Chateau Nrsg & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Willowbrook, Illinois.
- Location
- 7050 Madison Street, Willowbrook, Illinois 60521
- CMS Provider Number
- 145614
- Inspections on file
- 36
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Chateau Nrsg & Rehab Center during CMS and state inspections, most recent first.
A resident experienced a fall and subsequently complained of significant left hip pain, with pain scores escalating from 7/10 to 10/10 and documented difficulty with bed mobility. An NP ordered a STAT hip X-ray after the resident refused range of motion due to pain, but the RN initially entered it as a routine order and later changed it to STAT. Despite the facility’s policy that STAT imaging be completed within four hours and that nursing follow up with the radiology provider and notify the MD/NP if delays occurred, there was no documentation that the MD was notified of the resident’s worsening pain or that the incomplete X-ray was escalated that day. The X-ray was not performed until the next day, when another RN noticed it had not been done and contacted the X-ray company, and imaging then revealed an acute intertrochanteric femur fracture.
A resident experienced a fall, was found on the floor with a left elbow skin tear, and later reported significant left hip pain with inability to tolerate ROM. An NP ordered a STAT hip X-ray and indicated that STAT imaging should occur within four hours, with nursing responsible for contacting radiology. The assigned RN initially entered the order as routine, later changed it to STAT, and called the X-ray company, but the physician orders did not reflect STAT status. The X-ray was not performed until the following day, at which time imaging revealed an acute comminuted left femoral intertrochanteric fracture.
A resident with severe cognitive impairment and multiple medical conditions fell off the bed during incontinence care, resulting in a femur fracture. The CNA involved turned the resident away from her, causing the fall. The facility lacked a specific policy on bed mobility, leading to inconsistent practices among staff. Other staff indicated the resident often required two-person assistance due to her weight and inability to assist in turning.
A resident with impaired cognition and a history of falls fell out of bed and sustained a forehead laceration requiring stitches after a CNA removed fall interventions to provide care. The CNA left the resident unattended to retrieve a mechanical lift sling, during which the resident fell. Staff interviews highlighted the need for fall mats and bolsters to be in place at all times, but the resident's care plan did not mention fall mats.
A resident with severe cognitive impairment was verbally abused by a CNA during a lunchtime incident, where the CNA used explicit language and threatened the resident. Despite being reported to the ADON and DON, the incident was not classified as abuse, violating the facility's abuse prevention policy.
A facility failed to report a verbal abuse incident involving a resident with severe cognitive impairment. A CNA used explicit language towards the resident during a dining room altercation. Despite staff witnessing and discussing the incident, it was not reported to the state agency as required. The DON sent the CNA home but did not classify the incident as abuse, leading to a deficiency in reporting.
A resident's personal gift check was improperly handled by the facility, as it was deposited into the resident's account for care costs without her consent. The resident, who is alert and oriented, was expecting a $500 gift check from the Policemen's Annuity and Benefit Fund of Chicago, which was not delivered to her. The facility's admission contract did not authorize handling of personal checks, yet the check was deposited into the transferring account. The facility issued a replacement check after the resident's inquiries.
The facility failed to maintain sanitary conditions in its kitchen, affecting food storage, preparation, and serving. Observations revealed improper use of the 3-compartment sink, incorrect sanitizer testing, and staff with long artificial nails. The walk-in cooler and freezer had unsanitary conditions, with food products improperly stored and freezer burnt. Staff did not adhere to hygiene practices, and facility policies on food storage and sanitation were not followed.
The facility failed to assist residents with personal hygiene, as observed in four residents with cognitive and physical impairments. Residents were found with unclean fingernails, food debris on clothing, and unshaven facial hair, despite care plans indicating the need for maximum assistance. The Director of Nursing acknowledged the expectation for staff to assist with ADLs, but these were not met, resulting in deficiencies.
The facility failed to follow the approved recipe for chef salad, resulting in residents receiving inadequate meals with only lettuce and minimal additional ingredients. Several residents expressed dissatisfaction, noting they were left hungry, and some filed grievances. The Dietary Director and Cook acknowledged the issue, but discrepancies in meal preparation persisted.
