Complete Care At The Boulevard
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5905 West Washington, Chicago, Illinois 60644
- CMS Provider Number
- 145885
- Inspections on file
- 49
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Complete Care At The Boulevard during CMS and state inspections, most recent first.
The facility failed to ensure sufficient qualified dietary staff to prepare meals, as multiple dietary aides without cook certification were observed and reported to be cooking and baking for residents. Staff described being assigned to bake desserts and cook breakfast and lunch despite only holding food handler certificates, and one aide reported feeling scared to use the large oven. The Dietary Manager acknowledged that only she and one aide were qualified cooks, yet the schedule listed several food handlers as cooks, and these staff were actively preparing food and operating the tray line for residents receiving meals.
Surveyors found that dietary staff failed to follow hand hygiene protocols while working in the dish room. A dietary aide repeatedly handled soiled dish racks, pushed them into the dishwasher, and then removed clean trays and domes, changing gloves but not washing hands between dirty and clean tasks, despite a handwashing station being available. Another dietary aide reported that dishwashing was often done with fewer staff than intended, and the dietary manager confirmed that facility procedures and policies required handwashing between handling dirty and clean items. This failure had the potential to affect over one hundred residents who received meals from the kitchen.
A resident with multiple comorbidities and intact cognition, who had a care plan addressing a history or risk of abuse, reported that a former dietary manager aggressively approached and verbally confronted them in the dining room after misinterpreting a remark made during a conversation with a CNA. The resident stated they reported the incident to the administrator, completed a written report and statement, and that the event was witnessed by others and captured on camera; a former dietary aide confirmed that the confrontation occurred in front of others and was reported to administration. The administrator acknowledged that the event was initially treated only as a customer service issue, without initiating an abuse investigation or timely reporting as required by the facility’s abuse policy, and the facility could not produce an abuse investigation report when requested by surveyors, only later deciding to treat the incident as reportable abuse after further questioning.
A resident with multiple comorbidities and high risk for skin breakdown developed a severe, unstageable sacral pressure ulcer after staff failed to consistently implement and update individualized care interventions, including regular turning and repositioning. Despite clear physician orders and facility policies, the care plan was not revised after the wound developed, and the resident was left in a chair for extended periods without repositioning, leading to wound deterioration, infection, and hospitalization.
A resident with moderate cognitive impairment and high fall risk was allowed to use a wheelchair with a broken brake for at least two days. Staff were either unaware of the issue or did not act promptly to repair or remove the unsafe equipment, and required notifications to social services were not made when the resident refused to relinquish the chair. Facility policy requiring immediate removal and repair of malfunctioning equipment was not followed.
A resident with severe cognitive impairment and significant care needs experienced a fall resulting in a contusion and bruising around the right eye. The facility staff failed to notify the physician or follow protocol, delaying the resident's transfer to the hospital for necessary evaluation. Multiple staff members were involved in the incident and were terminated for not adhering to the facility's policies.
The facility failed to maintain adequate nursing staff, resulting in delayed call light responses. Residents reported insufficient CNA coverage during 2nd and 3rd shifts, with staffing data confirming low weekend staffing. The staffing coordinator acknowledged the shortfall, and records showed fewer CNAs than required, placing 104 residents at risk of inadequate care.
The facility failed to follow its food safety and sanitation protocols, affecting 101 residents on an oral diet. The dishwasher did not reach required temperatures for proper sanitization, and expired chlorine test strips were used in the three-compartment sink. Additionally, staff did not fully cover their hair, and open food items were not properly labeled, increasing the risk of contamination and foodborne illnesses.
The facility failed to ensure that the designated Infection Preventionist (IP), an LPN, completed the required specialized training for infection prevention and control in nursing homes. The IP, responsible for managing various infection control activities, had not completed the necessary training modules and test to demonstrate competency until after the survey began. This deficiency potentially affects the 104 residents in the facility.
The facility failed to complete required PASRR screenings for several residents before admission, impacting their placement and care. Residents with serious mental health conditions were admitted without necessary evaluations, contrary to facility policy. This deficiency highlights a lapse in the admission process, affecting the residents' access to appropriate care.
The facility failed to administer medications timely and maintain accurate narcotic counts for four residents. Discrepancies in medication counts were observed, and medications were not administered as scheduled due to unavailability. Nurses failed to document administration accurately and did not notify physicians of missed doses, violating facility policy.
The facility failed to manage medications and enteral feedings properly, with expired medications found in medication carts and storage rooms, and some medications lacking proper pharmacy labels. Expired enteral feeding containers were also found with visible spoilage. These deficiencies could affect 68 residents, including those with gastrostomy tubes.
The facility failed to properly document and administer influenza and COVID-19 vaccinations for several residents. Some residents were not offered or documented for influenza vaccinations, and others did not receive necessary education. One resident's consent form lacked a witness signature, and another resident did not receive the vaccines despite consenting, due to insurance issues and lack of follow-up. The IP nurse admitted to inconsistent documentation, contrary to facility policy.
A facility failed to maintain resident dignity and confidentiality for three residents. A CNA fed a resident while standing, against recommended practices, risking aspiration and compromising dignity. Additionally, dietary information for two residents was visibly posted, violating confidentiality. The residents had specific medical and dietary needs, and the facility's actions compromised their rights.
A resident was observed self-administering Fluticasone Propionate without a physician order or assessment, as required by facility policy. An LPN allowed the self-administration because the resident did not trust staff to administer it correctly. The facility's policy mandates assessment and a physician order for self-administration, which was not followed.
