Arcadia Care Watseka
Inspection history, citations, penalties and survey trends for this long-term care facility in Watseka, Illinois.
- Location
- 715 East Raymond Road, Watseka, Illinois 60970
- CMS Provider Number
- 145389
- Inspections on file
- 66
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Arcadia Care Watseka during CMS and state inspections, most recent first.
Two residents were injured due to unsafe equipment and inadequate implementation of post‑fall interventions. One resident with hemiplegia and no functional use of one arm sustained a large hematoma and multiple skin tears when the flaccid arm likely became caught on an exposed metal hinge of a geri‑chair whose vinyl seat had pulled away; although the care plan was updated to require the arm to be supported on a pillow in the chair, CNAs reported they were never informed of this intervention and the resident was observed seated without arm support. Another resident with dizziness and moderate cognitive impairment had an unwitnessed fall in a room with a narrow walking path and later reported that a sharp, jagged section of the bed’s footboard caused a right forearm skin tear; observation confirmed the damaged, sharp laminate on the footboard and the tight space between the bed and wall unit, and staff acknowledged these environmental hazards were likely involved, despite the room not being rearranged and the bed not being repaired as identified in the fall assessment.
Two cognitively impaired residents with known physical and verbal behaviors became involved in an altercation when one resident attempted to take the other’s walker while the latter was seated at a table drinking. When the resident using the walker refused to let go, the other resident slapped the resident on the back with an open hand, constituting physical abuse. Staff witnesses, including an LPN, an activity aide, and a CNA, reported that as they intervened, the resident with the walker attempted to retaliate and instead struck the LPN in the mouth, while the aggressor resident lost balance and fell, hitting their head on a table leg. Both residents had existing care plans addressing behavioral issues, and the facility’s abuse prevention policy states that residents have the right to be free from abuse and that the facility prohibits such mistreatment.
RN Coverage Not Maintained: The facility failed to ensure RN coverage for at least 8 consecutive hours per day, 7 days a week. Staffing records showed no RN coverage across multiple 24-hour periods, and the DON stated the facility was aware of an RN shortage and often did not have an RN in the building on weekends while actively hiring RNs.
Food and Nutrition Services staffing deficiencies were identified when the Dietary Mgr was supervising kitchen operations but was not a clinically qualified CDM or equivalent and did not meet Illinois standards for a food service or dietary manager. A Cook served as the PIC even though he was not a Certified Food Protection Mgr. Surveyors also observed multiple sanitation issues in the kitchen, including dish sanitizing, disinfectant use, sanitation testing, ice machine drainage, and floor cleanliness concerns, affecting food prepared for 62 residents.
Failure to Serve Menu Items as Planned: The facility did not serve lunch items listed on the menu for residents on regular and puree diets. During meal service, no dinner rolls with margarine, pureed dinner rolls with margarine, or pureed peaches were available or served, and the Dietary Aide confirmed the items were not prepared or served. The Dietary Manager could not explain why the menu items were not prepared as planned.
Kitchen sanitation failures were observed with the dish machine, three-basin sink chemical dispenser, ice maker drain, and floor surfaces. The cook found no sanitizer in the dish machine, the sink dispenser was filled with a disinfectant instead of sanitizer and used for wiping buckets and food-contact surfaces, the ice maker drain was directly connected to the sewer without an air gap, and the kitchen/pantry floors were heavily soiled with damaged, unsealed tiles. The dietary manager confirmed the dish machine and sink chemical issues and stated the kitchen food was available to all residents.
Failure to coordinate PASARR Level II screenings for two residents with mental health diagnoses. One resident had Psychotic Disorder and Mood Affective Disorder, and another had Delusional Disorders, Anxiety Disorder, and a history of other mental and behavioral disorders. The SS Director stated Level II screenings should have been completed when the qualifying diagnoses were identified, but the residents' PASARR Level I screens stated Level II was not indicated unless new information or changes occurred.
Missed Weekly Skin Assessments for Resident With Stage 3 Pressure Sores: A resident with stage 3 pressure sores to the coccyx and both iliac crests did not have weekly skin assessments completed as required by facility policy. The wound nurse confirmed nurses were expected to complete and document skin checks on shower days, but no weekly skin assessments were found in the EMR after the last documented assessment, and the DON confirmed the gap in documentation.
Improper cleaning, dating, and storage of respiratory equipment occurred for a resident with COPD, chronic respiratory failure with hypoxia, and dependence on supplemental O2. Staff did not have the humidification bottle attached to the concentrator, tubing and cannulas were not dated, and a nebulizer mask was left uncovered with dried residue inside. The resident reported nose dryness and said staff had not changed the tubing or cleaned the nebulizer mask after treatments.
Failure to Complete Ordered Lab Tests and Notify Practitioner: Two residents had ordered lab work that was not completed as ordered. One resident’s Keppra level was not collected, and the chart lacked documentation of MD notification or a redraw order. Another resident’s BMP and BNP were also not collected, despite a later MAR entry indicating blood was drawn; the DON confirmed no specimen was obtained and there was no documentation that the ordering practitioner was notified.
A resident with severe cognitive impairment entered another resident's room multiple times, made inappropriate sexual comments, and engaged in unwanted physical contact. The cognitively intact resident, who had limited mobility and was at moderate risk for abuse, screamed for help, leading a CNA to intervene and remove the offending resident. Staff interviews and records confirmed the incident and the facility's failure to prevent the abuse.
The facility did not provide the required RN coverage for nine days, as confirmed by the DON and Regional Director of Operations, with zero RN hours scheduled for entire 24-hour periods. This affected all 61 residents present in the facility during the reviewed period.
The facility assigned a Dietary Manager to supervise and manage food service operations for all residents without ensuring the individual held the required certification or credentials, as specified by regulations and the facility's own assessment tool.
The facility did not complete required PASARR Level II screenings for three residents after they received new diagnoses of serious mental illness, despite policy and initial screening instructions to do so when such changes occur. This lapse was confirmed by the Social Service Director.
A resident did not receive several prescribed medications during a medication pass, and an LPN administered a medication with duplicate and conflicting orders, resulting in a 20% medication error rate. There was no documentation of the missed doses or notification to the provider or pharmacy, and a physician's note identifying an excessive dosing regimen was not followed up in the medical record.
Two residents at nutritional risk did not receive proper monitoring and intervention for significant weight changes. One resident with protein-calorie malnutrition was not weighed weekly as ordered, did not consistently receive or consume prescribed nutritional supplements, and poor meal intake was not reported to the dietitian. Another resident with a history of weight loss was not reweighed after a significant weight gain, and weekly weights were not documented, despite staff awareness of facility policy.
A resident with a history of aggressive behavior physically and verbally abused two other residents in the facility. Despite being aware of the resident's behavior issues, the facility failed to implement effective interventions to prevent these incidents, resulting in physical and verbal abuse. Staff witnessed the altercations and intervened, but the facility's administrator acknowledged the need for further measures to ensure resident safety.
The facility failed to provide RN coverage for at least eight consecutive hours a day, seven days a week, as required. On specific dates in March 2025, there was no RN coverage, affecting all 62 residents. The facility's assessment tool required one RN per shift, but the nursing schedule and daily assignments showed a lack of RN coverage. The Regional RN and DON confirmed the deficiency and are working on a solution.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 62 residents. The Dietary Manager, who was supervising operations, admitted to not being certified and not meeting state standards. The facility's assessment indicated the need for a qualified nutrition professional to support resident care.
The facility failed to have an Infection Prevention Nurse physically onsite at least part-time, affecting 62 residents. Observations showed no certified Infection Preventionist nurse present, and the Regional Infection Preventionist, responsible for infection tracking, works offsite and visits only once a week. The DON does not have access to infection logs, and the March 2025 schedule showed no onsite Infection Prevention nurse.
The facility failed to provide showers to three residents according to their care plans and preferences. One resident, dependent on staff for bathing, received showers sporadically, while another, requiring partial assistance, reported not receiving scheduled showers. A third resident, needing a mechanical lift, also reported inconsistent showering. Staff interviews revealed discrepancies in documentation and adherence to the facility's bathing policy.
The facility failed to engage residents in the memory care unit in structured activities, leaving them idle or asleep. Despite care plans outlining specific activity needs, residents were not participating in any activities due to short staffing and lack of engagement by CNAs. The Activity Director acknowledged the issue, citing staffing challenges.
