Avantara Chicago Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago Ridge, Illinois.
- Location
- 10300 Southwest Highway, Chicago Ridge, Illinois 60415
- CMS Provider Number
- 145700
- Inspections on file
- 37
- Latest survey
- January 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avantara Chicago Ridge during CMS and state inspections, most recent first.
A resident with vascular dementia, who was cognitively intact and previously described as calm and cooperative, was sent to the hospital for agitation and was not allowed to return based on behavior concerns decided by the Administrator and DON. The facility could not provide a physician assessment or psychiatric reassessment supporting that the resident could not be safely cared for, and the primary physician reported no evaluation had occurred. There was no written discharge notice, no discharge planning documentation, and no evidence the resident or representative was informed of appeal rights, despite facility policies requiring adherence to bed hold/readmission rules and proper discharge planning once a physician discharge order is obtained.
A resident with vascular dementia, CKD, CHF, A-fib, and diabetes did not have a documented physician visit within the required 60-day interval before a hospital transfer. Record review showed only an NP progress note, with no evidence that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed the resident’s medical management. The DON could not produce documentation of a timely physician visit, and the primary physician reported having neither seen the resident nor having records of NP visits, noting the last physician notes he saw were from another physician many months earlier. This failed to meet federal requirements and facility policy for physician visits and oversight.
A resident with multiple complex medical conditions and a gastrostomy tube had a physician order for continuous Osmolite 1.5 at 80 ml/hr with specified water flushes. During surveyor observation, an agency RN had the feeding pump set at 100 ml/hr and confirmed this rate, while the resident reported the nurse had increased the rate earlier. Review of the electronic record showed the ordered rate was 80 ml/hr, and the RN then reduced the pump setting to match the order. This resulted in the resident receiving enteral nutrition at a higher rate than prescribed, contrary to the facility’s enteral feeding policy and nursing job descriptions requiring adherence to physician orders.
A resident with a g-tube and complex medical conditions, including malignancies, COPD, CKD, and documented gastrostomy status, had a care plan and physician order requiring daily cleansing of the g-tube site with normal saline and application of a dry dressing. The order was not properly transcribed onto the Treatment Administration Record, and there was no documentation that g-tube site care was provided over multiple days. The resident reported that staff did not consistently clean the site or replace the dressing, and observation revealed a large amount of brownish-blackish crust around the stoma with no dressing in place. When the ADON and an agency LPN assessed the site, they acknowledged it should be cleansed and covered, and the resident exhibited pain on assessment, while facility policy and nurse job descriptions required daily stoma care and documentation of prescribed treatments.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
A resident with complex medical needs was financially exploited when a CNA stole the resident's credit card and made unauthorized purchases exceeding $1,000. The theft was discovered by the resident's family, who reported it to facility administration and law enforcement. Investigation confirmed the CNA's involvement, resulting in criminal charges for financial exploitation.
The facility failed to provide scheduled showers and grooming for residents dependent on staff for ADLs, affecting four residents. One resident with a pressure ulcer was left in urine and feces, while another reported never receiving a shower since admission. Documentation of showers or refusals was inconsistent, leading to the deficiency.
A resident at high risk for skin impairments developed a new moisture-associated skin disorder and experienced deterioration of an existing pressure ulcer due to the facility's failure to provide timely incontinence care. Despite being on a low air loss mattress, the resident was found soaked in urine and feces, and her call light was not answered. The facility did not adhere to its policies for skin care and incontinence checks, leading to significant harm.
The facility failed to label and store medications, such as insulin and inhalers, according to professional principles. Observations revealed that several insulin pens and inhalers on medication carts and in a medication room were not labeled with open dates, contrary to the manufacturer's guidelines. Staff interviews confirmed awareness of the requirement to date medications upon opening and discard them as recommended. This issue affected residents with conditions like Type 2 Diabetes Mellitus and COPD.
