Arcadia Care Peoria Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria Heights, Illinois.
- Location
- 1629 East Gardner Lane, Peoria Heights, Illinois 61616
- CMS Provider Number
- 145811
- Inspections on file
- 59
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Arcadia Care Peoria Heights during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and moderately impaired cognition was observed using a seated walker that was sticky, dusty, and soiled with a white splatter on the seat and a thick mud-like substance on all four wheels. Facility policy required weekly cleaning and sanitizing of medical equipment used by the same resident, and staff, including an LPN and the Administrator, reported that third-shift staff were assigned to clean wheelchairs and walkers on a scheduled basis. Despite these procedures and housekeeping schedules for common areas and resident rooms, the resident’s walker had not been cleaned as required, resulting in visibly dirty equipment.
A resident reported that his room was not cleaned regularly and that a shared toilet had not been cleaned for several days, with visible fecal smears on the seat. Surveyors observed debris and dirty spots on the floor, buildup in the toilet bowl, and dried brown smears in and on the shared toilet between two residents’ rooms. The Administrator acknowledged the room and toilet did not appear to have been cleaned recently, and the Housekeeping Supervisor stated that, due to short staffing, rooms were only receiving light cleaning and scheduled deep-cleaning had not been done consistently, despite housekeeping duties requiring thorough cleaning and sanitizing of fixtures and floors.
A resident with multiple comorbidities and an at-risk Braden score developed a facility-acquired Stage 3 pressure ulcer on the left buttock. Despite physician orders and the care plan requiring daily cleansing, application of silver sulfadiazine, and a gauze dressing, as well as regular repositioning and incontinence care, CNAs were observed transferring the resident with a soiled brief, providing no peri-care, and leaving the wound undressed before returning the resident to a wheelchair. The bed lacked a pressure-redistribution mattress, and staff confirmed the absence of a dressing, contrary to facility policy that required daily dressing checks, documentation of treatments, and care plan updates for skin breakdown.
A medication cart was left unlocked and unattended in a hallway where multiple residents reside, contrary to facility policies requiring all medication storage areas to be locked when not in use by authorized personnel. An RN left the cart unlocked while entering a room to check a resident’s blood sugar and later retrieve insulin, leaving medications accessible to residents, staff, and visitors. When questioned, the RN initially claimed the cart had been locked but then admitted to making a mistake, and the DON confirmed that carts must always be locked and free of accessible medications, needles, or keys when unattended.
Two cognitively intact residents became involved in a physical altercation after a dispute over loud music in one resident’s room. Staff, including LPNs and a CNA, heard yelling and a commotion and, upon entering the room, found both residents in wheelchairs hitting or punching each other. The residents were separated and assessed with no injuries identified. One resident reported that he turned off the other’s loud music after a request to lower the volume was ignored and was then struck in the face twice, while the other resident only stated that the first had been disrespectful. Staff confirmed the residents lived on the same hallway but were not roommates and that they only became aware of the incident after hearing the disturbance, reflecting a failure to prevent resident-to-resident abuse.
A resident with hemiplegia, hemiparesis, and documented one-sided upper and lower extremity ROM limitations was not placed on a Restorative Nursing Program despite facility policy requiring screening and individualized restorative plans. The resident’s care plan lacked any documentation or interventions for a contracted hand, and restorative observation records showed no PROM or AROM services were being provided. The resident reported minimal movement in the affected hand and that no interventions were being done, and the Administrator confirmed there was no documentation of restorative rehab efforts for this resident.
A resident receiving hospice services had multiple terminal diagnoses and had elected hospice benefits, but the facility failed to coordinate hospice communication and maintain required hospice documentation. The care plan only noted that hospice services were in place and did not specify hospice responsibilities or interventions, and the medical record lacked a hospice plan of care, election forms, physician certification of terminal illness, and hospice clinical notes. An LPN and CNA reported they did not know hospice visit frequency, disciplines, or specific care instructions, and the hospice binder at the nurse’s station contained no hospice documents or communication notes. The hospice RN, who was the primary hospice nurse, had not participated in care plan meetings and confirmed that hospice staff did not document in the binder and that an updated POLST form remained unresolved.
Staff failed to follow infection control policies requiring hand hygiene between glove changes and use of Enhanced Barrier Precautions. During wound care for a resident with multiple complex conditions, a nurse changed gloves several times without performing hand hygiene in between. For a resident with a feeding tube on EBP, an RN disconnected enteral feeding and flushed the G-tube wearing gloves but no gown, despite policy requiring both gown and gloves for device care. In another case, an RN performing a blood glucose check for a diabetic resident removed soiled gloves and donned clean gloves at the med cart without hand hygiene between glove changes, contrary to facility policy.
Multiple incidents occurred in which residents engaged in physical altercations, resulting in injuries and staff intervention, while a staff member verbally abused a resident using profane and derogatory language. These events indicate a failure to prevent both resident-to-resident physical abuse and staff-to-resident verbal abuse, as confirmed by witness statements and facility records.
A resident physically struck another resident after a verbal altercation involving inappropriate language toward CNAs. Both residents were cognitively intact, and the incident was confirmed through interviews and record review, indicating a failure to prevent abuse as required by facility policy.
A resident in an LTC facility was subjected to repeated verbal abuse by another resident, who made derogatory comments about their appearance and hygiene. Both residents were cognitively intact, and the incidents were documented by staff, including an LPN and the Social Service Director. Despite the reports, the facility failed to prevent or address the verbal abuse, resulting in a deficiency in resident protection.
The facility failed to report resident-to-resident verbal abuse incidents to the State Surveying Agency as required by their Abuse Prevention and Reporting policy. Two residents were involved in verbal altercations, one of which led to a police call. Despite these incidents, there was no evidence of reporting to the state agency, as confirmed by the facility's administrator.
The facility did not investigate two incidents of resident-to-resident verbal abuse, despite its policy requiring such investigations. An LPN witnessed one resident making rude comments, leading the other to call the police. Another incident involved cussing in the dining room. The facility's records lacked evidence of any investigation, as confirmed by the administrator.
A facility failed to report an incident involving a verbal altercation between a resident and a housekeeping staff member to the state surveying agency. The incident began when the resident requested hot water, which the staff member refused to provide, leading to an exchange of offensive language. The facility's policy requires such incidents to be reported, but the administrator confirmed it was not reported, resulting in a deficiency.
