Archer Heights Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4437 South Cicero, Chicago, Illinois 60632
- CMS Provider Number
- 145995
- Inspections on file
- 58
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Archer Heights Healthcare during CMS and state inspections, most recent first.
The facility failed to follow its abuse policy and protect residents from physical abuse when an argument between two roommates over noise escalated into a physical altercation. A CNA entered the room after hearing about a fight and found one resident standing over another, punching him, and separated them while calling for help. An LPN then found the injured resident on the floor bleeding from the head and obtained conflicting accounts from both residents about whether the dispute involved loud talking or television volume. The injured resident sustained facial and scalp lacerations and a nasal bone fracture, consistent with being struck and punched multiple times, as confirmed by ED evaluation. The facility’s own abuse policy defines such willful infliction of injury, including hitting, as physical abuse requiring medical attention, and staff intervention occurred only after the assault was already in progress and significant injuries had occurred.
A resident with asthma and other medical conditions, who was cognitively intact, shared a room with a cognitively intact roommate diagnosed with nicotine dependence and dementia who repeatedly smoked in their room despite a facility smoke‑free interior policy, a documented history of in‑room smoking, a care plan addressing this behavior, and a signed smoking contract prohibiting possession and use of smoking materials in the room. Staff, including an LPN, confirmed that the smoker continued to smoke in the shared room and that the asthmatic roommate complained about the smoke. The smoker admitted he chose to smoke in his room rather than go to designated outdoor areas, resulting in the facility’s failure to maintain a safe, clean, and comfortable environment free from in‑room smoking.
Staff failed to follow Enhanced Barrier Precautions and infection control policies during incontinence care for a cognitively intact resident with multiple comorbidities, including diabetes with foot ulcer, kidney failure, and dialysis dependence. A CNA wore contaminated gloves in the hallway, accessed the linen cart without changing gloves, and provided incontinence care without a gown, despite posted EBP instructions requiring gown and gloves for high-contact care. The privacy curtain was not used, the room door remained open, and a soiled brief was left on the floor. An LPN and the DON confirmed that facility policy requires gown and glove use for EBP residents and proper bagging and disposal of soiled linens and incontinent products.
Multiple residents reported and surveyors observed persistent uncleanliness in resident rooms, including trash and debris on floors and under beds, despite facility policies requiring daily cleaning. Staff interviews revealed inconsistencies in cleaning practices, and care plans did not address potential hoarding behaviors, resulting in a failure to provide a safe and homelike environment.
A resident with intact cognition was given medication at the medication cart and took it without a nurse present to observe ingestion. The LPN responsible was multitasking and did not ensure the medication was swallowed. There was no physician's order or assessment for self-administration, and facility policy requires direct observation during medication administration.
Multiple residents and staff reported and surveyors observed persistent cleanliness and maintenance issues, including unemptied garbage, insect infestations, soiled and unsanitary shower rooms, and broken equipment. These deficiencies were present throughout the facility, affecting resident rooms, shared bathrooms, dining areas, and staff spaces, despite facility policies requiring daily cleaning, pest control, and regular maintenance.
A resident who was cognitively intact but required substantial assistance for daily activities and had hand contractures was unable to access their call light, which was found out of reach. Staff confirmed the call light's placement prevented the resident from requesting help, despite facility policy and the care plan requiring it to be accessible.
A nurse administered an antihypertensive medication to a resident without assessing or documenting blood pressure as required by the physician's order and facility policy. Both the LPN and DON confirmed that blood pressure should be checked before giving such medications to ensure safe administration.
Multiple incidents of resident-to-resident physical abuse occurred, including altercations on the smoking patio, in a shared room, and in the dining room. In each case, verbal disputes escalated to physical violence, with staff intervening after the events. Some residents had documented behavioral issues or prior conflicts, but preventive measures were not effectively implemented, resulting in physical harm and distress.
The facility did not ensure proper cleaning or maintenance of water and ice machines, resulting in visible mineral buildup, leaks, and unsanitary conditions. Staff and residents accessed water and ice from these machines and from sinks also used for handwashing, which were not properly maintained. Facility leadership and staff were unclear about responsibilities for cleaning and servicing the machines, and established policies for regular cleaning and maintenance were not followed.
The facility did not provide enough seating in day/dining rooms for ambulatory residents and failed to maintain cleanliness and timely repairs in resident rooms and common areas. Multiple residents reported having to stand or use uncomfortable alternatives due to a lack of chairs, and observations revealed persistent issues such as sticky floors, stained walls, and delayed maintenance of reported problems. Housekeeping and maintenance staff were unclear about cleaning schedules, and resident council minutes reflected ongoing concerns about room cleaning.
Two residents with cognitive and behavioral impairments were involved in an incident where one physically struck the other over a wheelchair, with staff failing to provide adequate supervision or immediate intervention. In a separate case, a resident assessed as a moderate fall risk did not receive recommended side rails and alarms, resulting in a fall and head injury, despite staff and assessment documentation supporting the need for these interventions.
A resident with a history of substance abuse and mental health conditions became intoxicated and reported non-consensual sexual activity while under the influence of alcohol and drugs. Multiple residents were able to access and use alcohol and illicit substances within the facility, despite existing policies prohibiting contraband. Staff only checked residents' bags and not their persons, leading to lapses in supervision and enforcement, and resulting in harm to at least one resident.
Several instances were identified where medications, including pills, inhalers, and insulin pens, were left unsecured at the bedside or in unlocked carts, and residents were not on self-administration programs. Staff interviews and record reviews confirmed that medications were not always administered or stored according to facility policy, with some medications lacking physician orders and being left accessible to residents without proper authorization.
A resident dependent on staff for ADLs did not receive timely personal hygiene, including nail care, and was found in soiled conditions with unkempt hair, dirty hands, and a foul-smelling room. The assigned CNA had not provided required morning care or checked on the resident since the start of the shift, despite the care plan indicating a self-care deficit and the need for staff assistance.
A resident with chronic respiratory conditions did not receive prescribed BIPAP therapy at night as ordered following hospital discharge. Facility records showed no documentation of BIPAP or CPAP treatment, and staff interviews revealed a lack of communication and follow-through in reconciling and implementing hospital recommendations. The resident's care plan did not address the required therapy, and the necessary equipment was not available, resulting in a failure to provide and document appropriate respiratory care.
A resident with COPD and other medical conditions was given oxygen at 5L/min via nasal cannula, despite a physician's order for 3L/min. An LPN did not check the oxygen concentrator setting during her shift and was unaware of the incorrect dosage until it was pointed out by a surveyor. Both the DON and a nurse practitioner confirmed that the order was for 3L/min and that oxygen should be administered as prescribed.
A resident with a history of COPD and bilateral below-knee amputations did not receive prescribed morphine for pain management, despite documentation indicating administration. The facility failed to manage the medication process effectively, as narcotic sheets were missing and the medication was not found in the narcotic drawer. Staff interviews revealed inconsistencies in documentation and administration, leading to unmanaged pain for the resident.
The facility failed to adhere to proper food storage and sanitation practices, potentially affecting all 207 residents on an oral diet. Observations included undated and unlabeled food items, staff storing personal food in resident areas, and a lack of sanitizer in the kitchen. These actions violate the facility's policies on food safety and sanitation.
The facility failed to maintain a sanitary and comfortable environment for four residents. One resident reported infrequent room cleaning, while another's room had missing furniture parts and stained floors and curtains. A resident with a g-tube had a dried substance on the pole and dust on the oxygen concentrator. Staff were unclear about cleaning responsibilities, leading to these deficiencies.
The facility failed to secure and properly manage medications, particularly narcotics, on the fourth floor. An unlocked medication refrigerator allowed access to narcotics, and expired medications were found. Controlled substances like Diazepam were improperly stored, and inhalers lacked clear labeling. Discrepancies in narcotic medication documentation were noted, contrary to facility policies requiring secure storage and accurate inventory reconciliation.
The facility failed to monitor personal refrigerator temperatures and ensure thermometers were present for four residents, leading to expired food being found. Staff interviews revealed confusion about who was responsible for these checks, contrary to the facility's policy requiring daily temperature logs and monitoring.
The facility failed to ensure proper infection control measures, including PPE use during wound care, posting EBP signage, and maintaining PPE bins outside isolation rooms. Staff did not perform hand hygiene when passing meal trays, even after touching personal items. Interviews revealed a lack of adherence to infection control protocols, with the absence of an IP nurse contributing to these deficiencies.
The facility failed to ensure call light accessibility for two residents, affecting their ability to request assistance. One resident, with multiple diagnoses including osteoarthritis and dementia, had her call light on the floor behind her bed, out of reach. Another resident, also with dementia and other health issues, had the call light on the floor underneath the bed. Both residents' care plans required the call light to be within reach, but this was not adhered to, as confirmed by facility staff.
The facility failed to refer three residents for a Level II PASARR evaluation after new mental disorder diagnoses. One resident was admitted with bipolar and adjustment disorders, but the PASARR did not reflect these conditions. Another resident had Major Depressive Disorder, but the PASARR documentation did not indicate this, and the care plan did not address it. A third resident's PASARR documentation was incomplete, missing the Major Depressive Disorder diagnosis. The facility's policy requires PASARR screening prior to or shortly after admission, which was not followed.