The facility failed to display information about the [NAME] program, affecting 12 residents' ability to make informed decisions about community transition. The Social Service Director confirmed the absence of educational materials and posters, which were not provided until after a surveyor's visit.
A resident at the facility was found wearing a hospital wristband displaying personal information, which should have been removed upon admission to protect privacy. The wristband, visible to others, contained the resident's full name, date of birth, and medical record number, violating HIPAA regulations. Staff acknowledged the oversight and confirmed that such wristbands should not be worn in the facility.
A resident with a history of paraplegia and polyneuropathy did not receive consistent restorative therapy, including leg exercises and splint application, as required by their care plan. The resident reported that these interventions were not regularly provided, and documentation was missing for several days. The Restorative Aide confirmed that CNAs should provide therapy on weekends, but there was a lack of documentation. This failure placed the resident at risk of not maintaining their highest practical level of function.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. Two residents did not receive their scheduled medications due to an LPN's failure to check available resources and notify physicians of the missed doses. The facility's policy on medication administration and physician notification was not followed.
A resident reported not consistently receiving nighttime snacks, as required by the facility's policy. The Dietary Manager confirmed that snacks are distributed to CNAs for residents, but acknowledged reports of missed distributions. The DON was aware of the issue but did not provide staff training. The resident, who is cognitively intact, was not offered snacks on several occasions, despite the facility's policy.
A facility failed to accurately classify a resident's psychotropic medication on the consent form, potentially affecting the resident's understanding of the medication's side effects. The resident, with severe cognitive impairment and a history of mental health disorders, had their medication Remeron misclassified as an antipsychotic instead of an antidepressant on a previous form. This error led to consent being given under the wrong classification, which could result in misunderstanding the side effects associated with the medication.
A resident in an LTC facility experienced two incidents of verbal abuse by CNAs, both of which were substantiated by facility investigations. The resident, who requires maximum assistance and uses a wheelchair, reported being cursed at by one CNA and receiving derogatory remarks about her hygiene from another. Witnesses corroborated the resident's accounts, leading to the termination of both CNAs. The facility's policy prohibits such abuse, but these incidents demonstrated a failure to protect the resident.
A cognitively impaired resident was tied to their bed with pillowcases by an RN due to staffing shortages, leading to physical and mental anguish. The incident was witnessed by a CNA who reported it as abuse, although the facility's administrator initially disagreed. The facility's policy defines such actions as abuse, but the incident was not immediately reported to the Illinois Department of Public Health.
A resident in an LTC facility was improperly restrained by a nurse using a pillowcase, without a physician's order or consent, due to staffing shortages. The resident, who had multiple medical conditions and a history of falls, was tied to the bed to prevent falling, which was against the facility's restraint-free policy. The incident was reported by another staff member and identified as an immediate jeopardy situation.
A resident's inhaler was left unattended and not properly labeled, with no physician order for self-administration. Additionally, a treatment cart was found unlocked and unattended, contrary to facility policy. The DON confirmed these actions posed safety issues.
A staffing shortage in an LTC facility led to a resident being improperly restrained by a nurse using a pillowcase to prevent falls. The facility was short one CNA on a weekend shift, leaving only two CNAs to care for 41 residents on the second floor. The nurse, overwhelmed with duties, resorted to tying the resident's hands to the bed rail, acknowledging the action was wrong but felt necessary due to insufficient staffing.
A facility failed to immediately report an alleged abuse incident where a resident was tied to the bedside rails with a pillowcase by a nurse. The incident was reported internally, but not to the Illinois Department of Public Health (IDPH) as required by the facility's policy. The initial report to IDPH was made 32 days after the incident, violating the policy that mandates immediate reporting or within 24 hours if no serious injury occurred.
The facility failed to conduct timely PASRR Level I and II assessments for five residents with serious mental disorders, due to a transition period in the social services department and lack of communication with the screening agency. This oversight left residents without necessary specialized programs and treatment goals.
Two residents in the facility did not receive proper wound care, leading to significant health issues. One resident was hospitalized due to a surgical wound dehiscence, while another did not have daily wound dressings changed as ordered. Staff interviews revealed a lack of documentation and awareness of wound care needs, and facility policies were not adhered to.
Two residents experienced abuse in a facility, one physically and the other verbally. A resident with Alzheimer's was slapped by a CNA during care, confirmed by witnesses. Another resident with COPD was verbally abused by a CNA using profanity, recorded on social media. Both CNAs were terminated for their actions, which violated the facility's Abuse Prevention Program.
Unqualified Dietary Staff Used as Cooks and Bakers
Penalty
Summary
The facility failed to ensure there were sufficient qualified dietary staff available to cook meals for 127 residents who received meals from the kitchen. During interviews, multiple dietary aides reported that they were functioning as cooks or being required to perform cooking and baking tasks despite lacking cook certification. One former dietary aide stated that several individuals working as cooks did not have certification and that she was pressured to bake despite being a dietary aide and feeling scared to use the large, hot oven. During a kitchen tour, three dietary aides were observed performing meal preparation and tray line duties, including one aide who was cooking and plating breakfast while the others assembled and transported trays. The Dietary Manager reported that only she and one dietary aide were considered qualified cooks and that the remaining staff were food handlers, who she acknowledged were not supposed to prepare food because they had not taken the required classes. Despite this, the schedule listed several dietary aides as cooks, and staff interviews confirmed that food handlers were cooking breakfast and lunch and baking desserts. Documentation showed that most of these staff held only food handler certificates rather than cook certification, while the facility’s job description and safe food handling policy required appropriate procedures for preparing and cooking food in accordance with the FDA Food Code. The census showed 131 residents, with 127 receiving meals from the kitchen affected by these staffing and qualification issues.