A facility failed to thoroughly investigate a reported incident of potential mistreatment involving a resident and a housekeeping/laundry staff member. The incident involved a verbal altercation, and the facility's policy requires a comprehensive investigation. However, the administrator did not conduct additional interviews with other staff or residents, dismissing the incident as a bad day for the staff member, leading to a deficiency in the facility's handling of the report.
A resident on anticoagulants fell in the dining room, reportedly hitting his head, but was not sent for emergency evaluation as required by facility protocol. The resident's bruising and skin tear were not documented until days later, and no neurological checks were performed. The Medical Director confirmed the need for evaluation, highlighting a failure in care and documentation by the facility's staff.
The facility failed to label or date refrigerated foods and maintain a clean kitchen, as required by their policies. Unlabeled food items were found in the refrigerator, and the kitchen stove and grill were observed to be unclean over two days, despite a daily cleaning schedule. The Regional Dietary Manager confirmed these deficiencies.
The facility failed to maintain comfortable temperature levels, with residents frequently wearing heavy jackets due to cold conditions in the dining room and hallways. Room temperatures were documented below the comfortable range, and a gap in the dining room doors allowed cold air to enter. The Environmental Services Director and Administrator confirmed the low temperatures, indicating a failure to provide a homelike environment.
The facility failed to implement necessary precautions for two residents and did not follow hand hygiene protocols during catheter care for another resident. One resident suspected of having c-diff did not have contact precautions initiated, and another with a dialysis fistula lacked enhanced barrier precautions. Additionally, a CNA did not change gloves or perform hand hygiene after catheter care, as required by facility policy.
A facility failed to accurately document a resident's upper extremity fracture and range of motion impairment in the MDS. The resident had documented fractures of the clavicle and humerus, confirmed by X-rays and medical notes, but these were not reflected in the MDS. The DON acknowledged the inaccuracy, noting the absence of an onsite MDS Coordinator.
The facility failed to notify the state mental health authority after significant changes in the conditions of two residents with mental disorders, as required by their PASARR policy. One resident, initially diagnosed with various mental health conditions, was admitted to hospice without a subsequent PASARR review. Another resident, newly diagnosed with Schizophrenia, did not receive a PASARR II review despite the change in diagnosis and treatment. Staff were unsure of the PASARR process, leading to non-compliance with the policy.
The facility failed to implement personalized care plans for two residents, resulting in unaddressed medical needs. One resident with Non-Alzheimer's Dementia and PTSD lacked documented care plan goals or interventions for these conditions. Another resident experienced significant weight loss, yet their care plan did not identify this as a problem or include interventions. These deficiencies were confirmed by facility staff.
A resident experienced significant weight loss, but the facility failed to monitor and address it. The care plan did not document weight loss as a problem, and the dietician's recommendations were not communicated to the physician. The MDS inaccurately showed no weight loss, and the resident was not listed on the Significant Weight Loss list. The facility's administrator acknowledged these oversights.
A severely cognitively impaired resident, identified as an elopement risk, left the facility unsupervised, following staff out and taking a public bus. The resident wandered the city for over three hours before being found by family. The care plan required frequent checks and interventions to prevent wandering, but these were not adequately implemented. Staff interviews revealed a lack of awareness and insufficient security measures, contributing to the incident.
The facility failed to maintain a clean and homelike environment, with observations of unclean conditions in resident rooms and common areas. Residents reported infrequent laundry collection and unclean shower rooms, leading to dissatisfaction. The absence of a Housekeeping Supervisor contributed to the disorganization and lack of adherence to cleaning schedules, affecting all residents reviewed.
The facility failed to provide adequate personal hygiene care for four residents, including fingernail care, facial hair grooming, and scheduled showers. One resident had long facial hair and dirty fingernails, with no grooming documented in their records. Another resident expressed a desire for beard trimming, which was not provided. A third resident, dependent on staff for bathing, reported infrequent showers and poor hygiene care. The ADON acknowledged the need for regular grooming and shaving unless refused by the resident.
The facility failed to ensure call lights were within reach for three residents, compromising their ability to request assistance. One resident was found without a call light cord, another had their call light on the floor, and a third had it under the bed. These deficiencies occurred despite care plans indicating the need for assistance due to various health conditions.
A CNA failed to follow proper infection control practices during catheter and perineal care for a resident with an indwelling urinary catheter. The CNA did not change gloves or perform hand hygiene after cleansing the resident's perineal area and placed soiled washcloths on the bedside table. The resident, who had a history of UTIs, expressed concern about inadequate cleaning. The DON confirmed the CNA's actions were against facility policy.
A facility failed to date and store a resident's nebulizer mask and tubing in a bag between uses, contrary to its policy. The resident had a physician's order for Ipratropium-Albuterol Inhalation Solution four times a day. An LPN acknowledged that the facility does not bag the equipment between uses, and the ADON confirmed that the equipment should be dated weekly and bagged after each use.
A facility failed to follow its Enhanced Barrier Precaution policy for a resident with a gastrostomy tube, who required enhanced barrier precautions to prevent MDRO transmission. An LPN was observed disconnecting the resident's feeding tube and administering a water flush without wearing a gown, and two CNAs changed the resident's incontinence brief with only gloves on. The Assistant Director of Nursing confirmed the non-compliance with the precautionary measures.
The facility failed to keep the survey book accessible to residents, potentially affecting all 90 residents. The survey book was not found in the community areas and was eventually located in a drawer behind the receptionist's desk. The administrator confirmed that residents should have access to the survey book.
The facility did not adequately explain the arbitration agreement to residents or their representatives, affecting all 90 residents. The Business Office Manager, who did not fully understand the agreement, relied on a video for explanation and failed to inform that signing would waive legal rights. Interviews revealed residents and representatives were unaware of the agreement, with some overwhelmed by admission paperwork. The administrator acknowledged the complexity of the agreement and the need for staff training.
The facility failed to notify a physician about a resident's medication allergy and the unavailability of ordered medications. The resident's After Visit Summary indicated an allergy to Clonidine HCL, but the Progress Notes lacked documentation of notifying the physician or clarifying the admission orders. The DON confirmed the oversight.