A resident reported to the DON that an agency LPN was rough and used a harsh tone. The DON did not report this to the Administrator, assuming the resident had done so. The Administrator was unaware of the allegation, violating the facility's policy requiring immediate reporting of potential abuse.
The facility failed to coordinate PASARR Level II evaluations for two residents with serious mental health diagnoses. Despite having conditions such as Schizoaffective Disorder and Major Depressive Disorder, their PASARR Level I screenings inaccurately indicated no need for further evaluation. The Business Office Manager confirmed these discrepancies, highlighting the necessity for accurate and routine review of PASARR screenings.
A facility failed to provide a resident with an appropriate indwelling urinary catheter collection bag and secure it in a dignified manner. The resident, with multiple urinary-related diagnoses, was observed with a catheter bag visibly attached to his pants, contrary to the facility's policy. An LPN confirmed the absence of leg bags, and the administrator acknowledged the need to order more.
The facility failed to provide sufficient RN hours on six out of fifteen days reviewed, potentially affecting all 66 residents. The Nursing Daily Schedule documented zero hours of RN coverage for 24-hour periods on specific dates, confirmed by the Regional Director. At the time, 66 residents resided in the facility.
A resident with cognitive impairments was physically abused by another resident in the dining room following an argument. Despite the facility's abuse prevention policy, staff intervention occurred only after the altercation escalated, resulting in one resident being struck on the shoulder. The incident was reported, and an investigation was initiated.
A facility failed to implement a comprehensive care plan for a resident with dementia and schizophrenia who frequently undressed and walked around naked. Despite documented behaviors and staff observations, no care plan was developed to address these issues, contrary to facility policy requiring person-centered care plans with measurable objectives.
The facility failed to provide adequate personal hygiene care to four residents who were dependent on staff assistance. Despite policies requiring weekly showers and daily dental care, residents reported not receiving showers due to staffing issues, with records confirming infrequent showers over two months. One resident also reported not having her teeth brushed for several days. A CNA acknowledged the lack of showers due to insufficient staffing, highlighting a failure to adhere to the facility's hygiene care policies.
A resident with moderate cognitive impairment entered another resident's room and physically assaulted a fellow resident by kicking them in the shin and attempting to steal property. The incident was witnessed by an LPN who intervened and removed the aggressor. The facility's policy on abuse prevention was not effectively implemented to prevent this occurrence.
A resident with Multiple Sclerosis was injured when their foot caught on a rug while being transported in a shower chair lacking foot support. The facility failed to report the injury to the state survey agency and did not conduct a thorough investigation. The resident's care plan was not updated, and the use of the shower chair for transportation was deemed inappropriate by the resident's physician.
The facility did not staff an RN for eight consecutive hours per day, as required, affecting the care of 68 residents. On several dates, only LPNs were on duty, and the Director of Nursing worked limited hours without additional RN coverage. The facility relies on agency nurses, with corporate restrictions allowing only LPNs, and has limited RN staff.
The facility failed to administer insulin and diabetic medications timely and as ordered for four residents. The MARs were incomplete, and there was a lack of documentation and physician notification for missed doses. Residents reported delays in receiving medications, and agency nurses were unaware of the protocol to notify physicians when medications were unavailable, leading to significant medication errors.
A resident with a history of multiple health conditions suffered a leg fracture in a LTC facility, leading to severe pain. Despite the facility's Pain Management Program requirements, the resident's pain was not routinely assessed, and their care plan was not updated to address the injury and pain management. Discrepancies in pain medication documentation were noted, and staff interviews confirmed the lack of routine pain assessments following the injury.
The facility failed to protect residents from abuse, including sexual and physical incidents involving cognitively impaired residents. One resident was inappropriately touched by another, while separate physical altercations occurred due to misunderstandings and territorial behavior. Staff witnessed these events and intervened, but the incidents highlight a lack of effective prevention measures.
A facility failed to implement adequate fall prevention measures and supervision, resulting in falls for three residents with severe cognitive impairments. One resident fell twice due to environmental hazards and improper clothing, while another fell after leaving the bathroom without a walker. Investigations were inadequate, with insufficient staffing and lack of thorough assessments. A third resident experienced multiple falls without appropriate interventions, and a non-functional call light further compromised safety.
The facility failed to implement specific interventions for residents with dementia-related behaviors, leading to repeated incidents of aggression and safety concerns. One resident exhibited severe cognitive impairment and aggression, while another displayed aggressive behaviors and required psychiatric evaluations. A third resident's care plan lacked documentation of specific behaviors during meal times, resulting in altercations with others.
A resident experienced psychosocial harm due to the misappropriation of funds by a Business Office Manager and an Activity Aide, who allegedly took $600 from the resident's Trust Fund for personal use. The facility failed to adhere to its Abuse Prevention Program and Resident Funds Policy, as transactions lacked proper authorization and documentation. The resident, with moderate cognitive impairment, was unaware of these unauthorized transactions due to not receiving receipts or statements.
The facility failed to provide quarterly statements for Resident Trust Funds for several residents, as required by policy. Transaction logs were not signed, and no quarterly statements were available. Residents confirmed not receiving statements, and the Business Office Manager admitted to not being trained on this requirement, leading to their termination.
The facility failed to maintain adequate Surety Bond coverage for resident trust funds, with the bond amount of $73,500 falling short of the actual fund balances, which exceeded $136,000 over three months. This affected five residents with trust funds managed by the facility, as confirmed through interviews and a review of financial records.
A facility failed to report a sexual abuse allegation involving a resident and two staff members to the Illinois Department of Public Health as required. An anonymous call alleged inappropriate touching in exchange for money and misappropriation of $600 from the resident's Trust Fund. The facility reported only the financial misappropriation, omitting the sexual abuse claim, and did not document it in their abuse log.
A resident with kidney failure requiring thrice-weekly dialysis was hospitalized for hypervolemia after the facility failed to provide necessary dialysis services for nearly two and a half months. The Social Services Director did not coordinate dialysis appointments, and the facility initially failed to provide transportation for dialysis, leading to a critical delay in care.
A facility failed to manage pain for a hospice resident, leading to uncontrolled pain. The resident, with severe cognitive impairment and multiple medical conditions, was observed in distress. Pain assessments were not routinely conducted, and medication orders were delayed. Discrepancies in medication administration and documentation were noted, with several doses of Morphine being ineffective. Staff interviews revealed communication and documentation lapses in pain management protocols.
The facility failed to monitor potential Legionella exposure sites and did not adhere to contact precautions for a resident with ESBL. The Legionella policy lacked documentation of plumbing inspections and preventive measures. Staff entered a resident's contact isolation room without PPE, despite signs indicating isolation, exposing themselves to infection risks.
The facility failed to employ a certified Infection Preventionist, affecting all 44 residents. The DON and Assistant DON, who handle infection prevention tasks, are not certified. This gap undermines the facility's infection control program, despite having a policy for surveillance and monitoring.
The facility failed to maintain a safe and functional environment due to unresolved roof leaks, resulting in sagging and stained ceiling tiles near the nurse's station and resident areas. A resident reported worsening ceiling discoloration since their admission, and the DON confirmed the issue has persisted for over a year. Despite obtaining repair quotes, the roof remains unrepaired, potentially affecting all 44 residents.
The facility failed to provide timely laboratory services and document results for three residents. A resident with diabetes did not receive A1C tests as ordered, another resident's Hepatic Function Panel was not completed, and a third resident's blood glucose levels were not documented. The Assistant DON confirmed these deficiencies, citing a possible computer issue for the documentation lapse.
The facility failed to accurately account for controlled substances and ensure medications were provided as ordered. A resident's Fentanyl patches were unaccounted for, and discrepancies were found in medication administration records for multiple residents. Additionally, a resident did not receive prescribed Omeprazole due to insurance issues, with no physician notification documented. Facility policies on controlled substances and medication administration were not consistently followed.
The facility failed to obtain consent for psychotropic medications and justify their use for several residents. There was no documentation of resident-specific behaviors or tracking of behaviors to support the use of antipsychotics. Additionally, consents for medications were not signed until the survey date. The Director of Nursing acknowledged these issues, indicating a lack of adherence to the facility's policy on psychotropic medications.
