Briar Place Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Indian Head Park, Illinois.
- Location
- 6800 West Joliet, Indian Head Park, Illinois 60525
- CMS Provider Number
- 145784
- Inspections on file
- 50
- Latest survey
- April 25, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Briar Place Nursing during CMS and state inspections, most recent first.
The facility failed to provide and document required written notice, including reasons, before changing a resident’s room and assigning new roommates for four cognitively intact residents. One resident with multiple chronic conditions, including DM2, major depressive disorder, delusional disorder, and COPD, had a room change without any documented notification to her POA, and she reported not signing any room-change document. Three other residents with conditions such as schizophrenia, COPD, asthma, hypertension, low back pain, and obesity had new roommates without documented family notification or written notice. During interviews, residents reported not recalling written notifications, and facility leadership and psychiatric rehab staff acknowledged that neither written notices nor progress note documentation of these room and roommate changes were completed, contrary to facility policy and stated resident rights.
A resident with multiple psychiatric and medical diagnoses, who was cognitively intact and had a physician order for independent community pass, had their pass privileges restricted for 30 days after an unsubstantiated allegation of drug possession. Staff found no contraband during a search, and there were no clinical signs of intoxication. The restriction was imposed despite the facility's policy requiring evidence of intoxication or overnight absence, neither of which were present.
A resident's bank card was left unsecured in her room while she was hospitalized, leading to its theft and unauthorized use by a CNA, resulting in financial exploitation and distress for the resident. Facility staff failed to follow proper procedures for handling resident mail and protecting personal property, in violation of abuse prevention policies.
A resident's mail was left under their pillow by activity staff while the resident was hospitalized, contrary to facility policy requiring secure storage when residents are unavailable. The mail was subsequently stolen and used, indicating a breach of privacy and confidentiality procedures.
A resident's care plan incorrectly listed them as Full Code despite both the POLST and physician order sheet indicating DNR status. The DON confirmed the care plan was inaccurate and did not match the resident's documented advance directives, contrary to facility policy.
A resident's care plan was not reviewed quarterly and failed to reflect the current DNR status, despite both the POLST and physician orders indicating Do Not Resuscitate. The care plan inaccurately listed the resident as 'Full Code' and had a goal target date set beyond the required 90-day interval. The DON confirmed the care plan was not accurate and overdue for review, in violation of facility policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report does not specify further details about the individuals involved or the exact nature of the hazards.
The facility did not maintain proper functioning of hallway air conditioning units, resulting in hallway temperatures exceeding recommended levels while resident rooms remained adequately cooled. Staff and a resident reported significant discomfort in the hallways, and portable AC units failed to resolve the issue. The deficiency affected all residents, including those with significant medical conditions, and was not consistent with facility policies requiring a comfortable and homelike environment.
The facility did not maintain hallway temperatures below 81°F, resulting in excessively hot hallways while resident rooms remained adequately cooled. A resident with multiple medical conditions reported discomfort in the hallways, and staff confirmed the issue, noting that portable AC units were not effective. The malfunctioning hallway air conditioning system persisted for about two weeks despite repair attempts, leading to an environment that was not comfortable for residents, staff, or visitors.
The facility did not document that the bed hold policy was provided to two residents upon transfer to a hospital, despite facility policy requiring this notification. Both residents, with complex medical and psychiatric histories, were transferred for emergency services, and staff interviews confirmed that the required documentation and notification were not completed.
A resident experienced severe pain following neck surgery due to the facility's failure to provide timely pain management. Despite reporting pain levels of 9/10, the resident only received acetaminophen as the facility did not have a prescription for Oxycodone. The resident endured three days of severe pain before receiving the correct medication, and another lapse occurred when the prescription ran out. The facility's Pain Management Program was not followed, with inaccurate pain assessments and delayed physician contact.
A resident with epilepsy was left unsupervised during a shower, resulting in a seizure and a fractured humerus. Despite her care plan requiring supervision due to her seizure history, she was allowed to shower alone. The incident went unnoticed for about 20 minutes until a nurse responded to her cries for help. The facility's policy on supervision was not followed, leading to this preventable accident.
The facility failed to follow its hand hygiene policy, affecting all 216 residents. Surveyors observed staff, including CNAs and a Wound Care Nurse, not performing hand hygiene after resident care or between tasks. Staff cited the absence of hand sanitizers in hallways and rooms due to residents' cognitive conditions, and some did not carry personal hand sanitizers as required. The Infection Preventionist confirmed the policy but noted the lack of sanitizers in common areas.
The facility failed to maintain a clean and sanitary environment for 143 residents on the first and second floors. Surveyors noted strong odors and unsanitary conditions, including a urine puddle and sticky floors. Interviews revealed confusion among staff regarding cleaning responsibilities, with housekeepers and nursing staff not effectively coordinating to address body fluid spills, leading to inadequate sanitation.
The facility failed to date two opened insulin vials, as required by its pharmacy policy, potentially affecting two residents. An LPN confirmed that insulin must be dated upon opening to track its 28-day expiration. The DON acknowledged the need for dating medications to ensure effectiveness. The facility's policy mandates dating opened vials to maintain medication purity and potency.
A resident with schizoaffective disorder was physically abused by a CNA, resulting in a head injury and contusions. An LPN witnessed the CNA hitting the resident and intervened. The resident was hospitalized, and the CNA was terminated. The facility's records showed no history of aggression from the resident, and the CNA's account of the incident was inconsistent.
A resident was discharged from an LTC facility without proper written notice after being allowed to leave on a community pass. The resident, with a history of cerebral infarction, diabetes, asthma, hypertension, and substance abuse, was accused of drinking alcohol and was asked to go for a psychiatric evaluation, which he refused. Despite a low alcohol level and no documented aggressive behavior, the facility considered him discharged AMA. Upon return, he was denied access and medications, leading to health issues while waiting for a new primary care physician.