Failure to Perform Hand Hygiene Between Handling Soiled and Clean Dishes in Dish Room
Penalty
Summary
Surveyors identified a deficiency in kitchen infection control practices when a dietary aide working in the dish room failed to perform required hand hygiene between handling soiled and clean dishes. One dietary aide was observed scraping and dumping trays, placing utensils, plates, and cups into sanitizer, and explained that with two people present, one would run dishes through the dishwasher while the second person would handle the clean dishes. A second dietary aide then entered the dish room and was observed repeatedly pushing racks of dirty dishes into the dishwasher and then removing clean trays and dishes without changing gloves or performing hand hygiene, despite a handwashing station being present in the dish room. The same dietary aide continued to alternate between handling dirty dish racks and removing clean domes, trays, and dishes from the dishwasher, changing gloves multiple times but never washing hands between tasks. Another dietary aide reported by telephone that dishwashing was supposed to be done by three staff, but they often only had two, and described scraping, loading the dishwasher, and pulling carts with an emphasis on changing gloves as much as possible. The dietary manager stated that the facility’s process required two people in the dish room, with one scraping and setting up dishes and the other pushing dishes through the dishwasher and pulling them out, and confirmed that hand hygiene should be performed after pushing dishes through, followed by glove changes before handling clean dishes to prevent cross contamination. Facility policies and training documents on cleaning, sanitizing, ware washing, and handwashing required staff to wash hands prior to donning gloves and between glove changes, including after touching waste or contaminated surfaces and after leaving the dish area. This failure had the potential to affect 127 residents who received meals from the kitchen, out of a census of 131 residents, with four residents NPO.
Failure to Immediately Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy by not immediately investigating and reporting an allegation of verbal abuse involving one cognitively intact resident. The resident, who had multiple medical diagnoses including Type 2 diabetes mellitus with complications, end stage renal disease, peripheral vascular disease, gangrene, acquired absence of foot, hypertension, dependence on renal dialysis, cataracts, obesity, and primary insomnia, had a BIMS score of 15 indicating intact cognition and had a care plan focus for history of abuse or factors increasing susceptibility to abuse. The care plan interventions included reviewing assessment information and emphasizing treatment of causal factors and mental health issues. Despite this, when the resident reported an incident in which a staff member allegedly verbally abused and threatened them, the facility did not treat it as an abuse allegation at the time. The resident reported that one morning in January, during breakfast in the first-floor dining room before going to dialysis, the former dietary manager approached them from behind, got in their face, and accused them of calling her a derogatory name after overhearing the resident’s conversation with a CNA about something seen on television. The resident stated they clarified they were not speaking to the dietary manager, reported the incident to the administrator, wrote a report, and provided a written statement. The resident also stated their family called the state and that the incident was captured on camera. A former dietary aide corroborated that everyone in the dining room witnessed the incident, that the dietary manager approached the resident and backed the resident up while accusing the resident of calling her a derogatory name, and that it was reported to administration and the resident’s family reported it. Another dietary aide stated the former dietary manager had multiple run-ins with the resident and that these were reported to administration. When interviewed, the administrator stated that when the interaction between the resident and the former dietary manager was initially reported, it was handled as a customer service concern rather than an abuse allegation. The administrator described the interaction as a verbal misunderstanding and reported providing verbal counseling to the staff member, but did not provide documentation of an abuse investigation or names of individuals interviewed at that time. The surveyor requested the abuse reportable/investigation multiple times and the facility was unable to produce it, with the assistant DON/HR stating they were trying to get a key to retrieve the reportable while the administrator was unavailable. Only after the surveyor’s request and a subsequent re-interview of the resident did the facility decide to treat the incident as reportable abuse and initiate an abuse investigation, contrary to the facility’s written policy requiring an immediate investigation and timely reporting of all alleged violations of abuse.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to develop and update an individualized care plan and did not ensure that a resident at high risk for skin breakdown received appropriate treatment and services to prevent the development and worsening of a pressure ulcer. The resident, who had multiple medical diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, cognitive communication deficit, depression, and hypertension, was admitted with intact skin but was identified as high risk for skin breakdown based on a Braden scale score of 12. Despite this, the care plan was not updated with new interventions after a skin impairment was reported, and preventive measures such as turning and repositioning every two hours were not consistently implemented, especially when the resident was in a wheelchair. Staff interviews and record reviews revealed that the resident was dependent on staff for repositioning and hygiene, requiring two staff members for transfers and repositioning. Multiple staff members, including CNAs and LPNs, acknowledged that the resident was not always repositioned every two hours while in the chair, sometimes remaining seated for more than four hours. There was no documentation of the resident refusing care, and social services were not notified of any refusals. The wound care nurse and other staff were aware of the resident's high risk and the need for frequent repositioning, but the interventions remained unchanged even after the development of a new wound. The wound was noted to have an odor for about a week before the resident was sent to the hospital, and the care plan was not individualized or updated to address the new wound. The resident's condition deteriorated, with the sacral wound progressing from a small opening to an unstageable pressure ulcer with necrotic tissue, ultimately requiring hospitalization for sepsis and necrotizing fasciitis. Hospital records documented a stage 4 sacral decubitus ulcer with extensive tissue destruction and infection, necessitating surgical debridement. Facility policies required turning and repositioning as part of pressure injury prevention and evidence-based wound treatment, but these were not consistently followed or documented. The lack of timely and individualized interventions, failure to update the care plan, and inconsistent implementation of preventive measures directly contributed to the resident's development and worsening of a severe pressure ulcer.