The facility failed to maintain proper sanitizer concentration in the kitchen's sanitation bucket, with test results showing levels significantly below the manufacturer's recommended range. This issue, observed during a survey, affects 158 residents who receive food from the kitchen, as improper sanitation can lead to foodborne illnesses. The Dietary Aide admitted to estimating the sanitizer solution, and the facility was unable to provide the manufacturer's dilution instructions.
The facility failed to ensure call lights were within reach for four residents, as observed on a specific date. Despite the facility's policy and care plans requiring accessible call lights, they were found on the floor, making them inaccessible. Staff confirmed the expectation for call lights to be within reach, highlighting a lapse in policy adherence.
The facility failed to adhere to infection control practices, including improper handling of respiratory equipment and inadequate disinfection of medical equipment between resident uses. A nebulizer mask was left uncovered, and a nurse did not disinfect equipment between residents. Additionally, staff did not follow proper procedures for residents on transmission-based precautions, such as wearing PPE and performing hand hygiene.
A resident with a fractured hip from a fall in the facility did not receive timely skilled therapy services as ordered by the physician. The resident, who was a fall risk, was initially hospitalized for chest pain and later diagnosed with fractures. Upon readmission, therapy services were delayed due to insurance approval processes, and the facility staff were unaware of the fracture diagnosis until after readmission. The facility lacked a policy on therapy services, leading to a deficiency in coordinated care.
Two residents at high risk for falls experienced incidents due to inadequate safety interventions. One resident, admitted for rehabilitation, fell while reaching for a phone, resulting in a laceration. Another resident fell during care due to improper positioning. The facility's fall prevention guidelines were not adequately followed, leading to these incidents.
A facility failed to refer a resident for a PASRR Level 2 screening after a new diagnosis of major depression was made. The Social Service Director was unaware of the diagnosis until the survey, despite the Administrator claiming to have informed her. The resident had a PASRR Level 1 screening before admission, but the facility policy requires updated screenings for new mental health diagnoses.
The facility failed to supervise two residents during medication administration, leaving them to self-administer without authorization. An LPN left medication with a resident during breakfast, and an RN left a resident with medication unattended. Additionally, the facility did not maintain accurate controlled substance records, with missing signatures and discrepancies in medication counts.
The facility failed to document incontinence care every shift for two residents dependent on staff for bowel and bladder incontinence. A review of records showed a lack of documentation indicating care was provided at least once per shift. Family members reported instances where residents were left soaked in urine, and the Director of Nursing confirmed the expectation for CNAs to document care per shift.
A resident with hemiplegia and hemiparesis developed a new stage II pressure ulcer despite being at risk and dependent on staff for care. The facility's failure to prevent this was linked to potential issues with turning, repositioning, and treatment plans, although no nutritional concerns were noted. Initial skin alterations were documented but progressed to a pressure ulcer, indicating insufficient preventive measures.
A facility failed to replace a damaged call light cord with exposed wires in a resident's room, which was identified during a survey. The resident, who had a femur fracture and cognitive communication deficit, was discharged before the issue was discovered. A family member reported the hazard, and a staff member removed the cord after being informed. The facility's policy requires the removal of hazardous items to ensure safety.
A resident with a history of falls and cognitive deficits sustained a foot fracture after attempting to toilet herself due to delayed assistance from staff. The facility failed to complete required fall risk assessments and did not provide timely toileting assistance, leading to the resident's fall and injury.
A resident with end-stage renal disease experienced severe complications, including sepsis and peritonitis, due to the facility's failure to properly manage her peritoneal dialysis catheter. The resident was found with a missing cap on her catheter, leading to an infection that required hospitalization and a switch to hemodialysis.
