Elevate Care Windsor Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2649 East 75th St, Chicago, Illinois 60649
- CMS Provider Number
- 145970
- Inspections on file
- 43
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Elevate Care Windsor Park during CMS and state inspections, most recent first.
The facility failed to maintain adequate nurse and CNA staffing on multiple floors and shifts, resulting in delayed medication administration and delayed response to resident care needs. On several day and evening shifts, only one nurse or fewer nurses than scheduled were present at the start of the shift, causing 9:00 AM and 5:00 PM medications to be given outside the expected time windows. A resident with multiple comorbidities and intact cognition reported frequently receiving medications, including Gabapentin for leg pain, several hours late and described significant pain when doses were delayed. On high-census shifts, CNAs were assigned to care for 19–25 residents each, including many requiring total care and mechanical lifts, leading staff to prioritize basic rounds, incontinence care, call lights, and feeding while other tasks such as grooming, getting residents out of bed, and timely changes were not consistently completed. Staff, including the DON and an advanced practice nurse, acknowledged that these staffing levels were insufficient and that the facility lacked a formal staffing policy.
Nursing staff, including an RN and multiple LPNs, repeatedly failed to administer medications within the accepted one-hour before/after window of physician-ordered times for eight residents with conditions such as COPD, heart failure, diabetes, PVD, seizures, dementia, and chronic pain. Staff reported being the only nurse on a unit, covering extra assignments, arriving late, and being unable to complete 9:00 AM med passes on time. MARs and audit reports showed frequent late administration and some omitted doses of pain medications (e.g., Gabapentin, Lidocaine patch), psychotropics, anticonvulsants (e.g., Divalproex, Levetiracetam), antihypertensives (e.g., Metoprolol, Carvedilol), antidiabetics (e.g., Metformin, insulin), antibiotics (Bactrim), and respiratory meds (Advair, Albuterol, Symbicort). Cognitively intact residents reported not receiving medications as scheduled and experiencing significant pain, while the DON and NP confirmed that such late administration violates the facility’s policy and physician orders.
Two residents experienced repeated medication errors when nurses failed to administer multiple ordered medications within the facility’s required time window and, in some cases, did not administer them at all. One resident with diabetes, peripheral vascular disease, and respiratory issues repeatedly received late doses of Gabapentin, Advair, and Albuterol, and reported severe leg pain when Gabapentin was delayed. Another resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a scheduled lidocaine pain patch and had missing doses of Jardiance and Gabapentin during a late morning med pass, while still receiving other oral medications and an inhaler. Nursing staff and the DON acknowledged that medications are expected to be given within one hour before or after the ordered time and that late or omitted doses are not in accordance with physician orders, despite a facility policy requiring safe, timely administration and adherence to the five rights of medication administration.
A resident with hemiplegia and other comorbidities, who required a full-body mechanical lift for transfers and had intact cognition, was transferred from a shower bed to a mechanical lift in a hallway rather than in the room. A CNA used a sling that had been left under the resident from a prior shift and did not identify that its straps were worn before initiating the transfer. While the resident was suspended in the air near the bedroom doorway, the sling’s foot straps broke, causing the resident to fall to the floor, resulting in leg swelling, pain, and fear of subsequent transfers. An LPN who assisted confirmed the sling strap broke during the transfer, and facility leadership and the restorative nurse acknowledged that staff are trained and expected to inspect slings for wear and remove damaged equipment from use, consistent with facility policy and the lift manufacturer’s instructions.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with a history of repeated falls and cognitive impairment experienced an unwitnessed fall while pushing a wheelchair, resulting in transfer to the hospital. The fall was not reported to the DON or restorative nurse by the agency LPN involved, and as a result, no investigation or care plan update occurred. Staff responsible for the falls program were unaware of all the resident's falls, contrary to facility policy requiring post-fall investigations and care plan interventions.
A resident with significant immobility and incontinence was admitted with an unstageable sacral pressure ulcer and was identified as high risk for further skin breakdown. Despite physician orders for daily wound care and the use of a moisture barrier cream every shift, observations and record reviews showed that wound dressings were not changed as ordered and the moisture barrier was not consistently applied or documented. The wound increased in size and became infected, with cultures confirming the presence of multiple organisms.
A resident with a complex medical history, including a CRE-positive sacral wound, did not have contact isolation precautions implemented as required. Staff, including an LPN and a CNA, entered the room and provided care wearing only gloves and not gowns, and there was no signage or PPE supplies at the room entrance. Facility staff were aware of the wound culture results but did not ensure timely implementation of precautions, contrary to facility policy.
Two residents with histories of aggression engaged in a physical and verbal altercation during an unsupervised smoking break, resulting in one resident being struck and another having milk thrown at them. Staff were not present outside to supervise, and the incident was only addressed after it occurred, contrary to facility policy prohibiting abuse and neglect.
A facility failed to administer prescribed anticonvulsant medication, Dilantin, to two residents with seizure disorders, resulting in sub-therapeutic levels and missed doses. One resident experienced seizures after missing a dose, while another had their medication misplaced and not administered as ordered. The staff did not access the emergency medication supply, and the facility's policy for medication administration was not followed.
The facility failed to provide restorative services to four residents, including one with multiple sclerosis and another with rheumatoid arthritis, leading to emotional distress and unmet care needs. Despite assessments indicating the need for restorative care, residents did not receive consistent services due to a lack of scheduling and documentation.
A facility failed to provide proper oxygen therapy to residents, including one with misplaced nasal cannula leading to low oxygen saturation, another with undated oxygen tubing, and a third receiving incorrect oxygen concentration. These issues reflect non-compliance with physician orders and facility policies.
A resident was found to be receiving unnecessary psychotropic medications without documented gradual dose reductions or non-pharmacological interventions. The resident exhibited sedation and lethargy, with no documented behaviors justifying the medication use. The facility's psychiatric provider and pharmacy consultant acknowledged the inappropriate use of QUEtiapine for dementia-related behaviors, but the medication was not discontinued despite recommendations.
The facility failed to label food items in the refrigerator and freezer with storage and use-by dates, as observed during a survey. Four boxes of wild berry magic cup desserts and a package of cheese slices were found without proper labeling. The Director of Food Service confirmed that all kitchen staff are responsible for labeling food items to monitor their storage duration and prevent health risks to residents.