A resident with schizoaffective disorder and a history of medication refusal was allowed unsupervised community access, resulting in her being found by police in a state of psychosis days later. Despite known delusional behaviors and medication refusals, the facility reinstated her independent pass without addressing these issues. The facility's policy considered her discharged AMA when she did not return, but her absence was not noticed until the next day.
The facility improperly discharged two residents against medical advice (AMA) while they were on approved community passes. The facility's policy automatically classified residents as AMA if they did not return from a pass, regardless of their intentions or medical advice. This affected residents with independent community access, potentially impacting 37 residents. Specific cases involved two residents who were considered discharged AMA despite not expressing a desire to leave AMA, highlighting a conflict between the facility's policies and proper discharge procedures.
A resident with a history of drug abuse repeatedly brought contraband into the facility and tested positive for drugs, despite the facility's zero-tolerance policy. The facility's interventions were insufficient, and the resident ultimately died from combined drug toxicity involving fentanyl. The facility failed to adequately supervise and prevent the resident from obtaining and using illicit substances.
The facility failed to follow its wound policy and showering protocol, resulting in seven residents not receiving weekly showers and skin assessments as required. Observations and interviews revealed that staff did not monitor residents during showers or perform necessary skin assessments, and documentation was either incomplete or missing for several residents over two months.
The facility failed to ensure timely face-to-face physician visits for six residents, as required by their policy. Issues with documentation and technical problems with the facility's computer system contributed to the deficiency. The affected residents had serious medical conditions, and the lack of timely visits was not properly documented in their medical records.
The facility failed to assess a resident for the safety of self-administering hemorrhoid ointment, as required by their policy. The resident was allowed to self-administer without proper monitoring or documentation, and there was no physician's order or care plan in place.
The facility failed to determine how a resident sustained bruising to the left side, with staff either unaware of or not reporting the injuries. The resident, unable to communicate effectively, had multiple bruises that were not properly documented or investigated, contrary to the facility's abuse prevention policy.
A facility failed to follow its abuse policy and report injuries of unknown origin for a resident with aphasia. The resident was observed with a yellow discoloration on the left cheek and a purple discoloration on the left thigh, but these injuries were not documented or reported to the State Surveying Agency. Staff members were either unaware of the injuries or assumed they were old and did not report them. The facility's investigation was incomplete, and the required documentation and reporting were not followed.
The facility failed to follow its abuse policy and investigate injuries of unknown origin for a resident with aphasia. The resident had a yellow discoloration on the left cheek and a purple discoloration on the left thigh, which staff did not report or document properly. The attending physician confirmed the thigh bruise was new, contradicting the administrator's claim that it was old. The facility's abuse prevention policy was not followed, leading to a deficiency.
The facility failed to follow its presumed death policy, initiating CPR on two residents exhibiting clear signs of irreversible death, including rigor mortis and asystole. EMS confirmed the deaths upon arrival, noting the staff's inability to provide the last known time the residents were seen alive.
The facility failed to ensure medication was taken when administered and accounted for, affecting a resident with dementia. Medications were found on the resident's bedside table and on the floor, indicating a lapse in proper medication administration and monitoring by the nursing staff.
Failure to Provide and Document Required Written Notice of Room and Roommate Changes
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to receive written notice, including the reason, before a room or roommate change, and to document notification to residents and their representatives. Four cognitively intact residents were affected. One resident with Type 2 diabetes mellitus, major depressive disorder, delusional disorder, and COPD had a documented room change, but there was no progress note between 03/20/2026 and 03/28/2026 showing that her POA was notified of the room change. This resident stated she had a room change a couple of weeks prior, identified her POA, and reported she did not know if the facility had spoken to the POA and that she did not sign any document regarding the room change. Another resident with schizophrenia, low back pain, and myalgia, who was responsible for her own decisions and had been in her current room since 10/07/2022, had no documentation in her progress notes during the same review period that her family was notified of a new roommate. A third resident with COPD, asthma, and hypertension, and a fourth resident with hypertension, low back pain, and obesity, both cognitively intact and responsible for themselves, had been in their current rooms since 12/31/2023 and 08/22/2023 respectively. For both of these residents, there was no documentation in the progress notes that family members were notified of new roommates during the review period. During interviews, one resident stated she observed staff showing the new roommate the room but said she was not presented with written notification of the roommate change, while another resident could not recall being introduced to the new roommate or receiving written notification. Staff interviews confirmed that required notifications and documentation did not occur. The Assistant Administrator stated she relies on Social Services to contact the POA regarding room changes and acknowledged that residents were verbally notified of a new roommate but that these notifications were not documented. The Psychiatric Rehabilitation Services Director and Assistant Director both stated they did not notify the POA of the room change and did not notify or document notification to the families of the other affected residents regarding roommate changes. The Assistant Administrator further confirmed that no written notice was provided to residents or the POA regarding the room and roommate changes prior to the move, despite facility policy and the facility’s Statement of Resident Rights requiring residents to receive written notice, including the reason for the change, before their room or roommate is changed.
Failure to Follow Physician Orders and Community Pass Policy
Penalty
Summary
A resident with a history of alcohol abuse, anxiety disorder, major depressive disorder, PTSD, suicidal ideations, anemia, insomnia, psychoactive substance abuse, and schizophrenia was found to be cognitively intact and had an active physician order for independent community pass. Despite this, the facility restricted the resident's community pass for 30 days after another resident alleged that the individual had brought a marijuana pen into the facility. Staff searched the resident's room and found no contraband, and there was no documentation of symptoms indicating the resident was under the influence of any illicit substance. The resident refused to provide a urine sample and became agitated, but there was no evidence of intoxication or possession of drugs. The facility's community pass policy states that pass privileges may be revoked if a resident returns intoxicated or under the influence, and drug testing may be conducted if there is suspicion after an overnight pass. In this case, the resident had not been out overnight, and there was no credible evidence to support the restriction of the community pass. The decision to restrict the pass was based solely on an unsubstantiated allegation and the resident's refusal to provide a urine sample, without any documented clinical indications or policy-based justification.
