Asbury Gardens Nsg & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in North Aurora, Illinois.
- Location
- 212 Airport Road, North Aurora, Illinois 60542
- CMS Provider Number
- 146170
- Inspections on file
- 23
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Asbury Gardens Nsg & Rehab during CMS and state inspections, most recent first.
Two residents were left in a cool room with a nonfunctioning heating unit after one cognitively intact resident reported feeling cold and stated the heater had not worked for several days. Staff notified a maintenance assistant by phone, who assessed the unit, found it nonfunctional, left it unplugged, and did not enter a maintenance work order. The receptionist also failed to create a work order in the computer system, and the maintenance director was unaware of the issue until the survey, despite facility policy requiring maintenance of comfortable and safe temperature levels and properly operating heating units for resident comfort.
A dependent, cognitively impaired resident with severe dementia did not receive timely incontinence care as required by her care plan and facility policy. Surveyors observed the resident in bed with a strong foul urine odor persisting over an hour, a soiled urine-saturated brief, and dry urine-stained cloth pads beneath her. An RN acknowledged difficulty providing care due to the resident’s resistance and was unsure when incontinence care was last given, while a CNA reported last providing care several hours earlier. The DON later stated staff are expected to check for incontinence at least every two hours and that the resident should have received timely incontinence and hygiene care consistent with her assessed needs.
The facility failed to follow physician orders for CHF-related fluid management for three residents, including missing ordered daily weights and not applying prescribed compression stockings. One resident with CHF and bilateral lower extremity edema had orders and a care plan for daily weights with MD/NP notification for specific weight gains, yet several days lacked recorded weights. Another resident with chronic lower extremity edema related to CHF was repeatedly observed wearing regular socks and footwear instead of ordered compression stockings, despite being dependent on staff for their application. A third resident with CHF and generalized lower extremity edema also had orders and a care plan for daily weights with defined notification parameters, but multiple days showed no documented weights, contrary to facility policy on weight monitoring and fluid status assessment.
A resident with Parkinson’s disease, dementia, and moderate cognitive impairment stated he wanted unrestricted visits from his children, but staff followed a posted sign listing specific family members whose visitation was to be restricted per the POA. When a daughter arrived to visit, staff asked her name, informed her she was not allowed to see the resident based on the POA’s directive, and called the police when she refused to leave or provide ID; the police then told her she was trespassing. The Ombudsman reported that the POA was denying visitation and that there should not have been a barrier to the visit, while facility leadership acknowledged that the POA could not deny visitation and that the resident did want to see his daughter, yet the posted restriction and staff actions still prevented the visit.
A resident with hemiplegia and other complex medical conditions, who required substantial assistance for transfers, was moved from the toilet to a wheelchair by a CNA without the use of a gait belt as required by the care plan and facility policy. During the transfer, the resident's foot became caught, causing her contracted leg to strike the wheelchair frame and resulting in a laceration that required stitches. Staff interviews and documentation confirmed that proper transfer procedures were not followed.
The facility failed to assist residents with activities of daily living, including eating and personal hygiene. Several residents were observed with long facial hair and unkempt nails, and one resident's meal remained untouched until the DON intervened. The facility's policies on ADLs and nail care were not followed, leading to deficiencies in resident care.
The facility failed to properly puree maple glazed ham for eight residents on pureed diets. The cook blended pre-sliced ham with rind intact, resulting in a mixture with visible rind pieces, contrary to the required smooth, pudding-like consistency. This was identified by the Dining Director, highlighting a deviation from the facility's dietary policy.
A resident with medical conditions requiring assistance with hearing aid placement did not receive the necessary help from facility staff. Despite having a care plan indicating this need, the resident reported not receiving assistance and was observed without hearing aids, impacting her ability to hear. Staff members were either unaware of the resident's needs or had not been providing the required assistance, contrary to the care plan expectations.
A resident with spastic hemiplegia and contracture was not provided with a splint or positioning device to maintain ROM. Despite being moderately impaired and requiring assistance with ADLs, the resident was observed without necessary support. An OT recommended a hand roll and elbow orthosis, but these were not in place, highlighting a deficiency in care.
