Arcadia Care Aledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Aledo, Illinois.
- Location
- 304 S.w. 12th Street, Aledo, Illinois 61231
- CMS Provider Number
- 145886
- Inspections on file
- 53
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Arcadia Care Aledo during CMS and state inspections, most recent first.
A resident entered the dining room and made a provocative statement while walking past three other residents, leading to a loud altercation in which all parties yelled profanities and one resident directed derogatory language and threats such as “I’ll beat your ass” and “nobody wants your man” toward another. Staff, including a housekeeper and an LPN, witnessed the resident moving toward another in a threatening manner and intervened to separate them. Subsequent interviews with multiple residents described a pattern of this resident frequently yelling, talking loudly, and making threats, including threats to have another resident beaten up and to shoot him. One resident reported not feeling safe due to being housed next to the aggressive resident with a shared bathroom, and an LPN identified the incident as verbal abuse under the facility’s own abuse policy.
A resident with dementia, known wandering behavior, and a history of falls was allowed to remain near unit doors despite prior incidents of being struck by those doors. While a dietary cook was bringing in a lunch cart, the resident was standing behind the double doors and was hit when the doors were opened, resulting in a fall and subsequent right femur fracture with hip dislocation. After the fall, the cook and a CNA manually lifted the resident from the floor into a wheelchair without a gait belt or mechanical lift and before an RN/LPN assessment, contrary to the facility’s transfer policy requiring mechanical lifts for residents needing a two-person assist or who cannot be safely transferred by normal technique.
A resident with dementia fell when a dietary staff member opened double doors into the hallway where the resident was standing, causing a change of plane and resulting in the resident landing on the floor with right-sided discomfort. The dietary staff and a CNA then lifted the resident from the floor, stood her up, and placed her in a wheelchair without using a gait belt and before any nurse could perform a post-fall assessment. The LPN later found the resident already in the wheelchair and stated the resident had been moved before she could assess for possible injuries. The DON reported that facility practice requires a nurse to assess a resident after a fall, including ROM, pain, and vital signs, and that residents should not be moved prior to this assessment, consistent with the facility’s fall prevention policy.
A resident with multiple chronic conditions was not assessed for fall risk as required by facility policy, with no documented fall risk assessments completed for several consecutive quarters. This lapse was confirmed by both the DON and a regional RN after the resident sustained a hip fracture from a fall.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Multiple residents with cognitive impairment and behavioral issues were not adequately protected from physical abuse by peers, resulting in altercations and injuries. In one case, a resident was left suspended in a mechanical lift by a staff member, who was observed yelling and using the lift to control the resident's movements. Staff interviews and facility documentation confirmed that supervision and intervention were insufficient, and that the actions taken did not meet expected standards of care.
The facility failed to maintain cleanliness on the tops of stationary kitchen equipment next to food preparation areas. During a kitchen tour, it was observed that the tops of the upright refrigerator and freezer were covered with dirt and debris. The Dietary Manager confirmed that these surfaces should have been cleaned, acknowledging the role of ventilation and air movement in the accumulation of dirt. This deficiency could potentially affect all 38 residents in the facility.
The facility failed to keep the lids of outdoor trash dumpsters closed and secure, allowing potential access by pests and animals. This was observed during a kitchen tour with the Dietary Manager, who confirmed the lids should be closed. The deficiency could affect all 38 residents in the facility.
The facility failed to use standardized diagnosing tools for infections, as required by their Antibiotic/Antimicrobial Stewardship Program. Infection control logs lacked set standards for diagnosing infections, affecting all 38 residents. An LPN/Infection Preventionist acknowledged the absence of tools like McGeer's or Loeb's and planned to implement them. The Medical Director and DON were responsible for setting standards, but this was not adhered to, leading to the deficiency.
The facility failed to justify the use of psychotropic medications for several residents and did not attempt a Gradual Dose Reduction (GDR) for a resident, despite policy requirements. One resident was on Quetiapine without documented behaviors necessitating its use, while another resident's care plan lacked specific behaviors justifying antipsychotic medication. Additionally, a resident on Venlafaxine and Aripiprazole had no documented harmful behaviors, yet no GDR was attempted. The facility's Director of Nursing confirmed the lack of documentation for GDR attempts.
A resident requiring a mechanical lift for transfers was incorrectly transferred using a stand pivot method, leading to a near fall and a broken toe. The facility failed to assess the resident's transfer needs properly, resulting in an injury due to inadequate supervision and accident prevention.
A facility failed to assess and identify triggers for a resident with PTSD, as required by their Behavioral Health Services Program policy. The resident, who also has dementia and psychotic disorder, was not provided with a care plan identifying specific environmental factors triggering their behaviors. Despite the need to gain the resident's trust for background stories, no comprehensive PTSD assessment was completed, and the care plan lacked individualized interventions.
The facility failed to prevent physical abuse between two residents in the Memory Care Unit. On two occasions, one resident approached and struck another, leading to altercations. Staff intervened promptly, and no injuries were noted. Both residents had severe cognitive impairments.
The facility failed to prevent resident-to-resident abuse between two residents in the Memory Care Unit. Despite multiple altercations, effective interventions were not implemented. R2's room was moved, but this did not prevent further interactions with R1. R1 was placed on 15-minute checks instead of 1:1 monitoring, and R1's transfer to a non-secure unit was unsuccessful. No interventions were in place after R1's return to the Memory Care Unit, leaving R2 vulnerable.
A facility failed to notify a physician and obtain treatment orders for a resident with burns and did not investigate or implement fall interventions for two high-risk residents. One resident had untreated burns from spilled hot tea, and both residents experienced multiple falls without proper follow-up or new interventions. The facility lacked a system to track and monitor falls, contributing to inadequate care.
A nurse aide was employed full-time and provided direct care without completing a state-approved training and competency evaluation program. Initially hired as a housekeeper, the aide transitioned to a CNA role but did not pass the required skills competency portion. This oversight affected all residents in the facility.
Two residents at a facility, both identified as high risk for falls, experienced multiple falls due to inadequate supervision and failure to implement necessary interventions. One resident, with severe dementia, suffered a head laceration and hematoma after being left unattended without non-skid footwear. Another resident, with a history of weakness and recent fractures, sustained serious injuries including a fractured hip and pelvis after falling in an unsupervised dining room. Staff shortages and failure to adhere to care plans contributed to these incidents.
A resident with a history of fractures was readmitted to the facility and had an open area on the left buttock noted during the initial skin assessment. The facility failed to document the pressure wound, notify the physician, or obtain treatment orders as required by policy. The wound was later discovered by an LPN, who found a heavily soiled bandage and confirmed no prior assessment or treatment orders were completed.
