Elevate Care Waukegan
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukegan, Illinois.
- Location
- 2222 Audrey Nixon Boulevard, Waukegan, Illinois 60085
- CMS Provider Number
- 145669
- Inspections on file
- 41
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Elevate Care Waukegan during CMS and state inspections, most recent first.
A resident who required supervision or touching assistance with eating, as documented on the MDS, was observed eating alone in their room using a small, child-sized plastic spoon without any supervision, cueing, or touch assist. Due to vision loss and difficulty straightening fingers, the resident gripped the flexible plastic spoon with a loose fist, causing food to repeatedly fall off the spoon without being noticed, leading to frustration and only partial meal consumption. An LPN reported that only plastic spoons were available and did not know why, while the Dietary Manager stated plastic was used when there was not enough metal flatware. Resident council minutes also showed that two residents had complained about receiving plastic ware.
A resident receiving anticoagulation therapy for an upper extremity thrombosis had multiple physician orders for INR testing, and blood was reportedly drawn, but PT/INR tests were not completed and no lab results were documented for several ordered test dates. The DON acknowledged that although lab orders were placed correctly, the anticoagulation testing was not performed, and the physician reported frequently ordering INRs without receiving any results. The resident was later hospitalized with a supratherapeutic INR of 12.0 and a markedly prolonged PT, while the facility was unable to provide a relevant policy during the survey.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with ALS reported that a CNA attempted to damage and then turned off his oxygen concentrator and disabled his call light. The incident was reported internally to nursing supervisors and the Administrator, and the CNA was suspended during the investigation. However, the Administrator did not report the abuse allegation to the State Agency as required by facility policy.
Two residents who were dependent on staff for ADLs did not receive required oral care as ordered and outlined in their care plans. Both had visible debris and poor oral hygiene observed during the survey, despite staff statements that oral care is performed daily and facility policy requiring regular oral hygiene.
A resident with a history of stroke and on tube feeding experienced significant weight loss due to the facility's failure to monitor their weight as recommended. Despite being on a specific feeding regimen, the resident's weight was not recorded in December, leading to a 9.36% weight loss by January. The facility's policy required monthly weights and more frequent monitoring for those at nutritional risk, which was not followed.
The facility failed to provide palatable food, as observed during a lunch service where chicken was found to be hard, tough, and dry. Several residents reported dissatisfaction with the meal, and a test tray confirmed the chicken was overcooked. The Assistant Food Service Manager acknowledged the issue, stating that the chicken should be juicy.
A resident with chronic respiratory issues was observed self-administering a nebulizer treatment without the required assessment or physician's order. The facility's policy mandates an assessment and physician order for self-administration, but the resident's records lacked both. The Respiratory Therapy Manager provided the medication without knowing the requirement, and the resident's care plan did not address self-administration.
A resident was involved in a physical altercation with another resident, resulting in the resident being knocked out of her wheelchair. Both residents were alert and oriented, and the incident was witnessed by a CNA who intervened. The resident reported pain but refused further assessment. The facility's Administrator substantiated the abuse, and the involved resident was arrested and not allowed to return to the facility.
A facility failed to follow its abuse policy for a resident with a criminal history, leading to a deficiency. The resident's background check was delayed due to an error in recording race, and a HIT for domestic battery was not acted upon. The facility's policy required immediate fingerprinting, but this was not done, resulting in an incident with another resident. The admissions staff admitted to the error, and the necessary follow-up actions were not executed.
The facility failed to provide meaningful activities for two residents with dementia, leading to deficiencies in meeting their needs. One resident, who enjoys puzzles and arts, was left in bed without engagement, while another, who benefits from sensory activities, was not offered any activities and was repeatedly redirected to sit down. The lack of personalized activity offerings and insufficient staffing contributed to the residents' inactivity and dissatisfaction.
A resident with limited ROM was not evaluated for a brace and did not receive prescribed ROM exercises. Despite an order for evaluation dated in November, the resident had not been assessed for a splint by January, and documentation showed inconsistent delivery of ROM exercises.
The facility failed to supervise medication administration for two residents. One resident was found with an unconsumed Adderall pill, and another had multiple medications left at their bedside. Both instances lacked physician orders for self-administration, contrary to facility policy requiring nurse supervision during medication ingestion.