The facility failed to follow their policy for transferring a resident with severe cognitive impairment and multiple diagnoses. CNAs transferred the resident without using the mechanical lift and without the required assistance of a second staff member, contrary to the care plan.
Failure to Maintain Functional Room Heating and Comfortable Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a comfortable environment by ensuring proper room heating for two residents sharing a room. One resident, who was cognitively intact per an MDS dated 12/08/2025, reported feeling cold and was observed wearing a shawl to keep warm. She stated that the room’s heating unit had not been working since 1/10/2026 and that she had reported this to staff on that date. She further reported that a maintenance assistant assessed the unit on 1/12/2026, determined it could not be fixed, left it unplugged, and did not return to reassess it. During the survey on 1/13/2026 at 10 AM, the room felt cool and the heating unit was unplugged. The cognitively intact resident’s roommate, who was documented as severely cognitively impaired and nonverbal on her MDS, was unable to be interviewed about the room temperature. Nursing staff notified the receptionist on 1/12/2026 at 3 PM that the heating unit was not working; the receptionist then notified the maintenance assistant by telephone but did not enter a work order into the computer system as required by the facility’s process. The maintenance assistant confirmed he assessed the unit, found it nonfunctional, left it unplugged, and did not complete a work order. The maintenance director stated he was unaware of the problem and confirmed there was no active maintenance order. Upon his assessment, the unit’s motor was not working and an outside vendor would be needed. He noted the room felt cool with a temperature around 71°F and acknowledged that residents’ rooms needed properly operating heating units so residents could adjust temperatures to their comfort level. The facility’s policy required maintaining comfortable and safe temperature levels within a specified range to minimize susceptibility to loss of body heat and to ensure resident comfort.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living to a dependent resident with severe dementia. On 1/13/2026 at 10:10 AM, the resident was observed in bed wearing a gown, severely confused and fidgeting, with a strong foul urine odor in the room and incontinence products on the bedside table. At 11:00 AM, the resident remained in bed with the same strong foul urine smell. The RN (V14) stated that providing incontinence care was difficult because the resident tended to resist due to severe dementia. Upon assessing the resident’s incontinence brief, V14 found it soiled with urine and emitting a strong foul odor. The resident had two cloth pads underneath her, with the top pad soiled by a dark yellow stain that V14 said was dry, and V14 was unsure when the resident last received incontinence care. At 11:20 AM, two CNAs (V12 and V13) stated they were going to provide incontinence care to the resident. V12 reported that she had last provided incontinence care around 8:00 AM and, upon assessing the soiled cloth pad, believed it had not been present previously and was now dry. The resident’s care plan documented cognitive impairment and a need for assistance with ADLs, including toileting, with interventions directing staff to provide total incontinence and hygiene care. The DON (V2) stated that nursing staff were expected to check residents for incontinence at least every two hours and as needed, and that this resident should have received timely incontinence care, including premedication with PRN antianxiety medication if necessary to allow staff to meet basic toileting needs. The facility’s incontinence care policy dated 05/2025 stated that all incontinent residents would receive appropriate treatment and services based on their comprehensive assessment.
Failure to Follow CHF Fluid Management Orders and Daily Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for CHF-related fluid management, including daily weights and use of compression stockings, for three residents. One resident with CHF and bilateral lower extremity non-pitting edema reported that nursing staff were supposed to obtain daily weights but that this had not been done recently. The RN confirmed that this resident’s CHF management required a fluid restriction and daily weights with MD/NP notification for specified weight gains. The resident’s orders and care plan included daily weights with parameters for provider notification, yet the January 2026 weight record showed missing daily weights on multiple dates. The DON stated that staff were expected to follow CHF orders, including daily weights and application of edema compression stockings. Another resident with chronic lower extremity edema related to CHF was repeatedly observed on different days wearing regular ankle socks with shoes or slippers instead of compression stockings. An RN stated this resident required compression stockings for edema management, was dependent on staff to apply them, and that nurses were expected to follow the physician’s order to apply compression stockings in the morning and remove them at night. A third resident with CHF and generalized lower extremity edema had an active order and care plan for daily weights with MD/NP notification for specified weight gains, but the January 2026 weight record showed multiple days without recorded daily weights. The facility’s weight monitoring policy required assessment of weight and fluid status and development of individualized care plans based on professional standards, but the documented omissions in daily weights and failure to apply ordered compression stockings demonstrate that these orders and care plan interventions were not consistently implemented.