A resident with severe dementia and anxiety did not receive prescribed Alprazolam due to unavailability, leading to increased agitation. The facility's policy requires documentation of omitted doses, but none was provided. The DON confirmed the medication was not ordered or delivered, and alternative sources were not utilized.
A resident with MRSA in her leg wound was not administered a prescribed antibiotic, Linezolid, in a timely manner after returning from the hospital. The medication was delivered late, and the first dose was given 35 hours after the last hospital-administered dose, contrary to the facility's Medication Administration Policy.
A resident's physician-ordered lab tests were not collected on time, leading to a rescheduled appointment with an infectious disease physician. The DON confirmed the tests were delayed due to a lack of awareness and repeated failures by the lab to process the orders, despite multiple follow-up calls by a nurse.
The facility failed to label residents' clothing in a dignified manner, using black markers that bled through and smeared on the fabric, affecting the quality and readability of the labels.
The facility failed to address and resolve multiple resident grievances, including issues with missing laundry, call light response times, maintenance requests, and transportation. The Resident Council President reported that residents do not receive feedback on their complaints, leading to repeated unresolved issues.
The facility failed to post the daily direct care staff hours and resident census, potentially affecting all 44 residents. The DON was unaware of the requirement and had not posted the data since starting in March 2024. Subsequent checks also found no posted data, and no policy on staff posting was provided by the time of the Exit Conference.
The facility failed to maintain clean kitchen equipment, properly date cooked food items, and monitor and record required temperatures and sanitation levels. These deficiencies were observed during a survey, with missing logs and undated food items noted. The kitchen staff confirmed these lapses, potentially affecting all 44 residents.
The facility failed to place appropriate signage for transmission-based precautions for a resident with MRSA and lacked interventions and documentation for Legionella management. The Infection Control Plan and QAPI Agenda did not include a Legionella prevention policy, potentially affecting all residents.
The facility failed to implement an antibiotic stewardship program, including assessing and monitoring residents for infections, ensuring appropriate antibiotic usage, and using recognized surveillance criteria. The DON/ICP did not formally track or document infection control practices or conduct reports, affecting all 44 residents.
The facility failed to designate a qualified infection preventionist responsible for the Infection Prevention and Control Plan. The designated Infection Preventionist, who was also the DON, had not completed the required specialty training. This deficiency has the potential to affect all 44 residents in the facility.
The facility failed to offer and document required immunizations for five residents, as per their policy. The records for these residents lacked documentation for influenza and/or pneumococcal vaccinations, and refusals were not properly recorded.
The facility failed to ensure the memory care unit had warm water and was clean and free of odors for 19 residents. Observations revealed pungent urine odors, sticky floors, and debris in several rooms. Staff confirmed the lack of hot water for about a year, and maintenance issues were not addressed due to high repair costs. The facility's policies on water temperature monitoring and housekeeping were not followed.
An LPN was observed pre-popping medications and storing them in medication cups labeled only with residents' first names, contrary to facility policy. The DON confirmed that medications should be administered immediately after verification.
The facility failed to notify the Ombudsman monthly of a resident transfer to the hospital and did not provide the resident and their representative with a written notice of transfer. The Social Services Director confirmed these omissions.
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. The Social Services Director confirmed that neither the resident nor the resident's representative received the required bed hold policy or written notice of transfer.
The facility failed to monitor a physician's order for self-catheterization and did not update a resident's care plan to reflect self-catheterization needs. The resident, diagnosed with Hereditary Spastic Paraplegia and Neurogenic Bladder, had a physician's order for self-catheterization that was not included in the current Physician Order Sheet, and the care plan lacked documentation addressing these needs. A lab test showed the resident had a UTI with Escherichia Coli. The DON confirmed the missing documentation.
The facility failed to obtain a physician's order for dialysis treatments, did not update the care plan for a resident receiving dialysis services, and did not assess the resident's dialysis fistula for hemorrhage post-dialysis. The resident, who has End Stage Renal Disease, reported that the nurse never monitors the fistula after dialysis. The Director of Nurses confirmed these deficiencies.
A resident with a PICC line for Vancomycin to treat MRSA had several doses missed, as documented in the MAR. Despite the facility's policy to notify the physician of missed doses, this was not done. Interviews with nursing staff revealed a lack of communication and accountability, with the DON unaware of the issue.
The facility failed to prevent resident-to-resident sexual abuse when a resident with severe cognitive impairment was inappropriately touched by another resident in the dining room. The incident was observed by an Activities Aide and reported to the DON, who separated the residents and involved Social Services. The offending resident was moved to a different hallway.
The facility failed to update the care plans of two residents following an incident of resident-to-resident sexual abuse. Despite immediate actions taken to separate the residents and involve social services, the care plans were not revised to include the incident or necessary interventions, as confirmed by the Director of Nursing.
A resident with dementia fell and sustained a head injury, but the facility failed to notify the family as required. The resident's Health Care Power of Attorney and second emergency contact were not informed by the facility, leading to frustration and disbelief when they learned of the incident from a hospice nurse. The facility's registered nurse did not follow the established protocol for notifying family members.
The facility failed to monitor and implement new interventions for two residents after falls, and did not assess a resident's suicidal statement. One resident's neurological assessments were incomplete, and no new fall prevention measures were documented. Another resident expressed a desire to die after a fall, but no psychological assessment or increased monitoring was conducted. The DON confirmed these oversights, attributing them to previous staff members.
The facility failed to ensure accurate controlled medication inventory counts, proper double-locking of refrigerated medications, and accurate reconciliation of tracking sheets, affecting residents with controlled medication orders. A missing Hydrocodone dose was not immediately reported, and a leaking Morphine bottle was mishandled, with confusion over its documentation.
A resident's Hydrocodone-Acetaminophen medication was misappropriated when a nurse was found impaired, leading to a missing dose. The DON and another RN discovered discrepancies in the medication count, but the control sheet was lost, and two tablets remained unaccounted for, indicating a failure in the facility's medication management.
The facility failed to verify the nursing license status of an LPN prior to employment, resulting in the LPN working multiple shifts despite having a suspended license. This oversight has the potential to affect all 48 residents in the facility.
The facility failed to have a licensed Administrator and did not thoroughly investigate an incident involving used needles and a suspicious substance. The Administrator in Training had been in training for years without a license and did not investigate reports of suspicious behavior by an LPN. The LPN continued to work until it was discovered she did not have a valid nursing license.