The facility failed to ensure proper PPE use and isolation signage for residents on isolation. A CNA entered a resident's room on contact isolation for ESBL without wearing required PPE. Additionally, two residents who tested positive for COVID-19 lacked isolation signs and PPE outside their rooms, as confirmed by an LPN and the Infection Preventionist. These actions violated the facility's infection control policies.
The facility failed to assess and administer influenza and pneumonia vaccinations to three residents, leading to a deficiency in their immunization practices. A resident received an influenza vaccine late, and two residents did not receive timely pneumonia vaccinations. The Infection Control Preventionist Nurse acknowledged the oversight and lack of documentation regarding communication attempts with a resident's POA.
A resident with a hand contracture suffered a foul odor and an open wound due to inadequate hand and nail care. Despite being dependent on staff for personal hygiene, the resident's fingernails were excessively long, causing a cut to the palm. Facility staff failed to follow policies for nail care and bathing, resulting in the resident's injury and requiring intervention by the wound care team.
A resident with a history of chronic conditions experienced a fall and subsequent pain, but the facility delayed X-ray reporting and treatment. The X-ray, revealing a fracture, was not reviewed until over 20 hours later, delaying hospital transfer. Staff interviews highlighted communication and procedural issues.
A resident at high risk for falls experienced an unwitnessed fall resulting in a right hip fracture due to inadequate supervision. Despite a care plan indicating high fall risk, the facility failed to continuously monitor and document the resident's condition post-fall, delaying hospital evaluation. The resident, previously ambulatory with assistance, required a total lift and non-weight bearing status after the incident.
A resident in a long-term care facility, who was a Full Code, did not receive immediate CPR due to staff's inability to quickly verify the code status. The resident was found unresponsive and pulseless, but the CNA and RN involved were unsure of the code status and had to check the electronic medical record, causing a delay. This delay contributed to the resident's death, highlighting a deficiency in the facility's process for identifying code status.
A resident experienced verbal abuse from a staff member, V12, who used profanity and inappropriate language during an altercation about an oxygen concentrator. Despite attempts by other staff to de-escalate the situation, V12 continued the confrontation at the nurses' station, witnessed by multiple staff members. The facility's investigation confirmed the incident as a violation of the resident's right to be free from abuse.
A resident was physically abused by another resident after wandering into their room and taking food. The incident resulted in a fall and injuries, including a laceration and bruising. A housekeeper witnessed the altercation and confirmed the push. The facility's policy requires such incidents to be reviewed as potential abuse.
A facility failed to monitor a resident for 72 hours after a fall where she hit her head. The resident was observed with discoloration on her forehead, and the DON confirmed that required post-fall procedures, including vital signs and neuro checks, were not completed. Initial vital signs were recorded, but further monitoring was not conducted as per policy.
The facility failed to ensure a resident room was free from cockroaches, despite multiple reports and observations of the pests. The Maintenance Director was aware of the issue but had not taken steps to seal the room or repair the hole in the bathroom wall where the pests were entering. The facility's Pest Control policy was not followed, and the problem persisted for weeks without resolution.
Failure to Provide Required Eating Assistance and Appropriate Utensils
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and appropriate assistance with eating for a resident who needed supervision or touching assistance, resulting in the resident being left alone in the bedroom to eat with inadequate utensils. The resident’s MDS documented a need for supervision or touching assistance with eating, including verbal cueing and/or steadying/contact guard assistance throughout or intermittently during the activity. During a noon meal observation, the resident was seated alone in a wheelchair at an overbed table with the meal tray and was given a small, child-sized plastic spoon. The resident, who reported losing vision and being unable to straighten their fingers, gripped the tiny handle with a loose fist; when the resident attempted to scoop food, the flexible plastic spoon bent downward and the food repeatedly fell off without the resident noticing, leading to visible frustration and intake of only about 50% of the meal. Staff interviews revealed that only plastic flatware was being used on the unit, with an LPN stating there were no metal spoons and not knowing why plastic was used, and the Dietary Manager stating plastic was used when there was not enough metal flatware. Resident council minutes also documented that two residents had previously complained about receiving plastic ware. These observations, interviews, and record reviews show that the resident who required supervision and assistance with eating was not provided with the necessary supervision, cueing, or appropriate utensils during the meal, and that the facility’s practice of substituting plastic flatware when metal flatware was insufficient contributed to the deficiency.