The facility failed to update the PASARR for three residents with new mental health diagnoses, including Major Depressive Disorder and bipolar disorder. The initial screenings did not reflect these conditions, and necessary Level II screenings were delayed or not conducted. The Business Office Manager acknowledged the oversight and initiated corrective actions, but the facility did not adhere to its policy requiring timely PASARR screenings.
A resident with a history of diabetes and foot ulcers did not receive daily wound care as ordered, leading to dirty dressings and self-care by the resident. Facility records showed multiple days without documented care, and staff confirmed the expectation for daily dressing changes.
The facility failed to investigate a fall incident involving a resident with multiple medical conditions and did not implement fall interventions as per the care plan. Additionally, the facility did not ensure adequate supervision to prevent a resident from smoking in a room, despite policies prohibiting indoor smoking. These deficiencies highlight lapses in adhering to safety protocols and resident supervision.
The facility failed to provide proper respiratory care for two residents receiving oxygen therapy. One resident's nasal cannula tubing was not changed weekly, and their CPAP mask was improperly stored. Another resident received oxygen without a physician's order, and their tubing was found on the floor. Both residents were cognitively intact and had diagnoses requiring supplemental oxygen. The facility did not adhere to its policies for equipment change and physician orders.
A resident with severe cognitive impairment was prescribed and administered Remeron for depression without obtaining informed consent beforehand. The facility's policy requires informed consent prior to prescribing psychotropic medications, but consent was only obtained verbally after the medication had been administered for several weeks.
Two residents in a facility experienced abuse due to inadequate protection measures. One resident was pushed by another, resulting in a head injury, while another resident was physically assaulted during a verbal altercation. The facility's investigation and response were insufficient, failing to acknowledge and address the aggressive behaviors effectively.
A resident with a surgical wound did not receive necessary treatment and services, leading to wound deterioration and avoidable pain. The resident's dressing was not changed as ordered, and pain medication was not documented as administered. Staff interviews revealed a lack of proper documentation and assessment for self-care, contributing to the resident's condition worsening.
The facility failed to maintain a clean environment, affecting all 208 residents. Observations showed dirty floors with food particles and dirt in dining areas and hallways. Staff and residents acknowledged the unclean conditions, with some residents cleaning their own rooms due to housekeeping shortages. The facility's administrator confirmed recent housekeeping issues and the appointment of a new manager.
The facility failed to report suspected abuse incidents within the required timeframe, affecting four residents. In one case, a resident was pushed and injured by another resident, but the incident was reported six days late. In another case, a verbal disagreement escalated to physical abuse, but the administrator was not informed of the physical aspect. Staff did not follow the facility's policy for immediate reporting to the state survey agency and the abuse prevention coordinator.
The facility failed to investigate a fall incident where a resident was allegedly pushed by another, resulting in a head injury. Additionally, an allegation of verbal and physical abuse between two residents was not investigated. Key witnesses were not interviewed, and relevant records were not reviewed, leading to deficiencies in addressing potential abuse.
A resident left the facility unsupervised for an appointment and did not return for four days, as the facility failed to complete a timely community survival skills assessment. The resident's intact cognition was noted, but the assessment was delayed, leading to a lack of awareness of the resident's whereabouts. Staff interviews revealed communication gaps regarding pass privileges and monitoring processes.
The facility failed to maintain the third-floor community shower room in a sanitary and functional condition, affecting 52 residents. Observations revealed a stained toilet bowl, accumulated dust on the toilet water tank, and a broken shower faucet. An LPN confirmed the issues, and the Housekeeping Director acknowledged staffing challenges, with plans to hire more staff. The facility's housekeeping policy mandates daily cleaning, which was not followed.
A facility failed to protect two residents from abuse by another resident with known violent behavior. The aggressive resident was admitted without timely background checks or a care plan, despite a history of aggression and a criminal record. This oversight led to physical assaults on two residents, causing significant injuries. The facility's assessments and care planning were inadequate, contributing to the failure to prevent these incidents.
A resident with multiple diagnoses, including legal blindness and dementia, was inaccurately assessed, leading to unaddressed aggressive behaviors. The resident assaulted two other residents, causing significant harm to one. Facility staff confirmed the inaccuracies, noting the absence of a specific policy for aggression screening and trauma assessments.
A facility failed to develop a care plan for a resident with known aggressive behaviors, leading to two incidents where the resident physically assaulted other residents, causing harm. Despite prior knowledge of the resident's history of aggression and dementia, the care plan was not updated until after these incidents, contrary to facility policies requiring timely updates to care plans.
A resident with a known history of aggression was inadequately supervised, leading to assaults on two other residents, causing significant injuries. Despite prior incidents and staff awareness of the resident's violent tendencies, the care plan was not updated to address these behaviors, and no specific supervision measures were implemented.
The facility failed to conduct quarterly QAPI meetings and did not address abuse data collection, affecting all 200 residents. Meeting minutes from March 2024 lacked abuse reporting, and no further minutes were available until October 2024. Staff confirmed that incidents of physical abuse were not reviewed in QAPI meetings, and facility policies did not adequately address abuse prevention.
The facility failed to submit a final investigation report regarding a physical altercation between two residents to the state survey agency within the required five business days. The incident was initially reported, but the final report was delayed by 20 days. The administrator, who is also the abuse prevention coordinator, acknowledged the oversight and resubmitted the report. This failure to comply with the facility's policy affects the residents involved.
The facility failed to protect residents from verbal and physical abuse, leading to significant incidents. A resident with schizoaffective disorder was harassed by another resident, resulting in a physical altercation and self-inflicted injury. Another incident involved two residents in wheelchairs who engaged in a verbal and physical confrontation. The facility's policies on abuse prevention were not effectively enforced, leading to harm and distress among residents.
A resident on anticoagulants fell and sustained a head injury, but the LTC facility failed to assess, document, and inform the physician promptly. The resident was not sent to the hospital immediately, despite the risk of a subdural hematoma. Staff inconsistencies in reporting and documentation were noted, and facility protocols for neurological assessment were not followed.
A diabetic resident in an LTC facility suffered severe complications due to inadequate foot care and monitoring. Despite requiring substantial assistance, the resident's foot condition was neglected, leading to a wound infested with maggots. The nurse practitioner discovered the issue during a routine check, resulting in the resident's hospitalization and amputation of the right big toe due to gangrene. Staff interviews revealed inconsistencies in care and documentation, highlighting a failure to adhere to facility policies on skin assessments and foot care.
A resident reported that a nurse called them a 'crackhead' and threatened to transfer them, but the facility failed to report this allegation to IDPH within the required two-hour timeframe. The administrator did not initially consider it an abuse allegation, leading to a delay in reporting.
A facility failed to coordinate outside services and maintain complete medical records for a resident, leading to missed and uncoordinated follow-up appointments after hospitalizations. Staff were unaware of the resident's past and future appointments, resulting in a lack of transportation arrangements and incomplete records. The facility lacked an appointment policy, contributing to the deficiency.
A resident's medical records inaccurately listed a diagnosis of schizophrenia, which the resident did not have. The facility staff, including the DON and a psychiatric nurse practitioner, could not determine the source of this incorrect diagnosis. The facility's medical record policy requires accurate documentation, but this was not followed, leading to the error.
A resident with a history of aggressive behavior ran over another resident's foot with a wheelchair, causing significant pain and swelling. The incident occurred after a disagreement at the nurse's station, and staff failed to adequately monitor and manage the situation. The facility's delayed reporting to the state agency highlights a deficiency in protecting residents from harm.
Failure to Prevent and Timely Intervene in Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy and protect residents from physical abuse when two roommates became involved in a physical altercation. A CNA reported hearing someone say there was a fight and, upon entering the room, observed one resident standing over the other and punching him. The CNA separated the residents and escorted the aggressor out while calling for assistance. An LPN heard commotion from the same room, entered, and found one resident on the floor bleeding from the head. The LPN assessed him and obtained information from the other resident that an argument about the television volume had escalated, with one resident stating that the other got in his face, leading him to hit the resident, who then fell to the floor. The injured resident later stated that he had walked into his old room where his roommate was on the phone arguing with his girlfriend. He reported asking the roommate to lower his voice, after which the roommate approached him with a cane and hit him in the face, causing him to fall, and then punched him several more times until the aide intervened. The aggressor resident stated that he was in the room when his roommate came in and turned the television up loudly, and that after asking him to turn it down, the roommate walked toward him and cursed at him, leading him to punch the roommate first because he thought he was going to be hit. He reported punching the roommate again when he tried to get back up, and that the aide came in between them before he could hit him again. Clinical documentation shows that the injured resident was found on the floor with blood coming from his nose and the back of his head, with a busted lip and bleeding from the back of his head. Hospital records describe a 55-year-old male who presented with a chief complaint of battery, reporting that he was punched in the face at the nursing home. Examination revealed a scalp laceration, a 3 cm vertical laceration of the left upper lip and face, and imaging showed an acute on chronic fracture of the nasal bones with a new fracture of the nasal process of the left maxillary bone. The facility’s abuse policy defines abuse as the willful infliction of injury and physical abuse as infliction of injury other than by accidental means requiring medical attention, including hitting and controlling behavior through corporal punishment. The events described demonstrate that the residents engaged in a willful physical altercation resulting in injuries that met the facility’s definition of physical abuse, and staff did not intervene until after the altercation had already progressed to the point of significant injury.