Failure to Protect Resident from Financial Exploitation
Penalty
Summary
A cognitively intact female resident reported that her bank card was stolen and used for unauthorized purchases while she was admitted to the hospital. The resident stated she did not give her card to anyone and discovered unrecognized charges upon her return. The facility received her bank card through the mail and, instead of securing it, the mail was left under her pillow by the Activity Director, who was unaware that the resident was not present in the facility. This lapse in mail handling allowed the card to be accessed by unauthorized individuals. Subsequent investigation revealed that a Certified Nursing Assistant (CNA) was identified by police as the individual using the resident's card at a neighborhood store. The CNA denied taking the card but was suspended after the facility and police confirmed multiple unauthorized transactions. The Social Service Director and Human Resource Director both acknowledged that staff are not permitted to make purchases for residents, and the CNA's actions were outside the scope of their duties. The facility's abuse prevention policy states that residents have the right to be free from exploitation and misappropriation of property, which was not upheld in this instance.
Failure to Secure Resident Mail Results in Privacy Breach
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident's mail when staff left a card under the resident's pillow while the resident was admitted to the hospital. The resident later reported that the card was stolen and used at a neighborhood store. According to interviews, the activity staff are responsible for delivering mail directly to residents, and if a resident is not present, the mail should be given to social services for secure storage. In this instance, the activity staff did not follow the established procedure and left the mail in the resident's room, unaware that the resident was out of the facility. The facility's mail delivery policy requires mail to be handed directly to residents or securely stored if the resident is unavailable.
Failure to Accurately Reflect Advance Directives in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately reflected in the care plan, as required by policy. Record review showed that the resident's POLST form and physician order sheet both indicated Do Not Resuscitate (DNR) status, while the care plan incorrectly listed the resident as Full Code. During an interview, the Director of Nursing confirmed that the care plan was not accurate and acknowledged the discrepancy, stating that the resident was technically a DNR and that the care plan needed revision. The facility's policy requires that advance directives be addressed in the resident's plan of care, but this was not followed in this instance.
Failure to Review and Revise Care Plan to Reflect Accurate Advance Directive Status
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the development, review, and revision of comprehensive care plans. Specifically, the care plan for one resident was not reviewed quarterly as required, and the goal target date was set for approximately six months after the last revision, exceeding the 90-day interval mandated by facility policy. Additionally, the care plan was not updated to reflect the resident's current advance directive status, despite documentation in both the POLST and Physician Order Sheet indicating Do Not Resuscitate (DNR) status. Instead, the care plan continued to state 'Full Code,' which was inconsistent with the resident's documented wishes and physician orders. During interviews, the Director of Nursing confirmed that care plans should be reviewed quarterly or upon significant change, and acknowledged that the resident's care plan was inaccurate and overdue for review. The facility's policy requires care conferences for review and revision of care plans every 90 days or as needed, with the interdisciplinary team responsible for implementation. The failure to update and accurately reflect the resident's code status in the care plan represents a lapse in adherence to established procedures and documentation requirements.
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 by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals affected is included.
Failure to Maintain Safe Hallway Temperatures Due to Air Conditioning Malfunction
Penalty
Summary
The facility failed to ensure that essential equipment, specifically the chillers and air conditioning units serving the hallways, were maintained in proper working order. On the date of the survey, temperature checks revealed that while resident rooms were within an acceptable range (76.2°F to 80.0°F), the hallways on all floors were significantly above the recommended maximum, with temperatures ranging from 84.1°F to 89.1°F. Staff interviews confirmed that the air conditioning system for the hallways had been malfunctioning for approximately two weeks, with ongoing issues causing the units to lock out and overheat. Despite multiple visits from HVAC technicians and the use of portable air conditioning units, the hallways remained uncomfortably hot and did not reach adequate cooling levels. Residents and staff reported discomfort due to the high temperatures in the hallways. One resident, who is cognitively intact and has medical diagnoses including type 2 diabetes mellitus, morbid obesity, and hemiplegia, stated that the temperature outside their room was uncomfortable and that staff advised residents to stay in their rooms or other cooler areas. Staff confirmed that the hallways were too hot, particularly on the third floor, and that they were providing residents with cold water, ice, and popsicles to help manage the heat. Facility records and interviews indicated that the air conditioning system for the resident rooms was repaired, but the separate system for the hallways continued to malfunction. Maintenance staff described the building as old and noted that repairs to one unit often led to issues with another. The facility's preventative maintenance policy requires regular environmental tours and safety audits to ensure a pleasant temperature, and the resident rights policy emphasizes a safe, comfortable, and homelike environment. However, the persistent failure to maintain adequate hallway temperatures affected all 202 residents in the facility.
Failure to Maintain Safe and Comfortable Hallway Temperatures
Penalty
Summary
The facility failed to maintain hallway temperatures below 81 degrees Fahrenheit, resulting in excessively high temperatures in multiple hallways across all floors, with recorded temperatures ranging from 84.1 to 89.1 degrees Fahrenheit. While resident rooms were maintained at acceptable temperatures, the hallways remained uncomfortably hot due to a malfunction in the hallway air conditioning system. The issue was identified when staff and residents reported discomfort, and temperature checks confirmed the elevated temperatures in the hallways. A resident with diagnoses including type 2 diabetes mellitus, morbid obesity, and hemiplegia reported that while their room was comfortable, the hallways were uncomfortably hot, and staff advised residents to remain in their rooms or other cooler areas. Staff interviews corroborated that the hallways were too hot, particularly on the third floor, and that efforts were being made to keep residents hydrated and comfortable with water, ice, and popsicles. The maintenance director confirmed that the hallway air conditioning system had been malfunctioning for approximately two weeks, with repeated but unsuccessful repair attempts, and that portable air conditioning units brought in as a temporary measure were not sufficient to cool the hallways. Facility records and policies indicate that the expectation is for a safe, comfortable, and homelike environment, with regular environmental audits to ensure pleasant temperatures. Despite these policies, the failure to maintain adequate hallway temperatures created an environment that was not comfortable for residents, staff, or the public, potentially affecting all 202 residents in the facility.