Failure to Monitor Anticoagulation Lab Results Leading to Supratherapeutic INR
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and complete laboratory monitoring of a resident’s anticoagulation therapy. The resident had a diagnosis of thrombosis of the right upper extremity and was receiving anti-clotting medication regulated by INR (International Normalized Ratio) testing. A physician’s order dated 03/02/2026 directed that an INR blood test be drawn, and the DON stated that the blood was drawn on 03/03/2026. However, the resident’s medical record contained no results for this INR order, and the DON reported that although the laboratory orders were placed correctly, the PT (Prothrombin Time) and INR tests were not completed. The resident’s prior INR result in the record was from 01/16/2026, with an INR of 1.2, and no subsequent INR results were documented for the ordered tests. According to the DON, additional INR tests were scheduled on 03/13/2026, 03/14/2026, 03/16/2026, 03/17/2026, and 03/18/2026, but no INR results were obtained for any of those dates. The resident was later discharged from the facility and admitted to the hospital, where hospital laboratory results on 03/19/2026 showed a PT of 96.6 seconds (normal 12.3–15.1) and an INR of 12.0 (normal 0.8–1.2). The attending physician explained that a supratherapeutic INR indicates too much Coumadin, that the resident’s therapeutic INR range should have been 2–3, and that INR levels are used to regulate the resident’s anti-clotting medication. The physician stated that INR tests were ordered frequently at the facility but that no laboratory results were received. The facility did not provide a policy related to this issue at the time of the survey.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Abuse Allegation Involving Resident's Oxygen and Call Light
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own policy and regulatory standards. A male resident with Amyotrophic Lateral Sclerosis (ALS), who was alert and oriented, reported that a Certified Nursing Assistant (CNA) attempted to break his oxygen concentrator by hitting it, then turned it off, and also disabled his call light by pulling it out of the wall. The resident stated he informed a nurse about the incident, and an internal investigation was conducted. Multiple staff members, including the Administrator, DON, and nursing supervisors, were made aware of the allegations. The CNA involved was suspended during the investigation. Despite the seriousness of the allegations, including purposeful interference with life-sustaining equipment and communication devices, the Administrator decided not to report the incident to the Illinois Department of Public Health (IDPH), stating it was not considered a major abuse case. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any abuse allegations to the Department of Public Health, but this protocol was not followed in this case.
Failure to Provide Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral care to two residents who were dependent on staff for activities of daily living. For one resident with a history of poor oral hygiene and dental problems, physician orders and the care plan required oral care every eight hours. Despite this, observations revealed that the resident had visible white/yellow debris and a film on her teeth, and she confirmed that her teeth had not been brushed that morning. The resident's family also reported ongoing concerns about plaque and poor oral hygiene during recent visits. Staff interviews indicated that oral care should be performed daily, but the resident continued to have visible debris in her mouth during multiple observations. Another resident, who was nonverbal and had significant physical impairments including quadriplegia and a persistent vegetative state, also had physician orders for oral care every eight hours. A dental consult had previously documented poor general oral hygiene. During the survey, this resident was observed with yellowish debris between his teeth. The DON confirmed that morning care should include brushing teeth or using a sponge to remove debris, in accordance with the facility's oral hygiene policy. Despite these requirements, both residents did not receive the necessary oral care as ordered and outlined in their care plans.
Failure to Monitor Weight in Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident receiving tube feedings had their weight monitored, resulting in significant weight loss. The resident, identified as R112, had a history of difficulty swallowing due to a stroke and was on a gastrostomy tube feeding regimen. The Physician Order Sheet indicated that R112 was to receive Glucerna 1.5 at 60 ml per hour for 10 hours daily, supplemented by a general diet of mechanical soft with nectar thick fluids. Despite recommendations from the dietitian to monitor the resident's weight weekly, no weights were recorded for December 2024, and the resident experienced a weight loss from 173 pounds in November 2024 to 156.6 pounds in January 2025, a 9.36% decrease. The dietitian, V13, noted that R112's food intake was poor in November 2024 and had reinstated the tube feeding order with an increased rate of 75 ml per hour. However, the resident's weight was not monitored as recommended, and the December weight was not recorded. The facility's policy required monthly weights and more frequent monitoring for residents at nutritional risk, but this was not adhered to. The physician, V25, confirmed that weight monitoring should be done at least monthly for tube-fed residents, and weekly if weight loss is detected. The lack of timely weight monitoring led to the resident's significant weight loss, highlighting a deficiency in the facility's adherence to its weight monitoring policy.
