Alta Rehab At Wauconda
Inspection history, citations, penalties and survey trends for this long-term care facility in Wauconda, Illinois.
- Location
- 176 Thomas Court, Wauconda, Illinois 60084
- CMS Provider Number
- 145887
- Inspections on file
- 27
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Alta Rehab At Wauconda during CMS and state inspections, most recent first.
A resident admitted with metabolic encephalopathy, UTI, and Type 2 DM was documented as alert and oriented, but the advance directive section of the face sheet was left blank and no admission notes reflected any discussion of code status with the resident or family. The resident arrived from the hospital wearing a DNR wristband, which the admitting RN removed, and the family reported that no staff asked about the resident’s wishes despite the hospital indicating that advance directive forms would be sent. Later, when the resident was found unresponsive, an RN checked the chart, saw a full code order, and initiated CPR until EMS arrived and a pulse was regained. Staff interviews confirmed that facility protocol requires determining and documenting advance directives at admission, yet the admitting RN did not recall doing so, and the facility record contained a hospital discharge summary listing DNR status alongside a physician order for full code.
A resident admitted for short-term rehab with multiple comorbidities and identified fall risk experienced an unwitnessed fall from the bed onto a landing pad while restless and cognitively impaired. Staff CNAs and an RN later confirmed the fall, but the incident report lacked documentation of required notifications, had no completion date, and the record contained no completed post-fall assessment or subsequent assessments. Despite a facility fall prevention policy requiring post-fall assessment, communication, and implementation of safety interventions, these steps were not documented or clearly carried out for this resident.
A resident in a LTC facility reported verbal abuse by a CNA who was involved in a loud argument with an Activity Aide. The CNA used profanity and derogatory language towards the Aide and the resident who intervened. Multiple residents witnessed the incident, which was loud and disrespectful. The facility's Administrator confirmed disciplinary action against the CNA.
A resident reported witnessing a verbal altercation between a CNA and an Activity Aide, during which the CNA used profanity and pointed a finger at the resident. Despite multiple residents corroborating the incident, the facility's investigation was inadequate, as it did not interview all potential witnesses and relied on incomplete information. The facility's policy for investigating abuse allegations was not followed.
A resident at risk of falling was not safely transferred by a CNA who failed to use a gait belt as required by facility policy. The resident's legs became weak during ambulation, and the CNA assisted her to the floor by holding her pants instead of using the gait belt. The facility's policy mandates the use of a transfer belt, but it was not followed, resulting in a deficiency.
A resident experienced an assisted fall in the bathroom, resulting in a wrist fracture that went undiagnosed for several days due to the facility's failure to conduct a proper assessment and notify the physician or family. The nurse on duty did not document the incident as a fall, leading to a lack of follow-up assessments and communication, contrary to the facility's guidelines.
A resident with a history of falls and multiple health conditions fell from the edge of his bed while a CNA was reaching for his shoes, resulting in a subdural hematoma and requiring sutures. Despite being at high risk for falls and having a care plan that required staff to work in pairs, the resident experienced multiple falls, indicating a failure to implement effective fall prevention measures.
A facility failed to notify a physician before and after holding blood pressure medication for a resident. The resident's MAR indicated that Hydrochlorothiazide and Lisinopril were held on multiple occasions, but the physician was not informed. An LPN stated that the protocol is to contact the doctor when a medication is held. The facility's policy requires notifying the physician and family when treatment is significantly altered.
A resident at risk for pressure ulcers was observed with her heels directly on the mattress, despite orders to offload them using pillows or boots. The resident reported inconsistency in applying pressure-relieving boots, and the Wound RN confirmed the need for offloading. The facility's policy on pressure ulcer prevention was not followed.
A resident with hemiplegia and hemiparesis experienced a decline in hand function due to the facility's failure to implement occupational therapy recommendations for a restorative range of motion program. Despite being discharged from therapy with specific instructions, the resident's care plan and medical records showed no evidence of a restorative program, and the restorative aide confirmed the resident was not receiving such care.