Failure to Protect Residents From Verbal Abuse During Dining Room Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect four residents from verbal abuse during an altercation in the dining room. According to the facility’s final report and multiple staff and resident interviews, one resident (R1) entered the dining room and made an unclear or provocative statement while walking past three other residents (R2–R4). Witnesses, including a housekeeper and an LPN, reported that R1 and the other residents began yelling profanities and derogatory terms at each other. Statements indicated that R1 called another resident a “bitch” and “ho,” said “nobody wants your man,” and threatened to “beat [her] ass,” while R3 and R4 yelled profanities back. Staff observed R1 moving toward R3 in a threatening manner, requiring physical intervention by staff to keep them separated. The facility’s own abuse policy defines verbal abuse as willful use of disparaging or derogatory language, including threats of harm. Resident interviews conducted after the incident further described a pattern of verbally aggressive and threatening behavior by R1 toward other residents. R2 stated that R1 started the dining room incident, talked loudly, yelled at people, and threatened them frequently. R3 and R4 reported that R1 “flipped out” while they were sitting and “minding their own business,” that R1 went after R3 and had to be stopped by staff, and that there was a history of R1 threatening to have R4 beaten up and to shoot him. R3 stated she did not feel safe because R1’s room was next to hers with a shared adjoining bathroom, and that she did not feel safe even with staff monitoring in the hallway. An LPN interviewed by surveyors characterized the incident as verbal abuse, consistent with the facility’s definition, due to the yelling, cursing, and threats directed at other residents. These events demonstrate that residents were subjected to verbal abuse and were not adequately protected from such abuse by the facility.
Failure to Prevent Door-Related Fall and Unsafe Post-Fall Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dementia, identified as a wanderer with a history of falls and a prior right hip fracture, was adequately supervised and kept away from the dementia unit doors, despite known risks. The resident’s care plan documented risk factors requiring monitoring and interventions such as disguising exits, covering doorknobs and handles, and distracting the resident from wandering. Staff and the resident’s son reported that the resident had previously been struck by the same unit doors without injury, and staff were aware that the resident tended to stand behind the doors. On the date of the incident, a dietary cook entered the code and pushed open the double doors to bring in a lunch cart, did not see the resident standing in the crack between the door and the wall, and the door hit the resident, causing her to fall. An emergency room radiology report later showed a right femur fracture and right hip dislocation. The facility also failed to ensure a safe transfer of the resident after the fall. After the resident was found sitting on the floor by the doors, the dietary cook and a CNA lifted the resident from the floor without using a gait belt or any assistive device and placed her into a wheelchair, even though the resident could only bear weight on one leg. Both staff later acknowledged that they did not use a gait belt, that moving the resident before a nurse assessed her could worsen any injury, and that it was not safe to transfer her in this manner. The facility’s transfer policy stated that mechanical lifting devices should be used for any resident needing a two-person assist or who could not be transferred comfortably and safely by normal transfer technique, and that manual lifting was not permitted except in emergency or unavoidable circumstances.
Resident Moved After Fall Without Prior Nursing Assessment
Penalty
Summary
The facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred. The resident had been admitted with a primary diagnosis of unspecified dementia without behavioral, psychotic, mood disturbance, or anxiety features. An incident report documented that the resident was ambulating in the hallway behind double doors when the doors were opened, causing a change of plane and resulting in the resident falling, with noted discomfort to the right side. The dietary cook reported that she pushed the lunch cart through the double doors after entering a code and did not see the resident positioned by the crack between the door and the wall. When the door opened, the resident fell. Following the fall, the dietary cook went to get a CNA, and together they picked the resident up from the floor, stood her up, and placed her in a wheelchair, without using a gait belt and before a nurse could assess the resident. The CNA confirmed that she stood the resident up and transferred her to a wheelchair without a gait belt and acknowledged that moving the resident before a nurse assessment could worsen any injury. The LPN stated she returned from break to find the resident already in a wheelchair and that the aides had gotten the resident up before she could perform an assessment, noting they should not have moved the resident in case of a possible broken hip. The DON stated that after a fall, the nurse should perform an assessment first, including range of motion, pain level, and vital signs, and that the resident should not be moved prior to this assessment. The facility’s fall prevention policy indicated that transfer conveyances should be used in accordance with the care plan, and the DON noted there was no specific checklist for post-fall assessments.
Failure to Complete Required Fall Risk Assessments
Penalty
Summary
The facility failed to complete required fall risk assessments for one resident who was admitted with multiple diagnoses, including Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia. The resident experienced a fall resulting in a right hip fracture. According to the facility's Fall Prevention Program policy, a fall risk assessment should be performed at least quarterly, upon admission, after any fall, and with any significant change in condition. However, the resident's medical record did not contain documentation of a fall risk assessment from November 2024 through August 2025. This lack of assessment was confirmed by both the DON and a regional RN, who verified that the required quarterly assessments were not completed during this period.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. 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 Protect Residents from Abuse and Inappropriate Use of Mechanical Lift
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by both other residents and a staff member. Several incidents were documented in which residents with cognitive impairments and behavioral issues engaged in physical altercations. In one case, a resident with severe cognitive impairment and behavioral symptoms pushed another resident, resulting in a fall and injury. Staff interviews confirmed that the residents involved had a history of wandering and aggression, and that staffing levels were low, with only one aide and one nurse on the night shift, making supervision and intervention challenging. Another incident involved a resident being physically assaulted by a peer who accused him of theft. The staff responded quickly to separate the residents, and no physical harm was reported in this case. However, the facility's documentation and staff interviews indicated that the resident who initiated the altercation had escalating behaviors, including a subsequent arrest for staff assault, and required psychiatric care and one-to-one observation upon return to the facility. Additionally, a staff member was observed using a mechanical lift to keep a resident suspended above his bed, allegedly to prevent him from getting out of bed. Witnesses reported the staff member yelling at the resident and expressing frustration, while the staff member claimed he was changing bed linens and waiting for assistance. The facility's investigation confirmed that the use of the lift was inappropriate and did not meet the expected standards of care, as the resident was left in the lift as a means of control rather than for a legitimate care purpose.
Unclean Kitchen Equipment Surfaces
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, specifically on the tops of stationary kitchen equipment adjacent to food preparation areas. During an initial kitchen tour, it was observed that the tops of the upright refrigerator and freezer were covered with dirt and debris. These pieces of equipment were located next to food preparation tables, which could potentially affect the sanitary conditions of food preparation. The Dietary Manager confirmed that the tops of the equipment should have been cleaned, acknowledging that ventilation and air movement contributed to the accumulation of dirt and debris. This deficiency has the potential to impact all 38 residents residing in the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the lids of the trash dumpsters located outside were closed and secure, which is necessary to prevent pests and animals from accessing discarded food and trash. This deficiency was observed during an initial kitchen tour conducted with the Dietary Manager. The large, steel trash dumpster was found with its lids open and was not secured by any walls or access doors. The Dietary Manager confirmed that the lids should be kept closed to prohibit access by pests and animals. This oversight has the potential to affect all 38 residents residing in the facility.