A facility failed to ensure timely availability of physician-ordered medications for a resident. The resident's Clonidine patch was delayed from 3/25/24 to 4/7/24, Lacosamide was unavailable from 4/2/24 to 4/7/24, and Pregabalin was unavailable from 4/4/24 to 4/9/24. The DON confirmed the delay.
The facility failed to maintain functional bathing facilities, leaving residents without access to showers for up to two weeks. One shower room had been non-functional for eight months, and the other was out of order for two weeks, with no system in place for maintenance work orders.
The facility failed to ensure residents received showers as preferred due to plumbing issues that rendered both shower rooms unavailable. Residents were given bed baths or had to go to another facility for showers, leading to dissatisfaction among cognitively intact residents who preferred showers.
The facility failed to ensure that CNA staff were licensed and trained to perform haircuts, leading to a CNA cutting multiple residents' hair without proper licensure or training. Residents confirmed the absence of a licensed beautician, and the facility administrator acknowledged the lack of compliance with state regulations.
Failure to Maintain Clean Resident Medical Equipment
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s medical equipment clean in accordance with its own policy. The facility’s policy, effective 01/2026, states that medical equipment and devices used by the same resident will be cleaned and sanitized weekly or more often if needed. One resident, who had multiple diagnoses including gout, hypertension, GERD, major depressive disorder, stress incontinence, psychosis, hyperlipidemia, DM II, BPH, chronic respiratory failure, cerebral infarction, muscle wasting, and COPD, and whose BIMS score was 12/15 indicating moderately impaired cognition, was observed sitting in a lounge area with a seated walker in front of him. The walker was described as sticky with dust covering the frame, splatter of a white substance on the black seat, and a thick mud-like substance on all four wheels. The resident stated that his walker had never been cleaned and agreed it needed cleaning. Staff interviews further demonstrated that the facility’s cleaning processes were not effectively implemented for this resident’s equipment. An LPN stated that third-shift staff are assigned on the daily staffing sheet to clean all equipment, including wheelchairs and walkers, nightly. The Administrator reported that equipment cleaning such as walkers and wheelchairs is scheduled on third shift and that each room’s equipment is cleaned weekly per a schedule, with this resident’s room scheduled for Tuesday nights. The Administrator verified that the resident’s walker was dirty, needed cleaning, and agreed that it did not appear to have been cleaned on the scheduled night. Housekeeping schedules were also described, with one staff member assigned to common areas and another to resident rooms, but the observed condition of the walker showed that the facility failed to ensure this resident’s medical equipment was kept clean as required by policy.
Failure to Maintain Clean and Sanitary Resident Room and Shared Bathroom
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in resident rooms and shared bathroom areas, as evidenced by unsanitary conditions in the room currently occupied by R2 and the shared toilet between R2 and R3. R2, who was admitted on an unspecified date and now resides in the room previously occupied by R1, reported that his room was not cleaned very often and that the toilet had not been cleaned for five days, with feces smears on the seat. On observation the same day, surveyors noted obvious debris on the floor and near the baseboards, numerous dirty spots on the floor, a dark grey substance clinging to a large area in the toilet bowl, and three dried smears of dark brown substance in and on the shared toilet between R2 and R3’s rooms. The Administrator acknowledged that the condition of R2’s room and the shared toilet needed cleaning and did not appear to have been cleaned recently. The Housekeeping Supervisor stated that, due to short staffing, resident rooms were only receiving very light cleaning, the shared toilet between R2 and R3’s rooms probably had not been cleaned, and that regularly scheduled deep-cleaning of resident rooms, normally done on Fridays, had not been performed consistently, despite the housekeeper job description requiring cleaning and sanitizing of fixtures and floors. R1 had voluntarily discharged home with a family member prior to these observations and no longer resided in the facility at the time of the survey, but R2 was occupying R1’s former room when the unsanitary conditions were identified.
Failure to Provide Ordered Care for Facility-Acquired Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care for a facility-acquired Stage 3 pressure ulcer on a resident’s left buttock. The resident had multiple diagnoses, including paranoid schizophrenia, type 2 diabetes, hypertension, muscle wasting/atrophy, and unsteadiness on feet, and had Braden scores indicating they were at risk for pressure injury. The care plan documented the need for repositioning/ambulation at least every two hours, substantial/maximal staff assistance with ADLs, incontinence care after each episode, and minimizing pressure over bony prominences with treatment as ordered. Physician orders and the TAR directed that the left buttock wound be cleansed with wound cleanser, treated with silver sulfadiazine, and covered with a gauze dressing daily and as needed. The facility’s wound report and wound evaluation summaries documented that the Stage 3 pressure ulcer was facility-acquired and provided measurements and characteristics of the wound, including moderate serous drainage and significant slough. On observation, CNAs transferred the resident with a mechanical lift and found the incontinence brief soiled with urine, but they did not perform perineal care, did not apply a dressing to the left buttock wound, and instead placed a clean brief and pulled up the resident’s pants before returning the resident to the wheelchair without the ordered dressing. The resident’s bed did not have a pressure-redistribution mattress, despite the resident spending increased time in a wheelchair and having a facility-acquired Stage 3 pressure ulcer. Staff confirmed during interviews that the resident did not have a dressing on the left buttock at the time of observation, and the wound physician and administrator acknowledged that the pressure ulcer was acquired in the facility. The facility’s own skin condition and pressure injury policy required that dressings be dated by the licensed nurse, checked daily for placement and cleanliness, that care plans be revised to reflect skin alterations and approaches, and that physician-ordered treatments be recorded after each administration, but these requirements were not followed for this resident’s pressure ulcer care.
Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and medication carts were locked in accordance with facility policy and professional standards. The facility’s Medication Storage policy, last approved in December 2025, requires all medications and biologicals, including treatment items, to be securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. The Medication Administration Policy, last approved in October 2024, further specifies that medication storage areas, including medication carts, must be locked when not in use by authorized personnel, and that any other individual needing access must be supervised by an authorized person. On the date of the survey, an RN left a medication cart unlocked in the hallway across from a resident room on a hall where 23 residents reside. The RN left the cart to check a resident’s blood sugar, leaving medications accessible to residents, staff, and visitors. When questioned, the RN initially stated the cart had been locked and that they always lock the medication cart, but when asked why keys were not used to reopen the cart upon returning to obtain insulin for the resident, the RN became flustered and acknowledged making a mistake regarding the cart being unlocked. The DON confirmed that medication carts should always be locked when the nurse leaves the cart and that nothing, including medications, needles, or keys, should be accessible on top of the cart.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent resident-to-resident abuse when two cognitively intact residents engaged in a physical altercation in one resident’s room. On 12/25/25 at 5:55 PM, two LPNs and a CNA heard yelling coming from the room of one resident and, upon entering, observed both residents in their wheelchairs hitting or punching each other. The residents were separated and assessed, and no injuries were identified. One resident later reported that the other had his music playing loudly, and after a request to turn it down was ignored, he turned the music off himself, at which point he stated the other resident hit him in the face twice, though without causing injury. The other resident reported that the first resident had been disrespectful but would not provide further detail. Staff interviews confirmed that the residents were not roommates but lived on the same hallway and that staff heard a commotion and then found both residents in their wheelchairs physically striking each other in the room, with one LPN stating she did not hear loud music prior to the incident. This sequence of events, including the escalation of a dispute over loud music into physical contact between two cognitively intact residents, and staff only becoming aware once yelling and commotion were heard, demonstrates a failure by the facility to protect each resident from abuse, specifically resident-to-resident physical abuse, as required by its abuse prevention responsibilities.
Failure to Implement Restorative ROM Interventions for Resident With Contracted Hand
Penalty
Summary
The deficiency involves the facility’s failure to implement restorative therapies and interventions to maintain or improve range of motion (ROM) and prevent contracture for a resident with known functional limitations. The facility’s Restorative Nursing Program policy requires that each resident be screened for restorative nursing upon admission, annually, quarterly, and with any significant change in function, and that appropriate residents have individualized restorative programs with goals, measurable objectives, and documented interventions and responses. The resident in question was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, COPD, seizures, and heart failure. A Minimum Data Set (MDS) assessment documented intact cognition, functional limitation in ROM to upper and lower extremities on one side, dependence in dressing, hygiene, and transfers, and that the resident was not in a Restorative Nursing Program. Despite these identified ROM limitations, the resident’s current care plan contained no documentation regarding her contracted left hand and no interventions to prevent further decrease in ROM. A Restorative Observation assessment documented that the resident was not receiving restorative programs for PROM (passive ROM) or AROM (active ROM). During observation, the resident was seen lying in bed with a contracted left hand, and in interview she stated she had minimal movement in her left hand and that nothing was being done for it. The Administrator confirmed there was no documentation of any restorative rehabilitation attempts for this resident and acknowledged that, although the resident frequently refused care, there was no documentation related to restorative care and that no restorative tasks had been implemented for her until very recently.
Failure to Coordinate Hospice Communication and Maintain Required Hospice Documentation
Penalty
Summary
The deficiency involves the facility’s failure to coordinate hospice communication and maintain required hospice documentation for a resident who had elected hospice benefits. Facility policy and the hospice service agreement required that hospice assessments and a hospice plan of care be integrated into the resident’s overall care plan, that hospice progress notes and communication be available in the medical record or hospice binder, and that hospice staff participate in care planning. The resident, admitted with terminal diagnoses including dementia, congestive heart failure, protein malnutrition, paranoid schizophrenia, and traumatic brain injury, elected hospice benefits, but the resident’s care plan only noted that hospice services were being received and lacked specific hospice responsibilities and interventions. The medical record did not contain a hospice plan of care, hospice election forms, physician certification of terminal illness, or hospice clinical notes. Staff interviews confirmed that hospice visit frequency, disciplines involved, and care instructions were not documented or known by facility staff. An LPN stated there was no documentation in the electronic record regarding hospice visit frequency, disciplines, or care instructions, and that the hospice binder contained no hospice documents or communication notes. A CNA reported that hospice aides provided care but was unaware of the days, times, or frequency of visits. The hospice RN stated that the hospice binder at the nurse’s station was empty and that hospice staff did not document in it after visits, and also reported not having attended or participated in any care plan meetings with the facility despite being the resident’s primary hospice nurse. The hospice RN further noted an issue with an updated POLST form that had been sent back to the facility for correction and had not yet been received back by hospice. The administrator acknowledged that the facility failed to ensure hospice communication was coordinated and that required documents were available and accessible to staff.
Failure to Perform Hand Hygiene Between Glove Changes and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices, specifically related to hand hygiene between glove changes and adherence to Enhanced Barrier Precautions (EBP). For one resident with osteomyelitis, quadriplegia, dysphagia, pressure ulcers, neuromuscular bladder dysfunction, a suprapubic catheter, and a colostomy, the Infection Preventionist/Wound Nurse changed gloves multiple times during a wound care procedure but did not perform hand hygiene between glove changes, contrary to the facility’s Glove Use and Hand Hygiene policies that require hand hygiene after glove removal and before new glove placement. The Administrator later agreed that hand hygiene should have been conducted between glove changes. The facility also failed to follow its EBP policy requiring gown and gloves for residents with indwelling medical devices during high-contact care. A resident with a feeding tube, care planned for EBP due to the tube, was observed receiving an enteral feeding disconnection and water flush from an RN who performed hand hygiene and donned gloves but did not wear a gown during the procedure; the RN acknowledged a gown should have been worn, and the Infection Preventionist confirmed that gown and gloves are required for any care involving a G-tube. In another instance, an RN performing a medication pass for a resident with cerebral palsy and type 2 diabetes, who required QID blood glucose checks and insulin, removed soiled gloves after performing a blood sugar check and then donned clean gloves at the medication cart without performing hand hygiene in between, despite facility policy and the DON’s confirmation that hand hygiene is required between glove changes.
