Foster Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2840 West Foster Avenue, Chicago, Illinois 60625
- CMS Provider Number
- 146167
- Inspections on file
- 31
- Latest survey
- December 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Foster Health & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and intact cognition was verbally abused by an escort during a clinic visit, as witnessed by two clinic staff. The facility failed to provide required abuse prevention training to the escort, did not report the abuse allegation to IDPH within the mandated timeframe, and did not follow its own abuse prevention policy, resulting in a failure to protect the resident's rights.
A resident with significant mobility and medical needs was placed in a wheelchair that was too small and unstable for transport, resulting in a fall and prolonged distress. The facility did not follow its own incident reporting and investigation policy, failed to document the event, and did not reassess the resident or ensure proper wheelchair fit, as confirmed by staff interviews and record review.
A resident with cerebral palsy and other neurological conditions began experiencing new, severe spastic movements, representing a change from baseline. Despite this, the care plan was not updated to include new interventions or address the exacerbation until it was identified during survey review.
A resident with visual impairment experienced repeated hair-pulling by another resident, leading to feelings of fear and unsafety. Despite documentation of these incidents, the facility staff failed to report them promptly and did not implement adequate measures to prevent further abuse. The care plans lacked interventions to address the aggressive behavior, and the facility's abuse policy was not effectively enforced.
A resident with visual impairment reported repeated hair-pulling by another resident, which was not immediately reported or investigated by the facility staff as required by their abuse policy. Despite documentation of the incidents, the facility administrator and a registered nurse failed to report the abuse to the Department of Public Health within the mandated timeframe, highlighting a deficiency in the facility's adherence to its abuse policy.
A resident with visual impairment reported repeated hair-pulling incidents by another resident, leading to feelings of unsafety. Despite the facility's abuse policy requiring immediate reporting and investigation, staff failed to report and investigate the incidents promptly. The facility lacked a designated abuse coordinator during weekends, contributing to the delay in addressing the issue.
A resident with visual impairment and mental health diagnoses experienced repeated aggression from another resident, including hair-pulling and room intrusion, causing fear and distress. Despite documentation of these incidents, the facility failed to update care plans or implement safety measures, violating their Behavioral Assessment policy. The administration acknowledged the issue but did not take timely action to protect the affected resident.
The facility failed to properly label, date, and store food items, adhere to FIFO guidelines, and ensure kitchen staff wore appropriate hair coverings. Several opened food items lacked proper labeling, and dry storage items were not organized according to FIFO. The dietary manager acknowledged these lapses, and the registered dietitian highlighted the risk of serving expired food. Additionally, a cook was observed without a beard protector, violating the facility's policy on hair coverings.
The facility failed to implement proper infection control measures, including the absence of Enhanced Barrier Precautions signage for two residents with wounds, lack of annual review of infection control policies, and inadequate measures to prevent Legionella growth. Additionally, improper linen handling was observed, with staff failing to follow hand hygiene protocols, potentially leading to the spread of bacteria.
The facility failed to complete comprehensive MDS assessments within regulatory timeframes for 13 residents. An LPN acknowledged the failure to adhere to RAI guidelines, which require timely completion of admission and annual MDS assessments. This systemic issue in the assessment process could impact resident care quality.
The facility failed to complete MDS assessments within the required timeframes, potentially affecting 13 residents. The MDS/Care Plan coordinator, an LPN, acknowledged the late completion of assessments, citing personal illness as a contributing factor. This deficiency involved not adhering to CMS RAI guidelines, which require quarterly MDS assessments to be completed no later than 14 days after the ARD.
The facility did not ensure that MDS assessments for seven residents were certified by an RN, as required. Instead, an LPN signed off on these assessments, which are essential for evaluating residents' ADLs, cognitive function, and other health indicators.
The facility failed to develop comprehensive care plans for residents, missing crucial details such as code status and medication use. Several residents, including those with severe cognitive impairment and on psychotropic medications, lacked care plans addressing their needs. Additionally, a resident reported not receiving anticonvulsant medication, with no care plan in place for its use. This deficiency violates the facility's policy requiring person-centered care plans developed by the interdisciplinary team.