The facility failed to follow standard infection control practices during incontinence care and medication administration. CNAs and a nurse did not change gloves or perform hand hygiene between tasks, such as cleaning perineal areas, handling catheter bags, and administering medications via a g-tube. The facility's policy requires hand hygiene before and after glove use and between tasks to prevent infection.
Two residents with urinary catheters did not receive proper care, as CNAs failed to clean the catheter tubes and lifted urinary bags above the bladder, causing urine backflow. This was contrary to facility policy, which aims to prevent infections.
A nurse failed to check the placement of a gastrostomy tube (g-tube) before administering Hydrocodone-Acetaminophen to a resident, contrary to the care plan and medication administration record. The nurse admitted to forgetting this step, and the ADON confirmed the necessity of verifying g-tube placement by aspiration or auscultation to ensure proper medication delivery.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, was not properly assessed or managed for pain during care. Despite moaning and showing signs of pain, CNAs continued applying hand splints without informing a nurse. A nurse later administered Morphine Sulfate, documenting a pain level of 10. The facility's policy emphasized pain assessment and management, which was not followed in this instance.
The facility failed to inform residents of their rights both orally and in writing. During a Resident Council meeting, residents expressed unawareness of their rights, and an Ombudsman found the display frame for rights empty. The Activity Director confirmed rights were not discussed in meetings, and the Administrator's claim of rights being posted was contradicted by their absence in common areas. Meeting minutes from the past year showed no discussion of resident rights.
Two residents experienced delays in receiving incontinence care, despite being cognitively intact and having care plans requiring frequent checks. One resident was left in soiled briefs for an extended period, while another was left wet for at least two hours. Staff failed to adhere to the facility's policy of checking residents every two hours, and there were ongoing issues with delayed response to call lights.
Failure to Timely Assess Post-Fall Pain and Complete STAT Hip X-Ray
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess a resident for post-fall complications, including failure to identify worsening acute pain and to obtain timely diagnostic testing after a fall. The resident was found on the floor in front of his wheelchair in an upright sitting position at 5:30 AM, with a skin tear to the left elbow. A progress note documented cleansing and dressing of the elbow wound and notification of the resident’s wife and the NP. The ADON later stated that the resident had gotten up from his wheelchair, ambulated with a rolling walker to bed without assistance, then got up from bed, tripped over his leg rest, and fell to the floor. The NP reported that when she assessed the resident, he complained of left hip pain and refused range of motion due to pain, leading her to order a STAT hip X-ray. The record shows that the resident’s pain was documented as 7/10 on a post-fall monitoring form at 8:50 AM, and PRN Tylenol 650 mg was given. A medication administration note at 9:35 AM documented that the Tylenol was ineffective, that the resident complained of left hip pain, requested to be put back to bed, had an ice pack applied to the left hip, and refused therapy due to pain. The NP stated that a STAT X-ray should be completed within four hours and that if the X-ray company did not arrive within that time, nursing staff should call the company and notify her so the situation could be reassessed. The DON and NP both indicated that if a STAT X-ray was not completed within the expected timeframe, the nurse should follow up with the X-ray company and the provider. However, there was no documentation on the date of the fall that the MD was notified of the resident’s increased pain or that the X-ray had not been completed. The RN assigned to the resident on the day of the fall stated that she initially entered the X-ray as a regular order and later changed it to STAT after being instructed by the NP. She reported calling the X-ray company and being told they would come as soon as they could, and that if they did not come within four hours, the nurse was to call the X-ray company and notify the doctor. Documentation showed that the resident’s pain escalated to 10/10 by mid-afternoon and again at 9:09 PM, with increased difficulty in bed mobility related to left hip pain, and additional PRN Tylenol was administered. The X-ray was not completed until the following day, when another RN noticed it had not been done and contacted the X-ray company. The radiology report then showed an acute comminuted left femoral intertrochanteric fracture. Facility policies on physician orders, pain, and falls required execution of orders, appropriate testing to clarify pain, notification of the physician and family of significant pain changes, and follow-up on falls with injury until delayed complications such as fractures were ruled out, but the documentation and interviews showed these processes were not fully carried out on the day of the fall. The resident’s wife reported receiving an early morning call about the fall and arriving later that morning to find the resident in his wheelchair with an undressed elbow wound, an ice pack on his leg, and a bruise on his forehead, and stated that he was in a lot of pain. She described that a PT or PTA came to the room and asked if the resident was going to therapy, and that they informed therapy staff about the fall and the resident’s pain. She stated that the resident remained in significant pain, required a mechanical lift for transfer, and that the X-ray staff did not arrive until the next day, after which he was sent to the hospital when the fracture was identified. The facility’s own policies emphasized resident safety, timely execution of physician orders, and follow-up on falls to rule out delayed complications, but the record lacked evidence of timely diagnostics, escalation, or provider notification in response to the resident’s worsening pain and the uncompleted STAT X-ray order on the day of the fall.