Failure to Prevent In‑Room Smoking Exposing Roommate to Smoke
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and smoke‑free environment for a resident sharing a room with a known smoker. One resident with medical diagnoses including anxiety disorder, bipolar disorder, paraplegia affecting the right side, cerebral infarction, and asthma, and who was documented as cognitively intact, reported that his roommate was constantly smoking in their room. The roommate had medical diagnoses including nicotine dependence, cognitive communication issues, dementia, major depressive disorder, memory deficit following cerebral infarction, and chronic osteomyelitis, and was also documented as cognitively intact. Despite a facility policy that the interior of the facility remain smoke‑free and that smoking occur only in designated areas, the smoking roommate admitted to smoking in the shared room and stated he did so because he did not feel like going outside and did not care about the rules. The smoker’s record showed a long-standing pattern of smoking in his room, with social service notes documenting multiple dates over several months when he was observed smoking in his room. His care plan identified a behavior of smoking cigarettes in his room, and a Smoking Risk Review concluded he may not be capable of handling or carrying smoking materials and required supervision when smoking. A smoking contract specified that he would not smoke anywhere else in the building, would surrender all smoking materials, and would not possess smoking materials in his room or clothing, with stated consequences for violating the policy. Nonetheless, staff, including an LPN, confirmed that the resident continued to smoke in his room while he was roommates with the resident who had asthma, and that the asthmatic resident complained about the smoking because he did not want his asthma to flare up. These actions and inactions resulted in the resident with asthma being exposed to cigarette smoke in his room, contrary to the facility’s smoking safety policy and the resident’s right to a safe, clean, and comfortable environment.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s Enhanced Barrier Precautions (EBP) and infection control policies during incontinence care for one resident. On 1/17/2025 at 3:45 PM, a CNA (V7) was observed exiting and re-entering the resident’s room and walking down the hallway while wearing contaminated gloves, then going to the linen cart to obtain a facecloth without removing the gloves. V7 then returned to the resident’s room and performed incontinence care without wearing a gown, despite an EBP sign posted on the resident’s door stating that staff must wear both gown and gloves for high-contact resident care activities such as changing briefs or assisting with toileting. During this care, the privacy curtain was not pulled, the room door remained open, and a soiled brief was observed on the floor next to the resident’s bed. In subsequent interviews, V7 acknowledged that the resident was on EBP and stated she should not have been wearing gloves in the hallway. An LPN (V8) confirmed that the resident was on EBP and stated that to prevent the spread of infection, staff should wear a gown and gloves during care and that soiled linen and incontinent products should not be thrown on the floor but placed in a bag and disposed of properly. Another LPN (V9) and the DON (V2) both stated that staff should wear gown and gloves when performing incontinence care for residents on EBP and that soiled linen and incontinent products should be bagged and disposed of properly. The resident involved was cognitively intact, with diagnoses including Type 2 diabetes mellitus with foot ulcer, unspecified kidney failure, dependence on renal dialysis, and acquired absence of the right leg above the knee. The facility’s EBP policy required gowns and gloves for high-contact care activities, and the Infection Control Policy required all personnel to adhere to the Infection Control Program in their daily assignments.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by observations of uncleanliness and debris in multiple resident rooms. Surveyors observed trash, paper, and other debris on the floors and under beds in the rooms of four residents. One resident reported that housekeeping had not cleaned his room despite repeated requests over a two-week period, and trash was observed on the floor and under his bed. Another resident confirmed that trash was consistently present on the floor in his room. In another room, surveyors found multiple empty bottles, paper, napkins, and a meal tray slip stuck to the floor, which the housekeeper acknowledged was present despite stating the room had been cleaned that morning. The same resident reported that her room had not been cleaned for about ten days and that the bathroom remained uncleaned even after she reported the issue to staff multiple times. Interviews with staff revealed inconsistencies in cleaning practices, with the regional nurse consultant stating that rooms are cleaned daily and that floor nurses are responsible for ensuring cleanliness, while the housekeeper admitted to cleaning a room that still contained significant debris. Residents' care plans did not document any focus on hoarding behaviors, and the facility's policies require a safe, clean, and comfortable environment. The observations and resident interviews directly contradict the facility's stated cleaning protocols and policies, resulting in a failure to provide the required homelike environment.
Failure to Ensure Proper Medication Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition was observed taking medication at the medication cart without a nurse present to ensure the medication was swallowed. The resident's physician order sheet did not document a focus for self-administration of medication, and there was no evidence of a physician's order, resident education, care plan, or assessment for self-administration. The resident reported that the LPN handed her the medication and then walked away for a few seconds, during which time the resident took the medication and drank water without supervision. The LPN confirmed she did not observe the resident take the medication because she was multitasking. The Director of Nursing stated that self-administration of medication requires specific interventions for safety, including a physician's order and assessment, and that nurses are required to observe residents to ensure medications are swallowed. Facility policy requires medications to be administered in accordance with good nursing practices and only by authorized personnel, with sufficient staff and systems in place to ensure safe administration without unnecessary interruptions.
Widespread Environmental Cleanliness and Maintenance Failures
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for all 196 residents, as evidenced by multiple observations, interviews, and record reviews. Residents and staff reported and surveyors observed widespread cleanliness issues, including garbage not being emptied daily in resident rooms, accumulation of food waste, and the presence of flies and gnats throughout the facility. Specific instances included garbage cans in resident bathrooms and rooms remaining unemptied for several days, leading to infestations of fruit flies and gnats, and residents expressing dissatisfaction with the frequency and quality of cleaning services. Significant sanitation concerns were documented in shared shower rooms, where surveyors observed soiled and wet paper products, brown-stained towels, suspected fecal matter, and mold or mildew on ceiling tiles and grout. The shower drains were covered in hair and infested with small flying insects. Equipment in the shower rooms was found to be in disrepair, such as a shower head pole that was not properly secured to the wall, and a handheld shower nozzle left dangling without a mounting pole. Staff acknowledged these issues, with housekeepers and CNAs noting the persistent dirtiness, presence of mold or mildew, and lack of proper equipment maintenance. Maintenance staff were unaware of some of the problems, indicating a breakdown in communication and reporting. Additional observations included sticky and debris-laden dining room floors, a shower bed with a drain pan containing foul-smelling, murky liquid with solid brown particles, and further insect infestations in various facility areas, including staff bathrooms. Facility policies and job descriptions provided by the facility require daily cleaning, prompt garbage removal, pest control, and regular maintenance, but these standards were not met. Residents involved had intact cognition and were able to clearly articulate their concerns and dissatisfaction with the environment, and some were dependent on staff for all activities of daily living and mobility.
Call Light Not Accessible to Resident Requiring Assistance
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. The resident, who was cognitively intact but required substantial to maximal assistance for most activities of daily living and had left hand contractures, was observed attempting to sit up in bed and searching for the call light to request assistance. The call light was found hanging on top of the overhead light, far from the resident's reach, making it inaccessible for the resident to use when needed. Interviews with staff, including a CNA, the ADON, and the DON, confirmed that the call light was not within reach and that this would prevent the resident from being able to request help. The resident's care plan specifically instructed staff to ensure the call light was within reach and to encourage its use for assistance. The facility's policy also required that all residents have the call light system available and easily accessible at the bedside or another reasonable location.
Failure to Assess Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A deficiency occurred when a nurse failed to assess and document a resident's blood pressure prior to administering an antihypertensive medication, Procardia XL (Nifedipine), as ordered by the physician. The physician's order specified that the medication could be held if blood pressures were persistently 130/80 mmHg, and the facility's policy required medications to be administered as prescribed, including adherence to the five rights of medication administration. Despite these requirements, the resident's electronic medication administration record (eMAR) showed that blood pressure readings were not assessed or documented before administering the medication on multiple dates. Interviews with the LPN and the Director of Nursing confirmed the importance of checking blood pressure prior to administering antihypertensive medications to prevent unnecessary or potentially harmful dosing. The Director of Nursing stated that medications should not be given outside of physician parameters and that nurses are expected to assess blood pressure before administration. The facility's own policy also emphasized the need for medications to be administered in accordance with prescriber orders and good nursing practices.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. In one incident, a resident with intact cognition and a history of anger issues physically struck another resident during a dispute over seating on the smoking patio. The altercation was preceded by verbal exchanges and escalated to physical contact, with staff intervening after the event. The involved residents had no prior history of conflict, but both had behavioral concerns documented in their care plans. Another incident involved two roommates with a history of verbal arguments. One resident, who had previously threatened the other and had a diagnosis of paranoid schizophrenia, physically assaulted her roommate, causing visible injury. Staff were aware of ongoing verbal conflicts between the two but did not separate them prior to the physical altercation, citing lack of available rooms and resident refusals to move. The altercation resulted in one resident being sent to the hospital for psychiatric evaluation. A third incident occurred in the dining room, where a verbal argument between two residents escalated to physical violence. One resident, who had a history of mood distress and anger, was punched and pulled to the ground by another resident following an exchange of insults. Staff responded promptly to separate the residents, and both later apologized. The residents involved had no prior history of conflict, and the aggressor was a new admission who discharged herself against medical advice the same day. In all cases, the facility's policies on abuse prevention and resident rights were not effectively implemented to prevent these incidents.
