychotropic therapy with medications such as Mirtazapine, Quetiapine, and Lorazepam. The pharmacist highlighted potential risks associated with these medications, such as increased fall risk, and recommended reevaluation and dose adjustments. Despite these recommendations, there was a lack of timely physician response, and the facility did not document MRRs for several months, failing to ensure appropriate medication management for R44. Similarly, for R52, the facility did not provide complete documentation of MRRs, and there were delays in addressing pharmacy recommendations. R52, with diagnoses including depression, bipolar disorder, and a history of falls, was prescribed multiple antipsychotics. The pharmacist recommended reviewing the use of these medications due to potential side effects, but the physician's response was delayed. The facility's failure to provide complete MRR documentation and timely responses to pharmacy recommendations indicates a systemic issue in managing medication regimens for residents.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin to a resident. On July 17, 2024, an LPN was observed administering 25 units of Humalog insulin to a resident without priming the insulin pen, which is a necessary step to remove air bubbles and ensure the needle is functioning properly. The LPN acknowledged the need to prime the pen before administration, as did another LPN and the Director of Nursing, who confirmed that the procedure requires priming with two units of insulin. The resident involved had a medical history including type 2 diabetes mellitus, generalized osteoarthritis, hypertension, asthma, pain, low back pain, tremors, and repeated falls, and had a physician's order for Humulin KwikPen to be administered daily. The facility's insulin pen procedure, reviewed in August 2020, clearly stated the requirement to prime the pen before each injection.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to a resident who required new dentures. The resident, who had a history of hemiplegia, dysphagia, and dementia, was on a mechanical soft diet due to ill-fitting dentures. Despite the resident's family requesting a dental evaluation and the dental hygienist noting the need for better-fitting dentures, no dentist visited the resident. The dental hygienist's notes indicated that the family requested a dentist to evaluate and possibly make new dentures, but the facility did not follow up on this request. The facility's dental program, which was supposed to provide free dental services to eligible Medicaid recipients, was not effectively communicated or utilized. The Director of Nursing and other staff members were unclear about the enrollment process and responsibilities for scheduling dental appointments. The Medical Records Director confirmed that the dentist had not visited the resident, and the Social Services Director was unaware of the resident's denture needs. The lack of coordination and communication among facility staff led to the resident not receiving the necessary dental care.
Failure to Obtain Proper Arbitration Agreement for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly explain and obtain an appropriate arbitration agreement from a resident with impaired decision-making abilities. The resident, identified as R67, was admitted with multiple diagnoses, including dementia, and was documented as severely cognitively impaired. During an interview, R67 was found to be confused and unable to engage, with a registered nurse confirming the resident's inability to make decisions. Despite this, the facility had R67 sign an arbitration agreement, which was not in compliance with their policy requiring the agreement to be obtained from the resident's representative in cases of cognitive impairment. The admissions assistant, responsible for obtaining arbitration agreements, stated that she contacts the next of kin or the resident's decisional maker if a resident has a cognitive deficit. However, in this case, the arbitration agreement was signed by R67, who was not capable of making such decisions. The admissions director confirmed that the facility's policy mandates obtaining the agreement from a representative when a resident is cognitively impaired. The facility's policy on resident rights emphasizes promoting the exercise of rights for residents facing barriers such as cognitive limitations, which was not adhered to in this instance.
Residents Housed Below Ground Level Without Waiver
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents. During an initial tour, it was observed that these residents were residing on a lower-level floor in rooms below ground level. The facility's Resident Roster confirmed that these residents were indeed housed in rooms on the lower floor. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms located below ground level.
Failure to Implement Pressure Injury Prevention Strategies
Penalty
Summary
The facility failed to implement strategies and equipment to prevent pressure injuries for a resident (R2) with advanced dementia who requires moderate assistance with bed mobility and substantial assistance with all transfers. R2 was admitted to the facility on January 9, 2024, and had a pressure injury to the left heel, diagnosed as unstageable. Despite a physician's order dated February 12, 2024, to apply off-loading boots while in bed every shift, R2 was observed without heel floating boots during an intermittent observation period on April 17, 2024, from 1:00 pm to 3:05 pm. During this time, no staff entered R2's room with the boots, and the boots could not be located when checked by the RN at 3:00 pm. The wound assessment performed by the Wound Doctor on April 10, 2024, showed the wound as worsening, but an assessment on April 17, 2024, indicated improvement. However, the lack of adherence to the physician's order for off-loading boots was confirmed by both the RN and the Wound Care Nurse, who stated that the boots should be on the resident while in bed to prevent the wound from worsening. This failure to follow the prescribed care plan contributed to the deficiency in pressure injury prevention and treatment for R2.
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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