Failure to Implement Standardized Infection Diagnosis
Penalty
Summary
The facility failed to implement a standardized method for determining the presence of infections, which is a critical component of their Antibiotic/Antimicrobial Stewardship Program. The policy of the facility, dated 10/24, emphasizes the importance of using standardized diagnosing tools to ensure appropriate antibiotic use, improve patient outcomes, and reduce healthcare costs. However, the facility's infection control logs for December 2024, January, and February 2025 did not reflect any set standards for diagnosing infections. This oversight has the potential to affect all 38 residents currently residing in the facility. During an interview on 3/12/25, the Licensed Practical Nurse/Infection Preventionist acknowledged the absence of standardized diagnosing tools, such as McGeer's or Loeb's criteria, and expressed an intention to implement them immediately. The facility's policy assigns the Medical Director the responsibility of setting antibiotic prescribing standards and reviewing antibiotic use data, while the Director of Nursing and the Infection Control Officer are tasked with setting standards for assessing and monitoring residents' conditions. The lack of adherence to these responsibilities contributed to the deficiency identified by the surveyors.
Failure to Justify Psychotropic Medication Use and Attempt Gradual Dose Reduction
Penalty
Summary
The facility failed to provide appropriate indications for the use of psychotropic medications for four residents, and did not attempt a Gradual Dose Reduction (GDR) for one resident. The facility's policy requires that psychotropic medications be used only when necessary and that GDRs be attempted at least twice yearly unless contraindicated. However, the facility did not document behaviors that necessitated the use of these medications for residents R15 and R29, and failed to attempt a GDR for resident R2, despite the absence of documented harmful behaviors. Resident R15 was receiving Quetiapine for unspecified dementia with agitation, but the care plan did not identify specific behaviors requiring the use of this antipsychotic medication. Observations showed that R15 was easily reassured and redirected, and the behavior monitoring report documented various behaviors such as entering other residents' rooms and expressing frustration, but these were not linked to the use of the medication. Similarly, resident R29 was prescribed Quetiapine for senile degeneration of the brain, but the care plan did not specify behaviors justifying the medication. Observations indicated that R29 was mostly calm and cooperative, with occasional instances of refusing care and expressing frustration. Resident R2, who was on Venlafaxine and Aripiprazole for bipolar disorder, had no documented harmful behaviors in the past year. The facility did not attempt a GDR, citing clinical contraindications, but there was no documentation of any GDR attempts in the past year. The Director of Nursing confirmed the lack of documentation and noted that R2 typically did not exhibit behaviors warranting the use of antipsychotics, aside from occasionally refusing care.
Inadequate Resident Transfer Assessment Leads to Injury
Penalty
Summary
The facility failed to properly assess a new resident's transfer needs, leading to an inappropriate transfer method being used. The resident, identified as R27, was initially documented as requiring a mechanical lift for all transfers. However, the Director of Nursing (DON) instructed staff to use a stand pivot transfer with two-person assistance, without any doctor's order or assessment to support this method. This incorrect transfer method resulted in a near fall incident where the resident's right foot was dragged across the floor, causing pain and bruising. Subsequent nurse's notes and an x-ray confirmed that the resident suffered a broken toe due to the incident. The resident expressed fear of falling during the transfer, and it was noted that five staff members were needed to stabilize and eventually transfer the resident back to bed using a mechanical lift. The lack of a proper assessment and the incorrect transfer method directly contributed to the resident's injury, highlighting a deficiency in the facility's supervision and accident prevention measures.
Failure to Assess PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and identify triggers for a resident with a primary diagnosis of PTSD, as required by their Behavioral Health Services Program policy. The policy mandates that the facility should identify any previous history of mental illness, trauma, and other related disorders to develop an individualized plan of care. However, the facility did not conduct a comprehensive PTSD assessment for the resident, who was admitted with PTSD as a primary diagnosis. The Social Services Director acknowledged that attempts should have been made to assess the resident for history of trauma and triggers, but no such assessments were completed. The resident, who also has diagnoses of dementia, psychotic disorder, and experiences social isolation, hallucinations, and delusions, was not provided with a care plan that identified specific environmental factors triggering their behaviors. The Behavioral Practitioner noted the resident's chronic PTSD and the need to gain the resident's trust to obtain background stories, but the Trauma Informed Care assessment was refused by the resident. Despite this, the care plan did not reflect any identified triggers or individualized interventions, which is a requirement for residents with PTSD according to the facility's policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents in the Memory Care Unit. On two separate occasions, one resident approached another and made physical contact with closed hands. The first incident occurred when one resident was talking to another, and the aggressor approached and struck the resident on the shoulder. Staff intervened immediately, and no visible injuries or psychosocial needs were noted. Both residents involved had severe cognitive impairments, as indicated by their low BIMS scores. In a subsequent incident, the same two residents were involved in another altercation. The aggressor again approached the other resident and made contact with closed hands. The resident attempted to defend herself by striking back and using a wet floor sign. Staff separated the residents promptly, and no injuries or psychosocial needs were observed. Both residents remained at their baseline condition following the incidents.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to initiate appropriate interventions to prevent resident-to-resident abuse involving two residents, R1 and R2, in the Memory Care Unit. R1, diagnosed with Dementia without Behavioral Disturbance and other mood disorders, and R2, diagnosed with Unspecified Dementia with Agitation, were involved in multiple altercations. On 11/29/24, R1 struck R2 on the shoulder, and on 12/2/24, another altercation occurred where both residents made contact with each other. Despite these incidents, the facility did not implement effective interventions to prevent further interactions between R1 and R2. The facility's response to these incidents was inadequate. Although R2's room was moved to another wing on 12/2/24, this intervention did not prevent further interactions with R1, as R2 continued to wander into other residents' rooms, including R1's. The care plan for R2 did not address the incidents of being struck by R1 or include any interventions to ensure R2's safety from R1. Additionally, R1 was placed on 15-minute checks instead of the recommended 1:1 monitoring, and this was not documented in R2's care plan. Further complicating the situation, R1 was moved to a non-secure unit on 12/19/24, which was unsuccessful due to R1's elopement risk, leading to R1's return to the Memory Care Unit on 12/28/24. No interventions were implemented to keep R1 away from R2 after R1's return, leaving R2 vulnerable to further interactions. The facility's failure to implement and document effective interventions and monitoring contributed to the ongoing risk of resident-to-resident abuse.