Failure to Honor Return Rights and Complete Required Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to return following hospitalization and to conduct proper discharge procedures. An older adult resident with vascular dementia, documented as cognitively intact with a BIMS score of 14/15 and described in an 8/31/2025 psychiatric evaluation as pleasant, calm, cooperative, and without behavioral issues, was transferred to the hospital on 9/29/2025 after exhibiting agitation and did not return. On interview, the DON stated that she and the Administrator decided not to allow the resident to return due to behavior concerns. The facility was unable to provide any physician assessment determining that the resident could not be safely cared for in the facility, and the resident’s primary physician confirmed he had not seen the resident and had no record of evaluation. No documentation was provided showing a psychiatric reassessment following the behaviors cited by the facility, and there was no change in condition noted in the resident’s medical record. Record review revealed no written discharge notice, no discharge planning documentation, and no evidence that the resident or representative was informed of appeal rights. When surveyors requested any and all documentation or assessments used in determining the resident’s involuntary discharge, none were provided. This failure occurred despite facility policies stating that the facility would adhere to federal regulations on bed hold and readmission, including permitting residents transferred for hospitalization to return to the first available bed after exceeding the bed hold period, and that proper discharge planning and instructions would be conducted once a discharge order is obtained from the attending physician.
Failure to Ensure Timely Physician Visits and Oversight of NP Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and the attending physician had face-to-face visits within the federally mandated and facility-required 60-day timeframe. The resident, an older adult with vascular dementia, chronic kidney disease, congestive heart failure, atrial fibrillation, and diabetes, was transferred to the hospital on 9/29/2025 and did not return. Record review showed no documentation of a physician visit for more than 60 days prior to this hospital transfer, and the DON could not provide evidence of a required physician visit when requested on 1/24/2026. The only documentation provided was a nurse practitioner (NP) progress note dated 2/17/2025, with no documentation that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed or directed the resident’s medical care. During interview, the primary physician stated that he had not seen the resident, had no records of his NP seeing the resident, and that the last physician notes he saw in the electronic medical record were from another physician’s services dated 2/17/2024, adding that he would not see a resident who belonged to another physician. The facility’s own policy requires residents to be seen by a physician at least every 60 days with an evaluation of the resident’s condition and total program of care, which the facility was unable to demonstrate occurred within the required timeframes. The facility was therefore unable to show compliance with federal requirements and its own policy for timely physician visits and physician oversight of NP services for this resident.
Failure to Follow Physician Order for Enteral Feeding Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality for a resident receiving enteral nutrition. The resident is an adult male with multiple complex diagnoses, including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, gait and mobility abnormalities, gastrostomy status, and several psychiatric conditions. His BIMS score of 11 indicated moderate cognitive impairment. According to the Medication Administration Record for January 2026, the physician’s order dated 01/07/2026 specified continuous enteral feeding with Osmolite 1.5 at 80 ml/hr for a total feed volume of 1920 ml over 24 hours, with water flushes at 40 ml/hr for a total flush volume of 960 ml over 24 hours. Facility policy for enteral tube feeding care required the nurse to check the POS/MAR for the enteral feeding order, including formula, type, rate, and duration. On 01/17/2026 at 10:48 a.m., the resident was observed awake and alert in bed with the gastrostomy tube feeding infusing at 100 cc/hr of Osmolite 1.5. The resident stated that the nurse had changed his feeding rate to 100 earlier that morning. At 12:18 p.m., the feeding was still infusing at 100 cc/hr. At 12:20 p.m., an agency RN (V15) confirmed to the surveyor that the feeding pump was set at 100 cc/hr. After reviewing the resident’s order in the electronic record (PCC/PointClickCare), V15 acknowledged that the ordered rate was 80 cc/hr and stated that the rate needed to be changed to match the doctor’s order. At 12:25 p.m., V15 adjusted the feeding rate from 100 cc/hr to 80 cc/hr, stating that they were supposed to follow the physician’s order. This sequence of events shows that the resident received enteral feeding at a rate higher than ordered, contrary to the facility’s enteral feeding policy and the job descriptions for floor nurses, which require adherence to physician orders and established nursing policies and procedures.