Delay in STAT Hip X-Ray After Resident Fall With Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely STAT hip X-ray for a resident following a fall. According to progress notes, the resident was found on the floor in front of his wheelchair in an upright sitting position with a skin tear to the left elbow in the early morning, and the NP and the resident’s wife were notified. Later that day, the NP documented that the resident reported left hip pain and was unable to participate in range of motion, and ordered a STAT hip X-ray. The NP stated that a STAT X-ray should be completed within four hours and that nursing staff are responsible for contacting the X-ray company. The DON and ADON confirmed that the X-ray was not performed until the following morning, and the ADON recalled the resident’s daughter questioning why it took until the next morning for the X-ray to be done. The RN assigned to the resident that day reported that the resident complained of pain rated 7/10 and that she initially entered the X-ray as a regular order, then changed it to STAT after being instructed by the NP and called the X-ray company to communicate the STAT status. Progress notes from the next morning show the nurse contacting the X-ray company for an estimated time of arrival, and the radiology report indicates that the hip X-ray results, showing an acute comminuted left femoral intertrochanteric fracture, were not reported until the next day. The physician orders show two one-time hip X-ray orders entered on the day of the fall, neither marked as STAT, despite the facility policy requiring the nurse who takes the order to execute it, including contacting radiology services as required.
Failure to Prevent Resident Fall During Bed Mobility
Penalty
Summary
The facility failed to prevent a resident from falling off the bed during care, resulting in the resident sustaining a femur fracture. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including lack of coordination, morbid obesity, and muscle wasting. The resident required moderate assistance for bed mobility, and the incident occurred when a CNA attempted to change the resident's incontinence brief. The CNA turned the resident away from her, causing the resident's legs to fall off the bed, leading to the fall. The CNA involved in the incident stated that the resident was positioned closer to the right side of the bed rather than being centered. The CNA attempted to reposition the resident by turning her away, which resulted in the resident falling off the bed. The CNA acknowledged that the air mattress should have had bolsters to prevent such falls. Other staff members, including RNs and CNAs, indicated that the resident should have been pulled closer to the staff before being turned away to ensure safety. They also noted that the resident's weight and deconditioned muscles contributed to the risk of falling if not properly positioned. The facility lacked a specific policy regarding bed mobility, which contributed to inconsistent practices among staff. Several staff members reported that the resident often required two-person assistance for bed mobility due to her weight and inability to assist in turning. Despite this, the CNA involved in the incident attempted to provide care alone, which was contrary to the practices followed by other staff members. The absence of a clear policy and the failure to adhere to safe positioning practices led to the resident's fall and subsequent injury.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident at high risk for falls, resulting in the resident falling out of bed and sustaining a laceration to her forehead that required stitches. The resident, who has impaired cognition and a history of falls, was found by a CNA with her upper body out of the bed and her head on the floor after the CNA had removed the fall mat and bed bolsters to provide incontinence care. The CNA had left the resident unattended to retrieve a mechanical lift sling, during which time the resident fell. Interviews with staff revealed that the resident was known to be very active and at high risk for falls, requiring fall mats and bolsters