The facility failed to secure the emergency crash cart, leaving it unlocked and accessible in a hallway. The cart contained IV kits, needles, and other medical supplies, posing a safety risk to 19 ambulatory residents. The DON acknowledged the lack of a functional lock and the ongoing process to obtain a new one, while the facility's policy requires the cart to be locked at all times.
The facility failed to conduct monthly medication regimen reviews for residents on psychotropic medications. The DON confirmed that MRRs should be done monthly by a pharmacist, but no documentation was available for several residents. This included a resident with multiple diagnoses on medications like Fluoxetine and Valproic Acid. The facility's policy on psychotropic drugs was not followed, and the policy itself was not provided when requested.
The facility failed to label multi-dose inhalers with opened dates for four residents and stored expired Famotidine in the medication cart. The inhalers, including Breo, Incruse, Advair, and Fluticasone Furoate, lacked opened dates, violating the facility's medication storage policy. Additionally, expired Famotidine was found in the cart, contrary to the policy requiring disposal by expiration.
The facility failed to provide therapeutic diets as prescribed by physicians for several residents, leading to discrepancies between prescribed and served diets. A resident on a No Concentrated Sweets diet received a mechanical soft diet, while another on a renal diet was served regular meals. Additionally, there were inconsistencies in liquid consistencies served to residents requiring specific textures. These issues arose from poor communication and documentation between nursing and dietary departments.
A resident with multiple health issues and a high fall risk was found without a call light within reach, despite facility policies and care plans requiring it. The call light was on the roommate's side, with a string too short to reach the resident. Staff confirmed the deficiency, highlighting the importance of call light accessibility for resident safety.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the resident's POLST form indicating DNR status and facility records showing FULL CODE. The resident, with severely impaired cognition, had no care plan for advance directives, and the POLST form was missing from the nursing station binder. Staff interviews revealed the importance of consistent documentation to respect resident preferences, highlighting a lapse in maintaining accurate records.
The facility failed to conduct required Level 2 PASARR screenings for two residents with mental and intellectual disabilities. One resident, admitted with bipolar disorder, lacked documentation for a Level 2 PASARR evaluation, while another resident's record showed no PASARR documentation despite multiple diagnoses. The facility relied on hospital staff for PASARR checks, contrary to their policy requiring screenings prior to admission.
The facility experienced a 14.29% medication error rate due to several incidents involving three residents. A nurse was unable to administer prescribed insulin to a resident due to its unavailability. Another resident did not receive a prescribed nasal spray, and a third resident missed a dose of anticonvulsant medication and received an incorrect dose of Aspirin. The DON emphasized adherence to the 6 Rs of medication administration and physician orders.
Two residents in an LTC facility experienced significant medication errors due to unavailable medications. A resident with diabetes did not receive their prescribed insulin, and another resident with a history of seizures did not receive their anticonvulsant medication for four days. The facility's Director of Nursing acknowledged the importance of administering medications as per physician orders.
The facility failed to provide menu variety for residents on pureed diets, as kitchen staff did not follow recipes or production sheets, leading to repeated meals of mashed potatoes and applesauce. The dietary manager and cooks admitted to not pureeing certain foods, resulting in a lack of variety. The registered dietitian confirmed that the menus were designed for nutritional adequacy and variety, which was not achieved for residents with specific medical conditions requiring pureed diets.
A resident's personal refrigerator contained unlabeled and spoiled food items, including turkey bologna with a sour smell and discolored hotdogs. The resident, who has multiple medical conditions, was unaware of the need to label and date food items. The Dietary Manager and Registered Dietitian acknowledged the importance of labeling to prevent consumption of expired items, as per facility policy.
A resident with moderate cognitive impairment was physically assaulted by another resident during a meal in the dining room. The aggressive resident, who also had cognitive impairments and a history of behavioral issues, threw milk at the other resident's head after being told not to take food from another's tray. Staff intervened promptly, separating the residents and conducting an assessment, with no visible injuries noted.
A resident with severe cognitive impairment alleged ongoing physical abuse by staff, which was not investigated or reported by the facility. The DON dismissed the claims due to the resident's dementia, and the Administrator was unaware of the allegations until later. The facility's incident reports lacked documentation of the abuse allegation, violating their Abuse Prevention Program.