Failure to Document Provision of Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to document that the bed hold policy was provided to a resident or their representative upon transfer to a local hospital. Specifically, for one resident with diagnoses including bipolar disorder and suicidal ideation, there was no documentation in the electronic medical record indicating that the bed hold notification was given when the resident was transferred to the hospital via 911 with an involuntary petition. Interviews with facility staff, including the administrator, DON, and Assistant DON, confirmed that the expectation is for the bed hold policy to be provided and documented at the time of transfer, but in this case, documentation was missing. Additionally, another resident with a history of bipolar disorder, diabetes type 2, alcohol dependence, and hypertension reported not receiving a copy of the bed hold policy or being informed about the 10-day bed hold policy when transferred to the hospital for emergency services. The facility's policy and resident handbook both state that residents are to be informed of the bed hold policy before and upon transfer to a hospital. Staff interviews acknowledged that the process was not followed consistently, and documentation was not completed as required.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R182, following his return from the hospital after neck surgery. R182, who had undergone a C3-C7 decompressive laminectomy and posterior cervical fusion, was in severe pain rated at 9/10 upon his return to the facility. Despite his condition, the facility did not have a prescription for his pain medication, Oxycodone, and instead administered acetaminophen, which was ineffective. The resident reported that the night shift nurse informed him that they could not obtain the stronger pain medication until the following morning, leading to a delay in receiving adequate pain relief. The resident continued to experience severe pain and anxiety over the weekend, as the facility staff failed to contact a physician to obtain the necessary prescription. The resident's pain was not managed effectively until the early hours of the third day after his return, when the Oxycodone prescription was finally filled. Additionally, there was a lapse in pain management when the resident's Oxycodone prescription ran out, resulting in another three days of severe pain before a new prescription was provided. The facility's Pain Management Program, which requires accurate documentation and timely physician notification for unrelieved pain, was not followed. The resident's pain assessments were inaccurately recorded as 0/10 during the periods of reported severe pain, and there was a lack of communication and action from the nursing staff to address the resident's pain in a timely manner. The Director of Nursing and Medical Director acknowledged that the facility's protocol was not adhered to, and the resident should not have endured such prolonged pain without appropriate intervention.
Resident Unsupervised During Shower Leads to Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R85, during a shower, resulting in a serious accident. R85, a female resident with multiple diagnoses including epilepsy, experienced a seizure while showering independently. During the seizure, her arm became trapped between the shower rail and the wall, leading to a fracture of her right humerus. The incident was unwitnessed, and R85 was left unattended for approximately 20 minutes before a registered nurse, V11, responded to her cries for help. The resident's care plan indicated that she required supervision during showers due to her epilepsy and history of seizures, but this was not adhered to at the time of the incident. The facility's policy on resident supervision, which mandates adherence to individualized care plans, was not followed in this case. Despite R85's documented need for supervision due to her epilepsy and recent seizure history, she was allowed to shower alone. The incident report and interviews with staff confirmed that the shower room was locked, and staff were responsible for monitoring who accessed it. However, R85 was left unsupervised, contrary to her care plan's requirements. The medical director also confirmed that residents with uncontrolled seizures should be supervised for safety, underscoring the facility's failure to provide necessary supervision to prevent the accident.
Failure to Follow Hand Hygiene Policy
Penalty
Summary
The facility failed to adhere to its hand hygiene policy, which has the potential to affect all 216 residents. Surveyors observed multiple instances where staff did not perform hand hygiene after providing care or moving between resident rooms. On the third floor, a Certified Nurse Assistant (CNA) was seen exiting a resident's room without sanitizing hands, citing the absence of hand sanitizers in hallways and rooms due to residents' cognitive conditions. The CNA admitted to not having a personal hand sanitizer at the time. Similarly, on the second floor, another CNA was observed entering and exiting two residents' rooms without performing hand hygiene, and also did not have a personal hand sanitizer. Additionally, a Wound Care Nurse on the third floor was observed performing wound care without changing gloves or sanitizing hands between tasks, such as cleaning a wound and handling bowel movements. The Infection Preventionist confirmed that staff are instructed to carry personal hand sanitizers and perform hand hygiene at specific times, such as before and after resident care. However, the facility does not provide hand sanitizers in common areas or resident rooms due to the risk of residents ingesting them. The facility's hand hygiene policy emphasizes the necessity of hand hygiene after removing gloves and before and after resident care.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for 143 residents residing on the first and second floor units. During the survey, a strong odor was detected upon entering the first floor common area, and further observations on the second floor revealed an empty medicine cup, an empty milk carton on the elevator floor, and a wet, yellow puddle with a strong urine odor in the common area. The floors on the second floor were noted to be sticky, indicating inadequate cleaning practices. Interviews with staff revealed inconsistencies in cleaning responsibilities. A housekeeper assigned to the second floor mentioned that they were short-staffed on the day of the survey and expressed uncertainty about cleaning body fluids, stating it was the responsibility of certified nurse assistants. The Housekeeping Director confirmed that cleaning urine and feces was a shared responsibility between nursing staff and housekeepers, with nursing staff expected to remove the bulk of the soil before housekeepers sanitize the area. However, the facility's procedure for cleaning blood and body fluid spills was not effectively communicated or followed, contributing to the unsanitary conditions observed by the surveyors.