The facility failed to maintain proper coverage of outside trash dumpsters, as observed by a surveyor. Two dumpsters had missing parts of their lids, which are necessary to prevent trash from escaping and to deter animals. The Dietary Aide was unaware of who was responsible for maintenance, while the Director of Food Service indicated it was the housekeeping department's responsibility. The Director of Environmental Services acknowledged the issue and had previously informed the disposal service. The facility's policy requires dumpsters to be covered and the area to be litter-free.
The facility failed to maintain infection control by improperly storing a clean linen cart in the restroom of residents on Enhanced Barrier Precautions and not securely tying soiled linen bags before chute conveyance. Observations showed the cart was uncovered, and bags burst open in the laundry area, risking contamination. Staff confirmed these actions were against policy, highlighting the need for proper linen handling to prevent infection spread.
The facility failed to conduct care plan conferences, preventing residents and their families from participating in care plan development. This affected four residents with varying cognitive impairments, who were not invited to meetings or involved in their care plans. Documentation showed missing interdisciplinary team members and non-compliance with the facility's policy requiring quarterly reviews.
A facility failed to assist a resident with grooming, as observed when the resident had long fingernails with brown matter underneath. The resident, who has dementia and moderate cognitive impairment, expressed a desire for trimmed nails but did not receive the necessary assistance, contrary to the facility's policy on activities of daily living.
The facility failed to ensure Low Air Loss Mattresses were set correctly for several residents, affecting pressure ulcer prevention. Observations revealed discrepancies between residents' weights and mattress settings, despite guidelines requiring settings to match patient weights. This deficiency impacted residents with pressure ulcers and those at risk for skin integrity issues.
The facility failed to monitor personal refrigerator temperatures in residents' rooms, leading to expired food items and unsafe temperature levels. Staff interviews confirmed that maintenance and housekeeping were responsible for daily checks, but logs were outdated or missing, and temperatures were not within the safe range. This posed a risk of foodborne illness for cognitively intact residents.
The facility failed to maintain functional call lights, affecting four residents, including one who was visually impaired. Residents reported non-responsive call lights, requiring them to yell for assistance or pull cords from walls, posing safety risks. The Maintenance Director was unaware of the issues until informed by staff and surveyors, and the system was found to be old and malfunctioning.
A facility failed to obtain informed consent for a resident prescribed QUEtiapine Fumarate for dementia with behavioral disturbance. The consent form, dated months after the medication order, incorrectly listed the dosage and lacked necessary details. Staff interviews confirmed the requirement for informed consent before administering psychotropic medications, highlighting a lapse in adherence to facility policy.
The facility failed to store a bottle of lorazepam according to the manufacturer's instructions, affecting a resident. The lorazepam, which should have been refrigerated, was found in the medication cart's narcotics drawer. The LPN acknowledged the storage error upon observing the sticker indicating refrigeration was required. The facility's policy mandates that medications needing refrigeration be stored at specific temperatures, with controlled substances in a lock box within a refrigerator.
A resident with a history of falls and abnormal medication levels fell in the dining room, resulting in a hip fracture. The facility failed to implement its fall prevention policy, as staff did not provide adequate supervision or assistive devices. Despite being aware of the resident's high fall risk due to abnormal phenytoin and valproic acid levels, the staff did not monitor the resident closely, leading to the fall and subsequent injury.
The facility failed to maintain clean and functional shower rooms, affecting 195 residents. Observations showed broken tiles, missing fixtures, and cluttered spaces, despite staff claims of regular cleaning and maintenance. Interviews revealed a disconnect between policy and practice, with maintenance issues not promptly addressed.
The facility failed to provide adequate clean bed linen for its 197 residents due to a shortage of new linens and a malfunctioning washing machine. Observations showed empty linen carts and rooms across multiple floors, and staff interviews confirmed the lack of linens. The Administrator noted that a large order of sheets had not arrived, and the facility struggled to maintain linen stock. Facility policies on linen handling and equipment maintenance were not effectively followed.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, leading to a deficiency. The resident was not placed on EBP upon admission, and there was no EBP signage or PPE available outside the room. The occupational therapist and other staff were unaware of the wound, and the infection preventionist confirmed the absence of EBP measures. The Director of Nursing acknowledged the lapse in policy adherence, as the resident's condition was not included in the EBP list, and no EBP care plan was in place.
A resident with a stage 3 pressure ulcer was found lying on a low air loss mattress set at 280 lbs, higher than their actual weight of 182.2 lbs. This incorrect setting was confirmed by staff and contradicted the facility's policy, which requires mattress settings to match the resident's weight to prevent further skin damage.
The facility failed to maintain a properly functioning nurse call system, affecting four residents who required substantial assistance. Despite activating their call lights, the signals were not visible outside their rooms or at the nurses' station, leading to delays in receiving help. The maintenance director identified that the system needed updating, as the lights would not illuminate if the bathroom call light was accidentally bumped.
A facility failed to investigate and report an alleged incident of mental abuse involving a resident and a staff member. The resident reported feeling demeaned and that staff were ganging up against her after an interaction with a CNA. The facility administrator did not investigate further or report the incident to the IDPH, believing it was not reportable since the resident cursed at the staff first. This action violated the facility's abuse prevention procedures.