Facility Fails to Ensure Palatable Food for Residents
Penalty
Summary
The facility failed to ensure that food was palatable for resident consumption, affecting four residents in the sample. During a lunch service, the cooked chicken was observed on the steam table and required reheating in the oven before being served. Several residents reported that the chicken was hard, tough, dry, and overdone, with one resident unable to eat it and another only consuming half of the portion. A test tray provided to surveyors confirmed that the chicken appeared dry and overcooked, with a tough texture. The Assistant Food Service Manager acknowledged that the food should not be hard or dry, indicating that chicken should be juicy on the inside.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to assess and approve a resident for self-administration of medications, specifically nebulizer treatments. A male resident, who was admitted with chronic respiratory failure, tracheotomy, and chronic obstructive pulmonary disease, was observed self-administering a nebulizer treatment without an assessment or physician's order. The resident reported that the respiratory therapist provided him with the medication ampule, and he initiated the treatment himself. The Director of Nursing confirmed that an assessment and physician order are required for residents to self-administer any medication, including nebulizer treatments. The Respiratory Therapy Manager, who provided the medication to the resident, was unaware of this requirement. The resident's medical records lacked an assessment for self-administration and did not include a physician's order for the nebulizer treatment. Additionally, the resident's care plan did not address self-administration of medications, contrary to the facility's policy, which mandates an assessment and physician order for self-administration requests.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. An incident occurred where a resident, identified as R84, was involved in a physical altercation with another resident, R166. Both residents were described as alert and oriented with no cognitive impairments. The altercation began as a verbal disagreement in R166's room, which escalated to R84 being knocked out of her wheelchair onto the floor. A Certified Nursing Assistant (CNA), V15, witnessed the incident and intervened to prevent further harm. R84 reported pain in her left lower extremity and right arm but refused a full body assessment and any diagnostic tests. Following the incident, R84 expressed a desire to press charges against R166, leading to police involvement and R166's arrest. The facility's Administrator, V1, substantiated the abuse after an investigation, noting that R166 had a clenched fist directed at R84, although no further physical harm was inflicted. R84 was granted an order of protection against R166, who was not allowed to return to the facility. The facility's Abuse Prevention and Reporting policy, last revised in 2022, emphasizes that residents should be free from all forms of abuse, including physical and verbal abuse.
Failure to Follow Abuse Policy for Resident with Criminal History
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident, identified as R166, who was admitted with a criminal history that included a HIT for domestic battery. The initial criminal history background check was initiated on 5/28/24, but due to an error in recording the resident's race, the process was delayed. A second report dated 6/27/24 confirmed the HIT, but the facility did not act on this information. The administrator and assistant administrator were unaware of the HIT until after an incident on 11/1/24, when R166 was involved in a physical altercation with another resident, R84. The facility's policy required immediate fingerprinting upon identifying a HIT, but this step was not taken. The admissions staff, V28, admitted to the error in recording the resident's race and the subsequent delay in processing the background check. V28 was not present when the final background check results were received, and the necessary follow-up actions, such as notifying social services for fingerprinting, were not executed. The facility's abuse policy mandates requesting background checks within 24 hours of admission and taking all necessary steps to ensure resident safety while awaiting fingerprint results. However, these procedures were not followed, leading to the deficiency identified in the report.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide meaningful activities to two residents with dementia, leading to deficiencies in meeting their needs. Resident R70, who enjoys activities such as bingo, puzzles, and arts and crafts, was observed in bed multiple times without any activities being offered. Despite being part of the Activity on Wheels (AOW) program, R70 expressed boredom and a lack of engagement. The Activity Assistant, V8, was unaware of R70's preferences and only offered activities that R70 did not enjoy, such as music. This lack of personalized activity offerings contributed to R70's inactivity and dissatisfaction. Similarly, Resident R111, who benefits from sensory activities and enjoys watching movies and TV shows, was observed in her wheelchair without any activities being offered. Staff repeatedly redirected her to sit down without providing engaging activities. The Activity Assistant, V8, admitted to not seeing R111 due to leaving early and noted that R111 was often asleep. The facility's policy requires activities to meet the interests and preferences of each resident, but the lack of available sensory items and insufficient staffing on the dementia unit contributed to the failure to provide appropriate activities for R111.