Failure to Date Opened Insulin Vials
Penalty
Summary
The facility failed to adhere to its pharmacy policy regarding the expiration dating of medications in vials, specifically insulin, which was observed during a survey. Two opened vials of insulin, one belonging to a resident receiving insulin Glargine and another to a resident receiving insulin Lispro, were found undated in the second-floor storage room refrigerator. This oversight was identified during an observation with an agency LPN, who acknowledged that insulin must be dated upon opening to track its expiration, as it remains effective for only 28 days after opening. The Director of Nursing confirmed that medications should be dated according to their recommended usage time to ensure effectiveness. The facility's Pharmacy Policies and Procedures Manual mandates that opened vials be dated to maintain medication purity and potency, with a specific requirement for a 'date opened' sticker and a new expiration date. The failure to date these insulin vials potentially affected the two residents, as their medication administration records indicated regular administration of these insulins for diabetes management.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a vulnerable resident from physical abuse by a staff member, resulting in multiple injuries. The resident, who has schizoaffective disorder and mild cognitive dysfunction, was involved in an altercation with a CNA during the evening shift. The incident was witnessed by an LPN who observed the CNA hitting the resident while in bed. The resident sustained a closed head injury and contusions on the right thumb and forearm and was subsequently transferred to the hospital for evaluation. The resident, upon interview, could not recall the details of the incident but mentioned being hit in the head and experiencing ongoing pain. The LPN who witnessed the event intervened by removing the CNA from the room and assessing the resident's injuries before calling 911. The CNA claimed that the resident became agitated and threw objects, leading to a physical altercation. However, the CNA's account was inconsistent, and they were unable to provide a clear explanation of their actions during the incident. The facility's records and staff statements indicated that the resident did not have a history of aggressive behavior. The CNA, who was terminated following the incident, denied receiving training on abuse prevention, although their personnel file showed completion of relevant training. The facility's abuse policy emphasizes the prevention of abuse and the creation of a secure environment for residents.
Failure to Provide Proper Discharge Notice and Medication
Penalty
Summary
The facility failed to provide a detailed written notice 30 days prior to the discharge of a resident, identified as R1, who was not allowed to return to the facility after being on a community pass. R1, a male resident with a history of cerebral infarction, diabetes, asthma, hypertension, and substance abuse, was admitted to the facility on December 22, 2023. On July 27, 2024, R1 was given a white pass for an overnight visit, signed by the necessary staff and his sister, allowing him to leave the facility. However, shortly after leaving, R1 was informed by the manager on duty and the administrator that he would be considered discharged against medical advice (AMA) and could not return. The facility's actions were based on an incident on July 26, 2024, when R1 was accused of drinking alcohol outside the facility. Despite a breathalyzer test showing a low alcohol level of 0.02, the staff requested R1 to go to the hospital for a psychiatric evaluation, which he refused. The facility then filled out an involuntary petition for inpatient hospitalization due to alleged belligerent and verbally aggressive behaviors, although these behaviors were not documented in R1's progress notes. The psychiatrist evaluated R1 and found no psychiatric difficulties requiring management, and the facility did not provide R1 with any written notice of discharge. Upon returning from his overnight pass on July 29, 2024, R1 was denied access to the facility and his room, and his belongings were brought to him via the side door. R1 was also refused medications, which included those for asthma, high blood pressure, and diabetes. It took R1 approximately four weeks to secure a new primary care physician, during which he experienced health issues due to a lack of medication. The facility's discharge report listed R1 as discharged AMA, despite the active discharge care plan indicating no plans for discharge. The facility's policy on AMA discharges was not followed, as R1 was not given a written notice or the opportunity to discuss his discharge with the attending physician.
Failure to Restrict Community Access for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to restrict independent community access for a resident with a known history of refusing psychiatric and medically necessary medication, as well as exhibiting active delusions and hallucinations. This resident, who has diagnoses including schizoaffective disorder-bipolar type and generalized anxiety disorder, was allowed to leave the facility unsupervised despite these concerns. The resident did not return to the facility and was found three days later by local law enforcement, lying on the ground in the community, and was taken to the emergency room with active psychosis. The resident had a history of delusional behaviors and medication refusals, which were documented in progress notes. Despite these issues, the Social Service Director assessed the resident to be appropriate for independent community access and reinstated the green pass. The resident continued to experience hallucinations and delusional behaviors, and refused medications multiple times, including those for schizophrenia, hypertension, and diabetes, prior to being granted access to leave the facility. No interventions were documented to address these refusals. The facility's policy stated that residents who do not return from a community pass are considered discharged against medical advice (AMA). However, the facility failed to notice the resident's absence until the following day, and a missing person's report was filed. The resident was eventually located by police and admitted to a hospital's behavioral health unit. The facility's administrator acknowledged the oversight and the lack of communication regarding the resident's medication refusals.
Improper Discharge Procedures for Residents on Community Passes
Penalty
Summary
The facility failed to ensure that their policies related to independent community access were not in conflict with proper discharge procedures. This resulted in two residents being considered discharged against medical advice (AMA) while on approved day and overnight passes. The facility's policy automatically classified residents as AMA if they did not return from a pass, regardless of their intentions or medical advice, as a means to release liability. This policy affected residents who had been granted independent community access, potentially impacting 37 residents. The report highlights specific cases involving two residents, R1 and R3. R1 was considered discharged AMA after leaving on a supervised community pass, despite not expressing a desire to leave AMA. The facility had informed R1 that he would be considered AMA if he left, as he was supposed to go to the hospital. Similarly, R3 was considered discharged AMA after not returning by the facility's curfew time, even though she did not express a desire to leave AMA. The facility's policy dictated that residents who did not return on time from a pass were automatically considered AMA. The facility's policies, including the Community Pass Policy and the Outside Pass Policy, allowed for residents to be discharged AMA if they did not adhere to the standards set by the facility. The Discharge Against Medical Advice policy outlined procedures for staff to follow when a resident wished to leave AMA, including assessing the resident's competence and attempting to persuade them to stay. However, the automatic classification of residents as AMA when they did not return from a pass conflicted with these procedures, leading to the deficiency identified in the report.