A facility failed to administer medications as ordered for three residents, leading to significant medication errors. One resident missed a Fentanyl patch, another did not receive Lacosamide for seizures due to insurance issues, and a third lacked nebulizer treatments due to a missing machine and medication. Staff were unsure of reasons for omissions, and documentation was inadequate.
Failure to Maintain Safe Resident Equipment and Implement Post‑Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident equipment in safe, operable condition and to implement and communicate effective post‑incident interventions, resulting in injuries to two residents. One resident with hemiplegia and generalized muscle weakness was dependent on staff for bed mobility and transfers and lacked full sensation in the left arm due to a prior stroke. This resident developed a large, dark bruise and multiple skin tears on the left forearm. Nursing documentation and staff interviews indicated that the resident’s flaccid arm likely fell into an exposed metal hinge area on a geriatric recliner‑type wheeled chair when the back of the chair was pushed upright, causing a hematoma and skin tears. The vinyl seat material had pulled away, leaving the metal hinge fully exposed, and staff placed a piece of foam over the metal after the injury. The resident reported being unaware of the injury until a CNA noticed it before a shower, and described stinging pain when water hit the arm. Following identification of the injury, the care plan was updated to include an intervention for the resident’s left arm to be propped on a pillow while in the chair to prevent the arm from hanging. However, during observation, the resident was seated in the same type of geriatric wheeled chair without a pillow supporting the flaccid left arm, which rested at an angle on the armrest and abdomen. CNAs interviewed stated they were unaware of the pillow intervention and had not been informed of this change in care, despite having worked multiple shifts since the injury. One CNA stated that although they technically had access to care plans, they did not have time to review every resident’s care plan and relied on being told about new interventions. Another CNA confirmed that the resident did not have a pillow under the arm when transferred from chair to bed and that this was the first time they had heard of the pillow requirement. A second resident with dizziness, essential hypertension, dorsalgia, need for assistance, altered mental status, and moderate cognitive impairment experienced an unwitnessed fall in the room, resulting in a right forearm skin tear. The fall assessment documented that the resident was found on the floor next to the bedside, wearing nonskid footwear, with a dry, debris‑free floor, and identified lightheadedness, dizziness, and a narrow pathway to the nightstand as root causes. The care plan noted the resident was at risk for falls and skin impairment, with an intervention to rearrange the room. The resident later reported that the skin tear occurred when the arm struck the sharp edges of the bed’s footboard during the fall and repeatedly told staff that the foot of the bed caused the injury. Observation revealed a damaged, jagged, sharp‑edged laminate area approximately seven inches long on the left edge of the footboard, and the bed was positioned close to an air conditioner/heater, leaving a narrow walking path where the resident stated she fell. Nursing and administrative staff acknowledged that the damaged footboard and narrow path were likely involved in the injury and that maintenance had been aware the bed was in disrepair, but the footboard had not been evaluated during the fall investigation and the room had not been rearranged as planned.
Resident-to-resident physical abuse during altercation over walker
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse when one resident struck another. According to the facility’s preliminary and final abuse investigation reports, a cognitively severely impaired resident with Alzheimer’s disease, anxiety disorder, restlessness, and agitation approached another cognitively severely impaired resident who requires a walker for ambulation while the second resident was seated at a table sipping a drink. The first resident attempted to take the second resident’s personal walker, and when the second resident refused to relinquish it, the first resident slapped the second resident on the back with an open hand. Witness statements from an LPN, an activity aide, and a CNA consistently described the first resident trying to take the walker, the second resident holding onto it, and the first resident then smacking the second resident on the back. The records show that both residents had prior care plans addressing physical and verbal behaviors toward staff and peers, and both had BIMS scores of three, indicating they were cognitively severely impaired. The MDS for the first resident documented independence in walking and the presence of physical and verbal behaviors, while the MDS for the second resident documented the need for a walker to assist with walking. During the incident, when staff intervened to separate the residents, the second resident attempted to retaliate and instead struck the LPN in the mouth, and the first resident became unsteady, lost balance, and fell, hitting their head on a table leg. The facility’s abuse prevention policy affirms residents’ rights to be free from abuse and states that the facility prohibits abuse and is responsible for preventing occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services, and mistreatment of residents.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure RN coverage of at least eight consecutive hours per day, seven days a week. The facility midnight census dated 2/21/26 documented 62 residents in the building. The Facility Assessment Tool dated 11/2025-11/2026 Appendix 3 showed staffing requirements for two shifts: 6:00am to 6:00pm requiring one RN, two LPNs, and six CNAs, and 6:00pm to 6:00am requiring one RN, one LPN, and five CNAs. Daily schedules dated 1/3/26, 1/4/26, 1/17/26, 1/18/26, 1/31/26, 2/1/26, 2/7/26, 2/8/26, 2/21/26, and 2/22/26 documented no RN coverage for each 24-hour timeframe. On 2/24/26 at 2:40 PM, the DON stated the facility was aware of a shortage of RNs and often did not have an RN in the building on weekends, and that the facility was actively hiring RNs.
Food and Nutrition Services Staffing and PIC Certification Deficiencies
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to have a Person in Charge (PIC) with the required Food Protection Manager Certification. On 2/24/2026 at 10:58 AM, V7, identified as the Dietary Manager, was actively supervising dietary operations in the kitchen and reported being the full-time manager of the facility food service, but stated that they were not a clinically qualified Certified Dietary Manager or equivalent. V7 also denied meeting Illinois standards for a food service manager or dietary manager and reported completing only a one-day Certified Food Protection Manager course focused on sanitation, without instruction in clinical nutrition. On 2/22/2026 at 8:34 AM, V8, a Cook, reported being the Person in Charge for the shift, and V7 later confirmed that V8 was not a Certified Food Protection Manager. V7 stated that V8 was the PIC for first shift on 2/22/2026. The report also states that throughout the survey from 2/22/2025 to 2/25/2025 on first and second shifts, the facility failed to effectively sanitize dishes, follow manufacturer instructions for safe disinfectant use, use appropriate sanitation test equipment, ensure an ice machine drain line was properly plumbed to prevent potential cross-contamination of ice, and maintain sanitary floor surface areas. V7 reported that the food prepared in the kitchen was available for all residents, and that the facility dietician was not full-time and was present twice per month; the midnight census documented 62 residents.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to serve diets as planned on the menu. The Diet Spreadsheet dated 2/13/2026 documented that residents receiving regular diets were to receive a dinner roll with margarine at the lunch meal on 2/22/2026, and residents receiving pureed diets were to receive a #20 scoop of pureed dinner roll with margarine and a #12 scoop of pureed peaches with the same lunch meal. During observation of the 2/22/2026 lunch meal service, no dinner rolls with margarine, no pureed dinner rolls with margarine, and no pureed peaches were present at the service line where kitchen staff were preparing resident lunch meals, and no resident lunch meals included those items. At 12:32 PM on 2/22/2026, the Dietary Aide reported that pureed peaches were not made or served at lunch for residents on puree diets, and dinner rolls with margarine were not prepared or served that day for any resident. On 2/24/2026 at 11:27 AM, the Dietary Manager reported not knowing why staff did not prepare dinner rolls with margarine, pureed dinner rolls with margarine, or pureed peaches per the menu during lunch on 2/22/2026. The Midnight Census report dated 2/25/2026 documented 62 residents in the facility.