Failure to Remove Unsafe Wheelchair with Broken Brake
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including moderate cognitive impairment and a high risk for falls, was observed using a wheelchair with a broken right brake. The resident, who is dependent for transfers and uses the wheelchair as a primary mode of locomotion, reported the broken brake to the surveyor. Staff, including a CNA and the Maintenance Director, were either unaware of the issue or had not addressed it despite being informed. The Maintenance Director acknowledged being aware of the broken brake but had not inspected or repaired it, citing competing priorities. The Maintenance Assistant also did not check the maintenance log, and the Restorative Director attempted to remove the unsafe wheelchair but did not notify social services when the resident refused. Facility policy requires that malfunctioning equipment be immediately removed from use and reported for repair, and that social services be notified in cases of resident refusal. Despite these policies, the resident continued to use the unsafe wheelchair for at least two days, and the broken brake was not repaired or removed from service. Multiple staff members confirmed the wheelchair was unsafe and could lead to incidents, but the necessary steps to ensure resident safety were not taken in a timely manner.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, resulting in a delay in transferring the resident to the hospital for further evaluation. The resident, who has severe cognitive impairment and requires significant assistance with activities of daily living, was found with a contusion and bruising around the right eye after a fall. Despite the visible injuries, the responsible staff did not report the incident or the change in condition to the physician or the Director of Nursing, as required by the facility's policies. The incident involved multiple staff members who failed to follow protocol. A Licensed Practical Nurse (LPN) observed the resident with bruising but did not notify the physician or the Director of Nursing. Additionally, two Certified Nursing Assistants (CNAs) were involved in the incident but did not report the fall to the nurse on duty. This lack of communication and failure to adhere to the facility's policies on reporting falls and changes in condition contributed to the delay in the resident receiving necessary medical attention. The facility's policies clearly state that any change in a resident's condition should be immediately assessed and reported to the physician, with emergency medical care provided if necessary. The failure to follow these procedures resulted in a delay in care for the resident, who was eventually transferred to the hospital with a head contusion and edema. The staff members involved were terminated for gross misconduct and failure to adhere to the facility's policies and procedures.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to ensure adequate nursing staff to respond to call lights in a timely manner, as evidenced by resident council meeting minutes and staffing data. Residents reported that during the 2nd and 3rd shifts, there were instances where only one or two CNAs were available, leading to delays in answering call lights. The facility's staffing data, submitted via the PBJ system, indicated excessively low weekend staffing, which triggered concerns. The facility's staffing coordinator, V26, confirmed that the facility aims to staff nine CNAs for the morning and evening shifts and eight for the night shift, but there were occasions when these numbers were not met. The facility assessment document from March 2024 indicated that the nursing services staffing should include 12 CNAs for the day shift, nine for the evening shift, and eight for the night shift. However, records from July 2024 showed that the facility was operating with fewer CNAs than required, with instances of only eight CNAs working the morning shift and as few as five CNAs on the night shift. Additionally, resident council minutes from July 2024 noted complaints about CNAs using cell phones during work hours and not responding to call lights promptly. This staffing inadequacy placed all 104 residents at risk of receiving inappropriate care and services to meet their physical, mental, and psychosocial needs.
Deficiencies in Food Safety and Sanitation Protocols
Penalty
Summary
The facility failed to adhere to its policies on sanitation and food safety, which has the potential to affect 101 residents on an oral diet. Observations revealed that the dishwasher temperatures were not reaching the recommended levels necessary for proper sanitization. The dishwasher's wash cycle was observed to be below the required 150 degrees F, and the sanitation cycle was not reaching the necessary 180 degrees F. Testing strips used to verify the sanitization process did not change color as expected, indicating that the dishes were not being properly sanitized. Additionally, the dishwasher had recently been serviced, but issues with the testing strips and clogged sprays were noted, which contributed to the problem. The facility also failed to properly sanitize dishes in the three-compartment sink. The sanitizing compartment contained cloudy water with whitish particles, and the chlorine concentration was not reaching the required 100 PPM. The chlorine test strips used were expired, and the Dietary Manager was unaware of the expiration date, which further compromised the sanitization process. This oversight could lead to cross-contamination and potential foodborne illnesses among residents. Furthermore, staff in the kitchen were not following proper hair restraint protocols. A Dietary Aide was observed wearing a hair net that did not fully cover her hair, which could lead to contamination of food. Additionally, an open bag of peas and carrots in the freezer was not labeled with an open date or use-by date, increasing the risk of using expired food. These lapses in following established food safety protocols highlight significant deficiencies in the facility's food service operations.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a Licensed Practical Nurse (LPN), completed the specialized training required for infection prevention and control in nursing homes. This deficiency was identified during a survey when the facility could not provide valid documentation or certification of the IP's completion of the necessary training program. The IP, who has been in the role since January 2024, is responsible for various infection control activities, including antibiotic surveillance, immunizations, and managing outbreaks of infections such as COVID-19, flu, and C. diff. Despite these responsibilities, the IP had not completed the required training modules and cumulative test to demonstrate competency in the role until after the survey began. The Director of Nursing (DON) emphasized the importance of having a certified IP to stay updated with CDC recommendations and to protect both staff and residents from infections. The facility's policy on the Infection Prevention Program states that the IP should serve as a resource for all staff and departments regarding infection prevention. However, the lack of completed training for the IP indicates a gap in ensuring that the individual in this critical role has the necessary knowledge and competence to effectively manage the infection prevention program, potentially affecting the 104 residents residing in the facility.