Failure to Supervise Resident with Substance Abuse History
Penalty
Summary
The facility failed to effectively supervise a resident with a history of drug abuse, leading to multiple incidents of noncompliance and ultimately the resident's death due to combined drug toxicity. The resident, a [AGE] year old female, had a history of psychoactive substance abuse, including heroin and cocaine, and was noncompliant with her psychotropic medications. Despite being informed of the facility's zero-tolerance policy for alcohol and illicit drugs, the resident repeatedly brought contraband into the facility, including vapes and THC pens, and tested positive for THC and opioids during her stay. The facility's interventions, such as smoking restrictions and counseling, were insufficient to prevent the resident from obtaining and using illicit substances. The resident's noncompliance and continued drug use were documented in multiple social service notes, which detailed incidents of the resident being found with contraband and testing positive for drugs. Despite these documented incidents, the facility did not implement new specific interventions beyond the existing care plan. The resident's substance abuse issues were discussed with her mother and the Substance Abuse Coordinator, who recommended inpatient or residential treatment, but the resident refused. The facility's failure to adequately supervise and prevent the resident from obtaining contraband ultimately led to her death. On the day of the incident, the resident was found unresponsive in her bed and was pronounced dead after unsuccessful CPR attempts. The cause of death was confirmed as combined drug toxicity involving fentanyl and acetyl despropionyl fentanyl, substances for which there were no physician orders. The facility's policies and procedures for preventing contraband and supervising residents with substance abuse disorders were not effectively implemented, resulting in the resident's ability to obtain and use illicit drugs within the facility.
Removal Plan
- A system to ensure contraband does not enter the facility and is removed from the resident will be achieved through staff education.
- Education will be provided by the Administrator, to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager.
- This education will review the facility's contraband policy and will include that residents may be asked to voluntarily empty and show the contents of their pockets at any time if reasonable suspicion exists.
- Reasonable suspicion includes frequent leaves of absence with or without facility knowledge, odors, new needle marks, and changes in resident behavior such as unexplained drowsiness, slurred speech, lack of coordination, mood changes, particularly after interaction with visitors or absences from the facility.
- Residents may be asked to voluntarily reach into concealed clothing areas and remove any items and place these items on a horizontal surface.
- Staff are instructed to have the resident hand items to the staff members or place the items on the horizontal surface.
- It is the objective of this policy that the above steps occur in plain sight of multiple witnesses (if possible) to afford appropriate protection to both the resident and the involved staff member(s).
- These steps are necessary to assure that the resident is treated with respect and dignity throughout the procedure.
- It is appropriate to ask the resident to empty his/her pockets and display their contents or roll down his/her socks.
- It is not appropriate to bring a resident into a room for a more specific search unless there is strong suspicion that the individual is attempting to bring in objects/items that may cause serious harm.
- If a more specific search is required the staff are to follow guidelines as set forth by the administrator or the administrative representative.
- This may even involve requesting professional assistance from the local police.
- Only outerwear articles of clothing including, but not limited to, jackets, coats, scarves, hats, gloves, and vests, shall be removed in plain site of staff.
- This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past.
- If this appears to be the case and staff assess and suspect that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed.
- The facility emphasizes treatment with dignity at all times.
- The facility reserves the right to remove locks from drawers, cabinets, closets, lockers, or any other object if there is reason to suspect that the resident possesses any item or items that may potentially harm other persons.
- The facility may choose, at its discretion, to involve drug-sniffing dogs (e.g., from a K9 company) if residents are suspected to be trafficking drugs inside the facility.
- A root cause analysis will be completed upon identification of contraband.
- Upon completion of the training, staff will sign a record of continuing education sheet to confirm their knowledge and understanding of the topic presented.
- The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession.
- A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder.
- If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education.
- In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses.
- The facility has identified five staff members who are on a leave of absence/vacation.
- These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession.
- The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work.
- The staff member will sign a record of education to validate their understanding of the information presented in the binder.
- If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education.
- In the Administrator's absence, the Director of Nursing will answer questions regarding the education.
- Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually.
- A system to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through staff education.
- Education will be provided by the Administrator to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager.
- This education will review the facility's policy on Alcohol/Substance Use/Abuse.
- The education will review that Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order.
- Facility policy prohibits the use of illicit drugs.
- As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building.
- Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services.
- While this policy addresses illicit drugs and alcohol, the same standards and expectations are in place for persons with a prescription narcotic addiction.
- These individuals are also responsible for engaging in appropriate treatment to reduce/eliminate dependency on opioids.
- Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse.
- The nurse is responsible for assessing the person's physical condition and present behavior.
- The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications.
- Documentation will be placed in the chart emphasizing signs/symptoms of intoxication/inebriation (such as smell of alcohol, behavior changes, balance/gait problems, appearance of the eyes, and change in speech pattern).
- Documentation should include the resident's own admission of alcohol/drug use.
- The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected.
- Persons who are evaluated as medically unstable will be transferred for appropriate medical care.
- Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record.
- Outside treatment sources will be utilized as appropriate.
- Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare interventions, as appropriate to their personal situation.
- The facility has the right to implement money management interventions pursuant to federal law if substance abuse continues.
- Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge.
- Education will include instruction on how to identify which residents have a substance abuse disorder and how to locate resident-specific interventions to prevent them from obtaining contraband while in the facility.
- This information will be kept in binders at the nurse's stations.
- The binders will include a list of residents with substance abuse disorders and information on resident-centered interventions to prevent them from obtaining contraband while in the facility.
- These binders will be updated by social services weekly and with resident changes in condition.
- Upon completion of this education, staff will sign a record of continuing education to confirm their knowledge and understanding of the information presented.
- This education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually.
- The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility.
- A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder.
- If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education.
- In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses.
- The facility has identified five staff members who are on a leave of absence/vacation.
- These staff members will be contacted by the Administrator to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility.
- The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work.
- The staff member will sign a record of education to validate their understanding of the information presented in the binder.