Failure to Maintain Sanitary Water and Ice Machines
Penalty
Summary
The facility failed to maintain sanitary conditions for drinking water and ice by not properly cleaning or servicing water and ice machines used by residents and staff. Observations revealed significant mineral buildup and residue on the machines and surrounding areas, including the spouts, collection trays, and counters. The machines were also found to be leaking and in poor repair, with one machine's supporting panel split open and brown residue leaking out. Staff interviews confirmed that residents and staff accessed water and ice from these unsanitary machines, as well as from sinks that were also used for handwashing and had visible mineral buildup or personal items left on them. Housekeeping staff reported difficulty removing the buildup, and maintenance staff indicated that the machines had not been serviced by an outside company for an extended period. Further interviews with facility leadership revealed a lack of clarity regarding responsibility for the maintenance and cleaning of the water and ice machines. The Director of Nursing and Administrator were unaware of when the machines were last serviced or who was responsible for their upkeep. Facility policies indicated that the Dietary Department was responsible for monthly cleaning and disinfecting of the ice machines, while the Maintenance and Housekeeping Directors were to conduct regular safety audits. However, these procedures were not being followed, resulting in unsanitary conditions that affected nearly all residents who received oral hydration.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by insufficient seating in the day/dining rooms and inadequate cleaning and maintenance of resident rooms and common areas. Observations revealed that the first and second-floor day/dining rooms did not have enough chairs to accommodate ambulatory residents, resulting in some residents having to stand, sit on rollators, or lean on windowsills and heaters. Multiple residents reported difficulty finding seating, and staff confirmed the number of ambulatory residents exceeded the available chairs. Environmental issues were also noted throughout the facility. In one resident's room, there were black spots on the ceiling, bubbling paint on the wall, and a malfunctioning bathroom light that had not been repaired despite being reported. Other areas of concern included a hole in the second-floor hallway wall, chipped paint and stains in resident bathrooms, sticky and stained floors in dining rooms and hallways, and long-standing marks and smudges on walls and floors. Residents and staff reported that cleaning was not thorough, with some areas not being deep cleaned or stripped as needed, and maintenance issues such as water leaks and possible mold were not promptly addressed. Resident council minutes documented ongoing concerns about room cleaning, and interviews with housekeeping and maintenance staff indicated a lack of clarity regarding cleaning schedules and maintenance follow-up. Facility policies required regular environmental tours and quality control observations, but these were not effectively implemented, as evidenced by the persistent cleanliness and maintenance issues observed and reported by residents.
Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and immediate intervention during an incident involving two residents with cognitive impairments and behavioral disturbances. One resident, diagnosed with dementia and a history of physical aggression, physically struck another resident who was using a wheelchair. Staff statements and interviews revealed that the incident occurred when the aggressive resident believed the wheelchair belonged to them and, upon the other resident exiting the chair, struck the individual in the head before taking the chair. Multiple staff members did not witness the event directly, and the facility was unable to provide a witness statement from a hospice CNA who initially reported the incident. The care plans for both residents identified risks related to their cognitive and behavioral conditions, including the need for monitoring and supervision, but these interventions were not effectively implemented at the time of the incident. Additionally, the facility failed to implement necessary fall prevention interventions for another resident assessed as a moderate fall risk with a history of falls and left-sided weakness. Despite a completed assessment indicating the need for side rails and alarms, and the resident's consent for these devices, these interventions were not put in place. Instead, only floor mats and non-skid socks were used, which did not prevent the resident from rolling out of bed and sustaining a head injury. Staff interviews confirmed that side rails and alarms were considered appropriate and beneficial for this resident, but these measures were not included in the care plan or implemented in practice. Facility policies require that supervision and safety interventions be tailored to each resident's assessed needs and that the care team use assessment information to identify and address specific accident hazards. In both cases, the facility did not follow through with the interventions identified as necessary by assessment and care planning, resulting in preventable incidents affecting the safety and well-being of the residents involved.
Failure to Prevent Resident Access to Alcohol and Illicit Drugs
Penalty
Summary
The facility failed to prevent residents from accessing alcohol and illicit drugs while on the premises, resulting in at least one resident becoming intoxicated and subsequently reporting non-consensual sexual activity. One resident, with a history of substance abuse and mental health diagnoses, was found to be intoxicated and later tested positive for cocaine and marijuana. This resident reported engaging in drinking and drug use with other residents and described an incident of sexual activity that she claimed occurred while she was under the influence, leading to emotional harm and hospitalization. Multiple residents with documented histories of substance abuse and mental health disorders were identified as having access to alcohol and drugs within the facility. Progress notes and interviews revealed that residents were able to bring in contraband substances, often by concealing them on their person, as staff only checked bags and not individuals. Staff interviews confirmed that supervision was limited, and there were lapses in monitoring residents' activities, particularly during nighttime hours. Several residents admitted to drinking and using drugs together, and staff acknowledged that some residents had been found intoxicated or under the influence. Facility policies required the removal of contraband and outlined procedures for searching rooms and involving administration if contraband was suspected. However, these policies were not effectively implemented, as evidenced by repeated incidents of residents accessing and consuming alcohol and drugs. The lack of adequate supervision and enforcement of contraband policies directly contributed to the incidents of intoxication and associated harm among residents.
Failure to Securely Store and Administer Medications
Penalty
Summary
Multiple instances were observed where medications and biologicals were not securely stored according to facility policy and professional standards. In one case, a family member found a pink capsule and a white tablet on a resident's bed, which the resident stated were left by the night nurse. The resident reported that the nurse left the medication on the table and departed before ensuring the medication was taken, and that staff do not return even if called. The pills were later identified as melatonin, which was ordered, and Benadryl, for which there was no physician order. The resident's electronic medical record confirmed the absence of an order for Benadryl. Another resident was found with an inhaler left on top of an oxygen concentrator in their room. The resident stated the nurse left it for use as needed, but there was no physician order for self-administration, and the resident was not on a self-administration program. Additionally, insulin pens intended for another resident's son were found at a resident's bedside, and a cup containing eight pills was observed on a bedside table. Staff confirmed that these medications should not have been left at the bedside and that the residents were not authorized for self-administration. Further observations included medication and treatment carts left unlocked and unattended in the hallway, with staff acknowledging that carts should be locked when not in use or not in the immediate presence of a nurse. The facility's policy, last revised in 2018, requires that medications and biologicals be stored safely, securely, and only accessible to authorized personnel. These lapses in medication storage and administration practices were confirmed through staff interviews, resident statements, and review of medical records.
Failure to Provide Timely Personal Hygiene and ADL Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs) did not receive necessary personal hygiene care, including nail care, in a timely manner. On observation, the resident was found in a wheelchair, wearing a hospital gown that left the front of the body exposed, without an incontinent brief, and was wet. The resident had long nails with blackish particles underneath, dirty hands, and was eating food with their hands without cutlery. Food was observed on the resident's lap, between their legs, and on the floor. The room had a foul urine odor, and the resident's hair was unkempt and matted. The resident, who was unable to move both lower extremities, had dry, peeling, and swollen skin on the legs. The resident stated that no staff had come to assist since the previous day. Staff interviews revealed that the assigned CNA had not provided morning ADL care or incontinent care to the resident and had not checked on the resident since the start of the shift. The CNA confirmed that the resident had not refused care that morning. The resident's care plan indicated a self-care deficit and required staff assistance with personal hygiene and maintaining skin integrity, including keeping fingernails short. Facility policy and CNA job descriptions required staff to provide ADL care, including bathing, grooming, and incontinence care, but these were not carried out as required for this resident.
Failure to Provide and Document Prescribed BIPAP Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic hypercapnia who required nocturnal BIPAP therapy. Upon re-admission from the hospital, the resident was supposed to receive BIPAP treatment at night as per hospital discharge instructions. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that the resident received any BIPAP or CPAP therapy during the specified period. The resident confirmed that BIPAP treatment was only administered in the hospital and not at the facility, and stated that he did not refuse the therapy while at the facility. Additionally, the facility did not have the necessary equipment available for the resident's use. Review of the resident's care plan revealed that it did not include any plan of care for CPAP/BIPAP therapy, despite clear hospital instructions for nightly BIPAP use. There was also no physician order or documentation seeking clarification of the hospital's order for respiratory therapy. Interviews with facility staff, including LPNs, nurse practitioners, and the DON, indicated a lack of communication and follow-through regarding the reconciliation and implementation of the hospital's recommendations. Staff were unclear about their responsibilities for clarifying and carrying out admission orders, and there was no documentation that nursing staff sought clarification on the discrepancy in respiratory treatment orders. Facility policies and job descriptions required nurses to administer and document all treatments as ordered by the physician, including BIPAP/CPAP therapy. Despite these requirements, the resident's records showed no documentation of respiratory care being provided, and staff interviews confirmed that the necessary therapy was not consistently administered or documented. The lack of documentation and failure to implement the prescribed therapy constituted a deficiency in providing appropriate respiratory care as needed.