Failure to Prevent Resident-to-Resident Physical Abuse and Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent both resident-to-resident physical abuse and staff-to-resident verbal abuse involving four residents. In one incident, two residents with a history of anxiety disorder, major depression, and chronic pain engaged in a physical altercation in the smoking area and dining room. One resident sustained a hematoma above the right eye after a verbal disagreement escalated to physical contact, including chest bumping and pushing. Witness statements from staff and residents confirmed the sequence of events, with both parties acknowledging their involvement in the altercation. In a separate incident, two other residents argued over a borrowed phone, which led to one resident throwing a plate and physically striking the other. Staff present during the altercation intervened to separate the residents, and the missing phone was later found in the possession of the resident who initiated the physical contact. Additionally, the facility failed to prevent staff-to-resident verbal abuse. A staff member (receptionist) was reported to have yelled at a resident, used profane language, and made derogatory comments about the resident's mother after the resident returned from an outing. Another staff member witnessed the verbal abuse and intervened, confirming that inappropriate language was used and reporting the incident to nursing staff. These events demonstrate that the facility did not effectively implement its abuse prevention and reporting policy, resulting in multiple instances of abuse and failure to protect residents from harm.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse when one resident physically struck another resident. According to the facility's incident report and subsequent investigation, a resident (R1) admitted to slapping another resident (R2) on the left side of the head. This action occurred after R2 was reportedly calling certified nurse aides inappropriate names. Both residents were found to be cognitively intact, as indicated by their BIMS scores of 15. The incident was reported to the nurse on duty and subsequently to the state surveying agency. The facility's Abuse Prevention and Reporting policy prohibits abuse, neglect, and mistreatment of residents, and affirms the right of residents to be free from such actions. Despite this policy, the incident occurred when R1 confronted R2 in another resident's room and made physical contact in response to R2's verbal behavior toward staff. The facility's investigation confirmed the physical altercation and the circumstances leading up to it, demonstrating a failure to protect residents from abuse as required by facility policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, which constitutes a deficiency in ensuring a safe environment free from abuse. The incident involved two residents, both of whom were cognitively intact. One resident, identified as R3, reported feeling threatened and harassed by another resident, R4, who made derogatory and offensive comments. R3's care plan noted verbal aggression, and R4's care plan indicated a potential for verbal aggression due to ineffective coping skills and poor impulse control. The verbal abuse incidents were documented in nursing and social service notes, with R4 admitting to making derogatory comments about R3's appearance and hygiene. R3 reported feeling distressed and harassed by R4's repeated verbal attacks, which included being called offensive names. Staff members, including an LPN and the Social Service Director, confirmed the occurrences of verbal abuse, with R4 consistently using offensive language towards R3. Despite these reports, the facility did not effectively prevent or address the verbal abuse, leading to a deficiency in protecting residents from abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Reporting policy by not immediately reporting an allegation of resident-to-resident abuse to the State Surveying Agency. The policy mandates that any allegation of abuse or incident resulting in serious bodily injury must be reported immediately, but not more than two hours after the allegation. In this case, two residents were involved in verbal altercations on two separate occasions. The first incident occurred when a resident felt threatened by another resident's rude comments and called the police. The second incident involved a resident cussing out another resident in the dining room. Despite these events, there was no evidence that the facility reported these incidents to the State Surveying Agency as required. The deficiency was identified through interviews and record reviews, which revealed that the facility's Abuse Investigations and the residents' Electronic Medical Records did not document the reporting of these verbal abuse incidents. The facility's administrator confirmed that the incidents were not reported to the state surveying agency. This failure to report is a direct violation of the facility's own policy and the regulatory requirements for reporting abuse allegations, highlighting a significant lapse in the facility's abuse prevention and reporting procedures.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention and Reporting policy by not thoroughly investigating allegations of resident-to-resident verbal abuse involving two residents. The policy mandates that any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be investigated. However, the facility did not investigate two separate incidents of verbal altercations between the residents, which were documented in nursing and social service notes. The first incident occurred when a Licensed Practical Nurse (LPN) witnessed one resident making rude comments to another, prompting the latter to feel threatened and call the police. The second incident involved one resident cussing out the other in the dining room. Despite these documented altercations, the facility's records did not show any evidence of an investigation into these incidents, as confirmed by the facility's administrator.
Failure to Report Alleged Mistreatment Incident
Penalty
Summary
The facility failed to report an allegation of potential mistreatment involving a resident and a staff member to the state surveying agency. The incident involved a resident, identified as R4, and a staff member from housekeeping/laundry, identified as V9. According to a handwritten letter by an LPN, V8, the incident occurred when R4 requested hot water from V9, who refused to bring it to him. This led to a verbal altercation where R4 used offensive language towards V9, who responded by running down the hall and confronting R4 with similar language. V8, who witnessed the incident, described V9's demeanor as sassy and inappropriate, although V9 did not threaten R4. The facility's policy on abuse prevention and reporting requires that any allegations of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property be reported to the resident's representative and the state surveying agency's regional office. Despite this policy, the administrator, V1, confirmed that the incident was not reported to the state surveying agency. The failure to report this incident constitutes a deficiency in the facility's adherence to its abuse prevention and reporting policy.
Inadequate Investigation of Resident Mistreatment Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following a report of potential mistreatment involving a resident and a staff member. The incident involved a verbal altercation between a resident and a housekeeping/laundry staff member, where inappropriate language was exchanged. The facility's policy requires immediate reporting and a comprehensive investigation of any allegations of abuse, neglect, or mistreatment. However, the investigation conducted by the administrator was insufficient, as it did not include interviews with other staff members or residents who may have had interactions with the accused staff member. The administrator acknowledged that no additional interviews were conducted beyond the initial report, and the incident was dismissed as the staff member having a bad day. This lack of a thorough investigation is a violation of the facility's abuse prevention and reporting policy, which mandates that all potential abuse incidents be fully investigated to ensure the safety and well-being of residents. The failure to follow these procedures resulted in a deficiency in the facility's handling of the reported incident.
Failure to Provide Competent Care After Resident Fall
Penalty
Summary
The facility failed to ensure competent nursing care for a resident who sustained a fall with a head injury. The resident, who was on anticoagulant medication, experienced a fall in the dining room and reportedly hit his head, resulting in bruising on his left ear and arm. Despite the facility's standing orders requiring residents on anticoagulants to be transported to the emergency room for evaluation after any head trauma, this protocol was not followed. The resident's fall was initially documented as not involving a head injury, and no neurological checks were performed. The resident's bruising and skin tear were not documented until several days later, despite being visible and reported by the resident and his Power of Attorney. The facility's staff, including the LPN and CNA involved, failed to accurately assess and document the resident's condition following the fall. The Medical Director confirmed that the resident should have been sent for evaluation due to the anticoagulant use and the presence of a bruise, which was indicative of a head injury. The Director of Nursing acknowledged the failure to perform necessary neurological checks and the lack of documentation regarding the resident's injuries, which were only addressed after being brought to attention days later.