Failure to Address Burns and Falls in Residents
Penalty
Summary
The facility failed to notify the physician and obtain wound treatment orders for a resident who sustained second-degree burns. The resident, who has a diagnosis of mild intellectual disability, spilled hot tea on her lap, resulting in burns that were not treated or seen by medical staff. Despite the burns being reported to an agency LPN and the emergency department, there was no documentation of physician orders, measurements, or treatments for the burns until several weeks later. The facility's policy requires immediate notification and treatment for such injuries, which was not adhered to in this case. Additionally, the facility failed to investigate, monitor, and implement new fall interventions for two residents who were at high risk for falls. One resident experienced multiple falls, including incidents where she sustained a laceration to the forehead and was found lethargic, requiring Narcan administration. Despite these incidents, there were no follow-up vital signs documented for 72 hours post-fall, and no new interventions were implemented to prevent further falls. The facility's policy mandates thorough investigation and documentation of falls, which was not followed. Another resident also experienced multiple falls, including an unwitnessed fall and an incident where she was found with a cut on her forehead. Similar to the first resident, there was no investigation or post-fall interventions documented, and follow-up vital signs were not recorded. The facility lacked an accurate system to track and monitor falls, which contributed to the failure to address the residents' fall risks adequately.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that nurse aides providing direct patient care were not employed full-time for more than four months without successfully completing a state-approved training and competency evaluation program. This deficiency was observed when V4, a nurse aide, was seen working with residents on the secured unit. V4's personnel file indicated that she was eligible to work according to the Illinois Department of Public Health - Health Care Worker Registry, but her certification program information was incomplete, with no record of training or competency evaluation. V4 was initially hired as a housekeeper and later transitioned to a Certified Nurse Aide role. Despite enrolling in a CNA program, V4 did not pass the required skills competency portion. The Director of Nursing/Administrator in Training confirmed that V4 was employed full-time as a CNA and provided direct care, including toileting, transferring, and feeding residents, without completing the necessary state-approved competency training program. This oversight had the potential to affect all 44 residents in the facility.
Failure to Prevent Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of falls for two residents, R1 and R2, who were identified as high risk for falls. R1, who had severe dementia with agitation and was legally deaf, experienced multiple falls due to inadequate supervision and lack of proper footwear. Despite being assessed as high risk for falls, R1 was left unattended on several occasions, resulting in injuries including a laceration to the head and a hematoma. The staff failed to ensure R1 was under direct supervision and wearing non-skid footwear, as required by the care plan. R2, admitted with a history of weakness and recent fractures, also experienced falls due to insufficient supervision. R2's fall in the dining room, where no staff were present, resulted in serious injuries including a fractured right hip, pelvis, and T12 compression fracture. The facility's failure to provide adequate supervision, as documented in R2's care plan, contributed to these incidents. Staff interviews revealed that there were not enough personnel present to monitor residents effectively, leading to R2 being left alone and unsupervised. The facility's policy on fall prevention, which mandates staff to observe residents for safety and implement appropriate interventions for those at high risk, was not adhered to. The lack of adequate staffing and supervision, as well as the failure to follow care plans and ensure the use of non-skid footwear, directly contributed to the falls and subsequent injuries sustained by R1 and R2.
Failure to Assess and Treat Pressure Wound
Penalty
Summary
The facility failed to properly assess, notify the physician, and obtain a treatment order for a newly identified pressure wound on a resident's left buttock. The facility's policy requires that upon notification of skin breakdown, the pressure area should be assessed, documented, and the physician notified for treatment orders. However, this protocol was not followed for the resident, who was readmitted to the facility with a history of fractures and was noted to have an open area on the left buttock during the initial skin assessment. Despite the presence of the wound, there was no documentation of the pressure wound in the resident's Treatment Administration Record, nor was there a physician's order for its treatment. The wound was only discovered later by an LPN who found a heavily soiled bandage on the resident's left buttock, revealing a Stage 2 pressure wound. The LPN confirmed that she was unaware of the wound and that no previous assessment, physician notification, or treatment orders had been completed.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to obtain and administer physician-ordered medication for a resident diagnosed with severe dementia, agitation, and anxiety. The resident was prescribed Alprazolam, an anti-anxiety medication, to be taken three times daily. However, the medication was not administered on multiple occasions, specifically on June 29, June 30, July 1, and July 2, 2024, at the scheduled times of 8:00 A.M., 12:00 P.M., and 4:00 P.M. The facility's Medication Administration policy requires documentation of any omitted doses, but no such documentation was present for these dates. The Director of Nurses confirmed the omission of doses due to the unavailability of the medication, stating that the hospice nurse was supposed to order the medication, but it was not delivered. The facility had options to obtain the medication from an emergency box or local pharmacies like Walmart or CVS, but these were not utilized. An LPN also confirmed the medication was unavailable during their shifts, leading to increased agitation and anxiety in the resident. The facility's failure to ensure the availability and administration of the prescribed medication resulted in a deficiency in pharmaceutical services provided to the resident.
Failure to Administer Timely Antibiotic Medication
Penalty
Summary
The facility failed to administer a physician-prescribed antibiotic medication to a resident diagnosed with lower extremity cellulitis. The resident, who had Methicillin Resistant Staphylococcus Aureus (MRSA) in her leg wound, was discharged from the hospital with an order to take Linezolid 600 mg by mouth every twelve hours for seven days. The resident returned to the facility on June 15, 2024, at 1:45 PM, but the medication was not administered until 8:00 PM on June 16, 2024, resulting in a 35-hour gap between doses. The facility's Medication Administration Policy requires medications to be prepared and administered within one hour of the designated time or as ordered, using the six rights of administration. The Director of Nursing confirmed that the medication should have been delivered and administered as scheduled. The delay occurred because the medication was not delivered to the facility until 7:32 PM on June 15, 2024, and the first dose was not given until the following evening, leading to a significant medication error.
Failure to Timely Collect Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were collected as scheduled for a resident who was being monitored for infections. The resident had a physician order for a complete blood count (CBC), basic metabolic panel (BMP), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) test to be collected on a specific date and sent to an infectious disease physician. However, the laboratory tests were not collected until three days after the scheduled date, resulting in the rescheduling of the resident's appointment with the infectious disease physician. The Director of Nursing confirmed that the laboratory tests were supposed to be drawn on the scheduled date to coincide with the resident's appointment. The delay in collecting the laboratory tests was attributed to a lack of awareness of the orders by the nursing staff and repeated failures by the laboratory to process the orders despite multiple follow-up calls by a registered nurse. The nurse confirmed that she had ordered the tests as STAT and had contacted the laboratory multiple times, but the tests were still not drawn in a timely manner.