Inadequate Nurse and CNA Staffing Leading to Delayed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to ensure resident needs were met in a timely manner and medications were administered as ordered. On multiple occasions, nurse and CNA staffing on various floors and shifts fell below the facility’s usual staffing framework, resulting in delayed medication administration and delayed response to resident care needs. On one day shift, an LPN assigned to the first floor arrived around 10:14 AM to cover a 7-3 shift, causing some 9:00 AM medications on her assignment to be given after 10:00 AM. A registered nurse working that same day reported being the only nurse on the first floor at the start of the shift after another nurse called off, and stated that residents on the second set of rooms did not receive their 9:00 AM medications within the 8:00-10:00 AM window because of short staffing. A resident with diagnoses including chronic upper respiratory disease, congenital tracheal malformation, type 2 diabetes mellitus, morbid obesity, peripheral vascular disease, seizure disorder, schizophrenia, bipolar disorder, and anxiety reported often not receiving medications as scheduled, sometimes three hours late, and described one day when no medications were received until early afternoon. This resident, who receives Gabapentin for bilateral lower leg pain and has an intact cognition per MDS, stated that on a Saturday when the unit was short staffed and there was an emergency with another resident, his Gabapentin was not given on time and his pain level was eight out of ten. The RN confirmed that this resident’s standing 9:00 AM Gabapentin dose was administered around 11:15 AM and documented in the eMAR, outside the stated 8:00-10:00 AM window for 9:00 AM medications. The facility also failed to maintain adequate CNA staffing on several shifts. On one 7-3 shift with a census of 81 residents, only four CNAs worked on the second floor instead of the usual six, resulting in one CNA caring for approximately 19-20 residents, about half of whom required total care and three required a mechanical lift. That CNA reported prioritizing initial rounds, incontinence care, answering call lights, feeding residents, and passing out ice water, and stated that charting, nail care, shaving, and getting some residents who required a mechanical lift dressed or out of bed might not have been completed. Another resident with multiple comorbidities including partial traumatic amputation of the left lower leg, chronic venous hypertension with inflammation of both lower extremities, complex regional pain syndrome, dietary folate deficiency anemia, long-term insulin use, type 2 diabetes mellitus, long-term anticoagulant use, and chronic kidney disease, and who requires assistance with toileting, bathing, and transfers, reported that on a Saturday day shift there were only four CNAs working and that she had to wait a longer time for staff to respond to her call light and to be changed because staff were very busy. Additional staffing shortfalls occurred on other units and shifts. On one 3-11 shift on the third floor, only two nurses worked instead of the expected three, and an LPN reported that although all residents eventually received their 5:00 PM medications, some were administered outside the 4:00-6:00 PM timeframe due to the reduced staffing and the higher acuity of the dementia unit. On a separate 11-7 shift on the third floor, three CNAs worked instead of the usual four, with one CNA caring for 24-25 residents on the dementia unit and reporting that residents who wander and are at risk for falls could not all be watched and that residents had to wait longer to be changed if wet or soiled. On another morning, an LPN assigned to approximately 24 residents on the second floor arrived at 9:35 AM for a shift where 9:00 AM medications were to be given between 8:00-10:00 AM; by 10:01 AM she still had not completed the medication pass for all assigned rooms and acknowledged she would not be able to finish before 10:00 AM. The Director of Nursing and an advanced practice nurse both stated that inadequate staffing can delay medication passes, nursing assessments, accuchecks, and timely ADL care, and that CNA-to-resident ratios such as 1:20 and nurse shortages on heavier units like the locked dementia floor are problematic. The administrator reported that the facility does not have a staffing policy.
Widespread Failure to Administer Medications According to Physician-Ordered Times
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for timely medication administration for eight residents, resulting in repeated late or omitted doses. Nursing staff, including LPNs and RNs, reported being the only nurse on a unit, covering additional assignments, arriving late for shifts, and being unable to complete 9:00 AM medication passes within the accepted 8:00–10:00 AM window. One LPN stated that some 9:00 AM medications were given after 10:00 AM and acknowledged that late medications could mean residents’ pain or blood pressure were not well controlled. Another LPN reported arriving at 9:30 AM with no medications yet passed for her assignment and stated she would not be able to complete all 9:00 AM medications within the one-hour before/after window. Multiple residents experienced late administration of scheduled medications across several days, as documented in the MARs and medication audit reports. One resident with intact cognition and diagnoses including PVD, seizures, schizophrenia, COPD-related conditions, and diabetes reported often not receiving medications as scheduled, sometimes three hours late, and described a day when all medications were delayed until early afternoon. This resident’s records showed repeated late administration of Gabapentin for neuropathic pain, Advair and Albuterol for tracheal stenosis and shortness of breath, with doses scheduled for morning, afternoon, and evening frequently given several hours after the ordered times. Another cognitively intact resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a prescribed 6:00 AM Lidocaine patch and reported shoulder pain rated 8/10; the patch was not observed in place. The same resident’s 9:00 AM medications, including Bactrim DS for UTI, Hydroxychloroquine, Metformin, Symbicort, and Gabapentin, were administered after 11:00 AM, and some medications such as Empagliflozin and Gabapentin were not available and therefore not given. Additional residents with intact or impaired cognition and multiple chronic conditions also had late medication administration documented. One resident receiving psychotropic medications (Risperidone and Benztropine) and a bowel regimen had doses scheduled for 9:00 AM and 6:00 PM given several hours late on multiple days. Another resident with diabetes, hypertension, CKD, and anemia had Metoprolol, Metformin, Ferrous Sulfate, and Humalog insulin repeatedly administered beyond the ordered times, including insulin given well after the scheduled pre-meal time. A resident with neuropathic pain had Gabapentin doses scheduled three times daily administered late on several dates. Residents with seizure disorders and cardiovascular conditions had anticonvulsants (Divalproex, Levetiracetam), antihypertensives (Carvedilol), muscle relaxants (Baclofen), and other medications administered outside the one-hour before/after window, including one evening Levetiracetam dose given in the early morning of the following day. The DON and NP both stated that nurses are expected to follow the five rights of medication administration, that medications should be given within one hour before or after the ordered time, and that administration beyond this window is considered late and not following the physician’s order, consistent with the facility’s medication administration policy. The facility’s own policy on administration procedures for all medications, dated 10/25/14, requires medications to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Interviews with the DON and NP confirmed that medications given more than one hour outside the ordered time are considered late and not in accordance with physician orders. Despite this, the documented MARs and audit reports for all eight residents show a pattern of late administration and, in some cases, omitted doses due to unavailability of medications, affecting pain medications, psychotropics, anticonvulsants, antihypertensives, antidiabetics, antibiotics, and respiratory medications. These actions and inactions by nursing staff, combined with staffing and scheduling issues described by the nurses, led directly to the failure to provide pharmaceutical services in accordance with physician orders for the affected residents.