to be in place at all times when in bed. The facility's policy on falls and fall risk monitoring emphasizes the need for staff to identify and implement interventions to prevent falls and minimize complications. However, the resident's care plan did not mention the use of fall mats, and the CNA did not have all necessary supplies ready before starting care, leading to the incident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, violating its abuse prevention policy. The incident involved a resident with severe cognitive impairment who was verbally abused by a Certified Nursing Assistant (CNA) identified as V4. During a lunchtime incident, V4 removed the resident's tray, leading to a confrontation where the resident hit the tray, causing items to fall. V4 then verbally threatened the resident using explicit language, which was witnessed by other staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN). Despite the incident being reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the severity of the verbal abuse was not recognized or reported as such to the abuse coordinator. The DON sent V4 home for disruptive behavior but did not classify the incident as abuse. The facility's abuse prevention policy clearly states that residents have the right to be free from verbal abuse, which includes the use of disparaging and derogatory language. However, the failure to report and address the incident as abuse indicates a lapse in following the established policy.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting a verbal abuse allegation involving a resident with severe cognitive impairment. The incident occurred when a CNA verbally abused the resident during a dining room altercation, using explicit language. Despite multiple staff members witnessing and discussing the incident, the verbal abuse was not reported to the state agency as required. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed, but the incident was not escalated appropriately, leading to a failure in reporting. The resident involved, who has vascular dementia, was unable to clearly recall the incident. Staff members, including RNs and LPNs, provided accounts of the event, indicating that the CNA used inappropriate language towards the resident. The DON sent the CNA home for being disruptive but did not classify the incident as abuse, resulting in a lack of formal reporting. The facility's abuse prevention policy allows employees to report directly to the state agency, but this was not utilized in this case, leading to a deficiency in the facility's handling of the situation.
Improper Handling of Resident's Personal Gift Check
Penalty
Summary
The facility failed to honor a resident's right to manage her financial affairs by improperly handling a personal gift check. The resident, who is alert and oriented, was expecting a $500 gift check from the Policemen's Annuity and Benefit Fund of Chicago, which she usually receives every Christmas. However, the check was not delivered to her, and after multiple follow-ups, it was discovered that the check had been deposited into the facility's account without her consent. The former Business Office Manager admitted that the check was deposited into the resident's trust fund account, which is used for care costs, rather than being given to the resident. The resident's daughter, who is also her Power of Attorney for medical decisions, confirmed that the facility was only entitled to deposit the resident's social security and pension checks for room and board, not personal checks like the one from the PABF. The facility eventually issued a replacement check to the resident after her inquiries. The facility's admission contract with the resident allowed for business mail to be directed to the business office, but personal mail was to be delivered to the resident. The contract did not authorize the facility to handle personal checks or other financial resources beyond the social security and pension checks. Despite this, the facility deposited the PABF check into the resident's transferring account, which was intended for care costs, without the resident's permission.
Unsanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, affecting the storage, preparation, and serving of food. During an inspection, it was observed that the 3-compartment sink used for washing, rinsing, and sanitizing dishes was improperly used, with dirty dishes found in the sanitizing sink. A dietary aide, V6, was unsure of how to properly test the sanitizer's strength and used incorrect test strips initially. Both V6 and another dietary aide, V7, were noted to have long artificial nails, which is against the facility's policy for handling food. Additionally, the high-temperature dish machine area was found to have grayish patches and food debris, and washed bowls were not stored properly, with some still containing food debris. The walk-in cooler and freezer were also found to be in unsanitary conditions. The cooler had open bowls of pudding, and the freezer had extensive ice buildup and debris, with food products improperly stored on the floor and covered in ice. Some of the frozen meat products were freezer burnt, and the administrator, V1, acknowledged the issue but stated that repairs were scheduled. A resident's power of attorney reported that residents were served inedible, freezer-burnt food, which was confirmed by the dietary director, V4, who admitted to using the compromised food items before discarding them. Further observations revealed that staff members, including V4, V5, and V10, did not adhere to proper hygiene practices, such as using hair restraints effectively. V4 was seen using a contaminated spatula during meal preparation, and both V5 and V10 had long dreadlocks that were not fully covered. The facility's policies on food storage, dishwashing, and personnel sanitation were not followed, contributing to the unsanitary conditions and potential food safety risks for the residents.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for residents who were identified as needing help with activities of daily living (ADLs). This deficiency was observed in four residents, each with varying degrees of cognitive impairment and physical limitations. The residents were found with unclean fingernails, food debris on clothing, and unshaven facial hair, indicating a lack of proper grooming and hygiene care by the staff. One resident with severe cognitive impairment and dementia was observed with black substances under her fingernails and food debris on her clothing. Despite being totally dependent on staff for ADLs, the resident's care plan was not adequately followed, resulting in poor personal hygiene. Another resident with chronic kidney disease and diabetes also exhibited long, jagged fingernails with black substances and food debris on her clothing, despite requiring maximum assistance for personal hygiene and dressing. Additional observations included a resident with cerebrovascular disease and dementia who had long facial hair and unclean fingernails, and another resident with Parkinson's disease and hemiplegia who expressed a desire for assistance with shaving and nail care. The facility's Director of Nursing acknowledged the expectation for staff to assist residents with ADLs to maintain dignity, comfort, and hygiene, yet these expectations were not met, leading to the identified deficiencies.
Failure to Follow Approved Recipe for Chef Salad
Penalty
Summary
The facility failed to ensure that the dietary staff followed the approved recipe for chef salad, affecting eight residents. The Spring/Summer 2024 menu specified a chef salad with turkey, ham, cheese, and other ingredients, but residents reported receiving only lettuce with minimal or no additional components like meat or cheese. This discrepancy was noted by several residents who expressed dissatisfaction with the meal, stating that it left them hungry and was not what they expected based on the menu. Interviews with residents revealed that they received a bowl of lettuce with little to no meat, cheese, or other expected ingredients. Some residents mentioned receiving a grilled cheese sandwich as an addition, but this was not part of the chef salad meal. The residents expressed their displeasure, with some filing grievances about the inadequate meal portions. A resident's family member even took pictures of the meal and considered escalating the issue to the media. The facility's staff, including the Administrator and Dietary Director, acknowledged the residents' complaints. The Dietary Director noted that the chef salad should have included turkey as the protein, and the Cook claimed to have followed the recipe, which included turkey, ham, cheese, and other ingredients. However, a CNA observed that the salad had less chicken and lacked other components like egg or cheese, leading to resident dissatisfaction.
Infection Control Deficiencies in Hand Hygiene and Gloving Practices
Penalty
Summary
The facility failed to adhere to standard infection control practices during the provision of incontinence care and medication administration, as observed in multiple instances involving certified nursing assistants (CNAs) and a nurse. In one instance, two CNAs provided peri-care to a resident without changing gloves or performing hand hygiene between tasks, such as cleaning the perineum, handling an indwelling urinary catheter bag, and straightening bed linens. Another CNA assisted a resident with toileting and incontinence care, but did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before assisting the resident back to the wheelchair. Similarly, two CNAs provided incontinence care to another resident, failing to change gloves or perform hand hygiene between cleaning the perineum, changing bed linens, and handling a catheter bag. Additionally, a nurse administered medications via a gastrostomy tube to a resident without changing gloves or performing hand hygiene between tasks such as touching the bedside floor mattress, drawing the privacy curtain, and checking the placement of the g-tube. The facility's Director of Nursing confirmed that staff should perform hand hygiene before donning gloves, after contact with residents, and between different tasks to prevent infection. The facility's handwashing policy emphasizes the use of alcohol-based hand rubs when hands are not visibly soiled, particularly before and after putting on or removing personal protective equipment, and after contact with potentially contaminated objects.