Two residents experienced accidents due to inadequate safety measures and care plan updates. One resident hit her head on a mechanical lift during a transfer, while another fell from a wheelchair due to missing footrests. Both incidents highlight failures in following care plans and ensuring resident safety.
A resident did not receive scheduled doses of morphine due to the facility's failure to reorder the medication in time. The resident, with intact cognition, missed two doses on a specific day. The LPN involved could not recall the reason for the missed dose, and progress notes indicated delays in ordering and receiving the medication. The facility's policy to prevent medication interruptions was not followed.
Two residents on a pureed diet received incorrect portion sizes of pureed stuffed shells due to the use of a #8 scoop instead of the required #6 scoop. This discrepancy was observed during meal preparation and serving, and the facility's policy mandates the use of standardized recipes and appropriate scoop sizes to ensure correct nutrient delivery.
A resident received an extra dose of Norco due to a failure in documentation and communication between staff. The LPN documented the administration of Norco only in the narcotic logbook, not in the MAR, leading the RN to administer an additional dose. This resulted in the resident experiencing increased confusion and being sent to the hospital for evaluation.
The facility failed to supervise residents receiving medications and did not administer medications as ordered for seven of ten residents reviewed. One resident's blood pressure medication was held without proper parameters, and incorrect medication was administered. Multiple residents reported that nurses left medications at their bedside without supervision, and no self-administration assessments were conducted.
Failure to Determine and Document Resident Advance Directives on Admission
Penalty
Summary
The deficiency involves the facility’s failure to determine and document a resident’s advance directives upon admission, as required by facility policy. The resident was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, and Type 2 Diabetes Mellitus, and was documented as alert and oriented to person, place, time, and situation, though forgetful. The face sheet section for advance directives was left blank, and admission nursing documentation did not mention any discussion of advance directives with the resident or family. The resident’s son-in-law reported that the resident arrived from the hospital with a DNR wristband in place, which the admitting nurse removed, and that no staff asked him or his wife about the resident’s wishes regarding advance directives, despite the hospital indicating that advance directive forms would be sent with the resident. Subsequently, when the resident was found unresponsive with no respirations or carotid pulse, the RN on duty checked the medical record, saw an order for full code, and initiated CPR while 911 was called. CPR continued until EMS arrived, and a pulse was eventually regained before transfer to the hospital. Staff interviews, including with the RN who performed CPR, another RN present that morning, the DON, the ADON, and the admitting RN, confirmed that facility protocol requires that advance directives be determined and documented at admission, but the admitting RN did not recall whether this was done for this resident. The hospital discharge summary in the facility record listed the resident’s code status as DNR, while the facility’s physician order sheet contained an order for full code, demonstrating that the resident’s actual wishes regarding code status were not properly identified and documented at admission.
Failure to Assess, Document, and Communicate Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to timely communicate and document a fall, complete a post-fall assessment, perform subsequent assessments, and implement fall-prevention interventions for one resident. The resident was admitted for short-term rehabilitation with a medical history including seizures, anemia, hypertension, anxiety, osteoarthritis of the left wrist, and chronic kidney disease. On admission, a fall risk assessment scored the resident as not at risk for falls, but a subsequent assessment two days later identified the resident as at risk, and the care plan was updated to reflect fall risk. An unwitnessed fall incident occurred when the resident rolled or fell from the right side of the bed onto a landing pad while restless and hard to redirect, and the resident was unable to describe the event due to cognitive deficits. Staff, including a CNA and an RN, later confirmed that the resident had fallen from the bed. The unwitnessed fall report documented the incident time and basic description but lacked documentation of notifications to agencies or people, and there was no documented date of when the incident report itself was completed. Although staff reported that the nurse was called and assessed the resident, the record did not contain a completed post-fall assessment or any subsequent assessments following the fall. The facility’s Fall Prevention Program policy required fall risk assessments upon admission, quarterly, with significant changes, and after any fall incident, as well as implementation of safety interventions and communication with direct care staff, physician, and family/legal representative. The survey findings indicate that these required assessments, documentation, and interventions were not carried out or recorded as required for this resident following the fall event.