Undignified Labeling of Residents' Clothing
Penalty
Summary
The facility failed to ensure residents' clothing was labeled in a dignified manner. During a tour of the Laundry Department, the Housekeeping Supervisor stated that the facility no longer provides labels for residents' clothing and instead uses a black marker to write names on the inside of the clothing. This method is problematic as it is difficult to read on dark clothing and can ruin nicer articles of clothing. Observations showed multiple pieces of clothing with residents' names or initials written on the collars. During a Resident Council Meeting, two residents demonstrated how the marker had bled through and smeared on their white tops. Another resident was observed with black marks that had bled through the collar of their gray t-shirt.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances or recommendations from residents were considered, addressed, and acted upon. The Resident Grievances/Complaints policy outlines that complaints and grievances should be directed to the appropriate Department Head and resolved within 15 days, with the Administrator receiving copies of the minutes for follow-up. However, multiple grievances documented in the Resident Council Meeting Minutes, such as missing clothes, call light issues, maintenance requests, and transportation issues, were not properly investigated or resolved. The reports lacked documentation of an investigation, resolution, and notification to the residents about the outcomes. The Resident Council President stated that residents do not receive verbal or written reports about the initiation or resolution of their complaints/grievances. The President expressed frustration that the same issues are repeatedly brought up without resolution. Specific grievances included missing laundry, no heat in the dining room, and ants in the building, among others. Despite these complaints being documented, there was no evidence that the facility took appropriate actions to investigate and resolve them, leading to ongoing dissatisfaction among the residents.
Failure to Post Daily Direct Care Staff Hours and Resident Census
Penalty
Summary
The facility failed to post the daily direct care staff hours and resident census, potentially affecting all 44 residents. During a tour on 6/2/24 at 9:15 AM, no daily nursing hour data and census sheet were observed throughout the building. The Director of Nursing (DON) stated at 12:00 PM that she was unaware of the requirement to post this information and confirmed that she had not done so since starting in March 2024. Subsequent checks on 6/3/24, 6/4/24, and 6/5/24 also found no posted data. The facility did not provide a policy on staff posting by the time of the Exit Conference on 6/5/24. The CMS Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 6/5/24 and signed by the Administrator, documented 44 residents in the facility.
Deficiencies in Kitchen Sanitation and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that the kitchen equipment was clean and free of debris, and did not properly date cooked food items to ensure they were used before expiration. Additionally, the facility did not monitor and record the required refrigerator and freezer temperatures, food temperatures of served foods, and the required dishwasher sanitation levels. These deficiencies were observed during a survey, where undated food items and missing thermometers were found in the kitchen and food storage areas. The facility's policies on refrigerator and freezer storage, dish machine sanitation, and food storage were not followed, leading to these lapses in compliance. During the survey, it was noted that the facility's logs for refrigerator and freezer temperatures, sanitizing solution checks, and dishwasher temperature/sanitizer levels were incomplete or missing for several dates. The kitchen staff verified these missing logs and checks. The facility's room roster confirmed that 44 residents were currently residing in the facility, all of whom could potentially be affected by these deficiencies. The observations and interviews with the kitchen staff highlighted significant gaps in the facility's adherence to its own policies and procedures regarding food safety and sanitation.
Deficiencies in Infection Control and Legionella Management
Penalty
Summary
The facility failed to place appropriate signage in a conspicuous location to clearly identify the category of transmission-based precautions, instructions for PPE, and/or instructions to see the nurse prior to entering a resident's room. This deficiency was observed for one resident who required transmission-based precautions due to a diagnosis of MRSA in leg wounds. Despite the resident's readmission with this diagnosis, the room lacked the necessary signage between specific dates, which could lead to improper handling and increased risk of infection transmission. Additionally, the facility failed to have interventions in place to mitigate the growth and spread of Legionella and did not maintain logs of these interventions. The Director of Nursing/Infection Preventionist indicated that the Maintenance Supervisor was responsible for Legionella management, but the only documentation provided was a log of water flushes. The facility's Infection Control Plan and Quality Assurance Performance Improvement (QAPI) Agenda lacked inclusion of a Legionella prevention policy, monitoring measures, and a flow diagram of the building's water system. This oversight has the potential to affect all residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections, ensuring antibiotic usage was appropriate, and using a nationally recognized surveillance criteria to define infections. This deficiency was identified for three residents reviewed for the Antibiotic Stewardship Program out of a sample of 43 residents. The facility's Infection Control Surveillance and Monitoring policy, dated 4/11/22, outlines the procedures for routine surveillance and monitoring to ensure compliance with infection control practices. However, the Director of Nursing/Infection Control Preventionist (DON/ICP) admitted to not formally tracking or documenting observations of infection control practices and not conducting any reports since starting in March. Additionally, residents treated for infections were not tracked or trended according to caregivers, locations, or other sources that could be controlled, and antibiotic usage was not reviewed. The findings indicate that the facility's failure to adhere to its own infection control policy has the potential to affect all 44 residents residing at the facility. The DON/ICP's lack of formal audit processes and failure to track and trend infections and antibiotic usage contributed to the deficiency. The facility's policy requires the DON/ICP and/or Administrator to maintain records of surveillance and monitoring, but this was not being done, leading to a lack of proper infection control and antibiotic stewardship within the facility.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the Infection Prevention and Control Plan. The facility's policy required at least a part-time Infection Control Preventionist, which could be the Director of Nursing (DON) with an approved Infection Control Certification. However, the designated Infection Preventionist, who was also the DON, had not completed the required specialty training in Infection Prevention and Control. This was confirmed through interviews with the DON and the Administrator, who stated that the DON had not had time to complete the training due to other responsibilities. This deficiency has the potential to affect all 44 residents in the facility.
Failure to Document and Offer Required Immunizations
Penalty
Summary
The facility failed to offer and document immunizations and vaccinations for five residents as per their policy. The policy, dated 5/19/23, requires verification of the last vaccination date, assessment of vaccination status upon admission, and documentation of immunizations on the resident's Immunization Record and Medication Administration Record. However, the records for five residents lacked documentation that the influenza and/or pneumococcal vaccinations were offered, given, or refused. Specifically, the records for residents R12, R14, R39, R40, and R96 were missing this critical information. Additionally, the facility's Infection Preventionist/Director of Nursing confirmed that the immunizations should be documented but acknowledged that refusals were not properly recorded, either through signed declinations or verbal documentation. Resident R12's Immunization Record did not show any documentation regarding the influenza vaccination. Similarly, R14's record lacked documentation for the influenza vaccination. For residents R39 and R40, there was no documentation for either the influenza or pneumococcal vaccinations. R96's record was missing documentation for the pneumococcal vaccination. The Infection Preventionist/Director of Nursing admitted that while R39 and R40 had refused the influenza vaccination, this refusal was not documented properly, raising questions about the facility's adherence to its own immunization policy.