- If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education.
- In the Administrator's absence, the Director of Nursing will answer questions regarding the education.
- The procedure for developing resident-centered care plans to provide guidance to staff to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through education provided by the Administrator to the Social Services department staff on the importance of identifying residents with substance abuse disorders and assessing their risk of introducing drugs/contraband and obtaining drugs/contraband while in the facility.
- This risk assessment is documented in the resident chart in the Social Service Initial Interview for SMI/Substance Abuse Disorder (SS) assessment.
- This risk assessment must be used by the social services staff to develop a resident-centered care plan to address the potential risks of the resident introducing drugs/contraband into the facility and obtaining contraband/drugs while in the facility.
- Care plan interventions will be based on the resident's personal risk factors and coping mechanisms and may include but are not limited to efforts outlined in the facility policy for Alcohol/Substance Use/Abuse such as outside treatment services, acute/active treatment, sobriety counseling, or aftercare interventions.
- The effectiveness of the care plan must be reviewed quarterly and with changes in condition and updated as indicated.
- A binder will be placed at each nurse's station with a list of residents with substance abuse disorders as well as information on the resident-centered interventions for preventing them from obtaining contraband while in the facility.
- These binders will be updated by the social services department weekly and with resident changes in condition.
- Upon completion of this education, social services staff will sign a record of continuing education to confirm their understanding and knowledge of the topics presented.
- This education will be presented to new hire social services staff upon hire and will be reviewed with all social services staff annually.
- Agency staff is not utilized in the social services department.
- There are currently no social services staff on leave of absence or vacation.
- There have been no updates to facility policies.
- A system to supervise residents from obtaining contraband and from having or obtaining illicit drugs in the facility will be achieved through staff education.
- The Administrator will educate staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager on the facility standard for providing adequate supervision for residents with substance abuse disorders to prevent them from obtaining contraband/ drugs.
- This education includes a review of the facility policy for safety and supervision which focuses on ensuring a facility-oriented approach to safety to address risks for groups of residents including residents with substance abuse disorders/history.
- Education will discuss the importance of identifying safety risks and environmental hazards on an ongoing basis.
- Staff will be educated that resident supervision is a core component of resident safety and that the type and frequency of supervision are determined by the individual resident's needs.
- Staff must intervene immediately whenever an unfavorable event between residents, staff, or visitors is noticed.
- Staff must decrease safety hazards as much as possible and provide redirection when necessary.
Failure to Follow Showering and Skin Assessment Protocols
Penalty
Summary
The facility failed to follow its wound policy and showering protocol, resulting in seven residents not receiving weekly showers and skin assessments as required. Observations and interviews revealed that staff did not monitor residents during showers or perform necessary skin assessments. For instance, a resident was observed taking a shower without staff supervision or a subsequent skin assessment. Additionally, the Director of Nursing (DON) and other staff members confirmed that shower sheets and skin assessments were either incomplete or missing for several residents over two months. This included instances where residents received showers, but no documentation of skin assessments was found, and cases where residents did not receive showers at all. The facility's wound policy mandates weekly skin assessments by a licensed nurse, with findings documented and signed off. However, the review of shower sheets for August and September 2023 showed significant gaps in compliance. Several residents had no recorded showers or skin assessments for these months, and in cases where showers were documented, the required skin assessments were not completed. Staff interviews corroborated these findings, indicating a systemic failure to adhere to the facility's protocols for resident care and documentation.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to follow their physician visit policy and ensure that the attending physician conducted face-to-face visits within the first 30 days of admission and at least once every 60 days thereafter. This deficiency affected six residents, as documented through interviews and record reviews. The Nurse Practitioner (NP) and the Attending Physician both acknowledged issues with timely documentation and uploading of visit notes into the residents' electronic medical records. The NP admitted to being unable to find recent notes for several residents, and the Attending Physician cited technical issues with the facility's computer system as a reason for delayed documentation. Resident 7, who had multiple serious diagnoses including deep tissue injury, sepsis, and dementia, did not have documented face-to-face visits within 30 days of admission or re-admission. Similarly, Resident 15, with conditions such as anxiety disorder and dementia, lacked documentation of face-to-face visits within the required timeframes. The Administrator later presented documentation via email, but these documents lacked identifying information and were not found in the residents' medical records during the survey. Other residents, including Resident 16 with a history of stroke and diabetes, Resident 18 with a right femur fracture and dementia, Resident 19 with a right below-knee amputation and heart failure, and Resident 21 with diabetes and a history of falling, also had gaps in their documented face-to-face visits. The facility's physician visit policy mandates that each resident must be seen by a physician at least once every 30 days for the first 90 days after admission and then at least every 60 days thereafter. The failure to adhere to this policy was evident in the missing documentation and delayed uploading of visit notes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to follow its self-administration of medications policy by not assessing a resident (R17) to determine if it was safe for them to self-administer medications. A nurse (V26) allowed R17 to self-administer hemorrhoid ointment without monitoring or ensuring the medication was administered as prescribed. The Director of Nursing (V2) stated that no resident at the facility could self-administer medications without an assessment and clearance from a physician, which R17 did not have. Additionally, another nurse (V10) confirmed that a physician's order is required for self-administration, but there was no documentation or care plan for R17 regarding self-administration of medications. R17's medical record lacked any assessment by the interdisciplinary team to determine the safety of self-administration of the hemorrhoid ointment. The facility's policy, dated 09/2020, requires that residents be assessed for cognitive, physical, and visual ability to self-administer medications safely, and an order must be obtained from the attending physician. The policy also mandates documentation of the resident's understanding and response to the medication, which was not done for R17.