Failure to Provide Ordered G-Tube Site Care and Maintain Clean, Dressed Stoma
Penalty
Summary
The deficiency involves the facility’s failure to follow its own enteral tube feeding care policy and physician orders for a male resident with a gastrostomy tube (g-tube). The resident, admitted with multiple diagnoses including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, bipolar disorder, and documented gastrostomy status, had a care plan dated 11/6/25 indicating he was receiving gastric tube feeding due to atresia of the esophagus with tracheoesophageal fistula and was at risk for infections, fluid overload, dehydration, and aspiration pneumonia. The care plan included an intervention to check the g-tube site for signs and symptoms of infection and notify the physician. An order dated 1/05/2026 at 1:30 p.m. directed staff to cleanse the enteral tube feeding site with normal saline and apply a dry dressing, and the facility’s policy required the g-tube stoma site to be cleansed and covered with dry gauze daily. Record review showed that this g-tube site care order was not transcribed onto the scheduled area of the Treatment Administration Record, and there was no documentation that g-tube site care was performed from 1/5/2026 through 1/16/2026. Nursing progress notes for 1/5/2026 also contained no documentation of g-tube care. During an observation on 1/16/2026 at 1:18 p.m., the resident reported that staff were supposed to clean his g-tube site and apply a dressing but did not do so consistently, stating that sometimes they cleaned it and sometimes they did not. He reported that a nurse removed the gauze the previous day and did not clean the site or replace the dressing. The surveyor observed a large amount of brownish-blackish crust encircling the g-tube stoma and noted that there was no dressing in place. When the ADON assessed the g-tube site at 1:36 p.m. on the same day, she stated that the site should be covered and appeared to need cleaning due to crust build-up; the resident winced in pain and stated the area was sore. After the ADON left, the resident stated that because staff did not clean his g-tube site, he would clean it himself with alcohol and that removal of the gauze the previous day had hurt. Later, an agency LPN entered the room and stated she had not changed the dressing because it was changed on night shift, but acknowledged that the g-tube was supposed to be cleansed with normal saline and gauze applied, and that the site had crust around it. The DON stated that nurses should be changing the g-tube dressing daily, ensuring the area is cleaned, and documenting it on the TAR or MAR, consistent with the facility’s enteral tube feeding care policy and the floor nurse job descriptions for LPNs and RNs, which require administering and supervising prescribed treatments such as tube care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Resident Financial Exploitation by Facility Staff
Penalty
Summary
A resident with multiple medical conditions, including a history of femur fracture, major depressive disorder, diabetes, COPD, hypertension, anemia, and generalized anxiety, was admitted to the facility and later became the victim of financial exploitation. The resident's family member discovered unauthorized charges totaling over $1,000 on the resident's credit card, which had been stolen. The charges were made at local restaurants and stores, and the card was never returned to the resident. The family reported the incident to the facility and filed a police report, providing documentation of the charges and the police report number to the facility administrator. Investigation revealed that a CNA who worked on the same floor as the resident during the relevant period was identified as a suspect. Security camera footage and police investigation led to the arrest and felony charge of financial exploitation against the CNA. The facility's abuse and neglect policy, which prohibits misappropriation and exploitation of resident property, was not adhered to, resulting in the resident's loss of property and financial exploitation by facility staff.
Failure to Provide Scheduled Showers and Grooming for Residents
Penalty
Summary
The facility failed to ensure that staff provided scheduled showers and grooming for residents dependent on staff for Activities of Daily Living (ADLs). This deficiency affected four residents, who were observed to have unmet hygiene needs. One resident, who has a history of Parkinson's disease and severe protein-calorie malnutrition, was reported by family members to be left sitting in urine and feces multiple times a week, despite having a pressure ulcer that should not be exposed to moisture. The resident was scheduled for showers twice a week, but documentation was lacking, and there was no record of shower refusals. Another resident, with a history of chronic obstructive pulmonary disease and type 2 diabetes, reported never receiving a shower since admission and only occasionally receiving bed baths. This resident was found wearing two incontinence briefs, one saturated with urine and feces, which the CNA stated was against facility policy. The resident was scheduled for showers twice a week, but there was no documentation of showers being given or refused. Additional residents were also affected, including one with a history of malignant neoplasms and chronic kidney disease, who appeared unclean and reported not receiving showers, only bed baths. Another resident, with a history of hemiplegia and chronic heart failure, was observed to have not been washed up and had no documentation of receiving scheduled showers. The facility's policy required documentation of showers or refusals, but this was not consistently followed, leading to the deficiency.