Failure to Administer Oxygen as Ordered by Physician
Penalty
Summary
A deficiency occurred when a male resident with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), was administered oxygen at a rate of 5 liters per minute via nasal cannula, despite a physician's order specifying 3 liters per minute. The discrepancy was discovered during an observation, where the oxygen concentrator was found set at 5 liters. The LPN present confirmed that the correct setting should have been 3 liters, as per the active physician order, and acknowledged that oxygen is considered a medication that must be administered as ordered. The LPN also admitted that she had not checked the oxygen concentrator that day and was unaware of the incorrect setting until it was pointed out by the surveyor. Further interviews with the Director of Nursing and a Nurse Practitioner confirmed that the physician's order was for 3 liters per minute and that administering a higher dose was not appropriate for a resident with COPD unless specifically ordered. The facility's policy on medication administration requires that medications, including oxygen, be administered exactly as prescribed by the physician. The failure to follow the physician's order resulted in the resident receiving a higher dose of oxygen than intended.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain effectively and administer the prescribed pain medication, morphine, as documented. The resident, identified as R114, who is cognitively intact with a BIMS score of 15, reported not receiving his morphine medication since Thursday night, despite the Medication Administration Record (MAR) indicating that doses were given. The resident's medical history includes COPD, atherosclerosis, peripheral vascular disease, a pacemaker, and bilateral below-knee amputations, which necessitate pain management for phantom pain. Upon investigation, discrepancies were found between the MAR and the actual administration of the medication. The LPN, V32, could not locate the narcotic sheet or the morphine in the narcotic drawer, indicating a failure in the medication management process. The Director of Nursing (DON), V2, was also unable to find the narcotic sheet, and the medication was not present in the narcotic drawer, confirming the resident's claim of not receiving the medication. The facility's policy requires that controlled substances be regularly reconciled with the MAR, but this was not adhered to, leading to the resident's unmanaged pain. Further interviews with staff revealed inconsistencies in the documentation and administration of the medication. Several nurses, including V39, V45, and V14, claimed to have administered the medication as documented, but the lack of morphine in the narcotic box and missing narcotic sheets suggest otherwise. The pharmacist confirmed that a sufficient quantity of morphine was delivered to the facility, which should have lasted until March 27th. However, the medication was not available for the resident, indicating a breakdown in the facility's medication management and documentation processes.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, which could potentially affect all 207 residents receiving an oral diet. During a kitchen tour, the surveyor observed several deficiencies, including undated and unlabeled food items such as a box of tomatoes and a plastic bag containing various meats. Additionally, staff members were storing personal food items in the walk-in refrigerator, which could lead to cross-contamination. In the dry storage area, there were open packages and ingredient bins without labels or dates, which is against the facility's policy for food safety. Furthermore, the facility did not maintain proper sanitation levels in the kitchen. A sanitation bucket at the preparation station registered a sanitation level of 0 parts per million, indicating that no sanitizer was present. This lack of sanitizer could prevent the proper sanitization of food preparation areas, increasing the risk of spreading germs. The facility's policies clearly outline the need for proper food storage, labeling, and sanitation practices to prevent contamination and ensure food safety, but these were not followed as observed during the survey.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for four residents, as observed during a survey. One resident reported that their room was cleaned infrequently. Another resident's room was found to have a missing closet door and dresser drawer, with the floor and privacy curtain stained. A housekeeper confirmed the presence of dirt and trash on the floor and was unsure about the stains on the privacy curtain. Additionally, another resident's room was observed to be dirty with stains on the floor and no bedsheets on the bed. A resident with a gastrostomy tube was observed to have a dried brown substance covering the g-tube pole and dust on the oxygen concentrator. A Licensed Practical Nurse suggested that the substance was likely g-tube feeding and that housekeeping was responsible for cleaning the equipment. The Director of Nursing stated that housekeeping, nurses, and Certified Nursing Assistants were responsible for cleaning the g-tube and oxygen concentrator. The facility's policies and job descriptions outlined the responsibilities for maintaining a clean and homelike environment, but these were not adhered to, resulting in the deficiencies observed.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the security and proper management of medications, particularly narcotics, on the fourth floor. Observations revealed that the medication refrigerator was unlocked due to a non-functional latch, allowing access to narcotic medications without a key. An LPN admitted that the narcotic medication box inside the refrigerator was not locked, contrary to the facility's policy. Additionally, expired medications, including Lorazepam and Morphine Sulfate, were found in the refrigerator, and a multi-dose vial of Tuberculin Purified Protein solution was not labeled with an open date. Further deficiencies were noted with the storage and labeling of medications on the medication carts. Diazepam, a controlled substance, was improperly stored in an unlocked drawer instead of a locked compartment. Inhalers for several residents were not clearly labeled with open or expiration dates, leading to confusion among staff about their status. The facility's policy requires that opened medications be labeled with the open date and expiration date, but this was not consistently followed. Discrepancies in the documentation and inventory of narcotic medications were also identified. For instance, the controlled drug receipt form for a resident's Lorazepam showed a different count than the actual number of tablets present. The facility's policies mandate regular reconciliation of controlled substances with the Medication Administration Record and immediate reporting of any discrepancies, but these procedures were not adequately implemented, leading to potential risks for residents on the fourth floor.
Failure to Monitor Personal Refrigerators and Expired Food
Penalty
Summary
The facility failed to monitor personal refrigerator temperatures and ensure that personal refrigerators had thermometers for four residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, the refrigerators of residents with various medical conditions, including cerebrovascular disease, chronic obstructive pulmonary disease, and paraplegia, were found without temperature log sheets or thermometers. Expired food items, such as milk and yogurt, were also discovered in one resident's refrigerator, indicating a lack of proper monitoring and maintenance. Interviews with facility staff revealed confusion regarding the responsibility for checking the residents' refrigerators. A Certified Nursing Assistant (CNA) was unaware of who should perform these checks, while the Director of Nursing (DON) and a Nurse Consultant believed it was the responsibility of housekeeping. The facility's policy mandates that staff monitor personal refrigerators for food safety and ensure that all refrigerators have internal thermometers with daily recorded temperatures. However, this policy was not followed, leading to the potential risk of residents consuming expired food.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Staff did not don personal protective equipment (PPE) while performing wound care for a resident with methicillin-resistant Staphylococcus aureus (MRSA) infection. Additionally, Enhanced Barrier Precautions (EBP) signage was not visibly posted outside the rooms of two residents who required such precautions due to their medical conditions, including a resident with a hemodialysis catheter and another with wounds from bilateral below-knee amputations. The facility also failed to maintain PPE bins outside isolation rooms, as observed with a resident's room that had a Contact Precautions sign but no PPE bin available. Staff were observed not performing hand hygiene when passing meal trays, even after touching their own body or hair, which is against the facility's infection control policy. This was noted with a Certified Nursing Assistant (CNA) who did not sanitize hands after adjusting personal clothing and hair while distributing meal trays to residents. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), revealed a lack of adherence to established infection control protocols. The DON acknowledged that staff should perform hand hygiene before and after passing meal trays and that PPE should be donned before entering isolation rooms. The absence of an Infection Preventionist (IP) nurse prior to a recent hire contributed to lapses in maintaining PPE supplies and ensuring compliance with infection control measures.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call light devices for two residents, R35 and R41, were within their reach, which is a requirement for accommodating the needs and preferences of each resident. R35, who has a diagnosis including Bilateral Primary Osteoarthritis of the knee, Paralytic Syndrome, Hemiplegia and Hemiparesis, Vascular Dementia, Peripheral Vascular Disease, and Major Depressive Disorder, was observed with her call light on the floor behind her bed, out of reach. Despite her physical limitations, R35 stated she could use the call light if it were accessible. Her care plan emphasized the importance of having the call light within reach, yet the facility did not provide an alternative device for her use, as indicated by the blank response on her Call Light Ability Screen. Similarly, R41, diagnosed with dementia, protein-calorie malnutrition, intracapsular fracture of the left femur, sequela, hypertension, and abnormalities of gait and mobility, was observed with the call light on the floor underneath the bed. Although R41's Call Light Ability Screen indicated she could use the call light, it was not within reach, contradicting her care plan's directive. Both the Registered Nurse and the Director of Nursing acknowledged that the call light should be within reach of the residents at all times, as per the facility's policy. This oversight affected two residents and had the potential to impact all residents in the facility.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer three residents for a Level II PASARR evaluation after they received new mental disorder diagnoses. Resident R141 was admitted with diagnoses of bipolar disorder and adjustment disorder, but the initial PASARR did not reflect these mental health conditions. The Business Office Manager (V35) acknowledged that the PASARR should have included these diagnoses to ensure the resident was in the appropriate facility and that their needs could be met. A new Level I PASARR was initiated, which triggered a Level II evaluation. Resident R61 had a diagnosis of Major Depressive Disorder and other conditions, but the PASARR documentation did not reflect these mental health issues. The resident's care plan did not address the Major Depressive Disorder, and the PASARR Level I outcome did not indicate a mental health diagnosis. The Business Office Manager confirmed that a new PASARR Level I was submitted due to the new diagnosis, but it was not initially documented correctly. Resident R104 had a diagnosis of Major Depressive Disorder, but the PASARR documentation did not reflect this condition. The resident's PASARR Level I was not documented in the electronic health record, and the Business Office Manager confirmed that a new PASARR Level I was required due to the change in condition. The facility's policy requires each resident to be screened for Level I PASARR prior to or shortly after admission, but this was not adhered to in these cases.