Failure to Honor Resident’s Right to Receive Family Visitors
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of his choosing. The resident, who had Parkinson’s disease, unspecified dementia, and moderate cognitive impairment, reported that he had a blended family with three daughters and a stepson who served as his POA. He stated there had been internal family conflict, that his stepson did not get along with his daughters, and that the stepson had blocked his daughters from phone contact and visiting. The resident clearly stated there should not be any restrictions on any of his children visiting him. Despite this, a sign was posted at the nurse’s station stating that, per the resident and his wife/POA’s request, specific daughters and their spouses, as well as another family member, were to have their visitation restricted and that police could be contacted if they refused to leave. A daughter reported that she drove several hours to visit her father and, upon arrival, was told by staff she was on a list of people not allowed to visit per the POA; staff then called the police, who informed her she was trespassing and could not be there. The Ombudsman stated that the POA was denying visitation, that the facility believed there was to be no contact, and that there should not have been a barrier to the visit. Facility staff, including the receptionist and an RN, described following the posted note by asking visitors for their names, denying the daughter access, and calling the police when she refused to leave or provide identification. The RN stated the note restricting visitation was put up after a prior disturbance involving the daughter and that the POA had said to restrict visitation for these individuals. The Administrator and Director of Operations both acknowledged that the POA could not deny visitation and that visitation ultimately depended on the resident’s wishes, which were that he wanted to see his daughter, yet the posted restriction and staff actions continued to deny the daughter’s visit based on the POA’s request.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and cellulitis of the right lower limb required substantial to maximal assistance for toileting hygiene and transfers, as documented in the care plan and Minimum Data Set. The care plan specifically directed staff to use a gait belt for all transfers. Despite these instructions, a CNA transferred the resident from the toilet to a wheelchair without using a gait belt, instead holding onto the resident's brief during the transfer. During the transfer, the CNA did not notice that the resident's right foot was caught near the wheelchair's leg rest area. As the resident attempted to sit, her right leg, which was contracted due to her medical condition, swung forward and struck the frame of the wheelchair. This resulted in a laceration to the resident's right lower leg, which required emergency medical attention and stitches. The incident was confirmed by interviews with the resident, the CNA involved, and other facility staff, all of whom acknowledged that a gait belt should have been used according to facility policy and the resident's care plan. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer, and staff receive training on this policy during orientation and annually. The failure to follow this policy and the resident's care plan directly led to the resident sustaining a significant injury during a transfer. The event was documented in the facility's final report and corroborated by medical records from the emergency room.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and nutrition. One resident, identified as R50, who was cognitively intact and required assistance with eating and personal hygiene, was observed with long facial hair and unkempt fingernails. Despite being served a meal, the resident's food and drinks remained untouched until the Director of Nursing intervened to assist and cue the resident to eat. This lack of assistance was acknowledged by the Assistant Director of Nursing, who confirmed the resident's need for staff support in grooming and eating. Another resident, R51, who had multiple diagnoses including dementia and Parkinson's disease, also required maximum assistance with personal hygiene. Observations revealed that R51 had long facial hair and fingernails, despite expressing a desire for grooming. The Assistant Director of Nursing acknowledged the need for staff assistance in maintaining the resident's hygiene, which was not provided as per the care plan. Additional deficiencies were noted with residents R16 and R42. R16, who was severely cognitively impaired and dependent on staff for personal hygiene, was observed with long, unclean fingernails. Similarly, R42, who was admitted to hospice care and required substantial assistance with personal hygiene, was found with long nails and unkempt hair. The facility's policy on ADLs and nail care was not adhered to, as evidenced by the lack of documented nail care and grooming for these residents.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to properly prepare pureed maple glazed ham for eight residents on pureed diets, as observed during a meal preparation on November 13, 2024. The cook, identified as V9, was responsible for preparing the meal and was observed placing pre-sliced ham with rind intact into a blender, adding glaze for flavor, and pureeing the mixture. Despite blending the ham for about two minutes, the resulting product contained small pieces of rind that were visible and not fully pureed, posing a risk to residents who require a smooth, pudding-like consistency for safe consumption. The issue was identified when the Dining Director, V10, was informed that the pureed ham was unsafe due to the presence of rind pieces. The facility's 'Diet Type Report' confirmed that the eight residents were on pureed diets, and the facility's policy for pureed diets specified that the texture should be smooth, similar to mashed potatoes or pudding. The failure to achieve the required consistency for the pureed ham indicates a deviation from the facility's policy and the dietary needs of the residents.