Deficiency in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its own policies regarding food storage and kitchen cleanliness, as observed during a survey. Specifically, the facility did not label or date refrigerated open and stored foods, which is a requirement according to their Food & Supplies: Storage policy. This policy mandates that all prepared foods stored in the refrigerator must be covered, labeled, and dated with an expiration date. During an inspection, metal containers with various food items such as ground ham, chicken nuggets, raw sausage links, and sliced turkey were found in the walk-in refrigerator without any labels or dates. This was confirmed by the Dietary Cook, who acknowledged that the foods should have been labeled and dated. Additionally, the facility's kitchen was found to be unclean, with the stove's backsplash and back burners caked with dried food particles and the adjacent grill covered with a black sticky substance. The top shelf of the stove was also dusty and littered with dark-colored crumbly material. Despite the facility's Daily Cleaning Schedule, which includes tasks such as cleaning the stovetop and grill, these areas remained unclean over two consecutive days. The Regional Dietary Manager confirmed that the stove and grill are supposed to be cleaned daily by the dietary staff, as documented on the cleaning schedule, but acknowledged the presence of debris on the kitchen stove and grill.
Facility Fails to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for several residents, compromising their right to a homelike environment. Observations and interviews revealed that residents frequently wore heavy jackets in the dining room due to cold temperatures. The facility's logbook documented room temperatures ranging from 64.8 to 69.6 degrees Fahrenheit, which are below the comfortable range for residents. A significant gap in the dining room's double doors allowed cold air to enter, exacerbating the issue. The outside temperature was recorded at 32 degrees Fahrenheit, contributing to the cold conditions inside. Residents expressed discomfort, stating that the dining room and certain hallways were consistently cold. The Environmental Services Director confirmed the low temperatures, with readings between 66 and 70 degrees Fahrenheit in the dining room. The facility administrator also verified the low temperatures in various areas of the building. These findings indicate a failure to provide a safe and comfortable environment for the residents, as required by the federal Nursing Home Reform Law.
Failure to Implement Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement transmission-based precautions and Enhanced Barrier Precautions as per their policy for two residents. One resident, suspected of having Clostridium difficile (c-diff), did not have contact precautions initiated despite a physician's order for treatment and a stool specimen collected for testing. The Director of Nursing confirmed that contact precautions should have been initiated when c-diff was suspected. Another resident with a dialysis fistula did not have enhanced barrier precautions in place, despite the potential for bleeding at the fistula site, as verified by the Infection Preventionist. Additionally, the facility did not adhere to hand hygiene protocols during indwelling urinary catheter care for a resident. A Certified Nursing Assistant performed catheter care without changing gloves or performing hand hygiene before touching other items and the resident's clothing. This was acknowledged by the CNA, who confirmed that gloves should have been changed and hand hygiene performed immediately following catheter care.
Inaccurate MDS Documentation of Resident's Fractures
Penalty
Summary
The facility failed to accurately document a resident's upper extremity fracture and range of motion impairment in the Minimum Data Set (MDS). The resident, identified as R82, had a documented acute fracture of the distal clavicle and a comminuted supracondylar fracture of the left humerus. These injuries were confirmed by X-ray reports and medical notes from radiology and orthopedic physicians. Despite these documented injuries, the MDS completed on 11/07/24 did not reflect the resident's left arm and clavicle fractures, cast placement, and impairment of her upper extremity. The deficiency was identified through observation, interview, and record review. On 12/01/24, the resident was observed in a wheelchair with a pink fiberglass cast and sling on her left arm, self-propelling using her feet and right arm only. The Director of Nurses (DON) acknowledged on 12/03/24 that the MDS was inaccurate and should have included the resident's fractures and impairments. It was also noted that the facility lacked an onsite MDS Coordinator, with the Corporate Regional MDS Coordinator temporarily filling the role.
Failure to Notify State Authorities of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the state mental health authority following significant changes in the physical condition of two residents with mental disorders, as required by their Preadmission Screening and Annual Resident Review (PASARR) policy. Resident R19, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Disorganized Schizophrenia, and Major Depressive Disorder, experienced a significant change in condition and was admitted to hospice care. Despite this change, the facility did not conduct an annual PASARR review or notify the state mental health authority, as confirmed by the Business Office Manager and Social Service Director, who were unsure of the exact process for significant change PASARR reviews. Similarly, Resident R59, who was initially documented as not having a serious mental illness, was later diagnosed with Schizophrenia and prescribed Quetiapine Fumarate. Despite this new diagnosis and the administration of medication for Schizophrenia, the facility did not conduct a subsequent PASARR review or notify the state mental health authority. The Assisting Director of Nursing and the Administrator confirmed that a PASARR II was not conducted following the significant change in R59's condition, indicating a failure to adhere to the facility's PASARR policy.