Verbal Abuse Incident Involving CNA and Activity Aide
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and an Activity Aide. The incident occurred when a resident overheard a CNA and an Activity Aide arguing in the hallway. The resident attempted to intervene, at which point the CNA allegedly pointed her finger at the resident and used profanity. The resident reported feeling verbally abused by the CNA's actions. Multiple residents witnessed the incident, which involved the CNA yelling at the Activity Aide and using derogatory language. The CNA was accused of calling the Activity Aide derogatory names and belittling her job and age. The CNA's behavior escalated to the point where she also directed profanity at the resident who tried to intervene. Witnesses reported that the CNA's actions were loud and disrespectful, causing concern among the residents present. The facility's Administrator confirmed that the CNA received disciplinary action for swearing and leaving her assigned unit. The facility's Abuse Prevention and Reporting Policy defines verbal abuse as the use of oral, written, or gestured communication that is inappropriate, regardless of the resident's ability to comprehend. The incident was documented in the facility's records, and the resident involved was noted to be cognitively intact.
Inadequate Investigation of Staff Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported witnessing a verbal altercation between two staff members. The incident occurred when a resident overheard a CNA and an Activity Aide arguing in the hallway. The resident attempted to intervene, and the CNA allegedly used profanity and pointed a finger at the resident. Despite the resident's report, the facility did not substantiate the abuse claim, as the administrator concluded it was a staff altercation not directed at the resident. Interviews with the involved resident and other witnesses revealed that the CNA was yelling at the Activity Aide, using derogatory language, and the altercation was loud enough to be heard by other residents. The resident who reported the incident felt threatened and intervened to stop the CNA, who then directed profanity at the resident. Other residents corroborated the account, noting the CNA's aggressive behavior and the potential for the situation to escalate. The facility's investigation was inadequate, as it relied on incomplete information from the manager on duty, who was unavailable for further interviews. The administrator did not interview all potential witnesses, and the social services designee only spoke with the reporting resident. The facility's policy requires a thorough investigation of abuse allegations, including interviews with all potential witnesses, which was not followed in this case.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R2, who was at risk of falling. On the specified date, handwritten signs in R2's room indicated that she was a fall risk and required the use of a gait belt. However, during an incident, R2 was assisted by a Certified Nursing Assistant (CNA), identified as V13, without the use of a gait belt. R2 reported that she was walking with a walker when her legs became weak, and V13 assisted her to the floor without the gait belt, holding onto her pants instead. The Assistant Director of Nursing confirmed that R2 experienced a fall when her knees gave out while being assisted by V13. The facility's policy on ambulation assistance, dated January 15, 2018, mandates the use of a transfer belt during such activities. The Interdisciplinary Team (IDT) Fall Committee Meeting Note indicated that R2's fall was due to her knees giving out, likely related to recent illness, and no injuries were observed. Despite the policy, the CNA did not use the gait belt, leading to the deficiency in providing adequate supervision and safety measures for R2.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to properly assess and monitor a resident after a fall, which was identified during a review of quality of care for one of the three residents sampled. The incident involved a resident who experienced an assisted fall in the bathroom. Despite the resident expressing pain and tingling in her left arm immediately after the fall, the nurse on duty did not perform a comprehensive assessment or notify the physician or family. The nurse did not consider the incident a fall because the resident was lowered to the ground by a CNA, and thus, no documentation or follow-up assessments were conducted. The resident later reported persistent wrist pain, leading to an X-ray that revealed a fracture. The facility's records showed no documentation of the fall in the nursing notes, no initial assessment, and no notification to the physician or family. Additionally, there were no 72-hour post-fall assessments documented. The facility's guidelines require documentation of the incident, assessment, and notification of relevant parties, which were not followed in this case.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident was positioned safely, resulting in a fall that required medical attention. The resident, who had a history of falls and was at high risk due to multiple conditions including dementia and Parkinson's disease, fell from the edge of his bed while a CNA was attending to him. The CNA was reaching for the resident's shoes when the resident, who was impulsive and had a tendency to attempt movements on his own, fell forward and hit his head, leading to a subdural hematoma and requiring sutures. The resident's care plan noted his resistance to care and combative behavior, necessitating staff to work in pairs for safety. Despite these precautions, the resident experienced multiple falls over several months, indicating a lack of effective interventions to prevent such incidents. The facility's fall prevention policy required individualized assessments and appropriate interventions, which were not adequately implemented in this case, as evidenced by the repeated falls and the serious injury sustained by the resident.