Failure to Determine Cause of Resident's Bruising
Penalty
Summary
The facility failed to determine how a resident sustained bruising to the left side, affecting one resident reviewed for injury of unknown origin. On multiple occasions, the resident was observed with yellow discoloration to the left cheek and purple discoloration extending from below the left hip to above the knee. The resident, who is unable to communicate effectively due to aphasia, could not provide details on how the injuries occurred. Staff members, including CNAs and a nurse, were either unaware of the bruising or assumed it was old and did not report it. The facility's administrator stated that the thigh bruise was due to a fall and had been investigated, but there was no response regarding the facial bruising. The medical record did not document the left facial bruising, and the attending physician confirmed that the purple discoloration indicated a new bruise, contradicting the administrator's statement that it was old. The facility's investigation into care-related concerns for the resident was incomplete and did not address all observed injuries. Staff interviews were undated and inconsistent, with some staff denying recent falls and others noting a slip in the shower weeks prior. The resident's medical record noted a fall on 2/9/24, resulting in bruising to the left buttocks and thigh, but there was no documentation of the left cheek discoloration. The facility's abuse prevention policy requires documentation and investigation of injuries of unknown source, but this protocol was not followed, leading to a failure in protecting the resident from potential abuse or neglect.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and report an injury of unknown origin to the regulatory agency, affecting one resident reviewed for abuse reporting. The resident, who is unable to communicate effectively due to aphasia, was observed with a yellow discoloration on the left cheek and a purple discoloration extending from below the left hip to above the knee. Despite these observations, the facility did not document or report these injuries to the State Surveying Agency. Staff members, including CNAs and a nurse, were either unaware of the injuries or assumed they were old and did not report them. The facility's administrator claimed that the thigh bruise was due to a fall and had been investigated, but there was no response regarding the facial bruise. The resident's medical record indicated a fall on a previous date, but there was no documentation of the facial bruising. The attending physician confirmed that the purple discoloration indicated a new bruise, contradicting the staff's assumption that it was old. The facility's abuse prevention policy requires documentation and reporting of injuries of unknown origin, but this was not followed. The facility's investigation into the resident's care concerns was incomplete, with staff interviews not addressing the facial bruising and other injuries. The facility failed to provide documentation that the injuries were reported to the State Surveying Agency, as required by their policy.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and investigate an injury of unknown origin for a resident (R21). The resident was observed with a yellow discoloration on the left cheek and a purple discoloration extending from below the left hip to above the knee. The resident, who is unable to communicate effectively due to aphasia, could not explain how these injuries occurred. Staff members, including CNAs and a nurse, were unaware of the injuries or assumed they were old and did not report them. The facility's administrator claimed that the thigh bruise was due to a fall and had been investigated, but there was no documentation regarding the facial bruise. The attending physician confirmed that the purple discoloration indicated a new bruise, contradicting the administrator's statement that it was old. The facility's abuse prevention policy requires documentation and investigation of injuries of unknown origin, but this was not followed in R21's case. R21's medical records showed a history of a fall on 2/9/24, resulting in bruising to the left buttocks and thigh, but there was no documentation of the facial bruise. The facility's investigation into care-related concerns for R21 was incomplete, with staff interviews not addressing the facial bruising or scratches on R21's arms. Skin alteration reviews also failed to document the left cheek and thigh discolorations. The facility's abuse prevention policy mandates that injuries of unknown origin be documented and investigated, but this was not done for R21's injuries, leading to a deficiency in following the abuse policy and ensuring resident safety.
Failure to Follow Presumed Death Policy
Penalty
Summary
The facility failed to follow its presumed death policy and initiated CPR on two residents exhibiting obvious signs of irreversible death. Resident 17 was found unresponsive with rigor mortis in the jaw, lividity in the back and legs, and no vital signs. Despite these clear indicators of death, a code blue was called, and CPR was initiated. EMS arrived and confirmed the presence of rigor mortis and asystole, determining that the resident had been deceased for several hours. The staff could not confirm the last time the resident was seen alive, and the EMS left without taking the resident. Resident 28 was found unresponsive in bed with full rigor mortis throughout the body and asystole. The resident had a history of post-traumatic stress disorder, psychoactive substance abuse, anxiety disorder, major depressive disorder, attention-deficit hyperactivity disorder, and suicidal ideation. Despite the presence of rigor mortis, CPR was initiated, and EMS was called. Upon arrival, EMS confirmed the resident's death and noted that the facility staff could not provide the last known time the resident was seen alive. The facility's presumed death policy states that resuscitation should not be performed if a resident is presumed and confirmed dead by two licensed nurses, based on specific criteria such as fixed and dilated pupils, no spontaneous respiration, mottled discoloration of the body, no spontaneous movement, and absence of vital signs. In both cases, the facility staff failed to adhere to this policy, leading to unnecessary CPR attempts on residents who were already deceased.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medication was taken when administered and accounted for, affecting one resident (R15) who was reviewed for medication. On 3/20/24, a white oval tablet was found on R15's bedside table, which the resident was unaware of. The tablet was identified as Topiramate, a medication given to R15 to prevent seizures. The nurse (V44) was unaware of when the medication was placed on the bedside table. Additionally, on 3/26/24, two pills were found on the floor in front of the nurses' station, identified as atorvastatin and taltz. The Director of Nursing (V2) confirmed that nurses are expected to stay with residents to ensure they take their medication and to check for any dropped medications to prevent other residents from taking them. The medical director (V54) emphasized that medications should not be left at a resident's bedside, especially if the resident has dementia, and that it is standard practice for nurses to remain with residents during medication administration. R15's medical record notes a diagnosis of dementia, and the physician order sheet dated 5/8/23 includes an order for Topiramate 25mg tablets, to be given three times a day for a total of 75mg. The medication administration record for March 2024 shows that Topiramate is scheduled to be administered at 6:00 AM and 9:00 PM daily. The facility's medication administration policy, dated 1/1/2020, states that medications should be administered only to the individual for whom they are prescribed, within one hour of the prescribed times, and with positive verification of the resident's identity. The policy also requires that medications be administered according to the physician's written orders, verifying the right medication, dose, route, and time.
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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