Failure to Prevent Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to implement preventive measures to prevent the development and deterioration of pressure ulcers in a resident identified as R139, who was at high risk for skin impairments. The deficiency was observed when R139 was found soaked in urine and feces, with her bed wet from her upper back to her ankles. This incident was reported by her family member, who expressed concerns about the lack of incontinence care provided from the night shift until the morning shift. The resident, who was on a low air loss mattress, developed a new moisture-associated skin disorder (MASD) on her bilateral buttocks and her existing pressure ulcer on the sacrum deteriorated to an unstageable stage. R139, who was initially admitted with a stage 2 pressure ulcer on the sacral area, had a medical history that included hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, obesity, and other conditions that increased her risk for pressure ulcers. Despite being on a low air loss mattress and having specific orders for wound care, the facility failed to ensure that incontinence care was provided every two hours as required. The resident reported that her call light was not answered, and her brief was not changed when soiled, contributing to the worsening of her skin condition. The facility's policies on skin care and incontinence care were not followed, as evidenced by the lack of timely incontinence checks and the improper functioning of the low air loss mattress. The Assistant Director of Nursing (ADON) and the Wound Care Coordinator confirmed the issues, acknowledging that prolonged exposure to soiled conditions could lead to the development and deterioration of pressure ulcers. The facility's failure to adhere to its own protocols resulted in significant harm to R139, as her pressure ulcer progressed from stage 2 to unstageable, and she developed a new MASD.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and store medications, specifically insulin and inhalers, according to the manufacturer's recommendations and professional principles. During an observation, it was found that several insulin pens and inhalers on the 2nd floor East-West and [NAME] medication carts, as well as in the 3rd floor medication room, were not labeled with the date they were opened. This included insulin glargine, insulin lispro, and various inhalers, which should have been discarded after a specific period as per the manufacturer's guidelines. Interviews with the nursing staff confirmed that they were aware of the requirement to date medications upon opening and to discard them according to the manufacturer's instructions. The report highlights specific instances where medications were not labeled with open dates, such as insulin glargine and lispro pens, and inhalers for residents with conditions like Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The facility's policy on medication labeling, which requires opened medications to be labeled with the date of opening and discarded within a specified timeframe, was not adhered to. This oversight was observed across multiple medication carts and storage areas, indicating a systemic issue in medication management within the facility.
Improper Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation levels in the kitchen, specifically in the sanitation bucket used for kitchen rags. During an observation, the Dietary Manager (DM) tested the sanitation bucket using Quaternary test strips and found that the sanitizer concentration was significantly below the manufacturer's recommended levels. The expected concentration should have been between 300 to 400 parts per million (ppm), but the test results showed only 0-100 ppm. This discrepancy was observed despite multiple attempts to achieve the correct concentration by stirring the solution. The Dietary Aide responsible for changing the sanitation bucket admitted to estimating the water and sanitizer solution rather than following precise measurements. The facility's policy requires that the sanitation bucket be filled with sanitizer according to the manufacturer's recommendations, which specify a concentration range of 150-400 ppm for Quaternary solutions. However, the facility was unable to provide the manufacturer's dilution instructions. Additionally, the Dietary Manager initially provided incorrect information regarding the acceptable concentration range, later correcting it to 200-300 ppm. The facility's failure to adhere to these guidelines has the potential to affect 158 residents who receive food from the kitchen, as improper sanitation levels can lead to foodborne illnesses.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach, affecting four residents in a sample of 32. Observations on January 7, 2025, revealed that the call lights for residents R3, R15, R150, and R416 were hanging on the floor next to their beds, making them inaccessible. Certified Nurse Aides V23 and V24 confirmed that call lights should be within reach and not on the floor, as residents need to be able to call for assistance. The Director of Nursing also stated that call lights should be clipped to the bed or tied to the bed rail, according to resident preference. The medical records of the affected residents indicated various diagnoses and care plans that required assistance with activities of daily living. For instance, R15 had a history of cerebrovascular accident, visual impairment, and other conditions, with a care plan intervention to keep call lights within reach. Similarly, R150 and R416 had care plans emphasizing the need for accessible call lights due to their medical conditions. Despite the facility's policy, revised in July 2024, which mandates that call lights be within reach at all times, the deficiency was observed, indicating a lapse in adherence to the policy.