Failure to Ensure Timely and Complete Medication Administration for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically repeated late and omitted medication administrations for two residents with intact cognition and multiple chronic conditions. One resident reported frequently receiving medications up to three hours after scheduled times and described a day when all medications were delayed until early afternoon. This resident, admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, peripheral vascular disease, and other conditions, stated he receives Gabapentin for bilateral lower leg pain and reported experiencing pain at a level of eight out of ten when his Gabapentin was delayed. A registered nurse confirmed that on one day she was the only nurse on the unit due to another nurse calling off, and that she administered this resident’s 9:00 AM Gabapentin dose at approximately 11:15 AM, outside the facility’s stated 8:00–10:00 AM window for 9:00 AM medications. Record review for this resident’s physician orders, MARs, and medication audit reports showed multiple instances of late administration of respiratory and pain medications. On several dates, Advair inhaler doses ordered for 9:00 AM and 6:00 PM were given hours late, including a 6:00 PM dose administered at 10:50 PM. Albuterol tablets ordered three times daily were repeatedly given several hours after the ordered times, such as a 9:00 AM dose given at 12:06 PM and a 1:00 PM dose given at 4:19 PM. Gabapentin 600 mg ordered three times daily for neuropathy was also administered late on multiple occasions, including a 9:00 AM dose given at 12:13 PM, a 1:00 PM dose given at 4:19 PM, and doses ordered for 11:00 AM and 4:00 PM given in the mid-afternoon and late evening. The nurse practitioner stated that medications not given within one hour before or after the ordered time are considered late and not following the doctor’s order, and that pain medications not given as ordered could result in residents being uncomfortable and having mobility affected. A second resident, admitted with diagnoses including COPD, sleep apnea, hypertensive heart disease with heart failure, heart failure, type 2 diabetes mellitus, and rheumatoid arthritis, also experienced medication administration issues. During observation, an LPN who had arrived late for her shift stated that none of the medications on her set had been passed yet and acknowledged she would not be able to complete all 9:00 AM medications within the 8:00–10:00 AM window. During a medication pass, the LPN prepared and administered multiple oral medications and an inhaler to this resident but stated that Empagliflozin (Jardiance) and Gabapentin were not available and therefore were not given. The resident, alert and oriented, reported not receiving her ordered 6:00 AM lidocaine pain patch to the left shoulder and rated her shoulder pain as eight out of ten; observation confirmed there was no pain patch in place. Review of this resident’s MAR and physician orders showed scheduled medications including a daily lidocaine patch at 6:00 AM, Bactrim DS twice daily for UTI, Hydroxychloroquine, Metformin, Symbicort inhaler twice daily, and Gabapentin three times daily for pain. The DON and nursing staff stated that medications are expected to be given within one hour before or after the ordered time, that late administration beyond this window is considered not following the doctor’s order, and that pain, hypertensive, diabetic, and antibiotic medications must be given timely as ordered. The facility’s policy on administration procedures for all medications, dated 10/25/14, states that medications are to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Despite this policy, the documented late administrations, missed doses due to unavailability, and failure to apply an ordered pain patch demonstrate that the facility did not consistently follow ordered times and the five rights of medication administration for these residents. Staff interviews, resident statements, and medication records collectively show that the facility did not ensure residents were free from significant medication errors related to timing and omission of ordered medications.
Failure to Inspect Mechanical Lift Sling Leads to Resident Fall During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a mechanical lift and to follow its fall prevention and transfer policies for one resident. The resident had medical diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, essential hypertension, type 2 diabetes mellitus, obesity, and peripheral vascular disease, and required a full-body mechanical lift for transfers. The resident’s cognition was intact, with a BIMS score of 15. On the day of the incident, the resident was transferred from a shower bed to a mechanical lift in the hallway outside the resident’s room, rather than in the room, after receiving a shower. According to progress notes and staff interviews, a CNA placed the resident in the mechanical lift and began the transfer toward the resident’s bed. The CNA reported that the resident had been on a sling that was already under the resident from an earlier shift and that she did not realize the sling was defective. The CNA stated she did not notice the worn-out strap before attempting the transfer. While the resident was suspended in the air on the mechanical lift near the doorway to the resident’s room, the foot straps of the mechanical lift sling broke, causing the resident to fall to the floor on her buttocks and one leg. A nurse who came to assist reported that the resident was already on the lift when she arrived, that the sling strap broke during the transfer, and that she did not know whether the CNA had assessed the sling for wear and tear before use. The resident reported that the CNA told her the room was too congested and that the transfer to the lift would be done in the hallway. The resident stated that after being lifted, the CNA said something did not feel right and sought help, at which point an LPN came to assist, and then the sling strap broke and the resident fell. The resident described falling on one leg and her buttock, experiencing swelling in her left leg and ongoing pain after the fall, and feeling frightened whenever staff transfer her. The restorative nurse stated that staff are trained to inspect mechanical lift slings for wear and tear and that the sling should have been inspected prior to placing it under the resident and before the transfer. The DON stated that a quick inspection of the mechanical lift sling could have prevented the fall and confirmed that the mechanical lift is for transfers and not for transporting residents, and that moving the resident from the hallway to the bed in this manner would be considered transporting. The facility’s policies and the lift manufacturer’s manual require inspection of slings for damage and removal of malfunctioning equipment from service, which was not done in this case, resulting in the resident’s fall from the mechanical lift.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Investigate Resident Fall and Update Care Plan
Penalty
Summary
The facility failed to investigate a fall experienced by a resident with a history of repeated falls and spinal stenosis, who also had some cognitive impairment as indicated by a BIMS score below 10. The resident was able to answer surveyor questions appropriately during the survey. According to progress notes, the resident fell in the hallway while pushing a wheelchair, and the fall was unwitnessed. The resident was transferred to the hospital per physician's request, with no observable injuries except for redness on areas impacted by the fall. The resident reported having had four falls at the facility, with the most recent occurring in the bathroom with staff present but unable to prevent the fall. The resident recalled a fall in June but could not remember exact dates. Interviews with facility staff revealed that the restorative nurse and DON, who oversee the falls program, were only aware of two falls, not the third fall documented in the progress notes. The restorative nurse stated that fall investigations are conducted and care plans updated with interventions after each fall, but was unaware of the third fall until reviewing the notes during the survey. The DON confirmed that the agency LPN who documented the fall did not notify either the DON or the restorative nurse about the incident, and described the LPN as substandard and no longer permitted to work at the facility. Facility policy requires fall risk assessments and investigations after each fall, with interventions to be added to the care plan, but this process was not followed for the resident's fall on the specified date.
Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
A resident with a history of hemiplegia, aphasia, dysphagia, acute respiratory failure, and an unstageable sacral pressure ulcer was admitted to the facility and identified as high risk for pressure wounds, with a Braden Score of 12. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The care plan included the use of a moisture barrier cream with zinc after each incontinent episode and daily wound treatments as ordered by the physician. Despite these orders, observations and record reviews revealed that wound care and dressing changes were not performed as prescribed. On observation, the resident's wound dressing was found to be dated four days prior, despite a daily dressing change order. The wound was noted to have increased in size and showed signs of infection, with cultures later confirming the presence of Proteus mirabilis and CRE. The Treatment Administration Record (TAR) showed multiple dates where the application of the moisture barrier cream was not documented as completed, indicating missed treatments. Interviews with nursing staff, the wound care director, the nurse practitioner, and the wound physician confirmed that wound care and dressing changes were not consistently performed or documented as required. Staff acknowledged that failure to provide and document these treatments could lead to wound deterioration and infection, which was observed in this case as the resident's wound worsened and became infected.
Failure to Implement Contact Precautions and Provide PPE for Resident with CRE-Positive Wound
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident with multiple complex medical conditions, including a sacral pressure ulcer that tested positive for CRE (Carbapenem-resistant Enterobacteriaceae) and other organisms. Despite the resident's wound culture result indicating the need for contact isolation precautions, there was no order for transmission-based precautions or contact isolation in the physician order sheet, and enhanced barrier precautions were only noted for wounds and G-tube care. Observations revealed that the resident's room lacked required signage for transmission-based precautions, and there was no isolation setup or PPE supplies accessible at the room entrance. Staff members, including an LPN and a CNA, were observed entering the resident's room wearing only gloves and not donning gowns as required for contact precautions. The CNA provided direct care, including changing an incontinence brief and repositioning the resident, without proper PPE. Interviews with facility staff, including the infection preventionist and the director of nursing, confirmed awareness of the wound culture results and the necessity for contact isolation precautions, but these measures were not implemented in a timely manner. The infection preventionist acknowledged that the resident should have been transferred to a single room and that proper signage and PPE should have been in place immediately upon receipt of the culture results. The facility's own infection precaution guidelines require the use of transmission-based precautions, including contact precautions for residents with infections that can be transmitted by direct or indirect contact. The guidelines also specify the need for signage and PPE availability at the room entrance. The failure to follow these protocols resulted in staff providing care to the resident without proper PPE and without clear communication of the required precautions, creating the potential for cross-contamination among other residents assigned to the same staff.
Failure to Prevent Resident-to-Resident Abuse During Unsupervised Smoking Break
Penalty
Summary
Two residents were involved in a physical and verbal altercation during a smoking break on the facility's patio. Both residents have documented histories of aggression and combative behavior, as indicated in their care plans and abuse risk reviews. During the incident, one resident hit the other in the face, and the other retaliated by throwing an open milk carton, resulting in milk being spilled. Both residents exchanged insults and physical contact, with no staff present outside at the time to supervise the interaction. The altercation was only addressed after it had occurred, when a psychosocial aide/social service assistant intervened. The incident was not reported to the police, and one of the residents was sent to the hospital for evaluation. Both residents have intact cognition, as shown by their BIMS scores, and have diagnoses including schizophrenia, major depressive disorder, chronic obstructive pulmonary disease, and end stage renal disease. The facility's policy affirms residents' rights to be free from abuse and neglect, but the lack of staff supervision during the smoking break allowed the altercation to occur without immediate intervention.
Failure to Administer Anticonvulsant Medication
Penalty
Summary
The facility failed to provide prescribed anticonvulsant medication, Dilantin, to a resident diagnosed with a seizure disorder, resulting in sub-therapeutic levels and missed doses. Resident R444, who is cognitively intact, reported missing a dose on the night of 3/1/25 due to the facility running out of the medication, which led to two seizures the following morning. The emergency medication supply had doses available, but the staff did not access it, and the nurse on duty did not have access to the emergency medication dispenser. Additionally, another resident, R15, who also has a seizure disorder, did not receive their prescribed Phenytoin suspension as the medication was not located in the cart. The medication was found on the resident's dresser, and the nurse confirmed it was prescribed for R15. The resident's Phenytoin levels were consistently low, and the medication was not administered as ordered, leading to sub-therapeutic levels. The facility's policy requires medications to be administered as prescribed and to contact the pharmacy or use the emergency kit if a medication is unavailable. However, the staff failed to follow these procedures, resulting in missed doses and low therapeutic levels for both residents, increasing the risk of seizures.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide necessary restorative services to four residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Resident R445, who is cognitively intact and diagnosed with multiple sclerosis and other conditions, expressed emotional distress due to the lack of therapy or restorative services since her admission two weeks prior. Despite being assessed for restorative services, R445 was not added to the restorative list, and there was no schedule in place to ensure she received the necessary care. Resident R59, with diagnoses including rheumatoid arthritis and contractures, reported not receiving passive range of motion exercises for about a week. The restorative aide, V29, mentioned that R59 seemed to be in pain during exercises, but R59 clarified that she never refused exercises due to pain. The lack of consistent restorative services was further highlighted by the absence of a structured schedule and documentation of services provided. Resident R88, who requires assistance for range of motion exercises, and R85, who was recently discharged from therapy to restorative care, also experienced lapses in receiving restorative services. R85, in particular, noted that restorative staff did not accommodate his dialysis schedule, resulting in missed exercises. The facility's policy mandates individualized restorative programs with documented interventions, but the lack of documentation and adherence to care plans contributed to the deficiency.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide continuous supplementary oxygen to a resident, resulting in an oxygen saturation level of 89%. The resident, who has chronic obstructive pulmonary disease and other serious health conditions, was found with a nasal cannula hanging from their ear instead of being properly placed in the nostrils. This incident occurred despite the resident's care plan requiring continuous oxygen at 3 liters per minute. The resident expressed difficulty in breathing and had attempted to call for help, indicating that the nasal cannula had been misplaced for some time. Another resident was found with oxygen tubing that was not dated, contrary to the facility's policy which requires labeling of respiratory equipment with the date of use. The resident's physician order required continuous oxygen at 4 liters per minute, and the facility's policy mandates weekly changes of oxygen tubing to prevent infection. However, the Director of Nursing admitted that the tubing was not dated due to a lack of space for writing the date, although the water canister was dated. Additionally, a third resident was receiving oxygen at a higher concentration than prescribed. The resident's physician order specified oxygen at 2 liters per minute, but the oxygen concentrator was set to deliver 4 liters per minute. The Director of Nursing was unsure of the correct setting and the resident confirmed that they did not adjust the oxygen themselves. This discrepancy highlights a failure to adhere to physician orders and facility policies regarding oxygen delivery.