Kitchen sanitation and food service deficiencies
Penalty
Summary
The facility failed to effectively sanitize dishes in the kitchen mechanical sanitizing dishwasher. On 2/22/2026, the cook operating the dishwasher tested the sanitizer concentration and found no sanitizer present, while the dishwasher log required wash and rinse temperatures between 120-140 degrees Fahrenheit and sanitizer concentration between 50-100 parts per million. The cook stated not knowing anything about the dishwasher and reported the dietary manager would be informed that the sanitizer dispenser was not dispensing correctly. The dishwasher data plate was worn and no longer displayed the operating specifications, and the log contained recorded temperatures of 300 degrees Fahrenheit and sanitizer levels of 75 parts per million despite the cook later stating those temperatures were not possible and that the dishwasher had not been dispensing sanitizer correctly. The facility also failed to use the correct chemical at the three-basin sink. A chemical dispenser above the sink was supplied by a one-gallon jug of quaternary ammonia disinfectant, even though the dispenser was designed to be supplied with sanitizer and not disinfectant. The cook reported the facility used the solution from this dispenser to fill wiping buckets for kitchen food preparation surfaces and resident dining room tables. Test strips showed the solution was well above the measurable range for the sanitizer strips, and the disinfectant label stated it was not labeled for use as a sanitizer or to wash dishes and required a potable water rinse after disinfection. The cook reported staff did not complete that rinse, and the dietary manager later reported the wrong jug had been installed and that it was unknown how long it had been used. The ice maker discharge drain was directly plumbed into the facility sewer with a flexible hose attached to a pipe coupler near the floor, and no air gap or air break was present. The kitchen and pantry floor surfaces were also observed to be excessively soiled with food debris and other items, with unsealed flooring, crumbling or partially detached tiles, and the dietary manager stated the floors had last been cleaned about a month earlier. The dietary manager also reported the food prepared in the kitchen was available for all residents in the facility, and the midnight census documented 62 residents.
Failure to Coordinate PASARR Level II Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate PASARR Level II screenings for two residents with mental illness diagnoses during their residency at the facility. R5's record showed diagnoses of Psychotic Disorder and Mood Affective Disorder, and the resident's PASARR Level I dated 9/20/23 stated that a Level II screening was not indicated unless changes occurred or new information refuted those findings. R23's record showed diagnoses including Delusional Disorders, Anxiety Disorder, and Personal History of other Mental Disorders and Behavioral Disorders, and the resident's PASARR Level I dated 2/20/23 also stated that a Level II screening was not indicated unless changes occurred or new information refuted those findings. During interview on 2/24/26, the Social Services Director stated PASARR Level II screenings should have been done for R5 and R23 at the time their qualifying diagnoses were identified. The facility's PASARR policy dated 01/2026 stated PASARR would be evaluated annually and upon any significant change for those individuals identified, and that the facility would refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative.
Missed Weekly Skin Assessments for Resident With Stage 3 Pressure Sores
Penalty
Summary
The facility failed to complete weekly skin assessments for one resident who had pressure sores. The facility’s Skin Condition Assessment & Monitoring policy states that pressure and other ulcers are to be assessed and measured at least weekly by a licensed nurse and documented in the resident’s clinical record, and that residents are to have weekly skin assessments with daily observation for skin breakdown during care and on the assigned bath day. The resident’s wound round assessment documented stage three pressure sores to the coccyx and both iliac crests. The medical record showed skin assessments completed on 1/13/26, 12/12/25, 12/6/26, and 11/27/26. The wound nurse stated wound assessments were completed weekly on Thursdays and that nurses were to complete skin assessments on shower days and document them in the electronic medical record, but confirmed there were no weekly skin assessments completed for the resident. The DON also confirmed weekly skin assessments had not been completed since 1/13/26.
Improper Cleaning, Dating, and Storage of Respiratory Equipment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for a resident with COPD with acute exacerbation, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, pan lobular emphysema, orthopnea, and interstitial pulmonary disease. The resident’s record documented admission on 2/7/26, and during observation on 2/22/26 the resident’s oxygen concentrator was between the bed and the window with the humidification bottle in the tank holder but not attached to the concentrator and no date on the bottle. A nasal cannula was attached to the concentrator and in use, but the tubing was not dated. A nebulizer machine was on the bedside table with tubing and mask attached, the mask was uncovered and lying on top of the machine, and the mask had a dried white crystal-like substance covering the inside of the mask and filter. No date was noted on the mask or mask tubing. A nasal cannula attached to the portable oxygen tank on the back of the wheelchair was also not dated. During interview on 2/23/26, the resident stated staff had not connected the oxygen to humidification, had not changed any tubing, and that the facility gave a new nebulizer mask but no one had cleaned the mask after treatments. The resident was observed moving down the hallway in a wheelchair with a portable oxygen tank and tubing on the back of the chair, but not using the oxygen, and the resident complained of nose dryness. On 2/24/26, the DON stated all respiratory tubing and masks should be changed weekly and dated, and the ADON stated the resident’s tubing had not been labeled. The ADON then stated all of the resident’s respiratory tubing and masks were changed and labeled just then. The facility policy stated handheld nebulizer, nasal cannulas, and oxygen humidifiers should be changed weekly and as needed, and that a clean plastic bag should be provided with each new setup and marked with the date set up was changed.
Failure to Complete and Report Ordered Laboratory Tests
Penalty
Summary
The facility failed to follow physician orders to complete ordered laboratory tests for two residents reviewed for Laboratory Services. One resident had an order for a Keppra level, but the laboratory report documented that no specimen was collected and that a redraw was needed. The resident’s progress notes did not document physician notification of the missed test or that a new redraw order was obtained. The resident had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, aphasia, epilepsy, chronic pain syndrome, hyperlipidemia, and dysphagia. A second resident had physician orders for a BMP including GFR and a BNP, but the laboratory report documented all results as pending because no specimen was collected and the nurse was to redraw. The resident’s progress notes did not document physician notification that the ordered tests were not collected, and the MAR documented blood was collected on a later date even though the DON confirmed no blood was actually drawn. The resident had diagnoses including COPD, chronic DVT, CHF, asthma, protein-calorie malnutrition, diabetes mellitus type 2, chronic respiratory failure with hypoxia, atrial fibrillation, venous insufficiency, and anxiety disorders.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment entered another resident's room multiple times in the early morning hours. The resident who was cognitively intact and at moderate risk for abuse/neglect reported that the other resident made inappropriate sexual comments and engaged in unwanted physical contact by placing a hand under the blanket and touching the resident's leg. The incident escalated to the point where the resident screamed for help, prompting a Certified Nursing Assistant (CNA) to intervene and remove the offending resident from the room. Interviews and record reviews confirmed that the resident who was subjected to the inappropriate behavior felt helpless due to limited mobility and inability to protect herself. Staff accounts corroborated the sequence of events, including the CNA's observation of the resident's hand under the blanket and immediate removal of the resident from the room. The facility's abuse prevention policy prohibits such conduct, yet the incident demonstrated a failure to protect the resident from inappropriate touching and sexual comments by another resident.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide sufficient Registered Nurse (RN) coverage, as required, on nine out of forty-four days reviewed. According to the Facility Nursing Daily Schedule, there were zero RN hours scheduled for entire 24-hour periods on specific dates, which was confirmed by both the Director of Nursing (DON) and the Regional Director of Operations. The facility's records indicated that 61 residents were present during this time, and the lack of RN coverage had the potential to affect all residents. The deficiency was identified through interview and record review, with the facility's own documentation confirming the absence of required RN staffing on the noted days.
Unqualified Dietary Manager Supervising Food Services
Penalty
Summary
The facility failed to ensure that the director of food services met the required regulatory qualifications. Observations and interviews over several days confirmed that the individual serving as the Dietary Manager was actively supervising dietary operations and managing food service for all 61 residents, but did not possess certification as a Certified Dietary Manager, certified food service manager, or equivalent credentials as required. The facility's own assessment tool specified the need for a clinically qualified nutrition professional to serve as the director of food and nutrition services, yet the current manager did not meet these qualifications. This deficiency affected all residents in the facility at the time of the survey.
Failure to Initiate PASARR Level II After New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate Pre-admission Screening and Resident Review (PASARR) Level II assessments for three residents who had new or updated diagnoses of serious mental illness during their stay. Specifically, the records for these residents showed diagnoses such as Schizoaffective Disorder, Bipolar Disorder, and Major Depressive Disorder, which were documented after their initial PASARR Level I screenings. The initial Level I screenings had determined that Level II was not indicated, but the screenings also stated that a new screen must be submitted if changes or new information arose. Despite the emergence of new diagnoses indicating serious mental illness, the facility did not initiate or complete PASARR Level II screenings for these residents. This was confirmed by the Social Service Director, who acknowledged that the required Level II assessments were not performed following the updated diagnoses. The facility's own PASARR policy requires referral for Level II review upon significant changes in status or new evidence of serious mental disorder, but this procedure was not followed in these cases.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications according to physician's orders for one resident, resulting in a medication error rate of 20%, which exceeds the acceptable threshold. During a medication pass, an LPN administered several medications to the resident but omitted Carvedilol 25mg, Fluticasone 50mcg nasal spray, and Duloxetine 60mg, all of which were ordered to be given at that time. Additionally, the resident's medication administration record (MAR) showed duplicate and conflicting entries for Fluticasone-Salmeterol (Advair) Inhaler, leading to the potential for over-administration. A physician's note had previously identified that the dosing regimen for this inhaler exceeded the recommended frequency, but there was no documentation of follow-up or correction in the electronic medical record. There was also no documentation in the electronic medical record regarding the missed doses or any notification to the prescribing physician or pharmacy about the omissions. The facility's policy requires that medications be administered as ordered and that any errors or omissions be documented, with appropriate notifications made. The Director of Nursing confirmed that staff should use backup pharmacy stock if available and notify the provider and pharmacy if medications are not in stock, as well as document any missed doses, but these steps were not followed in this instance.