Failure to Maintain Safe and Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to ensure the memory care unit had warm water and was clean and free of odors for 19 of 42 residents. During a tour, it was observed that the hallway and several rooms had pungent urine odors, sticky floors, and debris. Specific rooms had additional issues such as a bucket with brownish/black liquid and feces smeared on various surfaces. The joint bathroom between two rooms had the hot water knob turned off, resulting in only cold water being available. Maintenance staff confirmed that the hot water had been turned off for a while and that the pipes needed to be re-routed, a task that had not been scheduled for repair due to high costs. Interviews with staff revealed that the lack of hot water had been an ongoing issue for approximately a year. CNAs reported that they had to use cold water for handwashing and resident care, as the dietary staff did not consistently fill the orange jug with hot water. The Director of Nursing and the Housekeeping Supervisor both acknowledged the problem, with the latter stating that CNAs were supposed to clean the bucket in one of the rooms every two hours, but often did not. Maintenance staff also confirmed that the hot water issue had not been addressed due to the need for extensive and costly repairs. The Administrator confirmed that the Dementia Unit had been without hot water for about a year and that the necessary repairs would cost over $60,000. The lack of hot water and the unsanitary conditions in the memory care unit were not addressed promptly, leading to a failure in providing a safe, clean, and comfortable environment for the residents. The facility's policies on water temperature monitoring and housekeeping were not followed, contributing to the deficiencies observed during the survey.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were stored in their original packaging with proper labels until administered for four residents. An Agency Licensed Practical Nurse (LPN) was observed pre-popping medications and storing them in medication cups labeled only with the residents' first names. The LPN admitted to pre-popping the medications and storing them in the cart, despite knowing it was against policy. The Director of Nursing (DON) confirmed that nurses should not pre-pour medications and should administer them immediately after verifying the medication, label, and date.
Failure to Notify Resident and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and did not provide the resident and resident representative with a written notice of transfer. Specifically, a resident was transferred to a local hospital, and there was no evidence of a facility notification to the resident of the transfer/discharge in the resident's chart. The Social Services Director confirmed that the facility did not provide the resident or their representative with a written notice of transfer and also did not send notification to the local Ombudsman of monthly facility transfers/discharges.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. Specifically, the medical record of a resident who was hospitalized on an unspecified date did not contain documentation of written notice of the facility's bed hold policy. This deficiency was confirmed by the Social Services Director, who verified that neither the resident nor the resident's representative received the required bed hold policy or written notice of transfer.
Failure to Monitor Self-Catheterization and Update Care Plan
Penalty
Summary
The facility failed to monitor a physician's order for self-catheterization and did not update a resident's care plan to reflect self-catheterization needs. The facility's policy requires comprehensive assessment and periodic reassessment of each resident to develop a person-centered comprehensive plan of care. However, for one resident diagnosed with Hereditary Spastic Paraplegia and Neurogenic Bladder, the physician's order for self-catheterization was not included in the current Physician Order Sheet. Additionally, the resident's care plan did not document any problem/need areas, goals, or interventions related to self-catheterization. The resident, who is cognitively intact with a BIMS score of 15:15, had a physician's order dated several months prior, allowing self-catheterization as needed for retention, with staff required to educate and monitor for retention and UTIs weekly. Despite this, the current care plan lacked any documentation addressing these needs. Furthermore, a laboratory test result showed the resident had a urinary tract infection with Escherichia Coli. The Director of Nurses confirmed the missing documentation for monitoring and care planning related to the resident's self-catheterization.
Failure to Obtain Physician's Order and Monitor Dialysis Fistula
Penalty
Summary
The facility failed to obtain a physician's order for dialysis treatments and did not update the care plan for a resident receiving dialysis services. Additionally, the facility did not assess the resident's dialysis fistula for hemorrhage post-dialysis. The resident, who is cognitively intact and has been receiving thrice-weekly dialysis for many years, reported that the nurse never monitors the fistula after dialysis for signs of hemorrhage. The resident's current Physician Order Sheet did not include a physician's order for dialysis treatments, and the care plan did not address the resident's dialysis needs. The Director of Nurses confirmed the missing physician's order and the lack of a care plan addressing the resident's dialysis needs. The facility's policy on comprehensive care planning and dialysis care was not followed, leading to these deficiencies. The resident's Minimum Data Set Assessment indicated a diagnosis of End Stage Renal Disease, but the necessary documentation and monitoring procedures were not in place, as verified by the Director of Nurses.
Failure to Administer IV Medication as Ordered
Penalty
Summary
The facility failed to administer an IV medication, Vancomycin, as ordered by the physician for a resident identified as R32. The resident, who was cognitively intact with a BIMS score of 15, had been readmitted to the facility with a PICC line and new orders for Vancomycin to treat a wound infected with MRSA. The medication administration record indicated that the Vancomycin doses were missed on several occasions, specifically on 5/24, 5/27, 5/28, and 5/29. The facility's policy required notifying the physician when a scheduled dose was not administered, but this was not done. Interviews with the nursing staff revealed a lack of communication and accountability regarding the missed doses. The primary nurse, V21/RN, acknowledged that the resident informed her about the missed doses, and upon reviewing the records, she confirmed that at least 3 to 4 doses were missed. Other staff members, including V23/RN and V22/RN, noticed discrepancies in the medication administration but did not take action to address them. The Director of Nurses, V2/DON, was unaware of the missed doses and stated that no requests were made to administer the medication. The oversight resulted in the resident expressing concern about the potential worsening of their condition due to the missed antibiotic doses.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two residents. The incident occurred in the dining room where one resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was inappropriately touched by another resident. The inappropriate behavior was first observed by an Activities Aide, who noticed the resident's hand on the other resident's leg. The Aide immediately reported the incident to the Director of Nursing, who then separated the residents and took the offending resident to speak with Social Services. The Director of Nursing confirmed that the resident's hand was inside the other resident's pants on the hip/groin area but did not reach further. The offending resident was then moved to a different hallway away from the victim's room. The facility's Abuse Prevention Program policy, dated 11/28/16, explicitly prohibits any form of abuse, including sexual abuse, and aims to create a secure environment for residents. Despite this policy, the facility failed to prevent the incident, which was observed by staff and reported immediately. The incident report and staff interviews confirm that the offending resident is capable of moving around the facility independently, which may have contributed to the occurrence of the abuse. The facility's immediate response involved separating the residents and addressing the situation with Social Services, but the initial failure to prevent the abuse constitutes a significant deficiency in resident protection.