Infection Control Deficiencies in Equipment Handling and Precautionary Measures
Penalty
Summary
The facility failed to ensure proper infection control practices in handling respiratory equipment and disinfecting medical equipment between resident uses. An observation revealed that a nebulizer mask used by a resident was left uncovered and hanging from a nightstand, contrary to the facility's policy that requires such equipment to be stored in a labeled plastic bag. Additionally, a Licensed Practical Nurse was unaware of who left the nebulizer mask in this condition, indicating a lapse in adherence to infection control protocols. Further deficiencies were noted in the disinfection of medical equipment. A Registered Nurse was observed taking vital signs of multiple residents without disinfecting the blood pressure apparatus and pulse oximeter between uses. This practice was contrary to the facility's policy, which mandates cleaning reusable equipment between residents. The Director of Nursing and the Infection Preventionist both acknowledged that the equipment should have been disinfected after each use. The facility also failed to implement appropriate infection control practices for residents on transmission-based precautions. A Certified Nurse Assistant entered a resident's room without performing hand hygiene and without wearing the required personal protective equipment. Additionally, a Licensed Practical Nurse did not change gloves or perform hand hygiene between different procedures on a resident. The transmission-based precaution setup outside certain residents' rooms lacked necessary personal protective equipment, such as gloves and masks, and some rooms did not have hand soap available, further compromising infection control measures.
Delayed Therapy Services for Resident with Fractured Hip
Penalty
Summary
The facility failed to provide coordinated care services to a resident who suffered a fractured hip from a fall within the facility. The resident, identified as R74, was not provided with skilled therapy services as ordered by the physician in a timely manner. The deficiency was identified during an observation, interview, and record review, affecting one of the three residents reviewed for quality of care. The resident was found in bed, alert but with some confusion, and was identified as a fall risk. Despite the fall occurring on 12/14/24, the facility staff, including the Director of Nursing, were not aware of the fracture diagnosis until after the resident's readmission. The resident was initially sent to the hospital due to chest pain and was diagnosed with a non-ST-elevation myocardial infarction (NSTEMI). During the hospital stay, the resident reported right thigh pain, and a subsequent CT scan revealed an intertrochanteric fracture of the right femur and closed fractures of the right superior and inferior pubic ramus. The resident underwent right hip pinning on 12/23/24. Upon readmission to the facility, the resident had orders for occupational, physical, and speech therapy, but there was a delay in starting these therapies due to insurance approval processes. The Rehab Director was unaware of the fracture diagnosis until notified by the Nurse Practitioner on 12/30/24, and therapy services did not commence until early January. The delay in therapy services was attributed to the need for pre-approval from insurance, as stated by the facility's Administrator. The facility was unable to provide a policy on therapy services and skilled rehabilitation services, highlighting a lack of coordination and communication regarding the resident's care needs and therapy orders.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to ensure safety interventions were in place for a resident, identified as R216, who was at high risk for falls. R216, who had a history of falls and was admitted for rehabilitation following a humerus fracture, experienced an unwitnessed fall on the day of admission. The fall occurred when R216 attempted to reach for a phone on the nightstand, resulting in a laceration to the right eyebrow that required hospital treatment. The admission assessment identified R216 as high risk for falls, but no specific interventions were documented in the care plan to mitigate this risk. Another resident, R27, also experienced a fall due to inadequate supervision and positioning. R27, who has a history of hemiplegia and hemiparesis following a cerebral infarction, was turned by a CNA during care and slid off the bed because they were positioned too close to the edge. The CNA did not realize the resident's proximity to the edge, which led to the fall. A post-fall investigation confirmed that R27 was too close to the edge of the bed, and staff were reminded to ensure proper positioning before performing activities of daily living. The facility's fall prevention program guidelines require the implementation of safety interventions for residents identified at risk for falls. However, in both cases, the necessary precautions were not adequately implemented or maintained, leading to the incidents. The Director of Nursing acknowledged the oversight in R216's care plan and the need for baseline fall interventions to be indicated upon admission.