Failure to Implement Personalized Care Plans
Penalty
Summary
The facility failed to implement personalized care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with Non-Alzheimer's Dementia and Post Traumatic Stress Disorder, did not have documented goals or interventions in their care plan to address these conditions. This was confirmed by the facility administrator. Another resident experienced significant weight loss over a six-month period, with a 10.92% decrease in weight, and a 7.58% loss over three months. Despite this, the resident's care plan did not identify weight loss as a problem or include any goals or interventions to address it. This oversight was acknowledged by both the administrator and the regional dietary manager.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to monitor and prevent weight loss for a resident, identified as R77, who was admitted with diagnoses including cerebral vascular accident, partial paralysis, a speech disorder, and difficulty swallowing. Despite a significant weight loss of 10.92% over six months and 7.58% over two months, the care plan did not document weight loss as an identified problem or include interventions related to weight loss. The facility's policies required dietician recommendations to be communicated to the medical provider and for nutritional assessments to be completed according to specific criteria, but these were not followed. The resident's Minimum Data Set (MDS) inaccurately documented no weight loss, and the dietician's assessment recommending supplements was not acted upon. The physician's progress notes did not reflect any assessment or notification of the resident's weight loss, nor were any interventions ordered for weight loss management. The facility's administrator acknowledged that the resident's weight loss was not monitored by the dieticians, the physician was not notified, and there were no specific interventions in the care plan. Additionally, the Mini Nutritional Assessment inaccurately indicated normal nutrition with no weight loss, and the resident was not listed on the Significant Weight Loss list in November 2024, despite previous documentation of significant weight loss.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident identified as an elopement risk. The resident, who had a documented history of elopement risk and required supervision when accessing the community, managed to leave the facility unsupervised. This incident occurred when the resident followed ancillary staff out of the building, boarded a public bus, and wandered the city for over three hours before being located by a family member. The resident's care plan indicated the need for 15-minute checks and specific interventions to prevent wandering, such as offering diversions and redirecting the resident away from exits. However, on the day of the incident, the resident was last seen during the morning medication pass and was not located until a family member reported finding them in the community. The facility lacked special interventions for residents assessed as elopement risks, and there was no receptionist at the desk to monitor exits. Interviews with staff revealed that checks on the resident were not conducted as required, and there was a lack of awareness regarding the interventions in place for elopement risks. The facility's security measures were insufficient, as evidenced by the resident's ability to leave the premises without being stopped. The absence of a receptionist and the failure of staff to monitor the resident contributed to the incident.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations of unclean conditions in resident rooms and common areas. The report highlights that the floors, blinds, and a shower room toilet were not kept clean and free of debris. Specific instances include a resident's tube feeding splattered and dried on blinds, dirty baseboards, and sticky floors with debris. Additionally, the shower room toilet was observed with smeared, dried feces, and the floor was dirty with debris against the wall. Interviews with residents revealed dissatisfaction with the frequency of laundry collection and cleaning services. Residents reported that laundry was only picked up once a week, resulting in dirty clothes overflowing onto the floor, creating unpleasant odors. Concerns were also raised about the cleanliness of the shower room, with residents having to clean it themselves before use. The lack of a Housekeeping Supervisor was noted as a contributing factor to the disorganization and lack of adherence to cleaning schedules. The facility's housekeeping guidelines and cleaning schedule policies were not effectively implemented, as confirmed by staff interviews. The Housekeeping Manager's job description emphasized maintaining a clean and safe environment, but the absence of a supervisor led to confusion among housekeeping staff about their responsibilities. The administrator acknowledged the need for daily cleaning of shower rooms and blinds, but the lack of oversight resulted in these tasks being neglected. The report indicates that the facility's failure to ensure a clean environment affected all 39 residents reviewed in the sample.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care, including fingernail care, facial hair grooming, and scheduled showers, for four residents. Resident R43 was observed with long facial hair and dirty, jagged fingernails, and their electronic medical record showed no evidence of grooming in the months of May and June 2024. R43's Power of Attorney expressed concerns about the resident's lack of cleanliness and grooming. Similarly, R45 was found with long, dirty fingernails, and their records also lacked documentation of nail care during the same period. Resident R50 expressed a desire for beard and mustache trimming, which had not been provided, and their records showed no evidence of grooming. R83, who is cognitively intact and dependent on staff for bathing, was found with greasy hair, unkempt facial hair, and dirty fingernails. R83 reported infrequent showers and expressed a desire for better personal hygiene care. The Assistant Director of Nursing acknowledged that residents' fingernails should be cleaned and clipped at least twice a week on shower days, and residents should be shaved unless they refuse or request otherwise.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, R43, R45, and R83, as observed during a survey. R45 was found lying in bed without a call light cord attached to the call light panel, making it inaccessible. This issue persisted over two consecutive days, despite R45's care plan indicating a need for assistance with activities of daily living due to encephalopathy. Similarly, R43's call light was found on the floor, out of reach, and the resident expressed concern about not being able to reach it when needed. R43's care plan highlighted a dependency on assistance for bed mobility and transfers due to conditions such as respiratory failure and encephalopathy. In another instance, R83's call light was found under the bed, out of reach, after a Licensed Practical Nurse left the room without ensuring it was accessible. R83 demonstrated limited mobility by attempting to reposition himself in bed, further emphasizing the need for the call light to be within reach. A Certified Nurse Assistant later verified the call light's inaccessibility. These observations indicate a failure to adhere to the facility's call light policy, which mandates that call lights be accessible to residents at all times.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the provision of indwelling urinary catheter and perineal care for a resident. The facility's policies on urinary catheter care and hand hygiene were not followed by a Certified Nursing Assistant (CNA), identified as V6, who was observed performing care on a resident with an indwelling urinary catheter. The CNA did not change gloves or perform hand hygiene after cleansing the resident's perineal area and before touching the resident's bare skin to assist with turning. Additionally, the CNA placed soiled washcloths on the resident's bedside table instead of disposing of them properly. The resident involved, identified as R5, had a history of urinary tract infections and expressed concern that inadequate cleaning might have contributed to their condition. The Director of Nursing confirmed that the CNA should have changed gloves, performed hand hygiene, and prepared the area with a plastic bag for soiled linens. These actions and inactions led to a deficiency in providing appropriate care to prevent urinary tract infections and maintain infection control standards.
Failure to Properly Store and Date Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident by not dating and storing a nebulizer mask and tubing in a bag between uses. The facility's policy, dated 1/7/19, requires that handheld nebulizers and masks be changed weekly and as needed, with each setup marked with the date of change and stored in a clean plastic bag. However, during an observation, it was found that the nebulizer mask and tubing for a resident, who had a physician's order for Ipratropium-Albuterol Inhalation Solution four times a day, were left undated and unbagged on the bedside table. A Licensed Practical Nurse admitted that the facility does not bag the nebulizer mask and tubing between uses, although they should have been dated. The Assistant Director of Nursing confirmed the deficiency, stating that the nebulizer masks and tubing should be dated weekly and bagged after every use.