Failure to Evaluate and Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) was properly evaluated for a brace and received the necessary ROM exercises. The resident's care plan, initiated in October 2022, indicated the need for an active assisted ROM program 3-7 days a week. However, an order for restorative nursing to evaluate the resident's left wrist and finger contractures for a splint was not acted upon. This order was dated November 26, 2024, but by January 14, 2025, the resident had not been evaluated for a possible splint, and the resident reported not receiving routine ROM exercises. Observations and interviews revealed that the resident's left wrist was contracted at about 90 degrees, and the resident was unable to move the wrist and index finger. The resident mentioned requesting a brace from a doctor over a month ago, but no action had been taken. The restorative nurse was unaware of the evaluation order and confirmed that the resident had not been evaluated for a splint. Documentation showed that the resident did not receive ROM exercises 3-7 days a week for several weeks, with multiple instances of missing documentation or notes indicating that ROM was not applicable, meaning it was not done.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for two residents. In the first instance, a resident was found with an orange pill, identified as Adderall, on their bedside stand. The resident admitted to not taking the medication because they did not want to stimulate their system further. The resident's Physician Order Summary (POS) indicated an active order for Adderall to be administered twice daily, but there was no order permitting self-administration. The nurse responsible for administering the medication believed the resident had taken it, highlighting a lapse in supervision. In the second instance, another resident was found with two plastic medication cups containing approximately 18 medications. The resident stated that the medications were left with them to take later with food. The Director of Nursing confirmed that no residents had orders to self-administer medications, and nurses were required to supervise medication ingestion. The resident's POS did not include an order for self-administration, and the Medication Administration Summary showed a scheduled administration of 16 pills that morning. The facility's policy mandates supervision during medication administration, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Use and Isolation Signage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and signage for residents on isolation, leading to deficiencies in infection control. In one instance, a Certified Nursing Assistant (CNA) entered the room of a resident on contact isolation for extended-spectrum beta-lactamases (ESBL) without wearing the required gown and gloves. The resident's care plan and the facility's contact precautions policy both indicated the necessity of these protective measures, yet they were not followed. This oversight was observed during a survey, highlighting a lapse in adherence to infection control protocols. Additionally, the facility did not display isolation signs or provide PPE outside the rooms of two residents who tested positive for COVID-19. A Licensed Practical Nurse (LPN) confirmed the absence of necessary signage and PPE, which should have been in place following the residents' positive test results. The Infection Preventionist acknowledged the oversight, noting that the signs were not moved after room changes. The facility's infection prevention manual mandates isolation with signage and PPE for residents testing positive for COVID-19, but these measures were not implemented as required.
Failure to Assess and Administer Vaccinations
Penalty
Summary
The facility failed to properly assess and administer vaccinations for influenza and pneumonia to three residents, leading to a deficiency in their immunization practices. Resident 27, who was over the age of 65, received an influenza vaccine on January 14, 2025, but it was noted that the vaccine should have been offered at the start of the flu season. The Infection Control Preventionist (ICP) Nurse, V24, attempted to contact the resident's Power of Attorney (POA) but was unsuccessful and did not document the communication attempt. Resident 23, also over the age of 65, had received a Prevnar 13 dose on April 21, 2024, but was due for another pneumonia vaccine dose, which had not been administered. Resident 17 had received a Pneumovax dose in 2018, but there was uncertainty about which dosage was administered, and no follow-up was conducted to verify this information. The facility's policy, revised on April 21, 2022, states that residents should be educated about the benefits and side effects of immunizations upon admission, and once consent is given, the influenza vaccine should be administered annually. Additionally, residents should be offered influenza immunizations from October 1 through March 31 annually and pneumococcal immunizations per CDC recommendations. However, the facility failed to adhere to these policies, as evidenced by the lack of timely vaccination and follow-up for the residents in question. The ICP Nurse acknowledged these oversights, indicating a lapse in the facility's vaccination assessment and administration processes.