Failure to Complete PASRR Screenings Before Admission
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed for five residents prior to their admission. The Social Services Director, V16, acknowledged that PASRR screenings are crucial for determining the appropriate placement of residents and should be completed before admission. However, it was found that PASRR Level 1 screenings for residents R9, R16, and R37 were only submitted on February 4, 2025, after their admission. Additionally, R15 and R33 had inaccurate Level I PASRR screenings, and V16 admitted that new screenings were necessary to determine if Level II evaluations were required. Resident R9, diagnosed with schizophrenia, schizoaffective disorder, and major depression, and Resident R37, with severe cognitive impairment and multiple mental health diagnoses, both required Level II evaluations according to their PASRR Level 1 screenings. However, these evaluations were not conducted prior to their admission. Resident R16, diagnosed with major depression and psychosis, did not require a Level II evaluation according to the PASRR Level 1 screening. The facility's policy mandates compliance with state and appointed screening agencies, but this was not adhered to in these cases. Furthermore, Resident R54, with a history of schizoaffective disorder and major depressive disorder, was admitted without a completed PASRR Level 1 screening from the hospital. The Social Services Director, V17, stated that the admissions office should have ensured the completion of the PASRR Level 1 screening before admission. The lack of a PASRR Level II evaluation for R54 meant that the resident was not receiving the specialized treatment required for their mental health conditions. The facility's failure to conduct timely and accurate PASRR screenings for these residents highlights a significant deficiency in their admission process.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer prescribed medications in a timely manner and maintain accurate narcotic medication counts for four residents. During a controlled substance count, discrepancies were observed in the medication bingo cards for a resident, where the actual pill count did not match the documented count. The registered nurse admitted to administering the medications but failing to document the administration. Additionally, a resident's liquid medication count was also inaccurate, with one less bottle than recorded. Furthermore, medications were not administered as scheduled for two residents due to unavailability. A licensed practical nurse failed to administer a resident's Gemtesa medication on two consecutive days and did not notify the physician of the missed doses. Similarly, another resident's Mupirocin medication was not administered on two days, and the nurse erroneously documented its administration without notifying the physician. The facility's policy requires medications to be given within one hour of the specified time and narcotics to be recorded accurately, which was not adhered to in these instances.
Medication and Enteral Feeding Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and enteral feedings, leading to several deficiencies. During a survey, expired medications were found in three of six medication carts, including an open bottle of Morphine Sulfate with an expiration date of 05/17/2024, and Bisacodyl Enteric Coated tablets with expiration dates of 12/2024 and 09/2023. Additionally, a vial of Lispro insulin was found without a proper pharmacy label, and a nasal medication, Fluticasone Propionate, was also missing a pharmacy label. These medications were not discarded as required by the facility's policy, which states that expired medications should not be administered and that medications must have proper labeling. Furthermore, expired enteral feeding containers labeled Nepro 1.8 CAL were found in a medication storage room, with visible milk curdles at the bottom, indicating spoilage. These containers had an expiration date of 11/2024 and were not removed from storage, posing a risk to residents who rely on enteral feedings. The facility's policy mandates that medications and feedings should be discarded after their expiration date and that any unmarked or improperly labeled medications should be returned to the pharmacy for proper labeling. These oversights have the potential to affect 68 residents in the facility, including those with gastrostomy tubes for enteral feedings.
Deficiency in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to minimize the risk of acquiring, transmitting, or experiencing complications from influenza and COVID-19 for six residents. The deficiency was identified through interviews and record reviews, revealing that several residents were not properly offered or documented for influenza vaccinations. For instance, one resident was offered and refused the influenza vaccine in August 2024, but there was no documentation of subsequent offers or refusals for the current flu season. Additionally, three residents did not receive immunization education prior to vaccine administration or refusal, and another resident's consent form for the influenza vaccine lacked a witness signature. Furthermore, one resident consented to receive the influenza vaccine, but it had not been administered by the time of the report. The same resident also consented to the COVID-19 vaccine, which had not been given due to insurance issues and lack of follow-up with the pharmacy. The Infection Preventionist (IP) nurse, responsible for managing immunizations, admitted to not documenting offers and education consistently. The facility's policy requires offering influenza and pneumococcal vaccinations to all residents, with proper documentation of education and vaccination status, which was not adhered to in these cases.
Violation of Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to maintain resident rights pertaining to dignity and confidentiality for three residents. One resident was not fed with dignity, as a Certified Nursing Assistant (CNA) fed the resident while standing, which is against the recommended practice of feeding at eye level to ensure the resident's ability to chew and swallow safely. The CNA continued to feed the resident without ensuring that the resident had finished chewing, which could potentially lead to aspiration. The Director of Nursing and the Director of Rehabilitation both confirmed that feeding should be done at eye level to prevent such issues and to maintain the resident's dignity. Additionally, the facility failed to protect the confidentiality of medical information for two residents. Signs indicating the residents' names and dietary information were visibly posted above their beds, which could be seen by visitors. This practice was confirmed by the Director of Rehabilitation, who acknowledged that the information on the swallow precaution signs is part of the residents' medical records and should be kept confidential. The visible posting of such information violates the residents' rights to confidentiality as outlined in the facility's Resident Rights policy. The residents involved had various medical conditions that required specific dietary needs and assistance. One resident had severe cognitive impairment and required one-on-one assistance during meals, while another resident was cognitively intact but had specific dietary instructions. The facility's failure to adhere to proper feeding practices and to protect the confidentiality of medical information compromised the dignity and rights of these residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess and monitor a resident for self-administration of medication, which was observed during a medication pass. A Licensed Practical Nurse (LPN) provided a nasal medication, Fluticasone Propionate 50mcg, to the resident, who then self-administered two sprays into both nostrils. The LPN stated that the resident was allowed to self-administer because she did not trust the facility staff to administer it correctly. However, a review of the resident's Physician Order Sheet, Medication Administration Record, and Electronic Health Record revealed that there was no physician order or assessment for the resident to self-administer her medication. The facility's policy on medication administration and storage requires that self-administration of medications by residents is only permitted when the resident has been assessed and deemed capable, and a physician order has been written for self-administration. This policy was not followed in the case of the resident, leading to the deficiency.