Failure to Monitor and Manage Nutritional Status and Weight Changes
Penalty
Summary
The facility failed to ensure adequate nutritional management for two residents identified as nutritionally high-risk. One resident with a diagnosis of protein-calorie malnutrition experienced significant weight loss over a six-week period, with documentation showing a 5.8% decrease in body weight. Despite physician orders for weekly weights, fortified ice cream, and nutritional shakes three times daily, the resident's records lacked documentation of weekly weights on two occasions, and meal intake records showed poor consumption on 22 occasions. Observations revealed that nutritional supplements were not consistently provided with meals, and when they were, staff did not encourage consumption or inform the resident about the supplement. Additionally, there was no documentation that the dietitian was alerted to the resident's poor intake, as required by the care plan. Another resident, who was on hospice care and had a history of significant weight loss, was not reweighed after a documented significant weight gain, as required by facility policy. The resident's weight increased dramatically between two recorded dates, but there was no evidence of weekly weights or follow-up actions in the medical record. Staff interviews confirmed awareness of the policy to reweigh residents in case of discrepancies, but this was not carried out or documented. The facility's policies on significant weight changes and obtaining accurate weights were not followed for these residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by incidents involving three residents. Resident R26, diagnosed with Bipolar Disorder, Borderline Personality Disorder, and Dementia with Agitation, exhibited aggressive behavior towards other residents. R26's care plan noted a history of verbal and physical aggression, yet incidents continued to occur. R61, who is cognitively intact and at high risk for abuse, reported being yelled at and slapped by R26 during a dining room altercation. A CNA witnessed the incident and intervened to prevent further harm. R61 expressed fear of R26, who frequently engaged in aggressive behavior towards others. Another resident, R24, also cognitively intact, reported being punched in the arm by R26 in the dining area. R24 described R26 as often verbally and physically abusive, using foul language towards other residents. An LPN confirmed R24's distress following the incident. The facility's administrator acknowledged R26's behavior issues and the need for interventions to ensure resident safety. Despite the facility's abuse prevention policy, these incidents highlight a failure to protect residents from abuse, as required by regulations.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage on specific dates in March 2025, including 3/8, 3/9, 3/13, 3/14, 3/17, and 3/18. The facility's assessment tool indicated that staffing should include one RN during both the day and night shifts. However, the nursing schedule and daily assignments documented the absence of RN coverage over a 24-hour period on the aforementioned dates. This lack of RN coverage has the potential to affect all 62 residents currently residing in the facility. The Regional Registered Nurse and the Director of Nursing confirmed the deficiency and acknowledged that they are working on correcting the issue.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 62 residents. The deficiency was identified through observation, interview, and record review. On multiple occasions, the Dietary Manager, who was actively supervising dietary operations, admitted to not being a Certified Dietary Manager and failing to meet the State of Illinois standards for a food service manager/dietary manager. The facility's assessment indicated the need for a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services to provide competent support and care for the resident population.
Infection Preventionist Not Onsite
Penalty
Summary
The facility failed to employ an Infection Prevention Nurse who physically works onsite at least part-time, potentially affecting all 62 residents. Observations made over several days revealed that no certified Infection Preventionist nurse was present in the facility. The Regional Registered Nurse confirmed that the facility's Infection Preventionist works offsite and is responsible for infection tracking and logs, which are not maintained in the facility. The Director of Nursing acknowledged that she does not have access to the infection tracking log and relies on the Regional Infection Preventionist, who visits the facility only once a week. The clinical nurse schedule for March 2025 showed no onsite Infection Prevention nurse, and the resident census documented 62 residents residing in the facility.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to residents according to their care plans, physician orders, and preferences, affecting three residents. One resident, who is dependent on staff for bathing due to dementia and other medical conditions, was scheduled for showers twice a week but only received them sporadically over a two-month period. Another resident, requiring partial assistance, reported not receiving the scheduled showers, with records showing refusals but no alternative bed baths documented. A third resident, dependent on staff and requiring a mechanical lift, also reported not consistently receiving showers, with records indicating only five instances of bathing over nearly two months. Staff interviews revealed that showers are documented on shower sheets, which are supposed to reflect whether a shower, bed bath, or refusal occurred. However, discrepancies in documentation and resident reports indicate a failure to adhere to the facility's bathing policy, which mandates at least one shower per week or according to resident preference. The lack of consistent documentation and adherence to scheduled bathing routines contributed to the deficiency in providing adequate hygiene care for the residents.
Failure to Provide Activities for Memory Care Residents
Penalty
Summary
The facility failed to provide and implement activities to meet the interests and needs of residents in the locked memory care unit, affecting four residents. Observations on multiple occasions revealed that these residents were either asleep or sitting unengaged in their rooms, with no structured activities provided. The care plans for these residents outlined specific activity preferences and needs, such as horticulture-based activities, crafts, exercise, and structured activities to promote engagement and prevent boredom. However, these plans were not being followed, as the residents were not participating in any activities. The Activity Director, V14, acknowledged the lack of activities, citing short staffing as a reason for the deficiency. V14 mentioned that a new assistant had been hired to address this issue, but until the assistant is trained, the facility's corporate office instructed that memory care CNAs should conduct activities on weekends. Despite this directive, V14 confirmed that staff had not been engaging residents in activities, resulting in residents sitting idle or sleeping due to boredom. The facility's Dementia Unit Program emphasizes providing a safe environment with attributes that support the best quality of life, which was not being met in this instance.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident. The Director of Nursing (DON) was informed by the resident that an agency LPN was rough in her approach, used a harsh tone, and discussed other residents with him. Despite this, the DON did not report the incident to the Administrator, mistakenly believing the resident had done so himself. The Administrator confirmed that no report of abuse was made by the resident or staff. The facility's policy requires immediate reporting of any potential abuse to the Administrator, which was not followed in this instance.
Failure to Coordinate PASARR Level II Evaluations
Penalty
Summary
The facility failed to coordinate a Pre-Admission Screening and Resident Review (PASARR) Level II evaluation for two residents, R21 and R62, who were reviewed for PASARR II completion. R21 was admitted with diagnoses of Schizoaffective Disorder: Bipolar Type and Anxiety Disorder. Despite these diagnoses, R21's PASARR Level I screening indicated that a Level II screening was not required due to the absence of a serious behavioral health condition. However, the Business Office Manager confirmed that the PASARR Level I screening was inaccurate, as it did not reflect R21's actual mental health diagnoses. Similarly, R62 was admitted with diagnoses of Major Depressive Disorder, Brief Psychotic Disorder, and Generalized Anxiety. R62's PASARR Level I screening also incorrectly indicated that a Level II screening was not necessary, citing no evidence of a serious behavioral health condition. The Business Office Manager acknowledged the discrepancy, confirming that the PASARR Level I screening did not accurately represent R62's mental health conditions. The staff was reminded of the need to routinely review PASARR screenings for accuracy.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide an appropriate indwelling urinary catheter collection bag and secure it in a safe and dignified manner for a resident reviewed for indwelling urinary catheters. The resident, who has diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease Stage IV, Calculus of Ureter, and presence of Urogenital Implants, was observed with a catheter bag attached to his pants, visible to all. The catheter tubing was looped through his pant leg and secured on the outside, which was not in accordance with the facility's Urinary Catheter Care Policy. A Licensed Practical Nurse confirmed the absence of leg bags and acknowledged that the resident should have had one for safety and dignity. The facility administrator was aware of the need for more leg bags and acknowledged it was his responsibility to place the order.