Failure to Conduct PASRR Level 2 Screening for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a PASRR Level 2 screening after the resident received a new diagnosis of a serious mental illness. The Social Service Director (SSD) was responsible for ensuring that residents with new mental illness diagnoses received an updated PASRR Level 2 screening. However, the SSD was not made aware of the new diagnosis for the resident until the survey, at which point she contacted the agency to have the screening completed. The Admissions Director confirmed that a PASRR Level 1 screening was completed before admission and stated that social services would be responsible for obtaining a Level 2 screening if a new mental illness diagnosis was made. The Administrator acknowledged awareness of the resident's new diagnosis since admission and claimed to have informed the SSD of the need for a new PASRR Level 2 screening. The resident's medical records indicated a new diagnosis of major depression and other mental health conditions. The facility's policy, revised in August 2024, mandates that residents with mental disorders receive PASRR screenings within the allowed timeframe, but this was not adhered to in this case.
Medication Administration and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to properly supervise residents during medication administration, as observed in two cases. In the first instance, a Licensed Practical Nurse (LPN) left a medication cup with three pills on a resident's food tray while the resident was eating breakfast, trusting the resident to take the medication independently. The Director of Nursing (DON) later confirmed that no residents in the facility are authorized to self-administer medications and that nurses are expected to supervise medication intake. The resident's Medication Administration Record indicated that the medications were recorded as administered, despite the lack of supervision. In another case, a Registered Nurse (RN) left a resident with a medication cup containing seven pills and a cup of water mixed with a laxative, then left the room to retrieve additional medication, failing to supervise the resident's medication intake. The RN assumed the resident would take the medications due to their alertness and orientation. Additionally, the facility failed to maintain accurate records for controlled substances, as evidenced by missing signatures on the Controlled Substance Count Log and discrepancies in the medication count for a resident's Tramadol prescription. The facility's policy requires nurses to sign the controlled medication sheet immediately after removing medication, which was not adhered to in this instance.
Failure to Document Incontinence Care Per Shift
Penalty
Summary
The facility failed to document incontinence care every shift as per its policy, affecting two residents, R1 and R2, who were reviewed for incontinence care. R1, a female resident with hemiplegia, hemiparesis, and a stage I pressure ulcer, was admitted on 8/6/24 and assessed as dependent on staff for bowel and bladder incontinence. R2, admitted on 8/30/24 with a femur fracture and cognitive communication deficit, was also dependent on nursing staff for mobility and incontinence care. A review of the point of care (POC) tasks over a 30-day period revealed a lack of documentation indicating that R1 and R2 received incontinence care at least once per shift every day. On 9/18/24, a family member of R2 expressed concerns that R2 did not receive overnight incontinence care, resulting in R2 being soaked in urine by morning. Similarly, on 9/11/24, a family member of R1 reported that R1 was left soaking in a disposable brief and did not receive incontinence care for over an hour after requesting assistance. Documentation for 9/11/24 showed only one instance of incontinence care for R1, recorded at 1:27 pm. The Director of Nursing confirmed that CNAs are expected to document incontinence care or toileting at least once every shift, as per the facility's policy revised in 7/24, which mandates rounds every 2 hours to check for incontinence.