Failure to Update PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the completion of a new Pre-Admission Screening and Resident Review (PASARR) when a new mental health diagnosis was identified for three residents. Resident 61 had a diagnosis of Major Depressive Disorder and other conditions, but the PASARR Level I Outcome did not reflect any mental health diagnosis. Despite being prescribed medication for depression, the care plan did not address this condition, and the PASARR was not updated accordingly. Resident 104 had a diagnosis of Major Depressive Disorder, but the initial OBRA-I screen did not suspect any mental illness. Although a PASARR Level I review was eventually conducted, it was not documented in the electronic health record initially, and the necessary Level II screening was delayed. The Business Office Manager confirmed the need for a PASARR Level I to trigger a Level II due to the change in condition. Resident 141 was admitted with diagnoses of bipolar disorder and adjustment disorder, but the initial PASARR did not include these mental health conditions. The Business Office Manager acknowledged the oversight and initiated a new PASARR Level I, which triggered a Level II screening. The facility's policy requires each resident to be screened for Level I prior to or shortly after admission, but this was not adhered to in these cases.
Failure to Follow Wound Care Treatment Orders
Penalty
Summary
The facility failed to adhere to wound care treatment orders for a resident, identified as R138, who was reviewed for wounds. R138 has a medical history that includes orthopedic surgical amputation, Type 2 diabetes with foot ulcers, peripheral vascular disease, and other conditions. Observations on March 24, 2025, revealed that the dressings on both of R138's great toes were dirty, with the left toe dressing showing black dark drainage. R138 reported that the dressings had not been changed since March 21, 2025, despite orders for daily changes. The resident, who is cognitively intact, sometimes changed the dressings themselves due to excessive drainage. The facility's records, including the Treatment Administration Record (TAR), showed multiple days in March 2025 when the wound care was not documented as completed. Interviews with the Wound Care Nurse, Wound Care Coordinator, and Director of Nurses confirmed that the dressings should be changed daily and that the resident should not be responsible for changing their own dressings. The facility's policy emphasizes the importance of following physician orders to promote healing, yet the failure to implement these orders as prescribed led to the deficiency.
Failure to Investigate Fall and Enforce Smoking Policies
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving a resident, R65, and did not implement fall interventions as listed on the revised care plan. R65, who has a history of multiple medical conditions including polyarthritis, diabetes, and schizoaffective disorder, experienced a fall in the shower room. Despite the presence of a staff member, the fall was not reported immediately, and no nurse assessed R65 following the incident. The fall was only documented the following day after R65 reported pain and bruising. The care plan for R65, which included placing nonskid strips beside the bed, was not followed, as observed by the Director of Nursing. Additionally, the facility failed to ensure adequate supervision to prevent a resident, R172, from smoking in a residential room. R172, who has intact cognition and a history of psychoactive substance abuse, was found with a strong smell of marijuana in his room, and a haze of smoke was observed. Although R172 claimed the smell was from his clothing after smoking outside, the social service staff suspected that R172 was smoking inside the room. The facility's policy prohibits smoking inside the facility, and residents are required to comply with smoking safety contracts. These deficiencies highlight the facility's failure to adhere to its policies and procedures regarding fall prevention and smoking regulations. The lack of immediate assessment and documentation of R65's fall, along with the failure to implement care plan interventions, contributed to inadequate resident safety. Similarly, the inability to enforce smoking policies and supervise residents effectively posed potential safety hazards within the facility.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, R73 and R98, who were receiving oxygen therapy. For R73, the facility did not change the nasal cannula tubing weekly as required, with the tubing observed to be dated 3/4/25, despite the policy stating it should be changed weekly. Additionally, R73's CPAP mask was found lying uncontained on the nightstand, which is against the facility's policy for equipment storage and infection control. R73, who is cognitively intact, was receiving oxygen at 3 liters per nasal cannula, but there was no documentation of a physician's order for this administration. For R98, the facility failed to obtain a physician's order for oxygen administration, despite the resident receiving 4 liters of oxygen. The oxygen tubing for R98 was observed lying on the floor, and there was no order for pulse oximetry checks, which are necessary to monitor the resident's oxygen needs. R98, who is also cognitively intact, was admitted with diagnoses including dependence on supplemental oxygen and COPD. The facility's policy requires a physician's order for oxygen administration and regular monitoring of oxygen saturation levels, which was not adhered to in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before prescribing a psychotropic medication to a resident, identified as R61, who was diagnosed with Major Depressive Disorder. The resident's Minimum Data Set indicated severe cognitive impairment. Despite this, the resident was prescribed Remeron (Mirtazapine) for situational depression, with the medication being administered daily from March 1, 2025, to March 25, 2025. However, the consent for the psychotropic medication was only obtained verbally on March 24, 2025, which was after the medication had already been administered for several weeks. The Director of Nursing (DON) confirmed that the facility's policy requires informed consent to be obtained before prescribing psychotropic medications. The policy mandates that psychotropic medications should not be prescribed without the informed consent of the resident, their guardian, or an authorized representative. The DON acknowledged that the consent process was not followed correctly in this instance, as the verbal consent was obtained after the medication had been prescribed and administered.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, affecting two residents. One resident, identified as R8, sustained a laceration to the back of the head requiring staples and hospitalization after being pushed by another resident, R12, in the dining room. Despite conflicting accounts from staff, a Certified Nursing Assistant confirmed witnessing the incident where R8 attempted to take food from R12's plate, leading to R8 being pushed and hitting their head on the ground. The facility's investigation did not initially acknowledge the push, attributing the fall to R8's anemia, and the Director of Nursing did not review hospital records indicating the push. Another incident involved R3 and R15, where R3 verbally threatened and physically assaulted R15 by slapping him across the face. This incident was witnessed by another resident, R9, and reported to staff, but the facility's administration initially only acknowledged a verbal disagreement. The Social Services Director confirmed being informed of the physical assault, and the police were involved, but the facility's records did not reflect appropriate interventions to address R3's aggressive behaviors. Both incidents highlight the facility's failure to adequately investigate and address resident-to-resident abuse, as well as a lack of appropriate care plan interventions for residents with known aggressive behaviors. The facility's abuse prevention policy and residents' rights documents emphasize the importance of protecting residents from abuse, yet these incidents demonstrate a significant lapse in ensuring resident safety and well-being.
Failure to Provide Adequate Wound Care and Pain Management
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a surgical wound, leading to the worsening of the wound and avoidable pain. The resident, who had a surgical amputation and other complex medical conditions, was observed with a poorly maintained dressing on her left foot. The dressing was secured with band-aids, unraveling, and appeared dirty, with no date indicating when it was last changed. The resident reported that her wound dressing had not been changed as per the physician's orders, and she experienced pain due to not receiving her prescribed pain medication. The resident's medical records showed active physician orders for daily wound care and pain management with Oxycodone. However, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicating that these treatments were administered. Interviews with staff revealed that the resident was not assessed for self-care, yet was given supplies to change her own dressing. The Director of Nursing confirmed that medications should be documented when administered and that the resident was not capable of changing her own wound dressing. The resident expressed concerns about her wound not healing and the possibility of further amputation. The Wound Care Nurse confirmed that wound dressings should be dated and documented, and that failure to change dressings as ordered could lead to infection and deterioration. The facility's policies on medication administration and wound care were not followed, contributing to the resident's condition not improving and potentially requiring further medical intervention.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary, clean environment, affecting all 208 residents. Observations revealed dirty floors with unidentified food particles, dirt splatters, and sticky surfaces in the dining room and hallways across multiple floors. Staff, including a CNA and the Director of Nursing, acknowledged the unclean conditions, with the Director noting the need for housekeeping intervention. Residents expressed dissatisfaction, with some resorting to cleaning their own rooms due to the lack of housekeeping services. Staff shortages in housekeeping were cited as a contributing factor, with some staff members taking on cleaning duties themselves. The facility's administrator confirmed recent issues with housekeeping, noting the appointment of a new housekeeping manager. Despite the facility's policy on residents' rights to a clean environment, multiple staff members, including a Restorative Technician and a Social Services Director, reported receiving complaints from residents about the cleanliness. The report highlights the facility's failure to provide a safe, clean, and comfortable environment as required by residents' rights, with staff and residents both acknowledging the ongoing cleanliness issues.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility staff failed to report suspected abuse incidents to the state survey agency within the required timeframe and did not notify the abuse prevention coordinator as mandated. This deficiency affected four residents. In one incident, a resident fell and sustained a head injury after being pushed by another resident. The incident was not reported to the state survey agency until six days later, and the abuse prevention coordinator was unaware of the pushing incident until much later. The staff involved did not follow the facility's policy of immediate reporting to the administrator or the state survey agency. In another incident, two residents had a verbal disagreement, which escalated to one resident hitting the other. The administrator was aware of the verbal disagreement but not the physical altercation. The social services director and a licensed practical nurse were aware of the physical aspect of the incident but did not ensure it was reported as abuse. The facility's policy requires that any suspicion or allegation of abuse be reported immediately to the administrator and the state survey agency. The facility's policies on abuse prevention and incident reporting clearly outline the need for immediate reporting of abuse incidents to the state survey agency and the administrator. However, in both incidents, the staff failed to adhere to these policies, resulting in delayed reporting and inadequate investigation of the abuse allegations. This lack of timely reporting and communication among staff members contributed to the deficiency identified by the surveyors.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following a fall incident involving a resident, R8, who sustained a head injury. The incident occurred when R8 attempted to take food from another resident, R12, who then allegedly pushed R8, resulting in a fall and a laceration to the head. Despite hospital records indicating that R8 was pushed, the facility's investigation concluded that the fall was due to R8's anemia, without interviewing key witnesses or reviewing hospital records. The Director of Nursing, V2, and the Administrator, V1, acknowledged that the hospital records should have been reviewed and that the Certified Nursing Assistant, V14, who witnessed the incident, was not interviewed. In another incident, the facility failed to investigate an allegation of verbal and physical abuse involving residents R3 and R15. R3 was reported to have verbally threatened and physically struck R15 over a misunderstanding about clothing. Although staff were aware of the verbal altercation, the Administrator, V1, was only informed of the verbal disagreement and not the physical assault. The Social Services Director, V19, confirmed that R15 reported being hit by R3, but no investigation was conducted to substantiate the incident. The facility's policies on abuse prevention and incident reporting require thorough investigation of all allegations or suspicions of abuse, neglect, or mistreatment. However, in both cases, the facility did not adhere to these policies, failing to gather necessary witness statements and review relevant documentation. This lack of thorough investigation and documentation led to deficiencies in addressing potential abuse and ensuring resident safety.