Failure to Protect Resident from Verbal Abuse and Report Allegation
Penalty
Summary
A facility failed to protect a resident from verbal abuse by a staff member, did not provide required abuse prevention training to the alleged perpetrator, and did not report an allegation of abuse to the Illinois Department of Public Health (IDPH) within the required timeframe. The incident involved a resident with multiple diagnoses, including hyperlipidemia, type 2 diabetes, repeated falls, anxiety disorder, dysphagia, major depressive disorder, spinal stenosis, pain, fibromyalgia, morbid obesity, and generalized anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 15, and had a care plan specifying the need for a safe environment and protection from mistreatment. During a medical clinic visit, the resident's escort was reported by two clinic staff members to have verbally abused the resident by telling him to "shut the f_ _k up" after a brief exchange regarding appointment wait times. The resident became quiet and appeared sad following the incident. The clinic manager reported the incident to the facility, but the office manager and administrator did not believe the allegation and did not report it to IDPH as required by facility policy. The administrator later acknowledged not being aware of the abuse allegation at the time and admitted that the escort's abuse training documentation could not be located. Interviews revealed that the escort did not recall receiving abuse training and was unaware of the abuse coordinator. Facility policy required immediate reporting of abuse allegations and documentation of abuse prevention training for all employees. The lack of timely reporting, failure to provide or document abuse training, and the staff's disbelief of the allegation contributed to the facility's failure to protect the resident's rights and comply with abuse prevention protocols.
Failure to Assess Wheelchair Sizing and Follow Incident Reporting Policy
Penalty
Summary
A resident with multiple complex medical conditions, including morbid obesity, repeated falls, and non-ambulatory status, was not properly assessed for appropriate wheelchair sizing. The resident was transferred to a smaller, unstable wheelchair to accommodate transportation van limitations, despite the resident's usual need for a larger, more supportive wheelchair. The smaller wheelchair was reported to be broken and unable to safely support the resident, resulting in the resident falling and remaining on the floor of the van for an extended period. Multiple staff interviews confirmed that the wheelchair used was not suitable for the resident's size and needs, and that the resident expressed discomfort and dissatisfaction with the substitute wheelchair. The facility failed to follow its own Accident Incident/Fall Reporting Policy after the incident. There was no immediate assessment documented upon the resident's return, no incident report completed, and no evidence of a thorough investigation or root cause analysis as required by policy. The Director of Nursing acknowledged that risk management procedures were not followed, and that the incident was not properly documented or communicated to the necessary parties, including the resident's physician and family. Additionally, there was no documentation of a 72-hour post-incident assessment or neuro-checks as outlined in facility policy. Staff interviews revealed a lack of clear procedures for wheelchair assessment and documentation. The restorative nurse stated that while residents are measured for wheelchair suitability, there is no formal documentation of wheelchair size or reassessment following incidents. The absence of a documented process for ensuring proper wheelchair fit contributed to the use of an inappropriate wheelchair, which directly led to the resident's fall and subsequent complications during transport.
Failure to Update Care Plan Following Exacerbation of Neurological Symptoms
Penalty
Summary
The facility failed to update the care plan for a resident experiencing an exacerbation of neurological symptoms. The resident, who had a history of cerebral palsy, metabolic encephalopathy, and reduced mobility, began exhibiting new and severe spastic movements of the upper and lower extremities. These symptoms represented a significant change from the resident's baseline condition, as confirmed by the Director of Nursing, who noted that the resident had not previously displayed such jerking movements. Despite the onset of these new symptoms and the implementation of 1:1 supervision, the resident's care plan was not promptly revised to address the change in condition or to include new interventions specific to the exacerbation. Record review showed that the resident's care plan, initially created to address musculoskeletal alterations related to cerebral palsy, had not been updated with new interventions until the day of the survey. The facility's policy requires that care plans be revised as information about the resident and their condition changes, and that all identified problem areas be incorporated into the care plan. However, the care plan for this resident did not reflect the recent changes in neurological status or the need for additional interventions until after the deficiency was identified by surveyors.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from mental and physical abuse, as evidenced by repeated incidents involving another resident. The affected resident, who has visual impairment and intact cognition, reported multiple instances of hair-pulling by another resident, which caused her to feel unsafe and fearful. Despite the resident's complaints and the documentation of these incidents in behavioral notes, the facility did not take adequate measures to prevent further abuse or address the resident's concerns. The facility's staff, including the administrator and registered nurse, were aware of the incidents but failed to report them in a timely manner as required by the facility's abuse policy. The registered nurse documented the incidents but did not inform her supervisor, and the administrator only became aware of the situation after being informed by the resident. The facility lacked a designated abuse coordinator during weekends, which contributed to the delay in addressing the abuse. Additionally, the care plans for both residents involved did not address the aggressive behavior or provide interventions to prevent further abuse. The Director of Social Services did not document the incidents in the psychosocial notes and failed to recognize the resident's expressed feelings of unsafety. The facility's abuse policy emphasizes the importance of preventing mistreatment and ensuring resident security, but these measures were not effectively implemented in this case.