Neglect in Hand and Nail Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate hand and nail care to a dependent resident with a hand contracture, resulting in a foul odor and an open wound on the resident's palm. The resident, who has a history of encephalopathy, traumatic subdural hemorrhage, and other significant medical conditions, was dependent on staff for activities of daily living, including personal hygiene. Despite the care plan indicating the need for active assistive range of motion and monitoring of skin integrity, the resident's hand care was neglected. Observations revealed that the resident's fingernails were excessively long, with one nail causing a cut to the palm of the contracted hand. The resident's room had a foul odor, and there was a noticeable build-up of debris on the resident's hand. Interviews with staff indicated that hand care should be performed daily for residents with contractures, but this was not done for the resident in question. The facility's policies for nail care, morning/nighttime care, and bed baths were not followed, as evidenced by the lack of documentation and the condition of the resident's hands. The Director of Nursing and other staff acknowledged the oversight, noting that the resident's nails should have been trimmed and hand care provided regularly. The wound care team had to intervene to treat the open wound caused by the long fingernail. The facility's failure to adhere to its own policies and procedures for resident care led to the resident's injury and the need for immediate medical attention.
Delayed X-ray Reporting and Treatment After Resident Fall
Penalty
Summary
The facility failed to ensure timely completion and reporting of an X-ray and delayed treatment for a resident who experienced a fall. The resident, who had a history of chronic kidney disease, hemiplegia, and vascular dementia, was found on the floor by a nursing supervisor. Despite the resident's complaints of pain and visible discomfort, the X-ray order was not marked as urgent, leading to a delay in obtaining and reviewing the results. The X-ray, which revealed an acute intertrochanteric fracture of the right femur, was completed and signed by the radiologist on the evening of the fall. However, the results were not reviewed by the facility's staff until the following afternoon, resulting in a delay of over 20 hours before the resident was transferred to the hospital for emergency care. During this time, the resident continued to experience pain, and there was a lack of documentation regarding ongoing monitoring of the resident's condition. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing acknowledged that the X-ray should have been ordered as STAT and that the results should have been monitored more closely. The Nurse Practitioner, who ordered the X-ray, was not informed of the results until the next day, which contributed to the delay in the resident receiving appropriate medical attention.
Inadequate Supervision Leads to Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to provide adequate supervision for a resident at high risk for falling, resulting in an unwitnessed fall and a right hip fracture. The resident, who had a history of moderate cognitive impairment, hemiplegia, and was at high risk for falls, was found on the floor by a nursing supervisor during rounds. The resident was unable to recall the details of the fall and complained of pain in the right leg. An X-ray confirmed an acute intertrochanteric fracture of the proximal right femur. The resident's care plan indicated a high risk for falls due to confusion and gait/balance problems, yet there was a lack of continuous monitoring and documentation of the resident's condition following the fall. The nursing staff did not document any progress notes from the time of the fall until the resident was sent to the hospital the next day. The resident was in pain and had decreased mobility, but the facility delayed sending her to the hospital for evaluation and treatment. Interviews with staff revealed that the resident was previously able to ambulate with a walker and minimal assistance but required a total lift and non-weight bearing status after the fall. The facility's fall prevention program aimed to ensure resident safety by assessing fall risks and implementing appropriate interventions, but these measures were not effectively executed in this case, leading to the resident's injury.
Failure to Quickly Identify Code Status Delays CPR
Penalty
Summary
The facility failed to have an effective process in place for staff to quickly identify a resident's code status, leading to a delay in providing cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive and pulseless. The resident, who was a Full Code according to their POLST form and physician orders, did not receive immediate CPR due to staff's inability to quickly verify the code status. This delay contributed to the resident's death in the facility. The incident involved a cognitively impaired resident with diagnoses including dementia, cerebral infarction, dysphagia, and schizophrenia, who was dependent on staff for care. On the evening of the incident, a Certified Nursing Assistant (CNA) found the resident unresponsive in their room but did not check for a pulse or call for help immediately due to uncertainty about what to do. The CNA sought assistance from a Registered Nurse (RN), who also did not know the resident's code status and had to leave the room to check the electronic medical record, further delaying the initiation of CPR. Interviews with facility staff revealed that there was no quick method to verify a resident's code status, as it required checking the electronic medical record or DNR lists in binders on crash carts. The facility's CPR policy required immediate assessment and initiation of CPR for Full Code residents, but staff were not adequately prepared to follow this protocol, resulting in a critical delay in emergency response for the resident.
Removal Plan
- Social Services Director and Director of Nursing completed full facility audit of DNR status to ensure all POLST forms are in place and match code status in PCC.