Failure to Notify Physician of Held Blood Pressure Medication
Penalty
Summary
The facility failed to notify a physician before and after holding a blood pressure medication for a resident. This deficiency was identified for one resident who was part of a sample of 27 reviewed for notification of changes. The resident's August 2024 Medication Administration Record (MAR) indicated that Hydrochlorothiazide and Lisinopril, both prescribed for essential hypertension, were held on three separate occasions. However, the resident's electronic medical record showed that the physician was not notified on any of these dates. An LPN confirmed that the protocol is to contact the doctor whenever a medication is held. The facility's policy, dated November 13, 2018, requires informing the resident, consulting with the physician, and notifying the resident's legal representative or family when there is a need to alter treatment significantly.
Failure to Implement Pressure Ulcer Prevention for At-Risk Resident
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for a resident at risk for developing pressure ulcers. On multiple occasions, the resident was observed lying in bed with her heels directly on the mattress, contrary to the physician's order and care plan that required her heels to be offloaded using pillows or pressure-relieving boots. The resident expressed uncertainty about the presence of wounds on her heels and noted that the pressure-relieving boots were not consistently applied. The Wound Registered Nurse confirmed that the resident was at risk for pressure ulcers and that her heels should not be directly on the bed. The facility's Pressure Ulcer Prevention Policy also emphasized the use of positioning devices to reduce pressure on vulnerable areas, which was not adhered to in this case.
Failure to Implement Restorative Therapy for Resident with Contracted Hand
Penalty
Summary
The facility failed to follow occupational therapy recommendations for a resident with a contracted hand, leading to a deficiency in maintaining or improving the resident's range of motion. The resident, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was observed with his right hand in a fist-like shape, indicating a worsening condition since his admission. Despite the resident's efforts to perform hand exercises, he reported that the facility did not assist with any exercises for his hand. The occupational therapy assistant confirmed that the resident had been discharged from therapy with recommendations for a restorative range of motion program, which included using a rolled-up towel in his hand and continuing exercises. However, the facility did not implement these recommendations. The resident's restorative observations and electronic medical records showed no documentation of a restorative therapy program, and the resident was not included in any restorative program at the time of the survey. The restorative aide responsible for the resident's hallway confirmed that the resident was not on any restorative program. Additionally, the resident's care plan lacked any plans for restorative or range of motion care, despite the facility's policy outlining the importance of individualized restorative programs for maintaining or regaining independence.
Deficiencies in Resident Safety and Care Plan Updates
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R19, resulting in an accident. R19, a female resident with dementia and anxiety, sustained bruising on her forehead after hitting her head on a mechanical lift during a transfer. The incident occurred when R19 became excited and raised her head, causing it to come into contact with the lift. The care plan for R19 indicated a risk for bruising and required extreme care during transfers, but this was not adequately followed, leading to the injury. Another incident involved a resident, identified as R5, who fell from her wheelchair while being transported by a CNA. R5, who requires substantial assistance and uses a wheelchair, fell forward and hit her face on the ground after putting her foot down due to the absence of footrests on her wheelchair. Despite the fall, R5's care plan was not updated with new interventions to prevent future falls. The lack of footrests during transport was identified as a safety hazard, and the staff was not adequately informed about the necessity of using footrests, contributing to the accident.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident received their routine medication, specifically morphine, as prescribed. The resident, who had intact cognition, was supposed to receive morphine three times a day for pain management. On a specific day, the resident did not receive the 1:00 PM and 9:00 PM doses because the facility ran out of the medication. The resident reported missing these doses due to the facility not reordering the medication in time. The Medication Administration Record confirmed the missed doses, and the Licensed Practical Nurse (LPN) involved could not recall the reason for the missed 1:00 PM dose. Progress notes indicated that a prescription for morphine was sent to the pharmacy after the 1:00 PM dose was due, and the medication was not available for the 9:00 PM dose. The pharmacy confirmed receiving the refill request on the same day, with delivery occurring the following morning. The facility's policy required refilling prescriptions to prevent interruptions, which was not adhered to in this case.