Failure to Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting incidents or allegations of abuse involving a resident, R1, who experienced repeated hair-pulling by another resident, R2. R1, who is visually impaired and has intact cognition, reported feeling unsafe due to R2's actions, which included multiple instances of hair-pulling and unauthorized entry into R1's room. Despite R1's complaints and the documentation of these incidents in behavioral notes, the facility did not take immediate action to report or investigate the abuse as required by their policy. On December 15, 2024, R1 reported to the facility's administrator, V1, that R2 had pulled her hair again, an incident that was also documented by a registered nurse, V6. However, V6 failed to report the incident to her supervisor, citing forgetfulness, and V1 did not report the incident to the Department of Public Health within the required timeframe. The facility's abuse policy mandates immediate reporting of such incidents, but this protocol was not followed, leading to a delay in addressing the abuse. R2, who has a history of restlessness, agitation, and cognitive impairment, was observed to require constant redirection by staff. Despite this, the facility did not have a designated abuse coordinator during weekends, and V1 only became aware of the incident after R1 personally informed her. The lack of immediate reporting and investigation of the abuse incidents involving R1 and R2 highlights a significant deficiency in the facility's adherence to its abuse policy.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to adhere to its abuse policy by not investigating incidents and allegations of abuse involving a resident, R1, who experienced hair-pulling by another resident, R2. R1, who has visual impairment and other medical conditions, reported feeling unsafe due to repeated incidents of hair-pulling by R2. Despite R1's intact cognition, as indicated by a BIMS score of 15, the facility did not take timely action to address her concerns. R1 expressed fear for her safety, especially after R2 entered her room uninvited, and mentioned that other residents had also experienced aggression from R2. The facility's staff, including V6, a Registered Nurse, and V1, the Administrator, failed to report and investigate the incidents promptly. V6 documented the incident but did not report it to her supervisor, citing forgetfulness. V1, upon learning of the incident from R1, did not file a reportable incident due to the delay in reporting, despite acknowledging that the incident constituted abuse. The facility lacked a designated abuse coordinator during weekends, which contributed to the delay in addressing the incident. The facility's abuse policy mandates immediate reporting and investigation of abuse allegations, with a final investigation to be completed within five working days. However, the facility did not follow these procedures, as evidenced by the lack of immediate reporting and investigation of the incidents involving R1 and R2. The policy also requires the appointment of an investigator and a thorough review of documentation, which was not conducted in this case.
Failure to Address Aggressive Behavior in LTC Facility
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as R1, who expressed fear and anguish due to repeated aggressive behavior from another resident, R2. R1, who has a diagnosis of visual impairment, anoxic brain damage, bipolar disorder, and depression, reported multiple incidents where R2 pulled her hair and entered her room uninvited, causing her to feel unsafe. Despite R1's intact cognition, as indicated by a BIMS score of 15, the facility did not address these incidents in R1's care plan or provide adequate interventions to prevent further occurrences. R2, who has a diagnosis of restlessness, agitation, schizophrenia, bipolar disorder, and major depressive disorder, exhibited physically aggressive behavior towards R1 and other residents, R3 and R4. R2's behavior was documented in behavioral notes, yet the facility staff, including the Director of Social Services, failed to incorporate these incidents into the care plans of the affected residents. The facility's policy on Behavioral Assessment, Intervention, and Monitoring was not followed, as the interdisciplinary team did not evaluate the severity of R2's behavior or implement safety strategies to protect R1 and others from harm. The facility's administration, including the Administrator and Director of Nursing, acknowledged the impact of R2's behavior on R1's mental well-being but did not take timely action to address the situation. The Administrator was unaware of the incidents until informed by surveyors, and the Director of Social Services did not document R1's expressed feelings of unsafety in psychosocial notes. This lack of communication and failure to update care plans contributed to the ongoing risk and distress experienced by R1 and other residents.