Failure to Implement Gradual Dose Reductions for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R58, was free from unnecessary psychotropic medication use and did not complete gradual dose reductions (GDR) as required. This failure resulted in harm to R58, who exhibited symptoms of sedation. Observations noted that R58 was difficult to arouse, appeared lethargic, and had unclear speech. The resident's care plan did not document any non-pharmacological interventions attempted prior to the administration of psychotropic medications, and there was no evidence of targeted behaviors that would justify the use of such medications. R58 was prescribed QUEtiapine Fumarate for dementia with behavioral disturbance and Sertraline for hypersexuality. However, the facility's records did not document any abnormal or targeted behaviors from October 2025 to March 2025. The facility's psychiatric provider, V34, acknowledged that QUEtiapine is not approved for dementia-related psychosis and that the medication can have sedative effects. Despite this, the provider continued the prescription, citing a lack of alternative treatments for dementia-related aggression. The facility's pharmacy consultant, V31, confirmed that the use of QUEtiapine for dementia with behaviors and hypersexuality was inappropriate and had recommended discontinuation of the medications, which was denied by the provider. The facility's policy on psychotropic medication and GDR was not followed, as evidenced by the lack of documented attempts to reduce the medication dosage. The failure to adhere to these protocols resulted in R58 experiencing sedation and being at increased risk of adverse effects from the medication.
Failure to Label Food Items in Storage
Penalty
Summary
The facility failed to ensure that food items stored in the refrigerator and freezer were labeled with the date they were placed into storage and a use-by date. During an observation of Walk-in Freezer #1, four boxes of wild berry magic cup desserts were found without any labeling indicating when they were stored or their use-by date. Similarly, in the walk-in refrigerator, a package of yellow pasteurized process American cheese slices was observed without any date labeling. These labeling omissions were noted during a survey conducted in the presence of the Director of Food Service. The Director of Food Service acknowledged that all kitchen staff are responsible for labeling food items with the date of storage and a use-by date, as per the facility's expectations. The purpose of this practice is to monitor the storage duration of food items and ensure they are consumed or discarded in a timely manner to prevent potential health risks to residents. The facility's policy on food storage, although lacking a letterhead, mandates that all food items be labeled with the name of the food and the date by which it should be sold, consumed, or discarded. The Director of Food Service's job description includes supervising the receiving and storage of food, highlighting the importance of adherence to these labeling practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the outside trash dumpsters were properly covered, as observed by a surveyor on March 4, 2025. The facility has two green-colored outside trash dumpsters, each with a black plastic lid divided into three parts. It was noted that the first part of the black plastic lid was missing on both dumpsters. The Dietary Aide, V38, confirmed that the lids are necessary to prevent trash from flying out and to deter animals from accessing the dumpsters. However, V38 was unaware of who was responsible for maintaining the dumpsters. The Director of Food Service, V4, indicated that the housekeeping department was responsible, while the Director of Environmental Services, V18, acknowledged the missing lids and stated that they had informed the disposal service about the issue some time ago. The facility's policy requires outdoor trash receptacles to be covered and the surrounding area to be free of litter.
Infection Control Deficiencies in Linen Handling
Penalty
Summary
The facility failed to maintain proper infection control practices by storing a clean linen cart inside the restroom of residents on Enhanced Barrier Precautions (EBP). Observations revealed that the cart, containing washcloths, fitted sheets, and adult diapers, was uncovered and placed inside the restroom of two residents, one of whom was cognitively intact and the other moderately impaired. The facility's policy dictates that clean linen carts should be kept in hallways and covered to prevent contamination, as entering a resident's room or restroom renders the linens contaminated. Staff interviews confirmed that the presence of the cart in the restroom was against policy and posed a risk of contamination. Additionally, the facility failed to ensure that soiled linen bags were securely tied before being conveyed via a chute to the laundry department. During an interview and observation, it was noted that a bag of soiled linen burst open upon landing in the laundry area, spilling its contents onto the floor. Further inspection revealed that some bags were not tied, and a towel was found outside of a bag. The Director of Nursing acknowledged the issue and indicated a need for staff reeducation on securely tying bags to prevent contamination during transport. The facility's Linen Handling Principles emphasize the importance of securely tying soiled linen bags to prevent the spread of microorganisms. The failure to adhere to these guidelines resulted in potential contamination risks, as the air in the laundry area could become contaminated, affecting all residents who receive linens from the facility. The report highlights the need for proper handling and containment of both clean and soiled linens to maintain infection control standards.
Failure to Conduct Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences, which resulted in residents and their families not being able to exercise their right to participate in the development and implementation of their care plans. This deficiency affected four residents, each with varying levels of cognitive impairment. For instance, one resident with mild cognitive impairment expressed a desire to discharge from the facility but was unaware of any discharge plan within their care plan. This resident, along with others, denied being asked to participate in the development of their care plans or being invited to care plan conferences. The facility's documentation revealed that care plan meetings were not held as required, and key interdisciplinary team members were absent from the meetings that did occur. The facility's policy mandates that residents and/or their representatives be invited to review the care plan with the interdisciplinary team at least quarterly, but this was not adhered to. The facility's failure to follow its comprehensive care planning policy was acknowledged by the Director of Nursing, who admitted that care plan conferences were not being completed according to policy, and no documentation of corrective action was provided.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide necessary assistance with grooming for a resident, identified as R46, who was unable to perform this activity of daily living independently. On March 3, 2025, it was observed that R46 had long fingernails with brown matter underneath them. R46 expressed a preference for shorter nails and a desire to have them trimmed. Despite this, the facility did not provide the required assistance, which is a failure to adhere to the resident's care plan and the facility's policy on activities of daily living. R46 was admitted to the facility with multiple diagnoses, including dementia, which contributed to a self-care performance deficit. The resident's Minimum Data Set indicated moderate cognitive impairment, necessitating supervision or assistance with most activities of daily living. The facility's policy aims to promote residents' independence and includes grooming as a key component. However, the facility did not fulfill this policy requirement for R46, leading to the observed deficiency.