Insufficient RN Coverage in Facility
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on six out of fifteen days reviewed, which has the potential to affect all 66 residents in the facility. Specifically, the facility's Nursing Daily Schedule from February 20, 2025, through March 6, 2025, documented zero hours of RN coverage for a 24-hour period on February 22, 23, 27, and March 3, 4, and 5, 2025. This deficiency was confirmed by the Regional Director on March 6, 2025, who verified that the hours listed on the facility's nursing daily schedule were correct, indicating a lack of RN coverage on the specified dates. At the time of the deficiency, the facility's Resident Midnight Census documented that 66 residents resided in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. The incident involved two residents, both with moderate cognitive impairments, who were involved in a physical altercation in the dining room. One resident, who has a history of cerebrovascular disease, hemiplegia, schizoaffective disorder, and other medical conditions, was struck on the right shoulder by another resident with dementia and bipolar disorder. The altercation occurred after an argument between the two residents, and staff members attempted to intervene by separating them. The facility's abuse prevention policy emphasizes the right of residents to be free from abuse and the establishment of a secure environment. However, the incident indicates a failure to prevent the physical altercation, as staff intervention occurred only after the argument escalated to physical contact. The facility's documentation shows that the administrator and other relevant parties were notified, and an investigation was initiated following the incident.
Failure to Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident with behaviors related to undressing and walking around naked. The resident, who has been diagnosed with dementia and schizophrenia, was observed on multiple occasions to be restless during the night, refusing personal care, and removing clothing. Despite these behaviors being documented in nursing notes and witness statements, there was no comprehensive care plan addressing these specific behaviors. Interviews with staff, including CNAs and an LPN, confirmed that the resident frequently undresses and walks around the facility without clothes, requiring continuous redirection. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet residents' needs, but this was not done for the resident in question. The administrator confirmed the absence of a care plan for the resident's behavior, highlighting a deficiency in the facility's compliance with its own policies.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care, specifically showers and dental care, to four residents who were dependent on staff assistance. The facility's policy required that showers or baths be offered at least once a week according to resident preference, and dental care be provided both morning and night. However, observations and interviews revealed that residents R6, R7, R8, and R9 did not receive showers as per the policy. R6 had not received a shower for over a week, as evidenced by his disheveled appearance and long, untrimmed nails. R7, who required a mechanical lift and preferred evening showers, reported not receiving showers due to staffing issues. R8 could not recall the last time he had a shower, and R9, who was supposed to receive whirlpool baths twice a week, reported not having had a bath or dental care for several days. The facility's records corroborated these deficiencies, showing infrequent showers for the residents over the past two months. R6 received showers only three times, R7 once, R8 once, and R9 had no recorded showers. Additionally, R9 reported not having her teeth brushed for four days, which was confirmed by her stale smell and her statement to the administrator. A Certified Nursing Assistant acknowledged the lack of showers due to insufficient staffing, and the Regional Nurse confirmed that residents should receive at least one shower per week. These findings indicate a failure to adhere to the facility's policies for personal hygiene care, impacting the residents' comfort and dignity.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by another resident. An incident occurred where a resident with moderate cognitive impairment, who was able to propel themselves in a wheelchair, entered another resident's room unprovoked and physically assaulted a fellow resident. The aggressor resident kicked the victim in the shin and attempted to steal property from another resident in the room. The incident was reported to the facility administrator, and the residents were separated immediately. The victim, who also had moderate cognitive impairment and was dependent on staff for transfers, reported pain in the shin after being kicked and hit with a cane. The incident was witnessed by a Licensed Practical Nurse who intervened by removing the aggressor from the room. The facility's policy on abuse prevention and reporting was not effectively implemented to prevent this occurrence of resident-to-resident abuse.
Improper Use of Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in a significant injury. A resident with Multiple Sclerosis, who is wheelchair-bound and has impaired range of motion in both legs, was being transported in a shower chair by a CNA. The shower chair, which lacked foot pedals or leg support, was used to move the resident down a hallway. During this process, the resident's foot caught on a rug, causing a fracture to the tibia and fibula. The incident was witnessed by another CNA, who confirmed that the resident's foot was low to the ground and struck the edge of the carpet. The facility did not adhere to its incident/accident policy following the injury. The injury was not reported to the state survey agency, and a thorough investigation to determine the root cause was not conducted. The resident's care plan was not updated to reflect the injury, and there was no documentation of interventions developed to prevent future occurrences. The facility's administrator acknowledged the failure to report the injury and confirmed that the incident should have been investigated. The use of the shower chair for transportation was deemed inappropriate by the resident's physician, who noted that a wheelchair would have been safer due to its foot support. The facility's policy requires reporting serious injuries within 24 hours and conducting a comprehensive investigation, which was not followed in this case. The shower chair's owner's manual explicitly states that it is not intended for use as a transfer device, highlighting the facility's failure to use proper equipment for resident transportation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day, which is a requirement for the care of the 68 residents residing in the facility. On multiple dates, the facility's Daily Assignment Sheets did not document the presence of an RN for the required duration. Specifically, on dates such as 11/21/24-11/24/24, 11/27/24, 11/28/24, 11/30/24, and 12/1/24, only Licensed Practical Nurses (LPNs) were on duty, and no RN was present for eight consecutive hours. Additionally, on 11/20/24, 11/25/24, and 11/26/24, the Director of Nursing (V2) worked only three to four hours on the second shift, with no other RNs listed to cover the remaining hours. V2 confirmed the lack of RN coverage and mentioned the facility's reliance on agency nurses, with corporate restrictions allowing only LPNs. The facility has one full-time RN and a part-time RN who works only on Mondays and Tuesdays.
Failure to Administer Insulin and Diabetic Medications Timely
Penalty
Summary
The facility failed to administer insulin and diabetic medications timely and as ordered for four residents. The Medication Administration Policy requires that medications be administered according to physician's orders, including the right time, and that any medication errors be reported to the physician. However, the facility did not adhere to these guidelines, as evidenced by the incomplete documentation on the Medication Administration Records (MARs) and the lack of notification to physicians about missed doses. For one resident, there were multiple instances where Humulin R was not administered as ordered, and there was no documentation explaining the missed doses or any notification to the physician. Another resident's MAR was incomplete for several scheduled insulin administrations, and although the physician was notified once, there was no documentation for other missed doses. Additionally, a resident reported waiting up to four hours for medications, and their MAR showed several instances of late or missed doses of Lantus, Trulicity, and Humalog, with no follow-up documentation or physician notification. The facility's issues were compounded by agency nurses not being aware of the protocol to notify physicians when medications were unavailable. This led to further missed doses and lack of documentation for another resident, whose MAR showed missed doses of Ozempic, Tresiba, and Lispro. The Director of Nursing confirmed that medications with specified times should be administered within an hour window and documented accordingly, but this was not consistently done, leading to significant medication errors.