Failure to Complete Community Survival Skills Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a community survival skills assessment for a resident, which is necessary to determine if the resident can safely be out in the community independently. This deficiency affected a resident who left the facility for an eye doctor appointment and did not return until four days later. During this time, the facility and the resident's family were unaware of the resident's whereabouts, causing concern for the resident's safety. The resident, who has a BIMS score indicating intact cognition, was admitted to the facility with multiple medical conditions, including orthopedic aftercare and muscle wasting. Despite being cognitively intact, the resident's community survival skills assessment was not completed upon admission, as required by the facility's policy. The assessment was only completed after the resident had already left the facility unsupervised, and the staff was not aware of the resident's absence until the following day. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's pass privileges and the process for monitoring residents who leave the facility. The social service director admitted that the community survival skills assessment was not completed at admission, and the psychosocial rehabilitation services coordinator acknowledged that the assessment was delayed due to oversight. The facility's policy requires the assessment to be completed upon admission, quarterly, and when there is a significant change in condition, but this was not adhered to in this case.
Sanitation and Maintenance Deficiencies in Third-Floor Shower Room
Penalty
Summary
The facility failed to maintain the community shower room on the third floor in a sanitary and functional condition, potentially affecting all 52 residents on that floor. During an inspection, it was observed that the toilet bowl had visible brown stains and a ring of stains, indicating it had not been cleaned for several days. Additionally, the toilet water tank and cover were covered in accumulated dust. The third shower stall's faucet was broken and non-functional, which was confirmed by an LPN who mentioned that the issues were typically reported via a scanner system, although calling maintenance was considered faster. The housekeeping staff was not adequately assigned to ensure cleanliness on the third floor. A housekeeper was observed cleaning on the second floor and was unaware of who was responsible for the third floor. The Housekeeping Director acknowledged challenges in staffing the second and third floors, noting that they were in the process of hiring additional staff to address these deficiencies. The facility's housekeeping policy requires daily cleaning assignments to maintain a clean and orderly environment, which was not adhered to in this instance.
Failure to Protect Residents from Known Aggressive Resident
Penalty
Summary
The facility failed to protect two residents from abuse by another resident with known violent behavior. The resident in question was admitted without a timely background check or fingerprinting, despite having a history of aggression and a criminal record. This oversight allowed the resident to physically assault two other residents, resulting in significant injuries, including multiple facial fractures to one of the victims. The facility did not develop a care plan for the aggressive resident upon admission, despite being aware of the resident's history of aggression and previous altercations at another facility. The care plan was only updated after incidents of violence occurred, failing to address the resident's behavioral symptoms and wandering as identified in the initial assessments. The facility's social services department acknowledged that the aggressive behaviors should have been addressed in the care plan upon admission. Additionally, the facility's assessments of the resident's aggressive and harmful behaviors were inaccurate, failing to reflect the resident's known history of aggression and mental health diagnoses. Staff interviews revealed that the resident frequently exhibited aggressive behavior, yet there was no documentation of behavior monitoring or interventions. The facility's lack of timely and accurate assessments and care planning contributed to the failure to prevent the assaults.
Inaccurate Assessments Lead to Resident Aggression and Harm
Penalty
Summary
The facility failed to accurately complete assessments for a resident, identified as R3, which led to significant incidents involving aggressive behavior. R3, who was admitted with multiple diagnoses including cerebral infarction, bipolar disorder, Alzheimer's disease, vascular dementia, and legal blindness, was inaccurately assessed in several areas. The Minimum Data Set (MDS) inaccurately documented R3 as having adequate vision despite being legally blind. Additionally, the Screening Assessment for Trauma Factors and the Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors were completed inaccurately, failing to identify R3's criminal history, history of aggression, and psychiatric diagnoses. These assessment inaccuracies resulted in R3's aggressive behaviors going unaddressed, leading to physical altercations with other residents. R3 physically assaulted two residents, R2 and R7, causing significant harm to R7, who suffered multiple facial fractures. The incidents were partly attributed to R3's inability to recognize others due to blindness, as noted by the Social Services Director. The facility's lack of accurate assessments meant that R3's care plan did not address critical needs, such as visual impairment, which could have triggered appropriate interventions. Interviews with facility staff, including the Medical Director and MDS Coordinator, confirmed the inaccuracies in R3's assessments. The MDS Coordinator acknowledged that R3's vision should have been coded as impaired, which would have prompted a Care Area Assessment for visual function. The facility did not have a specific policy for completing aggression screening and trauma assessments, relying instead on the Resident Assessment Instrument (RAI) guidelines. This lack of policy may have contributed to the oversight in accurately assessing and addressing R3's needs.
Failure to Address Aggressive Behaviors in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, R3, who had a known history of aggressive behaviors and dementia. Prior to admission, R3's referral records indicated a history of physical altercations, anxiety, and confusion, posing a danger to themselves and others. Despite this, the facility did not address these behaviors in R3's care plan upon admission or after subsequent incidents of aggression. On two separate occasions, R3 physically assaulted other residents. The first incident involved R3 hitting a roommate, R2, on the head with a cane, causing a bleeding wound. Staff and other residents expressed concerns about R3's aggressive behavior, noting that R3 was regularly agitated and could potentially harm others. Despite these concerns, R3's care plan was not updated to address these behaviors until after a second incident occurred. The second incident involved R3 physically assaulting another resident, R7, resulting in multiple facial fractures. This incident further highlighted the facility's failure to update R3's care plan in a timely manner. The facility's policies required that care plans be updated to reflect changes in a resident's condition, but R3's aggressive behaviors were not addressed until after both incidents had occurred. This oversight resulted in harm to multiple residents and demonstrated a lack of adherence to the facility's care planning policies.
Failure to Supervise Resident with Violent Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with known violent behavior, leading to physical assaults on two other residents. The resident in question, R3, had a documented history of aggression and was involved in altercations at a previous facility before being admitted to the current one. Despite this history, R3's aggressive behaviors were not addressed in the care plan upon admission, nor were they updated after incidents of violence occurred within the facility. On one occasion, R3 assaulted a roommate, R2, by hitting them on the head with a cane, causing a bleeding wound. This incident was witnessed by staff, who noted R3's regular agitation and aggressive tendencies. Despite these observations, there was no specific supervision plan in place for R3, and staff expressed concerns about R3's potential to harm other residents. The facility's policy on supervision was not adequately followed, as additional supervision measures were not implemented for R3. Another incident involved R3 physically assaulting another resident, R7, resulting in multiple facial fractures. R7, who had severe cognitive impairment, was knocked out of their wheelchair during the altercation. Staff and medical personnel were aware of R3's aggressive behavior, yet the care plan was not updated to address these behaviors until after the incidents occurred. The lack of timely and appropriate care planning and supervision contributed to the harm experienced by the residents involved.
Failure to Conduct QAPI Meetings and Address Abuse Data
Penalty
Summary
The facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings quarterly and did not ensure that abuse data collection was implemented or coordinated within these meetings. This deficiency potentially affects all 200 residents in the facility. A review of the facility's QAPI meeting minutes from March 7, 2024, revealed no reporting, tracking, or discussion of abuse or abuse outcomes. The template used for these minutes lacked any section for reporting or tracking abuse allegations. Furthermore, no QAPI meeting minutes were available from March 7, 2024, until October 21, 2024, indicating a significant gap in the facility's quality assurance processes. Interviews with facility staff, including a nurse consultant and the administrator, confirmed that QAPI meetings were not held between April 2024 and August 2024, and that incidents of physical abuse occurring on September 26, 2024, and October 10, 2024, were not reviewed in any QAPI meeting. The facility's policy on Quality Assurance Committee did not mention abuse, and the Abuse Prevention Program policy required quarterly reviews of reports to assess patterns or trends that might indicate abuse. However, these reviews were not conducted, and the incidents were not discussed in the QAPI meetings, highlighting a failure in the facility's abuse prevention and quality assurance processes.