Failure to Prevent New Pressure Ulcer in At-Risk Resident
Penalty
Summary
The facility failed to prevent the development of a new pressure ulcer in a resident who was already at risk for such conditions. The resident, a female with hemiplegia and hemiparesis following a cerebral infarction, was admitted with a stage I pressure ulcer on the sacrum. Despite being dependent on staff for activities of daily living, including turning, repositioning, and incontinence care, the resident developed additional skin alterations. These alterations were initially documented as a gluteal cleft tear and a right ischium skin tear, which were later reclassified as a stage II pressure ulcer. The Director of Nursing acknowledged that the worsening of the wounds could have been due to a lack of turning or repositioning, a decline in nutrition, or an ineffective treatment plan, although no nutritional concerns were noted for the resident. The facility's care plan, initiated prior to the development of the new ulcer, aimed to prevent additional skin breakdown by following facility protocols. However, the documentation and actions taken by the staff, including the application of wound paste and collagen, were insufficient to prevent the progression of the resident's condition.
Failure to Replace Damaged Call Light Cord
Penalty
Summary
The facility failed to replace a damaged call light cord in a resident's room, which was identified as a deficiency. A resident, who was admitted with a femur fracture, cognitive communication deficit, and generalized weakness, was discharged from the facility before the issue was discovered. On a subsequent visit, a family member informed a surveyor about the damaged call light with exposed wires in the resident's former room. The surveyor observed the damaged call light, which had been ineffectively taped to cover the exposed wires. A staff member from Guest Services, upon entering the room and seeing the damaged cord, removed it and stated it would be replaced immediately. The facility's policy on hazards, revised in July, mandates the removal of hazardous items to ensure resident safety, which was not adhered to in this instance.
Failure to Provide Timely Toileting Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to its fall prevention policy and procedures, resulting in a resident, R2, sustaining a left foot fracture. R2, a female resident with a complex medical history including partial paralysis, a history of falls, and cognitive deficits, required assistance with activities of daily living, including toileting. Despite these needs, the facility did not provide timely toileting assistance, leading to R2 attempting to toilet herself, which resulted in a fall and subsequent injury. On the day of the incident, R2 activated her call light to request assistance with toileting. However, the assigned Certified Nursing Assistant (CNA), V16, was occupied with other residents and did not immediately respond to R2's request. Although V16 acknowledged R2's call light and informed her that assistance would be provided shortly, R2 attempted to transfer herself to the bathroom, resulting in a fall. The facility's Director of Nursing later confirmed that R2 should not have attempted to transfer herself due to her physical limitations. The facility's failure to complete fall risk assessments quarterly and annually, as required by their policy, further contributed to the deficiency. R2's medical records only contained an admission fall risk assessment and a post-fall risk assessment, indicating a lack of ongoing evaluation of her fall risk. This oversight, combined with the delayed response to R2's toileting needs, highlights the facility's failure to provide adequate supervision and timely assistance to prevent accidents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to ensure dialysis services were provided in a manner consistent with professional standards for a resident who required peritoneal dialysis. The resident, who had a history of end-stage renal disease and was dependent on peritoneal dialysis, was found with a missing cap on her dialysis catheter. This incident was noted by the nursing staff prior to setting up the patient's dialysis, and the resident was subsequently transferred to an acute care hospital for a catheter exchange. The missing cap increased the risk of infection, and the resident was later diagnosed with sepsis and peritonitis, necessitating the removal of the peritoneal dialysis catheter and a switch to hemodialysis, which significantly altered her treatment regimen and required additional coordination for outpatient dialysis sessions. The resident's family reported that the facility's staff did not handle the dialysis in a sanitary manner, and the resident was left connected to the dialysis machine for an extended period, which contributed to the complications. The facility's policy required the peritoneal catheter to be capped when not in use and for the catheter site to be inspected daily for signs of infection, but these procedures were not followed, leading to the resident's severe infection and subsequent hospitalization.
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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