Failure to Assess and Manage Pain for Resident with Fracture
Penalty
Summary
The facility failed to routinely assess and manage pain for a resident who suffered a left leg tibia/fibula fracture. The resident, who has a history of Multiple Sclerosis, Type Two Diabetes Mellitus, a Sacral Stage Four Pressure Ulcer, and Osteoarthritis of the hip, reported severe pain following the incident where their foot caught on a rug while being pushed in a shower chair by a CNA. Despite the resident's complaints of pain and the administration of Ultram as needed, the facility did not have a care plan in place to address the resident's pain or injury. The facility's Pain Management Program requires pain assessments to be conducted under specific conditions, including changes in condition or when pain medication is administered. However, the resident's care plan was not updated to include interventions for the fracture and pain management. The resident's pain was not assessed every shift, and there were discrepancies in the documentation of pain medication administration, with some doses not recorded on the Medication Administration Record (MAR). Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident's pain was not routinely assessed following the injury. The Director of Nursing acknowledged that there should have been an order to assess the resident's pain every shift and that the care plan should have been updated to address the fracture and pain. The resident's physician also confirmed that pain assessments should have been conducted routinely after the injury.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. An incident occurred where a resident with severe cognitive impairment was inappropriately touched by another resident, also with severe cognitive impairment, in the leisure room. The inappropriate touching was witnessed by staff, who immediately separated the residents. The resident who was touched did not appear to be aware of the actions due to her cognitive impairment, and her family confirmed that she would not have consented to such contact if she were cognitively intact. The facility also failed to protect residents from physical abuse by other residents. One incident involved a resident with severe cognitive impairment who pushed another resident, causing a fall. Another altercation occurred when a resident with a history of physical aggression grabbed another resident's arm during a dispute over shared bathroom space. The aggressive resident had a history of territorial behavior, which was exacerbated by a recent room change. Additionally, the facility failed to prevent a physical altercation between two residents during a meal. One resident, who was eating, believed another resident was trying to take his food and responded by hitting the other resident's hand. The resident who was hit had a history of behaviors that could provoke others, including going into other residents' rooms and touching their belongings. Staff were aware of these behaviors and attempted to intervene when necessary.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement adequate safety measures and supervision to prevent falls among residents, as evidenced by incidents involving three residents. One resident, with severe cognitive impairment, fell twice due to environmental hazards and improper clothing. The first fall occurred when the resident tripped over a mole mound on the patio, resulting in facial lacerations requiring medical glue closure. The second fall happened when the resident slipped on pants that were too long, causing a cut above the eye. The facility's fall prevention policy was not effectively implemented, as staff failed to monitor and address the environmental hazard of mole mounds and did not ensure the resident wore properly fitting clothing. Another resident, also with severe cognitive impairment, fell after leaving the bathroom without a walker, sustaining a laceration above the eye and a bump on the forehead. The investigation into this fall was inadequate, with only one staff statement documented and no thorough assessment of the resident's toileting needs or last observed activity. The facility's staffing levels were insufficient, with only one CNA on duty at the time of the fall, which was identified as a contributing factor but not documented in the investigation. A third resident, with a history of falls and severe cognitive impairment, experienced multiple falls without appropriate interventions being documented or implemented. The resident's care plan was not updated to reflect recent falls, and necessary checks were not completed. During one incident, the resident fell from bed while being changed by a CNA who was unaware that two staff members were required for the task. The resident's call light was found to be non-functional, further compromising safety. The facility's failure to conduct thorough investigations and implement effective fall prevention strategies contributed to these incidents.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement specific interventions to address behavioral disturbances associated with dementia for three residents. One resident, identified as R3, exhibited severe cognitive impairment, hallucinations, and daily aggressive behaviors. Despite a history of violent aggression and psychiatric hospitalizations, R3's care plan lacked personalized interventions to manage these behaviors. Incidents included physical aggression towards other residents, such as grabbing a peer by the arm and pushing another resident, which were not adequately addressed in the care plan. Another resident, R4, also displayed severe cognitive impairment and aggressive behaviors, including hitting another resident's hand and attempting to hit a staff member. R4's care plan did not document these behaviors or provide personalized interventions to prevent them. The facility's behavior monitoring reports for R4 were generic and did not reflect the specific needs and behaviors of the resident, leading to repeated incidents of aggression and the need for psychiatric evaluations. The third resident, R6, had Alzheimer's Disease and Dementia with Behavioral Disturbances, exhibiting behaviors such as reaching for other residents' food and items during meal times. R6's care plan did not document these specific behaviors or interventions to address them, resulting in altercations with other residents. The facility's failure to provide personalized care plans and interventions for these residents with dementia-related behaviors contributed to ongoing conflicts and safety concerns within the facility.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds by an employee, resulting in psychosocial harm. The incident involved a Business Office Manager (BOM) who, along with an Activity Aide, was alleged to have taken $600 from the resident's Trust Fund for personal use, specifically for car repairs for a family member. The facility's Abuse Prevention Program and Resident Funds Policy were not adhered to, as evidenced by the lack of signed vouchers and resident authorization for transactions. The resident, who has moderate cognitive impairment, was unaware of unauthorized transactions due to not receiving receipts or quarterly statements. The investigation revealed that a check for $200 was made out to cash without the resident's signature authorizing the transaction. The BOM admitted to providing cash to the resident without proper documentation, and the facility's Administrator confirmed the absence of required resident signatures on the Trust Fund logs. The BOM's employment was terminated for failing to follow facility policy, which included not providing necessary receipts and statements to residents, further contributing to the misappropriation of funds.
Failure to Provide Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for Resident Trust Funds for five residents, as required by their policy. The policy mandates security measures to safeguard resident funds, including signed vouchers, computerized tracking, monthly oversight, and signed quarterly statements. However, upon review, it was found that the facility's Resident Trust Fund binder contained transaction logs for the months of July to September 2024, which were not signed by the residents, and there were no signed quarterly statements available. This deficiency was highlighted during an investigation following an allegation of misappropriation of a resident's property involving the Business Office Manager and an Activity Aide. Interviews with residents and staff revealed that residents did not receive receipts or quarterly statements for their trust fund accounts. One resident, with moderate cognitive impairment, confirmed not receiving any receipts or statements, which prevented them from noticing unauthorized transactions. Another resident, who was cognitively intact, also stated they never received quarterly statements. The Business Office Manager admitted to not being trained on providing these statements, resulting in their absence. The Administrator in Training confirmed the lack of documentation for quarterly statements and stated that the Business Office Manager's employment was terminated for not adhering to facility policy.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to ensure that its Surety Bond provided adequate coverage for the Resident Trust Funds. The Surety Bond, dated May 8, 2023, was for the sum of $73,500, which was insufficient to cover the total amount of resident funds held by the facility. The facility's bank statements for July, August, and September 2024 showed ending balances of $136,483.09, $146,255.16, and $168,628.65, respectively, indicating that the Surety Bond did not cover the total amount of resident funds, which consistently exceeded $136,000 over the past three months. The deficiency affected five residents who had trust funds managed by the facility. Interviews with these residents confirmed that they had Resident Trust Funds managed by the facility. The facility's Administrator in Training acknowledged that the Surety Bond amount was insufficient and needed to be increased to match the total resident trust fund balance. The deficiency was identified during a review of the facility's Resident Trust Fund binder and bank statements, which documented transactions, withdrawals, and balances for each resident.
Failure to Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident and two staff members to the Illinois Department of Public Health (IDPH) as required by their Abuse Prevention Program. The program mandates that any suspicion of sexual abuse must be reported within two hours, or within 24 hours for other types of abuse. An anonymous call was received by the facility, alleging that two staff members allowed a resident to touch them inappropriately in exchange for money. Additionally, it was alleged that these staff members misappropriated $600 from the resident's Trust Fund Account. However, the facility's report to IDPH only included the misappropriation allegation and omitted the sexual abuse claim. The facility's cumulative abuse log did not document the sexual abuse allegation, and the administrator in training, who was notified of the incident, admitted to not reporting the sexual abuse allegation to IDPH. The administrator stated that the thought of reporting the sexual abuse allegation did not occur until after the fact. This oversight indicates a failure to adhere to the facility's own abuse reporting protocols, which are designed to ensure timely and appropriate responses to allegations of abuse, thereby safeguarding residents' well-being.
Failure to Provide Dialysis Services
Penalty
Summary
The facility failed to provide necessary dialysis services to a resident, identified as R15, who required such services due to kidney failure. R15 was admitted to the facility with a renal shunt for dialysis and a diagnosis of kidney failure, necessitating dialysis three times a week. However, due to a lack of understanding and coordination by the Social Services Director, V11, R15 missed nearly two and a half months of dialysis treatments. This oversight led to R15 being hospitalized for hypervolemia, a condition resulting from fluid overload, on January 30, 2024. The deficiency was further highlighted by the facility's inability to provide transportation for R15's dialysis on the day of admission, which was supposed to be managed by the Social Services Director. The Director of Nursing, V2, acknowledged that nursing issues such as dialysis should be managed by the nursing department, indicating a lapse in the facility's internal processes. The Dialysis Registered Nurse, V32, confirmed that R15's first dialysis treatment at the facility occurred only after hospitalization, underscoring the critical delay in providing essential medical care.