- Facility staff were educated on where resident code status is available via PCC as well as POLST binders located at each crash cart on each unit to quickly identify a resident's CPR/code status.
- Staff educated on facility's Code Blue Policy and process on what to do should a resident be found unresponsive and pulseless to ensure no delay in CPR.
- Education on Code Blue policy and POLST binders location on each crash cart to quickly identify code status has been included in facility new hire orientation process and annually for all staff.
- Education has been provided to all RNs, LPNs, and CNAs staff currently present in the facility and all staff not present in the facility, have been in-serviced over the phone and will be re-inserviced before the start of their next shift.
- Emergency QA meeting conducted with facility Medical Director.
- The Director Of Nursing/DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure staff is able to state facility's Code Blue Policy, how to quickly identify a resident's code status, and immediately initiate CPR as/when indicated.
- The DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure they are aware of the POLST binders located on each crash cart in the facility for quick identification of code status.
- Social Services will conduct audits of POLST binders, 2 times a week for 3 months, to ensure the binders are up to date with the latest POLST information.
Verbal Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a resident and a staff member. The incident began when a resident, concerned about their brother's oxygen concentrator, approached a staff member for assistance. The staff member, identified as V12, responded inappropriately by using profanity and expressing frustration. This interaction escalated when the resident reported the issue to other staff members at the nurses' station, and V12 continued to use inappropriate language and behavior towards the resident. Multiple staff members, including nurses and a CNA, witnessed the altercation at the nurses' station. Despite attempts by other staff to de-escalate the situation, V12 persisted in using profanity and refused to step back when instructed. The facility's camera footage corroborated the accounts of the staff, showing V12 approaching the resident and engaging in a verbal confrontation. The resident expressed feeling unsafe when V12 was present, indicating the impact of the verbal abuse on their sense of security. The facility's investigation concluded that V12's behavior was unprofessional and constituted verbal abuse. The facility's policy affirms the right of residents to be free from abuse, and this incident was a clear violation of that policy. The report includes interviews with the involved parties and witnesses, as well as a review of the facility's camera footage, which all supported the finding of verbal abuse by V12.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving two residents. Resident 1 (R1) wandered into another resident's room and began taking food from trays. During this interaction, Resident 2 (R2) pushed R1, causing her to fall and sustain a small laceration on her right eyebrow. The incident report did not initially identify R2 as the resident who pushed R1. The facility's preliminary investigation noted an allegation of physical abuse involving R1 and R2. Observations and interviews conducted on 5/20/24 revealed that R1 had a scabbed laceration on her right eyebrow and bruising on her forehead and shoulder. R1 reported being pushed by a man, which caused her to fall and injure her right leg. A housekeeper, V8, witnessed the incident and confirmed that R2 pushed R1 with significant force, resulting in R1 hitting her head on the floor. The facility's abuse prevention policy requires that resident-to-resident altercations be reviewed as potential abuse situations, especially when they result in physical injury.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to adequately assess and monitor a resident for 72 hours following a fall in which the resident hit her head. This deficiency was identified for one resident in a sample of eight reviewed for quality of care. On May 8, 2024, the resident experienced a fall in front of her bathroom door and reported hitting her head. The Director of Nursing confirmed that post-fall procedures, including vital signs and neurological checks, were not completed for the required 72-hour period following the incident. The resident's fall report documented initial vital signs, but subsequent monitoring and documentation were not conducted as per the facility's policy, which mandates 72 hours of documentation by all three shifts after an incident.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to ensure a resident room was free from pests, specifically cockroaches, for one of the residents reviewed. On multiple occasions, staff and residents reported the presence of cockroaches in the room, with one resident showing the surveyor a hole in the bathroom wall where the pests were entering. Despite claims of spraying, the infestation persisted, and no efforts were made to seal the room or repair the hole. The Maintenance Director acknowledged awareness of the issue but had not taken steps to address it or communicated the problem effectively with other staff members. The facility's Pest Control policy, last revised on 9/1/22, mandates that employees promptly report pest observations and ensure all building openings are tight-fitting and free of breaks. However, this policy was not followed, as the maintenance request book did not contain recent reports of the roach problem, and the issue remained unresolved for weeks. The resident affected by the infestation had not been offered relocation to another room, and the problem continued to impact their living conditions.
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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