Failure to Display [NAME] Program Information
Penalty
Summary
The facility failed to display information about the [NAME] program in a public and accessible location, which is a requirement for informing residents of their rights regarding community transition. This deficiency was identified during a survey conducted on February 4, 2025, when it was observed that no posters or educational materials related to the [NAME] program were posted on any of the facility's floors, including the main dining room where residents frequently gather. The Social Service Director, identified as V16, was unaware of any postings and confirmed the absence of such materials after checking all floors. The deficiency affected 12 residents who were potential candidates for the [NAME] program, as they were not provided with the necessary information to make informed decisions about community transition. On February 5, 2025, V16 acknowledged that educational materials and information had not been distributed to residents until after the surveyor's visit. The lack of information potentially impacted the residents' ability to exercise their right to explore or decline community transition, as they were not informed of their rights or the contact information needed to participate in the program.
Failure to Remove Hospital Wristband Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal information, which is a violation of the Health Insurance Portability and Accountability Act (HIPAA). A resident, who was recently admitted to the facility, was observed wearing a hospital wristband that displayed his full name, date of birth, and medical record number. This wristband, which should have been removed upon admission, contained private information that was visible to other residents and visitors, thus compromising the resident's confidentiality. The resident, who has intact cognitive function as indicated by a BIMS score of 13/15, expressed a desire for his information to remain private. Despite this, the wristband remained on the resident until it was brought to the attention of the facility staff by a surveyor. The registered nurse acknowledged the oversight and identified it as a HIPAA violation. The unit manager and assistant director of nursing confirmed that hospital wristbands with identifying information should not be worn by residents in the facility, indicating a lapse in the facility's adherence to its policy on resident rights and confidentiality.
Inconsistent Restorative Therapy for Resident
Penalty
Summary
The facility failed to provide consistent restorative therapy to a resident, identified as R61, which compromised the resident's ability to maintain their highest practical level of function. R61, who is cognitively intact with a BIMS score of 15, has a medical history that includes rhabdomyolysis, paraplegia, and polyneuropathy. The resident reported that staff were supposed to assist with leg exercises and apply a splint, but these interventions were not consistently provided. During an observation, R61 mentioned that the splint was applied for the first time in a long period, coinciding with the presence of a state agency in the facility. The Restorative Aide, V12, confirmed that restorative aides document therapy in the resident's electronic medical record and that CNAs are responsible for providing therapy on weekends. However, there were multiple instances over the past 90 days where documentation of splint or brace assistance was missing. The Restorative Director, V24, acknowledged the importance of the restorative therapy program but was unsure why staff failed to document the interventions. The facility's failure to consistently provide and document restorative therapy placed residents at risk of receiving inappropriate care, potentially affecting their physical, mental, and psychosocial well-being.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate during the survey period. This deficiency was identified through the observation, interview, and record review of two residents. One resident, diagnosed with Type 2 Diabetes and other conditions, did not receive their scheduled dose of Metformin due to the medication not being available in the facility. The LPN responsible did not check the emergency automated medication dispenser (AMD), which had the medication in stock, nor did they notify the resident's physician about the missed dose. Another resident, with diagnoses including Multiple Sclerosis and hypertension, did not receive their scheduled Lidocaine patch. The LPN did not retrieve the patch from the central supply stock room, where it was available as house stock. The LPN admitted to being nervous and not thinking to check the available resources. Additionally, the LPN failed to inform the resident's physician about the missed medication. The facility's policy requires that physicians be notified when medications are not administered as per orders, which was not followed in these instances.
Inconsistent Nighttime Snack Distribution
Penalty
Summary
The facility failed to consistently offer and serve nighttime snacks to a resident, as per the facility's policy. During a resident council meeting, a resident expressed that they were not consistently receiving nighttime snacks. The Dietary Manager confirmed that snacks are supposed to be offered to all residents, and they are distributed to the floor CNAs to be given to residents. However, the Dietary Manager acknowledged that there are instances when residents report not receiving their snacks. The Director of Nursing was aware of the issue but did not conduct any in-services or training to address the concern. The resident involved is cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. The resident's medical history includes difficulty in walking, a non-pressure chronic ulcer, and low back pain. A review of the facility's records showed that the resident was not offered snacks on multiple occasions within a 30-day period. The facility's policy states that nourishments should be provided at bedtime and distributed by nursing staff, but this was not consistently followed.