Failure to Assist Resident with Hearing Aid Placement
Penalty
Summary
The facility failed to provide necessary assistance with hearing aid placement for a resident, identified as R31, who required such assistance. R31, a female resident with medical conditions including Carpal Tunnel Syndrome, Torticollis, Neuropathy, and Poly-osteoarthritis, was admitted to the facility with a care plan indicating a need for assistance with personal care, including the placement of hearing aids. Despite this documented need, R31 reported that staff did not assist her with her hearing aids, leading her to stop asking for help. During a resident council interview, R31 was observed without her hearing aids and expressed difficulty hearing, confirming that she had not received assistance from staff. Further investigation revealed that the staff, including a registered nurse (V15) and a certified nursing assistant (V16), were either unaware of R31's need for hearing aids or had not been assisting her with them. V15 acknowledged seeing R31 with hearing aids occasionally but stated that R31 had never requested assistance. V16 admitted to not helping R31 with her hearing aids and noted it had been a while since she had seen R31 wearing them. The Assistant Director of Nursing (V3) confirmed that residents requiring assistance with hearing aids should have such orders in their care plans and expected staff to follow these plans. Despite this expectation, R31 remained without her hearing aids throughout the day, highlighting a lapse in care and adherence to the resident's care plan by the facility staff.
Failure to Provide Splint for Resident with Contracture
Penalty
Summary
The facility failed to assess and provide appropriate care for a resident, identified as R38, to maintain and/or improve range of motion (ROM). R38 was admitted with multiple diagnoses, including spastic hemiplegia affecting the left dominant side, mild dementia, and contracture of the left hand muscle. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and functional limitations in ROM on one side of both upper and lower extremities, requiring maximum to total assistance with activities of daily living (ADLs). Despite these needs, observations on two separate occasions revealed that R38 had left hand weakness and contracture without any splint or positioning device in place. The Assistant Director of Nursing (V3) acknowledged the contracture and was prompted to have the therapy department screen R38. The Occupational Therapist (V11) conducted a screening and confirmed the presence of contractures in the left hand and elbow, which were partially stretchable. V11 recommended the use of a left hand roll and a left elbow orthosis to prevent further contracture, stiffness, deformity, and skin breakdown. However, these recommendations were not implemented prior to the surveyor's observations, indicating a deficiency in the facility's care for maintaining and improving the resident's ROM.
Failure to Follow Transfer Policy
Penalty
Summary
The facility failed to follow their policy to transfer a resident according to the resident's care plan. The resident, who had multiple diagnoses including Parkinson's disease, heart failure, dementia, anxiety, and falls, required extensive assistance from two facility staff for transfers between surfaces as per their care plan. However, on multiple occasions, CNAs transferred the resident without using the mechanical lift and without the assistance of a second staff member. One CNA admitted to transferring the resident manually by himself, while another CNA used the mechanical lift but did so alone, contrary to the care plan requirements. The Director of Nursing confirmed that the CNAs should have used the mechanical lift with two staff members present for the transfers. The facility documentation corroborated the CNAs' admissions, showing that they did not follow the prescribed transfer procedures. This failure to adhere to the care plan and facility policy resulted in improper nursing care for the resident, who had severe cognitive impairment and was non-ambulatory, requiring total staff assistance for transfers.
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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