Improper Low Air Loss Mattress Settings for Residents
Penalty
Summary
The facility failed to ensure that the Low Air Loss Mattresses (LALM) for pressure ulcer prevention were set at the correct weight settings for several residents. This deficiency was identified through observation, interviews, and record reviews, affecting five residents out of nine reviewed for pressure ulcer prevention and treatment. The facility had a list of 33 residents on LALM, with weights recorded on March 3, 2025. However, discrepancies were found between the recorded weights and the mattress settings for multiple residents. One resident, admitted with multiple pressure ulcers and severe cognitive impairment, was observed with a mattress setting significantly lower than their recorded weight. Despite the care plan specifying the need for appropriate mattress settings, the setting was not adjusted correctly. Another resident, with a history of dementia and other health issues, had a mattress setting at zero while not in bed, contrary to the requirement for settings to match or be below the resident's weight. Similarly, other residents had mattress settings that did not align with their documented weights, indicating a systemic issue in maintaining proper mattress settings. The facility's guidelines and in-service training emphasized the importance of setting air mattresses to the patient's weight and not altering the settings. However, observations revealed that these guidelines were not consistently followed, leading to improper mattress settings that could compromise pressure ulcer prevention. The failure to adhere to these guidelines and ensure correct mattress settings for residents at risk of skin integrity issues represents a significant deficiency in care provision.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerator temperatures in residents' rooms, which is crucial to prevent foodborne illnesses. Observations revealed that temperature logs were either missing or outdated for several residents, and expired food items were found in the refrigerators. For instance, in one resident's room, the temperature log was absent, and expired food items were discovered. Another resident's refrigerator had a temperature log from a previous year, and expired milk was found inside. The facility's procedure requires daily temperature checks and logging, but these were not consistently performed. Interviews with staff, including an LPN and the Assistant Director of Nursing, confirmed that the maintenance and housekeeping departments were responsible for monitoring refrigerator temperatures. However, the logs were not up-to-date, and temperatures were not within the safe range of 38F to 41F, with one refrigerator registering at 60F. The residents involved were cognitively intact, as indicated by their BIMS scores, but the lack of proper temperature monitoring posed a risk of foodborne illness. The facility's guidelines stipulate that outdated food should be discarded, and any temperature deviations should be reported immediately, but these protocols were not followed, leading to the deficiency.
Non-Functional Call Lights Affect Resident Safety
Penalty
Summary
The facility failed to ensure that residents' call lights were functional and in good working order, affecting four residents. During observations, interviews, and record reviews, it was found that several residents, including one who was visually impaired, experienced non-functional call lights. One resident reported that no staff responded to his call light for several days, requiring him to yell for assistance. Another resident had to pull the call light cord out of the wall to get it to work, which was acknowledged by a Licensed Practical Nurse (LPN) as a potential safety risk. The facility's policy requires that call lights be available and accessible to residents at all times, and defects should be promptly reported to maintenance. The Maintenance Director was unaware of the call light issues until informed by staff and surveyors. The facility did not maintain a maintenance logbook at the nursing station, and staff were expected to call maintenance directly. The Maintenance Director later confirmed that the call light system was old and malfunctioning, requiring repairs. The facility's policy emphasizes the importance of responding to residents' requests in a timely manner, but the lack of a functional call light system hindered this process, leaving residents without a reliable means to request assistance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication for a resident, identified as R58, who was prescribed QUEtiapine Fumarate (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbance. The physician's order for this medication began on 9/17/2023, but the informed consent form, dated 1/11/2024, incorrectly documented the dosage as 25 mg and lacked details on diagnosis, benefits, targeted behaviors, and alternatives. This discrepancy was noted during a survey, and no other consent forms were provided for review. Interviews with facility staff, including the Nursing Supervisor (V20) and the Director of Nursing (V3), confirmed that informed consent is required before administering psychotropic medications. V20 acknowledged the inconsistency in the dosage listed on the consent form and was unaware of why the consent was not obtained timely, as the order was initiated before their tenure. V3 emphasized the importance of obtaining informed consent to ensure residents are aware of the risks and benefits of their medications. The facility's policy on psychotropic medication also mandates obtaining informed consent prior to administration.
Improper Storage of Lorazepam
Penalty
Summary
The facility failed to store a bottle of lorazepam in accordance with the manufacturer's instructions, affecting one resident in a sample of 65. The resident had a physician's order for Lorazepam 2mg/mL concentrate, which was discontinued on December 20, 2024. On March 4, 2025, a Licensed Practical Nurse (LPN) was observed withdrawing the resident's bottle of lorazepam from the medication cart's narcotics drawer. The bottle had a sticker indicating it should be stored in the refrigerator, which the LPN acknowledged. The manufacturer's instructions specify that lorazepam oral concentrate should be protected from light and stored at temperatures between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). The facility's policy on medication storage, dated May 1, 2018, also requires medications needing refrigeration to be stored at these temperatures, with controlled substances stored within a lock box in the refrigerator or a locked refrigerator near the nurses' station or in a locked medication room.
Failure to Implement Fall Prevention Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement its fall prevention policy, resulting in a resident, identified as R1, experiencing a fall that led to a closed fracture of the neck of the left femur. R1's clinical record indicated a history of falling, epilepsy, dementia, and other medical conditions, and R1 was assessed as a high fall risk. Despite this, the facility did not provide adequate supervision or assistive devices, and R1 fell while attempting to stand in the dining room, leading to hospitalization and surgical repair of the fracture. The report highlights that R1's phenytoin levels were supratherapeutic, and valproic acid levels were low, contributing to gait instability and the fall. The nursing staff was aware of R1's abnormal medication levels, which increased the risk of falls, yet failed to monitor R1 closely or provide necessary interventions. Interviews with staff and family members revealed that R1's medication levels had been problematic before, and the staff was aware of the need for close monitoring when levels were abnormal. The facility's fall prevention program was not effectively implemented, as evidenced by the lack of supervision and failure to communicate R1's high fall risk to all staff members. The report indicates that the nursing staff did not follow established safety regulations, and there was a lack of leadership in directing nursing assistants to monitor R1 closely. This oversight led to R1's fall and subsequent injury, highlighting deficiencies in the facility's fall prevention measures.