Misclassification of Psychotropic Medication on Consent Form
Penalty
Summary
The facility failed to accurately classify a resident's psychotropic medication on the consent form, which could potentially affect the resident's understanding of the medication's side effects. The resident, who is severely cognitively impaired and unable to complete a mental status interview, has a medical history that includes dementia, anxiety disorder, major depression disorder, and psychotic disorder. The psychotropic medication form for this resident, dated 02/04/2025, incorrectly classified Remeron (Mirtazapine) as an antidepressant, whereas a previous form dated 03/03/2021 had incorrectly classified it as an antipsychotic. This misclassification led to consent being given under the wrong classification, which could result in misunderstanding the side effects associated with the medication. The Assistant Director of Nursing, who is responsible for updating psychotropic consents every 15 months, acknowledged the error in the classification of Remeron on the earlier form. According to the facility's policy, psychotropic medications should have appropriate indications for use and be monitored for side effects, with consents updated regularly. The FDA indicates that Remeron is used for treating major depressive disorder in adults, and the facility's consent form lists side effects for antidepressants that differ from those for antipsychotics. This discrepancy in classification and consent could lead to issues with informed consent regarding the medication's side effects.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal abuse, affecting one of the four residents reviewed for abuse. The resident, a female with epilepsy, anxiety disorder, and chronic embolism, is alert and oriented, requiring maximum assistance with activities of daily living and using a manual wheelchair. The resident reported two incidents of verbal abuse by CNAs. In the first incident, a CNA allegedly cursed at the resident after she requested assistance for another resident. Witnesses corroborated the resident's account, and the CNA was terminated. In the second incident, another CNA allegedly made derogatory remarks about the resident's hygiene, which the resident found offensive. Despite the CNA's denial, the investigation substantiated the claim, and the CNA was also terminated. The facility's abuse investigations confirmed both incidents of verbal abuse, with statements from the resident, other residents, and staff supporting the allegations. The facility's policy affirms residents' rights to be free from abuse, and the incidents were found to violate this policy. The administrator, who also serves as the Abuse Prevention Coordinator, conducted the investigations and confirmed the substantiation of the allegations. The facility's policy prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents, yet these incidents demonstrated a failure to uphold these standards, resulting in the termination of the involved CNAs.
Resident Tied to Bed with Pillowcases by Nurse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff, as evidenced by an incident involving a cognitively impaired resident, R2. R2, who has a history of restlessness, agitation, and repeated falls, was found with their wrists tied to the bed side rails using pillowcases by a registered nurse, V6. This action was taken by V6 due to a staffing shortage and the nurse's inability to supervise R2, who was known for climbing out of bed and falling. V6 admitted to tying R2's wrists to prevent falls while they were busy with medication rounds, acknowledging that there was no physician order for such a restraint and that it constituted abuse. The incident was witnessed by a CNA, V21, who found R2 tearful and in discomfort, with gestures indicating pain. V21 reported the incident to another nurse and the Director of Nursing, expressing that tying a resident to the bedrail with a pillowcase was a form of abuse. The facility's administrator, V1, initially did not consider the action as abuse, attributing it to the nurse being busy and short-staffed. However, other staff members, including a nurse consultant and a restorative director, recognized the action as abuse, emphasizing the psychological and physical harm it could cause. The facility's policy on abuse prevention defines abuse as the willful infliction of injury, unreasonable confinement, or causing pain and mental anguish. Despite this, the facility initially failed to report the incident to the Illinois Department of Public Health as required. The incident was later identified as immediate jeopardy, highlighting the facility's failure to protect the resident from abuse and appropriately identify and report the incident.
Removal Plan
- R2 screened, reassessed for risk for abuse with care plan interventions.
- All staff in-serviced training completed by V1, V2 and V29.
- Documentation showed that all residents were re-educated on abuse.
- R2, R14, R15, R16, R17, R18, R19 and R20 were screened for potential abuse with care plan reviewed and initiated.
- All staff will be responsible for monitoring residents for behavior that can make them vulnerable for abuse.
- All residents determined to be vulnerable or those that will be affected by this deficiency citation R2, R14, R15, R16, R17, R18, R19 and R20 were identified, and plan of care initiated, with ongoing, on admission, quarterly and annually.
- Review Quality Assurance audit tool started weekly ongoing to ensure compliance.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by an incident involving a resident, R2, whose wrists were tied to the bed with a pillowcase by a registered nurse, V6, without a physician's order, consent, or medical justification. R2, who was admitted with multiple medical conditions including restlessness, agitation, and a history of falls, was restrained due to staffing shortages and the nurse's inability to supervise R2 adequately. The nurse admitted to tying R2's hands to prevent falls, acknowledging that it was wrong and not part of the facility's fall prevention interventions. R2's medical records did not document any medical symptoms or behaviors justifying the use of restraints, nor was there any physician order, restraint assessment, or consent obtained. The facility's policy requires that any use of restraints must be medically justified, ordered by a physician, and consented to by the resident or their representative. The incident was reported by another staff member who found R2 restrained and described the resident as experiencing psychosocial distress, including crying and agitation. Interviews with various staff members, including the Director of Nursing and the Restorative Director, confirmed that the facility is a restraint-free environment and that the use of a pillowcase as a restraint was inappropriate and considered abusive. The facility's policies on restraint use and fall prevention were not followed, and the incident was identified as an immediate jeopardy situation, highlighting a significant lapse in adherence to regulatory standards and resident care protocols.
Removal Plan
- All staff were trained on what constitute proper training, unnecessary use of restraint, with ongoing training scheduled Quarterly.
- All residents have been assessed to ensure that none are restrained improperly or unnecessarily.
- Assessment will be ongoing and conducted at admission, quarterly and annually.
- Outside consultant and V2 and V29 conducted in-service training on behavior management.
- Documentation showed all the facility residents were in-service on abuse and restraints.
- R2, R14, R15, R16, R17, R18, R19 and R20 were care planned/interventions with potential for abuse and proper restraints related to their diagnoses.
- A system put in place for audit to be done weekly to ensure compliance with unnecessary use of restraint to be monitored by V1, V2 and V29.