Failure to Update Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to revise the care plans of two residents following an incident of resident-to-resident sexual abuse. According to the facility's Comprehensive Care Plan (CCP) policy, care plans should be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychosocial needs. However, after an incident where one resident was observed placing his hand inappropriately on another resident, the care plans for both residents were not updated to include the incident or interventions to prevent further abuse. This failure was confirmed by the Director of Nursing, who acknowledged that the care plans should have been updated to reflect the risk for abuse and the need for supervision. The incident report documented that the inappropriate behavior was observed by an activities employee and reported immediately to the Director of Nursing. The residents were separated, and the offending resident was taken to speak with social services. Despite these immediate actions, the care plans remained unchanged, leaving staff without updated guidance on how to manage the residents' needs and prevent future incidents. This oversight highlights a significant lapse in the facility's adherence to its own policies regarding care plan updates and resident safety.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family of a resident about a change in condition following a fall, as required by their policy. The resident, who was admitted to the Alzheimer's Unit with a diagnosis of dementia and other mental health conditions, was found on the floor with a hematoma and laceration on her forehead. The nurse's notes indicated that a message was left for the family on the day of the incident, but there was no documentation of which family member was contacted or any further attempts to reach them. This lack of communication led to the family being unaware of the fall and head injury until informed by a hospice nurse. The resident's Health Care Power of Attorney and second emergency contact expressed their frustration and disbelief at not being informed by the facility. They stated that they had made it clear to the facility that if the primary contact was unreachable, the second contact should be notified. Despite this, the facility staff, particularly a registered nurse, failed to follow through with these instructions, leading to the family being upset and unaware of the resident's condition. The registered nurse involved did not respond to calls for a statement regarding the notification process.
Inadequate Monitoring and Intervention Post-Fall
Penalty
Summary
The facility failed to adequately monitor and implement new interventions for two residents following falls, resulting in deficient practices. One resident was found on the floor with a head laceration, and the required neurological assessments were not completed as per the facility's policy. The resident's care plan did not document the fall or the resulting injury, and no new interventions were put in place to prevent future falls. The Director of Nursing confirmed the lack of documentation and interventions, which led to the resident's condition worsening, requiring hospital evaluation. Another resident experienced a fall and expressed a desire to die, indicating potential self-harm risk. However, the facility did not conduct further assessments or implement increased monitoring as required by their Suicide Precautions policy. The resident's medical record lacked documentation of psychological assessments or any follow-up on the suicidal statement. The Director of Nursing acknowledged the oversight and attributed it to previous staff members who failed to investigate the resident's statements. The facility's policies on fall prevention and suicide precautions were not followed, leading to inadequate supervision and care for the residents involved. The lack of documentation and failure to initiate necessary interventions and assessments contributed to the deficiencies identified in the report.
Deficiencies in Controlled Medication Management
Penalty
Summary
The facility failed to ensure accurate shift-to-shift controlled medication inventory counts, proper double-locking of refrigerated controlled medications, and accurate reconciliation of controlled medication tracking sheets. This deficiency potentially affects all 16 residents who have physician orders for controlled medications. The facility's policy mandates that all controlled drugs be counted by the oncoming and outgoing nurse at each shift change, with both nurses signing the inventory sheet to confirm accuracy. However, the report indicates incomplete signature documentation for the shift change accountability record sheet from March to May, suggesting a lack of compliance with the policy. An incident involving a missing dose of Hydrocodone-Acetaminophen for a resident was reported. The Director of Nursing (DON) stated that a nurse was found impaired and subsequently replaced, but the controlled medication count was off by one tablet. The missing tablet was not immediately reported, and the control sheet for the medication could not be located. Additionally, there was confusion regarding the count of Hydrocodone tablets, with two tablets unaccounted for, and the control sheet was still missing at the time of the report. Further issues were observed with the storage and handling of controlled substances. A bottle of Lorazepam was found in an unlocked refrigerator, contrary to the policy requiring double locks. A leaking bottle of Morphine was also discovered, with the label soaked and unreadable, making it impossible to accurately account for the medication. The facility failed to report the leaking bottle to the pharmacy or document the leakage, and there was confusion regarding the association of the Morphine with the correct proof of use form. The facility's responsibility to track control sheets and ensure proper handling of medications was not met.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident, identified as R1, when a dose of Hydrocodone-Acetaminophen was found missing. The incident began when a registered nurse, V3, was found impaired and subsequently taken to the hospital. During this time, the Director of Nursing (DON), V9, was informed that the controlled medication count was off by one tablet. The police were notified, and upon their arrival, it was confirmed that one tablet of R1's medication was missing. Despite efforts to locate the missing control sheet, it remained unaccounted for, and the discrepancy in the medication count persisted. Further investigation revealed that V4, another registered nurse, conducted a self-count of the controlled medications and discovered the inaccuracy. However, V4 did not immediately report the missing Hydrocodone to the DON. It was only after the police arrived that V4 informed them of the missing tablet and subsequently notified V9. When V9 and V4 later recounted the medications, they found that two tablets were unaccounted for, with only one documented as administered. This lack of proper documentation and communication led to the misappropriation of R1's medication, highlighting a significant deficiency in the facility's handling of controlled substances.
Failure to Verify Nursing License Status
Penalty
Summary
The facility failed to check the nursing license status of a Licensed Practical Nurse (LPN) prior to employment, which has the potential to affect all 48 residents in the facility. The facility's Nurse Staffing Policy mandates that no person may provide direct resident care without a certification and records check. Despite this, the LPN worked multiple shifts in February and March 2024. It was later discovered that the LPN's license had been suspended effective February 5, 2024, for posing an imminent danger to the public. This was identified on March 12, 2024, by another LPN who then alerted the Administrator in Training and the Corporate Registered Nurse. The Administrator in Training admitted to not checking the LPN's license prior to employment, which was a requirement according to the facility's policy and job description for the Administrator.
Failure to Have Licensed Administrator and Investigate Incident
Penalty
Summary
The facility failed to have a licensed Administrator and did not thoroughly investigate an incident involving used needles and syringes. The Administrator in Training (V1) had been in training for about three to four years and had failed the licensing test twice. Despite this, V1 was acting as the Administrator on a daily basis with oversight from a Corporate Administrator (V6). The facility's Administrator job description requires a current unencumbered Nursing Home Administrator's License, which V1 did not possess. Additionally, V1 did not conduct a thorough investigation when used needles and a white powdery substance, suspected to be crystal methamphetamine, were found in the clean utility room. Staff members had reported suspicious behavior by V5, a Licensed Practical Nurse, but V1 did not interview or investigate V5 or other staff members regarding the incident. A police report documented that a police officer responded to the facility after the discovery of the suspicious items. The officer noted that V18, a Certified Nurse Aide, had found the items and suspected V5 due to her strange behavior. Other staff members, including another LPN (V3) and a housekeeper (V19), also reported V5's odd behavior to V1. Despite these reports, V1 did not take further action to investigate V5 or the incident. V5 continued to work at the facility until she was asked to leave for not having a valid nursing license. The facility currently has 48 residents who could potentially be affected by these deficiencies.
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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