Failure to Manage Pain for Hospice Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident on hospice care, resulting in the resident experiencing uncontrolled pain. The facility's Pain Prevention & Treatment policy requires routine pain assessments and timely implementation of pain medication orders, but these were not consistently followed. The resident, who had severe cognitive impairment and multiple medical conditions, was observed moaning, grimacing, and yelling out in pain. Despite the resident's care plan indicating a need for immediate response to pain complaints, there were no new interventions implemented after a certain date to address the resident's ongoing pain. The resident's medication records revealed inconsistencies in the administration of prescribed pain medications. A Fentanyl patch order was not implemented for 11 days, and there were discrepancies in the documentation of Morphine administrations. The resident's pain was frequently rated as severe, and several doses of Morphine were documented as ineffective in providing relief. Additionally, there was no documentation of the resident refusing pain medication, suggesting a lack of proper pain management and assessment. Interviews with facility staff indicated a lack of communication and documentation regarding the resident's pain management. The Director of Nursing and other staff members acknowledged the need for hourly pain assessments for hospice residents and the importance of consulting hospice for uncontrolled pain. However, there were lapses in following these protocols, as evidenced by the delayed implementation of medication orders and insufficient documentation of pain assessments and medication effectiveness.
Inadequate Infection Control and Legionella Monitoring
Penalty
Summary
The facility failed to monitor potential exposure sites for Legionella, which could affect all 44 residents. The facility's Legionella Policy and Procedures lacked documentation of plumbing inspections, assessments for redundant piping, and regular flushing of potential stagnation sites. The administrator confirmed the absence of an assessment or plan to address these issues, indicating a lack of surveillance and preventive measures against Legionella bacteria. Additionally, the facility did not adhere to its Contact Precautions policy. A resident on contact isolation due to ESBL in the urine was not properly protected, as staff entered the room without donning PPE. Despite a sign indicating contact isolation, there were no specific instructions on required PPE. Observations showed that a nurse and a housekeeping supervisor entered the resident's room without PPE, exposing themselves and potentially others to infection. The resident's laboratory reports confirmed the presence of bacteria, necessitating strict adherence to contact precautions.
Facility Lacks Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a certified Infection Preventionist, which is a requirement for maintaining an effective infection prevention and control program. This deficiency potentially affects all 44 residents residing in the facility. The facility's policy on Infection Control Surveillance and Monitoring, last reviewed in December 2018, outlines the responsibilities of the Administrator, Infection Control Preventionist (ICP), and the Director of Nursing (DON) in monitoring and ensuring compliance with infection control practices. However, during an interview, the DON admitted that neither she nor the Assistant Director of Nursing, who assists with infection prevention tasks, are certified Infection Preventionists. The facility's policy includes procedures for routine surveillance, monitoring work practices, investigating exposure incidents, and maintaining communication with physicians and the Illinois Department of Public Health regarding infectious cases. Despite these outlined procedures, the lack of a certified Infection Preventionist indicates a gap in the facility's ability to effectively implement and oversee these critical infection control measures. The Assistant Director of Nursing, who is involved in tracking infections, cultures, and antibiotics, also confirmed that they have not completed the necessary infection preventionist training.
Facility Fails to Address Roof Leaks, Affecting Resident Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and functional environment by not addressing roof leaks, which resulted in sagging and stained ceiling tiles. Observations on multiple occasions revealed sagging ceiling tiles with large brown stains near the nurse's station and at the beginning of the C Hall. In one instance, a ceiling tile had been removed, exposing cords hanging down. A wet floor sign and a bath towel with a basin were placed below the leaking area to collect water droplets. This issue was noted to have persisted for a significant period, as confirmed by the Director of Nursing, who mentioned that the problem existed even when they worked as a hospice nurse at the facility a year and a half ago. A resident, who was admitted to the facility in October 2023, reported that the brown discoloration on the ceiling tile in their room had increased in size since their admission, indicating ongoing roof leaks when it rains. The facility's administrator confirmed the presence of the brown, sagging ceiling tiles and acknowledged that the roof still leaks despite having been patched. The administrator stated that roof repair quotes had been obtained, but the repairs had not been completed as they were awaiting corporate approval. This deficiency potentially affects all 44 residents residing in the facility.
Deficiencies in Laboratory Services and Documentation
Penalty
Summary
The facility failed to provide timely and accurate laboratory services for three residents, leading to deficiencies in monitoring and documenting essential health information. Resident R4, diagnosed with Type 2 Diabetes Mellitus, had an order for an A1C test every three months. However, the last A1C test was conducted nine months prior, with results indicating high levels. The Assistant Director of Nursing confirmed the absence of A1C results for the required period, highlighting a lapse in following the physician's orders. Resident R25 had a physician's order for a Hepatic Function Panel, which was not documented in the medical record. The Director of Nursing confirmed the missing test results, and the facility's contracted laboratory phlebotomist clarified that the Hepatic Function Panel includes tests not covered by a Comprehensive Metabolic Panel. Additionally, Resident R46's care plan required regular blood glucose monitoring, but the Medication Administration Records for several months lacked documentation of these results. The Assistant Director of Nursing acknowledged the omission, attributing it to a potential computer issue.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately account for controlled substance medications and ensure medications were provided as ordered for several residents. For Resident R45, there was a discrepancy in the delivery and receipt of Fentanyl patches. The facility's investigation revealed that the package containing both Lorazepam and Fentanyl patches was delivered, but only Lorazepam was accounted for. The Administrator and Assistant Director of Nursing were involved in the handling of the package, but the Fentanyl patches were never located. Additionally, there was no requirement for a second signature to verify the receipt of controlled medications, which contributed to the oversight. Further discrepancies were noted in the medication administration records (MAR) for R45, where the documented administration of Lorazepam and Morphine did not match the controlled substances proof of use records. This inconsistency was acknowledged by the Administrator, who conducted a facility-wide audit and found similar issues. The lack of proper documentation and verification of medication administration was a recurring problem, as evidenced by the mismatched records for other residents as well. Other residents, such as R32 and R22, also experienced issues with controlled medication documentation. R32's Lorazepam count did not match the proof of use sheet, and R22's Lorazepam was administered without proper orders or documentation on the MAR. Additionally, R14 did not receive their prescribed Omeprazole due to insurance issues, and there was no documentation of physician notification regarding the missed doses. The facility's policies on controlled substances and medication administration were not consistently followed, leading to these deficiencies.
Failure to Obtain Consent and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain consent for psychotropic medications, identify resident-specific targeted behaviors, and justify the use of duplicative antipsychotic medications for five residents. The facility's policy on psychotropic medications, which requires obtaining consent and ensuring medications are not unnecessary, was not followed. For Resident 38, there was no documentation of behaviors justifying the use of antipsychotics, no tracking of behaviors, and no physician's documentation to justify concurrent duplicative orders for antipsychotic medications. Additionally, there was no consent documented for the use of Haldol. Similar issues were observed for Residents 19, 33, and 39, where there was no documentation of resident-specific behaviors justifying the use of antipsychotics and no tracking of behaviors. Resident 5's behavior tracking could not be located, and consents for medications were not signed until the day of the survey. The Director of Nursing acknowledged the lack of specific behaviors identified or tracked for the residents and the absence of physician documentation to justify the use of multiple antipsychotics. The facility's failure to adhere to its policy on psychotropic medications and the lack of proper documentation and consent contributed to the deficiency identified during the survey.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered for three residents, leading to significant medication errors. For one resident, a Fentanyl patch was not administered as ordered, with no documentation explaining the omission or any indication of refusal by the resident. The Licensed Practical Nurse was unsure of the reason for the missed administration, and the Hospice Registered Nurse confirmed that missing the Fentanyl could contribute to increased pain for the resident. Another resident did not receive their prescribed Lacosamide for seizures due to a pharmacy and insurance issue, resulting in the medication being unavailable for an extended period. There was no documentation that the physician was notified of the unavailability or the missed doses. The Assistant Director of Nursing confirmed the issue, and the Regional Nurse and Administrator stated that the facility should have provided cost coverage or sought an alternative medication. The physician was unaware of the insurance issue and the missed doses, which placed the resident at risk for seizures. A third resident did not receive their prescribed nebulizer treatments due to a lack of a nebulizer machine and medication. The resident's notes documented multiple instances where the treatment was not administered, with reasons ranging from the resident sleeping to the unavailability of a nebulizer machine due to insurance issues. The resident confirmed not receiving the treatments and experiencing chest pain. The Assistant Director of Nursing acknowledged the incorrect initial order and the insurance-related lack of a nebulizer machine.
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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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