Medication and Treatment Cart Safety Lapses
Penalty
Summary
The facility failed to ensure that a treatment cart and resident medication were not left unattended, posing a potential accident hazard. An inhaler belonging to a resident was observed on an over-bed table, visible from the hallway, and not in its manufacturer's container or with a pharmacy label. The resident stated they used the inhaler to help with breathing, but there was no physician order for the resident to self-administer the medication. The nurse confirmed that the resident was not part of a self-administration program and had not received the inhaler as scheduled, despite the medication administration record indicating otherwise. Additionally, a treatment cart was found unlocked and unattended in the hallway, not within the visual proximity of the nurses. The nurse acknowledged forgetting to lock the cart, which is against the facility's policy that requires treatment carts to be locked when not in use or under direct supervision. The Director of Nursing confirmed that only nurses should have access to the cart keys and that leaving it unlocked poses a safety issue. The facility's policies on medication administration and storage emphasize that medications should not be administered without a physician's order and that self-administration is only permitted with a proper assessment and physician order.
Staffing Shortage Leads to Resident Restraint
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly affecting a resident known for attempting to get out of bed without assistance. On a specific day, the facility was short-staffed, with only two CNAs available instead of the usual three for the second floor, which houses 41 residents. This shortage led to a situation where a registered nurse, overwhelmed with responsibilities, tied a resident's hands to the bed rail with a pillowcase to prevent falls, acknowledging the action was wrong but felt necessary due to the lack of staff. The facility's staffing policy requires adequate staffing levels and skills mix to deliver high-quality, person-centered care, with a designated nurse on-call for emergencies. However, on the day of the incident, a CNA called off, and the facility struggled to find a replacement, especially since it was a weekend. The Director of Nursing confirmed that the usual staffing for the second floor should include two nurses and three CNAs, but due to the call-off, only two CNAs were available, leading to the incident involving the resident being tied to the bed rail.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged abuse incident involving a resident who was tied to the bedside rails with a pillowcase by a nurse. This incident was reported to the facility's Administrator by the Director of Nursing, who sent the nurse home pending investigation. Despite the conclusion that the allegation was unfounded and there was no injury, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required by their policy. The facility's policy on abuse prevention mandates that any allegation of abuse should be reported to the Department of Public Health's regional office immediately, or within 24 hours if there is no serious bodily injury. However, the initial report to IDPH was made 32 days after the alleged incident. This delay in reporting was a violation of the facility's own policy, which requires timely reporting of such allegations to ensure proper investigation and response.
Failure to Conduct Timely PASRR Assessments for Residents with Serious Mental Disorders
Penalty
Summary
The facility failed to refer five residents for Preadmission Screening and Resident Review (PASRR) Level I and II assessments, which are necessary for residents with serious mental disorders. The Director of Social Services, identified as V4, acknowledged that these assessments were not completed for residents R2, R3, R4, R5, and R6. Each of these residents had diagnoses indicating serious mental illness, such as schizoaffective disorder, major depressive disorder, and bipolar disorder, which required timely PASRR evaluations to ensure they received appropriate care and services. The deficiency was partly due to a transition period in the facility's social services department, during which there was no Social Services Director to manage the PASRR process. V4, who was new to the facility, was unaware of the need for these assessments until the surveyor's interview. The facility's business office manager, V5, confirmed that the absence of a Social Services Director led to a lack of communication with the appointed screening agency, resulting in missed PASRR evaluations. The facility's policy requires that newly admitted residents with serious mental illness, intellectual disability, or developmental disability be assessed for PASRR Level II within a specified timeframe. However, due to the oversight, the necessary assessments were not conducted, leaving the residents without the specialized programs and treatment goals they needed. Notifications from the assessment tool and service letters from the screening agency were not acted upon, contributing to the deficiency.
Failure to Provide Adequate Wound Care for Residents
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, leading to significant health issues. Resident 1, who was admitted with a surgical site on the left inner thigh, did not receive the necessary wound treatment and skin care plan interventions. The facility did not complete weekly wound skin assessments or Braden scale assessments as required. This lack of care resulted in the resident being admitted to the hospital for dehiscence of the wound in the groin area. Resident 4 also did not receive the prescribed wound treatment. The resident's wound dressings were not changed daily as ordered by the physician, and the treatment was not documented as provided on specific dates. This oversight in care was noted despite the resident having multiple pressure ulcers and being dependent on assistance for activities of daily living. Interviews with facility staff, including the wound care nurse and the Director of Nursing, revealed a lack of awareness and documentation regarding the residents' wound care needs. The facility's policies on surgical wound care and skin inspection were not followed, contributing to the deficiencies in care for both residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, affecting two residents. The first incident involved a female resident with Alzheimer's and other health conditions, who was reportedly slapped by a CNA during ADL care after she became combative and scratched the CNA. The incident was witnessed by another CNA and the resident's roommate, both confirming the slap. The facility's investigation led to the termination of the CNA involved, although the resident was unable to be interviewed due to her mental status. The second incident involved a female resident with COPD, paraplegia, and other health issues, who was involved in a verbal altercation with a CNA. The CNA used profanity during a conversation with the resident, which was recorded on social media. Despite the resident's claim that the CNA always spoke to her in such a manner, the facility determined the interaction to be verbal abuse. The CNA was terminated following the incident, as the use of profanity was deemed inappropriate and against facility policy. Both incidents highlight the facility's failure to ensure a safe environment free from abuse, as required by their Abuse Prevention Program. The facility's policy emphasizes the residents' right to be free from abuse and mistreatment, yet these incidents demonstrate lapses in adherence to this policy, resulting in the termination of the involved staff members.
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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