Failure to Follow Enhanced Barrier Precautions for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution policy, which is designed to reduce the transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities. This deficiency was observed in the care of a resident with a gastrostomy tube, who was identified as requiring enhanced barrier precautions. The resident's care plan specifically required the use of gowns and gloves during high-contact activities, such as device care and incontinence care. During an observation, a Licensed Practical Nurse (LPN) was seen disconnecting the resident's gastrostomy tube feeding and administering a water flush without wearing a gown, despite being aware of the enhanced barrier precautions. Additionally, two Certified Nursing Assistants (CNAs) were observed changing the resident's incontinence brief with only gloves on, and no gown, while the Assistant Director of Nursing confirmed the lack of compliance with the precautionary measures. These actions demonstrate a failure to follow the facility's infection control guidelines for residents at higher risk of MDRO transmission.
Survey Book Accessibility Deficiency
Penalty
Summary
The facility failed to keep the survey book in a location accessible to residents, which has the potential to affect all 90 residents in the nursing facility. During an observation, the survey book was not found in the resident community areas. A transport driver, who was interviewed, stated that they had never seen the survey book but eventually located it in a drawer behind the receptionist's desk. The administrator confirmed that residents should have access to the survey book, indicating a lapse in ensuring the book's availability to residents.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand, potentially affecting all 90 residents. The arbitration agreement, which is a binding legal document, was not clearly communicated by the Business Office Manager (V8), who admitted to not fully understanding the agreement herself. V8 relied on a video to explain the agreement and did not inform residents or their representatives that signing the agreement would waive their right to take legal action against the facility. Furthermore, V8 was unaware of any time limit for residents to change their minds about signing the agreement. Interviews with residents and their representatives revealed a lack of understanding and awareness of the arbitration agreement. For instance, R85's Power of Attorney (V9) did not recall any discussion about the agreement and was overwhelmed by the amount of paperwork during admission. Similarly, R21, who has moderate cognitive impairment, did not understand the agreement and was not involved in the decision-making process, as confirmed by her Power of Attorney (V16). The facility's administrator acknowledged that the agreement is complex and requires proper explanation, highlighting the need for additional training for V8.
Failure to Notify Physician of Medication Allergy and Unavailability
Penalty
Summary
The facility failed to notify the physician of medications not available for one resident. The facility's policy requires informing the resident, consulting with the resident's physician, and notifying the resident's legal representative or an interested family member when there is a need to alter treatment significantly. The resident's After Visit Summary documented the need to apply a Clonidine transdermal patch weekly, starting on a specific date. The resident had an allergy to Clonidine HCL, which was noted in the After Visit Summary. However, the Progress Notes from the specified period showed no documentation that the resident's primary care physician was notified of the allergy or to clarify the admission orders. The Director of Nursing verified that there was no documentation of the allergy clarification on admission and that the physician was not notified of the resident not receiving the ordered medications.
Failure to Provide Timely Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available for a resident. According to the facility's Pharmacy policy, medications should be received from the pharmacy in a timely manner, and accurate records of medication orders and receipts should be maintained. However, the resident's After Visit Summary indicated that a Clonidine 0.2mg/24-hour transdermal patch was to be applied weekly starting on 3/25/24, but the Medication Administration Record (MAR) showed that the patch was not available until 4/7/24. Additionally, the MAR documented that the resident's Lacosamide 50mg was not available from 4/2/24 to 4/7/24, and Pregabalin 75mg was not available from 4/4/24 to 4/9/24. The Director of Nursing confirmed that the medications were ordered but did not arrive in a timely manner.
Failure to Maintain Functional Bathing Facilities
Penalty
Summary
The facility failed to ensure it was equipped with functional bathing facilities/shower rooms, affecting all 90 residents. The facility's preventive maintenance policy emphasizes the importance of maintaining fixtures and equipment in good working order. However, during a tour, it was observed that one of the two designated shower rooms was taped off and marked as out of order, while the other was operational. No resident rooms had individual bathing facilities. Multiple residents reported that the shower rooms were non-functional for varying periods, with some stating they had no access to a shower for up to two weeks. The Ombudsman confirmed that one shower room had been non-functional for at least eight months, and the other had been out of order for around two weeks, leaving residents without a place to shower for ten days. The facility administrator, who had been in the position since May 1, 2024, confirmed that both shower rooms were unavailable due to plumbing issues from April 24, 2024, through May 3, 2024. The administrator also noted that there was no system in place for maintenance work orders. This lack of functional bathing facilities and the absence of a maintenance system led to significant inconvenience and potential hygiene issues for the residents.
Failure to Provide Preferred Shower Facilities
Penalty
Summary
The facility failed to ensure residents received showers as preferred instead of bed baths for five of six residents reviewed. The facility's policy stated that showers, tub baths, or bed/sponge baths would be offered according to residents' preferences. However, due to plumbing issues, both shower rooms were unavailable from 4-24-24 through 5-3-24. As a result, residents were given bed baths or had to go to another facility to get a shower. This situation affected residents who were cognitively intact and preferred showers over bed baths, leading to dissatisfaction and a feeling of not being as clean as they would have been with showers. During a tour of the facility, it was observed that one shower room was operational while the other was taped off and marked as out of order. Interviews with residents revealed that they were unhappy with the bed baths and preferred showers. The administrator confirmed that the shower rooms were unavailable due to plumbing issues, and no alternative shower facilities were provided within the facility during that period. This failure to accommodate residents' preferences for showers resulted in a deficiency in the quality of care provided.
Unlicensed CNA Performing Haircuts
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were licensed and trained to perform resident haircuts. This deficiency was identified through observation, interview, and record review, revealing that a CNA was using electric hair trimmers to shave a resident's hair without the necessary licensure. The Illinois Barber, Cosmetology, Esthetics, Hair Braiding, and Nail Technology Act of 1985 mandates that only licensed individuals can perform such services, and the facility's CNA job description also requires adherence to all federal, state, and local requirements. Despite these regulations, the facility had not employed a licensed beautician or barber for over four years, and the CNA admitted to cutting multiple residents' hair without proper training or licensure. Residents expressed that there was no licensed beautician available, leading them to rely on staff for haircuts. One resident confirmed that the CNA had been cutting their hair, and the CNA acknowledged performing haircuts for several residents without formal training or a license. The facility administrator confirmed the absence of a licensed beautician or barber, highlighting a significant lapse in compliance with state regulations and professional standards. This failure had the potential to affect all residents reviewed for staff competency in the sample of 16.
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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