Delayed Submission of Abuse Investigation Report
Penalty
Summary
The facility failed to submit a final investigation report regarding a physical abuse incident to the state survey agency within the required timeframe. The incident involved a physical altercation between two residents, identified as R2 and R3, which was initially reported to the Illinois Department of Public Health on September 26, 2024. However, the final report was not submitted until October 16, 2024, which is 20 days after the incident and the initial report. This delay in reporting is a violation of the facility's policy and state regulations, which require a final report to be submitted within five business days of the incident. The administrator, who is also the abuse prevention coordinator, acknowledged the oversight and stated that they could not find evidence of the final report being submitted within the required timeframe. Consequently, the administrator resubmitted the final report on October 16, 2024. The facility's policy, dated January 4, 2018, clearly outlines the requirement for a completed written report of the investigation's conclusion to be sent to the Department of Public Health within five working days after the occurrence. This failure to adhere to the policy affects the two residents involved in the incident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect four residents from verbal and physical abuse, resulting in significant incidents. One resident, R2, who had schizoaffective disorder and bipolar disorder, was verbally and sexually harassed by another resident, R3, who was cognitively intact and used a wheelchair. Despite staff attempts to intervene, R3 continued to provoke R2, leading R2 to retaliate physically with a belt. The situation escalated, and R2, in a state of panic, attempted to flee the facility, resulting in a self-inflicted injury that required hospitalization. Another incident involved residents R4 and R5, both of whom were cognitively intact and used wheelchairs. R4, who had a history of bipolar disorder and ADHD, engaged in a verbal altercation with R5, which escalated into a physical confrontation. R4 taunted R5, leading to a struggle that caused both residents to fall. The facility's staff did not effectively intervene to prevent the escalation of the conflict. The facility's policies on abuse prevention and residents' rights were not adequately enforced, as evidenced by the repeated incidents of verbal and physical abuse among residents. Staff interviews revealed that R3 had a history of antagonizing other residents, and R4 was known for being verbally abusive. Despite these known behaviors, the facility failed to implement effective measures to prevent abuse and protect residents, resulting in harm and distress.
Failure to Timely Address Resident's Fall and Head Injury
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident, identified as R7, who experienced a fall. The incident involved a lack of timely assessment, monitoring, and documentation following the fall. R7, who was cognitively intact and on anticoagulant medication for atrial fibrillation, fell from their bed and sustained a head injury. Despite the fall being reported by R7's roommate, there was a significant delay in the nurse's response, and the incident was not documented or communicated to the physician in a timely manner. The report highlights that the facility did not send R7 to the hospital immediately after the fall, despite the resident being on blood thinners and having a head injury, which could lead to serious complications such as a subdural hematoma. The Licensed Practical Nurse (LPN) on duty did not observe or document the bruise on R7's forehead initially, although later documentation contradicted this. The facility's staff, including the Restorative Director and the former Director of Nursing, acknowledged the need for immediate medical evaluation and monitoring, which was not conducted. The facility's policies on neurological assessment and change in resident's condition were not followed, as evidenced by the lack of 72-hour follow-up charting and neuro checks. The Nurse Practitioner was not informed of the fall until several days later, which delayed the necessary medical intervention. The report indicates a systemic failure in communication and adherence to protocols, resulting in R7 being sent to the hospital only after developing symptoms of a headache, where a subdural hematoma was diagnosed.
Failure to Monitor Diabetic Resident's Foot Care Leads to Severe Complications
Penalty
Summary
The facility failed to provide adequate foot care and monitoring for a diabetic resident, resulting in severe complications. The resident, who had a history of type 2 diabetes mellitus, diabetic peripheral angiopathy, and other comorbidities, required substantial assistance with activities of daily living, including bathing and dressing. Despite being cognitively intact, the resident was dependent on staff for foot care due to limited mobility and the use of a manual wheelchair. The facility's negligence in monitoring the resident's foot condition led to the development of a wound on the right big toe, which was discovered to be infested with maggots by the nurse practitioner during a routine assessment. The nurse practitioner observed redness and swelling in the resident's right lower leg and, upon removing the resident's sock, found multiple maggots crawling from a wound at the base of the big toe. This alarming discovery prompted immediate medical intervention, including the administration of antibiotics and pain management, and the resident was transferred to the hospital for further evaluation. The hospital diagnosed the resident with gangrene, necessitating the surgical amputation of the right big toe. The facility's failure to conduct routine foot examinations and adequately assess and report skin alterations contributed to the severity of the resident's condition. Interviews with facility staff revealed inconsistencies in the care provided to the resident. The CNA responsible for the resident's care on the day of the incident could not recall performing a skin check, and there was no documentation of a skin assessment or bath/shower on the resident's shower sheet for that period. The facility's policies on skin assessments and foot care were not adhered to, as evidenced by the lack of regular monitoring and documentation. The facility's failure to implement its policies and ensure proper care for the resident's diabetic condition resulted in a preventable and severe health outcome.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe. A resident reported that a nurse called them a 'crackhead' and threatened to transfer them to a different floor. The resident communicated this incident to social services and the facility administrator. However, the administrator did not consider the incident as an abuse allegation and did not report it to IDPH until the time of the survey, which was beyond the mandated reporting period. Interviews with the involved nurse and social services director revealed differing accounts of the incident. The nurse claimed that the resident misinterpreted a comment made during a conversation about another resident. The social services director confirmed that the resident reported the nurse's alleged verbal abuse. The facility's policy requires immediate reporting of any abuse allegations to the administrator and IDPH, but this protocol was not followed in this case, leading to the deficiency.
Failure to Coordinate Resident Appointments and Maintain Complete Medical Records
Penalty
Summary
The facility failed to ensure proper coordination of outside services and maintain a complete medical record for a resident, identified as R3, who was reviewed for appointments. The deficiency was identified through interviews and record reviews, revealing that R3 had multiple follow-up appointments recommended after hospitalizations, including with hepatology, primary care, and urology. However, there was a lack of clarity and coordination among the staff regarding these appointments. The primary nurse, V3, was unaware of whether R3 attended a past appointment or the purpose of future appointments. Similarly, the Transportation Coordinator, V14, and the Appointment Scheduler, V15, were not informed of R3's appointments, leading to a lack of transportation arrangements and incomplete appointment records. The Director of Nursing, V2, acknowledged the oversight and the absence of a facility appointment policy. The facility's Medical Record Policy mandates maintaining an organized, accurate, and complete record of each resident's care, which was not adhered to in R3's case. The surveyor's investigation revealed that the facility was unaware of some of R3's scheduled appointments until the time of the survey, indicating a breakdown in communication and record-keeping. This deficiency highlights the facility's failure to provide equal access to quality care and maintain the resident's health at the highest practical levels, as required by the Illinois Long-Term Care Ombudsman Program's Residents' Rights.
Inaccurate Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a discrepancy in the resident's documented diagnosis. The resident, identified as R1, reported that their medical records incorrectly listed a diagnosis of schizophrenia, which they did not have. The resident expressed concern about potential discrimination due to this incorrect diagnosis. Upon review, the resident's admission record documented a diagnosis of Schizoaffective Disorder, Bipolar Type, but there was no mention of schizophrenia in the psychiatric nurse practitioner's notes or in the hospital records. The psychiatric nurse practitioner confirmed that they did not diagnose the resident with schizophrenia and did not include it in their assessment. The Director of Nursing (DON) and the facility staff were unable to determine the origin of the schizophrenia diagnosis. The DON noted that the hospital intake forms and other medical records did not document schizophrenia. An interview with the nurse responsible for entering the diagnosis revealed uncertainty about the source of the information, suggesting it may have been a mistake. The facility's medical record policy emphasizes the importance of maintaining accurate and complete records, but in this case, the policy was not adhered to, resulting in incorrect documentation of the resident's medical condition.
Resident Injury Due to Inadequate Monitoring and Management of Aggressive Behavior
Penalty
Summary
The facility failed to protect a resident, identified as R5, from abuse, resulting in an incident where another resident, R4, ran over R5's foot with a wheelchair. This incident led to R5 experiencing significant pain and swelling in the foot, with a pain score of 7-9 out of 10. R5, who has a medical history including asthma and difficulty walking, reported that R4 ran over her foot intentionally after a disagreement at the nurse's station regarding smoking times. R5 had previously had a verbal altercation with R4, which was not adequately monitored by the staff. R4, who has a complex medical history including schizoaffective disorder, paraplegia, and other mental health issues, was known to exhibit manipulative and aggressive behaviors. On the day of the incident, R4 was observed by staff to be moving quickly in his wheelchair and ran over R5's foot while she was at the nurse's station. Despite the presence of staff, R4's behavior was not effectively managed, leading to the altercation. The staff's response included separating the residents and contacting medical professionals, but the incident had already resulted in injury to R5. The facility's initial report to the state agency was delayed, as it was sent the day after the incident occurred. The facility's abuse prevention program defines abuse as the willful infliction of injury, which aligns with the nature of the incident between R4 and R5. The facility's failure to prevent the altercation and protect R5 from harm highlights a deficiency in their ability to manage resident interactions and ensure a safe environment for all residents.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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