Deficient Shower Room Conditions in LTC Facility
Penalty
Summary
The facility failed to provide a home-like environment and maintain clean and sanitary shower rooms, potentially affecting 195 residents. Observations revealed multiple issues in the shower rooms across different floors, including wet and used towels on the floor, broken floor tiles, missing shower fixtures, and cluttered spaces with equipment obstructing pathways. These conditions were observed despite staff claims that shower rooms are cleaned daily and after each use. Interviews with various staff members, including LPNs, CNAs, and the Director of Environmental Services, indicated that there is a system in place for reporting and addressing maintenance issues. However, the maintenance director acknowledged that repairs depend on the availability of parts and that monthly equipment rounds do not include checking shower rooms. Despite signs indicating some showers were temporarily out of service, staff stated that all shower rooms were still in use, and residents continued to use them despite the broken and cluttered conditions. The facility's policies and job descriptions for the Director of Environmental Services and Maintenance Director emphasize maintaining a clean, safe, and comfortable environment. However, the observations and interviews suggest a disconnect between policy and practice, as the shower rooms remained in disrepair and unclean. The facility's assessment tool highlights the importance of maintaining physical resources and equipment to ensure resident safety and comfort, yet the observed conditions indicate a failure to meet these standards.
Inadequate Linen Supply Due to Equipment Malfunction and Stock Shortage
Penalty
Summary
The facility failed to ensure the availability of adequate clean bed linen for its 197 residents due to an inadequate supply of new bed linens and a malfunctioning laundry machine. Observations on multiple floors revealed that clean linen carts and linen rooms were devoid of sheets. The basement supply storage room also lacked new bed linens, and one of the three washing machines in the laundry room was not functioning, contributing to the shortage of clean linens. Interviews with staff, including CNAs, the Housekeeping Manager, and the Laundry Aide, confirmed the absence of linens on the floors and the lack of new stock. The Administrator acknowledged the issue, stating that a large order of sheets had not yet been delivered and that the facility had been experiencing difficulties maintaining an adequate stock of linens. The facility's policy on Preventative Maintenance Laundry and Linen Handling Principles was not effectively implemented, as evidenced by the failure to maintain adequate linen supplies and ensure timely repairs of laundry equipment.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement their Enhanced Barrier Precaution (EBP) policy and procedures by not placing a resident with a pressure wound on EBP, which is intended to prevent the potential spread of multidrug-resistant organisms. This deficiency was identified during a survey when a resident, who had a stage 3 pressure ulcer on the sacral region, was not placed on EBP upon admission. The resident was readmitted to the facility, and despite having a documented wound, there was no EBP sign or personal protective equipment (PPE) available outside the resident's room. The occupational therapist, who interacted with the resident, was unaware of the wound and did not observe any EBP signage or PPE bin, indicating a lapse in communication and procedure adherence. The wound care nurse and infection preventionist confirmed the absence of EBP measures, acknowledging that the resident should have been placed on EBP due to the presence of a wound. The infection preventionist noted that the process involves checking new admissions for EBP requirements, but this was not done in a timely manner for the resident in question. The Director of Nursing confirmed that the facility's policy requires residents with wounds to be on EBP, with appropriate signage and PPE readily available. However, the resident's condition was not included in the EBP list, and there was no EBP care plan in place for the resident. This oversight resulted in a delay in implementing necessary precautions, as the enhanced barrier precaution was ordered three days after the resident's admission.
Improper Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately for a resident with a pressure ulcer. During an observation, it was noted that the mattress was set at 280 lbs, which was higher than the resident's actual weight of approximately 182.2 lbs. This discrepancy was confirmed by a Certified Nursing Assistant and an Agency RN, who both verified the incorrect setting. The Wound Care Nurse explained that the mattress setting should be adjusted to the resident's weight to prevent further skin damage, and a higher setting could make the mattress firmer, increasing pressure on the resident's skin. The resident in question had a documented diagnosis of a stage 3 pressure ulcer in the sacral region and was assessed as having a moderately impaired mental status. The facility's pressure injury prevention policy emphasized the importance of setting the low air loss mattress to the appropriate weight to prevent skin breakdown. Despite this policy, the resident's mattress was not set correctly, potentially compromising the effectiveness of the pressure-relieving device intended to aid in the resident's care.
Deficiency in Nurse Call System Functionality
Penalty
Summary
The facility failed to ensure that the nurse call system was properly functioning for four residents, leading to a deficiency in the availability of a working call system in each resident's bathroom and bathing area. During the investigation, it was observed that the call lights for these residents were not illuminating outside their rooms or at the nurses' station, despite being activated. This issue was noted for residents who required substantial assistance with daily activities, including toileting, dressing, and transferring. For instance, one resident was found sitting in bed crying out for help, and although the call light was activated, it was not visible outside the room or at the nurses' station. The maintenance director later identified that the call light system required updating, as the lights outside the bedrooms and at the nurses' station would not illuminate if the bathroom call light had been accidentally bumped. This malfunction resulted in residents being unable to effectively communicate their need for assistance, as evidenced by multiple residents expressing their need for help and medication without receiving timely responses. The facility's policy mandates that call lights be answered promptly and any defects reported to maintenance, but this was not adhered to, contributing to the deficiency.
Failure to Investigate and Report Alleged Mental Abuse
Penalty
Summary
The facility failed to investigate and report an alleged incident of mental abuse involving a resident (R1) and a staff member (V8). R1, who has intact cognitive function as indicated by a BIMS score of 15/15, reported feeling demeaned and that staff were ganging up against her after an interaction with V8. R1 requested assistance from V8 to clean her back, but V8 responded in a manner that R1 perceived as mean and dismissive. R1 felt demeaned and cursed at V8. The facility administrator (V7) acknowledged the incident but did not investigate further or report it to the Illinois Department of Public Health (IDPH), as she believed the incident was not reportable since R1 cursed at the staff first. The facility's policy on abuse prevention requires all incidents to be documented and investigated, with a final investigation report submitted within five working days. However, V7 did not follow this policy, as she did not conduct a thorough investigation or report the incident to the appropriate authorities. Instead, the incident was only logged in the concerns log. Additionally, V7 attempted to address R1's distress by involving a family member in a call, but this did not resolve the issue, and R1 remained upset. The facility's failure to investigate and report the alleged mental abuse is a clear violation of their own abuse prevention procedures.
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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