Incorrect Portion Size for Pureed Diets
Penalty
Summary
The facility failed to ensure that residents receiving a pureed diet were provided with the correct portion size of pureed stuffed shells. Specifically, two residents, identified as R390 and R81, were affected by this deficiency. The facility's diet type report confirmed that both residents were on a pureed diet. During the lunch service, a dietary aide, V12, used a #8 scoop instead of the required #6 scoop to serve the pureed stuffed shells, resulting in a portion size of 4 ounces instead of the required 5.33 ounces. This discrepancy was observed during the preparation and serving of meals on the 500, 600, and 700 units. The Food Service Director, V9, acknowledged that staff could use the diet spreadsheet in the kitchen to verify the correct scoop sizes for meal service. However, the dietary aide, V12, admitted to using the incorrect scoop size while pre-plating the pureed meals. The facility's Pureed Food Preparation policy, dated 2020, mandates the use of standardized recipes and appropriate scoop sizes to ensure the correct nutrient density is delivered to each resident. The failure to adhere to these guidelines could potentially lead to residents not receiving the necessary nutrients, as noted by V9.
Medication Administration Error Due to Documentation Oversight
Penalty
Summary
The facility failed to ensure a resident's opioid pain medication was administered as prescribed, resulting in a significant medication error. A resident was given Norco 10/325 mg, an opioid pain medication, three hours after the previous dose, despite the prescription indicating it should be administered every six hours as needed for pain. This error occurred because the RN administering the medication did not check both the electronic Medication Administration Record (MAR) and the narcotic logbook, leading to the resident receiving an extra dose. The resident subsequently exhibited increased confusion and was administered Narcan, a medication to reverse the effects of opioids, but showed no significant improvement and was sent to the hospital for further evaluation. The incident was compounded by documentation errors. The LPN who administered the initial dose of Norco at 6:45 AM documented it only in the narcotic logbook and failed to record it in the MAR. This oversight led the RN to believe no dose had been given recently, prompting the administration of an additional dose at 9:27 AM. The Assistant Director of Nursing confirmed that staff are required to document opioid administration in both the MAR and the narcotic logbook, which was not done in this case. The facility lacked a specific medication administration policy related to the documentation of opioid pain medications, contributing to the oversight.
Failure to Supervise and Administer Medications as Ordered
Penalty
Summary
The facility failed to supervise residents receiving medications and did not administer medications as ordered for seven of ten residents reviewed. Specifically, one resident's blood pressure was recorded as 120/54, and the LPN held both metoprolol and losartan despite only losartan having parameters to be held if blood pressure was less than 110/60. Additionally, the LPN administered sennosides instead of the ordered senna with docusate sodium. The RN confirmed that metoprolol should not have been held without parameters and that losartan should have been administered given the recorded blood pressure. The RN also noted the difference in medication composition between sennosides and senna with docusate sodium, which includes a stool softener. This indicates a failure to follow physician orders accurately and administer the correct medications as prescribed. Multiple residents reported that nurses often left medications at their bedside without supervising their intake. One resident's daughter confirmed that the nurse left medications at the bedside, and the resident had a tendency to hide or discard them. The LPN admitted to leaving medications at the bedside on at least one occasion and was not counseled against this practice. The DON acknowledged that nurses should follow up with residents to ensure they take their medications but admitted that the facility was relying on residents to self-administer without proper supervision. The facility's Pharmaceutical Services policy requires assistance with medication administration and an evaluation for residents to self-administer medications safely. However, the report indicates that no self-administration assessments were conducted for the residents involved. This lack of supervision and failure to follow established protocols led to the deficiency in medication administration and resident safety.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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