Improper Catheter Care and Handling
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. One resident, who had multiple medical diagnoses including Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, was observed with an indwelling urinary catheter. During peri-care, the Certified Nursing Assistants (CNAs) did not clean the catheter tube, and the urinary bag was lifted above the bladder, causing urine to flow back towards the bladder. This improper handling of the catheter and urinary bag was observed during the care process. Another resident, also diagnosed with BPH and a urinary tract infection, was observed with a suprapubic urinary catheter. During incontinence care, the CNAs failed to clean the catheter and lifted the urinary bag above the bladder, resulting in urine flowing back into the bladder. The Director of Nursing confirmed that the facility's policy requires the catheter tube to be cleaned near the insertion site and the urinary bag to be kept below the bladder to prevent backflow and potential infections.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to check the placement of a gastrostomy tube (g-tube) before administering medication to a resident. On August 7, 2024, a nurse administered Hydrocodone-Acetaminophen to a resident via g-tube without verifying the tube's placement, as required by the resident's care plan and medication administration record. The nurse flushed the g-tube with water before and after administering the medication but admitted to forgetting to check the tube's placement. The Assistant Director of Nursing confirmed that staff should check g-tube placement by aspiration of residual or auscultation with a stethoscope to ensure proper medication administration.
Failure to Manage Resident's Pain During Care
Penalty
Summary
The facility failed to recognize, evaluate, and manage a resident's pain during care. The resident, who had multiple diagnoses including senile degeneration of the brain and dementia, was severely impaired with cognition and required total assistance with activities of daily living. On a specific day, the resident was heard moaning from outside her room, and upon entering, it was observed that she was in bed, confused, and unable to verbalize pain. Two CNAs had just finished providing morning care and were unaware if the resident had received any pain medication prior to care. Despite the resident's increased moaning and apparent pain when her hand was touched to apply hand splints, the CNA continued with the application without informing the nurse. A registered nurse later assessed the resident and administered Morphine Sulfate for pain, documenting a pain level of 10. The resident's care plan indicated she was at risk for pain and included interventions such as monitoring non-verbal signs of pain and administering medications. However, there was no evidence that any pain medication was administered before the Morphine Sulfate. The Director of Nursing and a Nurse Practitioner both stated that the CNA should have stopped the application of the hand splints and informed the nurse to assess the resident for pain and administer appropriate medication before continuing with care. The facility's pain management policy emphasized the importance of assessing and managing pain, especially when residents are unable to describe it verbally.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide residents with both oral and written information regarding their resident rights. This deficiency was identified during interviews and record reviews, affecting 7 out of 10 residents reviewed in a sample of 25. The residents, who were mostly cognitively intact, reported during a Resident Council meeting that they were unaware of their rights and did not know where to find a list of them. An Ombudsman pointed out that the rights were supposed to be displayed on a wall in the dining room, but the frame was empty. Additionally, the Activity Director confirmed that resident rights had not been discussed during council meetings. The facility's Administrator stated that resident rights are included in the admission packet and posted in common areas such as dining rooms and hallways. However, during an inspection, the rights were not visible in the first-floor dining room or near the elevators. A review of the Resident Council meeting minutes from September 2023 to July 2024 showed no documentation that resident rights were discussed, indicating a lack of communication and reinforcement of these rights to the residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. The first resident, a cognitively intact individual with a history of pressure ulcers and incontinence, reported having a bowel movement at 10:00 a.m. but did not receive assistance until much later, despite using the call bell and expressing distress. The resident was left in soiled briefs for an extended period, which was confirmed by the presence of dry feces on the inner thighs when care was finally provided. The staff, including a Registered Nurse and Certified Nursing Assistants, failed to respond promptly to the resident's needs, and there was a lack of communication and coordination among the staff to address the resident's incontinence care in a timely manner. The second resident, also cognitively intact and with limited functional abilities, experienced a delay in receiving incontinence care. The resident was left wet for at least two hours before staff changed her briefs, despite being on diuretic medications and having a care plan that required frequent checks and care to prevent skin breakdown. The facility's policy required residents to be checked every two hours, but this was not adhered to, as evidenced by the resident's report and the staff's acknowledgment of the care schedule. Additionally, the facility had a history of grievances and resident council meeting notes indicating ongoing issues with delayed response to call lights and care needs, further highlighting the deficiency in providing timely incontinence care.
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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