Deficiencies in Food Safety and Staff Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of food items, as well as adherence to First In, First Out (FIFO) guidelines, and appropriate use of hair coverings by kitchen staff. During an inspection, it was observed that several opened food items in the walk-in refrigerator were not labeled with opened or use-by dates, including barbeque marinade, Italian dressing, honey mustard dressing, soy sauce, mayonnaise, and pickle chips. Additionally, some items in the dry storage room, such as cans of beans and bins of various dry goods, were not labeled with delivery dates or organized according to FIFO guidelines. The dietary manager, V13, acknowledged the importance of labeling and dating to prevent food-borne illnesses but admitted that some items were not labeled because they were used frequently. However, this practice contradicts the facility's policy, which requires all foods to be properly dated and labeled. Furthermore, the facility's registered dietitian, V6, emphasized the risk of serving expired food, which could lead to bacterial overgrowth and potential food-borne illnesses. Additionally, the facility failed to ensure that kitchen staff wore appropriate hair coverings. V15, a cook, was observed in the kitchen without a beard protector, despite having facial hair. V13 confirmed that hair and beard restraints should be worn at all times in the kitchen to prevent contamination. The facility's policy mandates that all kitchen staff wear hair coverings, including beard protectors, to maintain food safety standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several deficiencies observed during the survey. Two residents with active wounds did not have Enhanced Barrier Precautions (EBP) signage posted outside their rooms, which is necessary to alert staff to wear the appropriate Personal Protective Equipment (PPE) before providing care. This oversight was confirmed by both a Registered Nurse and the Director of Nursing/Infection Preventionist, who acknowledged the potential for infection transmission due to the absence of signage. Additionally, the facility did not conduct an annual review of its infection control policy and procedures, as the provided policy was undated, and the last documented review was over a year ago. The facility also failed to implement measures to prevent the growth of Legionella and other waterborne pathogens, with the last check for Legionella being conducted over a year prior. The Maintenance Director was unable to provide documentation of current measures in place. Furthermore, improper handling of linen was observed, with a Laundry/Housekeeping Aide handling clean gowns with contaminated hands and wearing dirty gloves in the hallway, which could lead to the spread of bacteria. The facility's policies on hand hygiene and linen handling were not adhered to, as confirmed by the Director of Nursing/Infection Preventionist.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes for 13 out of 26 residents reviewed. These assessments are crucial for evaluating the needs and care plans of residents. The deficiencies were identified through interviews and record reviews, revealing that the assessments were not completed within the required timeframes as specified by the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) process. For instance, one resident's annual MDS assessment was completed over a month late, while another's admission MDS assessment was completed more than two months after the assessment reference date (ARD). The Licensed Practical Nurse (LPN) MDS/Care Plan Coordinator acknowledged the failure to adhere to the RAI guidelines, which require that admission MDS assessments be completed no later than the 14th calendar day of a resident's admission, and annual MDS assessments be completed within 14 days from the ARD. The report highlights multiple instances where these timeframes were not met, indicating a systemic issue in the facility's assessment process. This failure to complete timely assessments could potentially impact the quality of care provided to the residents.
Failure to Complete MDS Assessments Within Regulatory Timeframes
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the regulatory timeframes as specified by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines. This deficiency potentially affected 13 out of 26 residents reviewed for resident assessment. The MDS assessments are crucial for determining residents' activities of daily living, cognitive function, urinary/bowel function, current diagnosis, medication use, skilled therapy, and any falls. The RAI guidelines require that quarterly MDS assessments be completed no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in late completion dates for several residents' assessments. During the survey, it was found that the MDS/Care Plan coordinator, an LPN, acknowledged the late completion of MDS assessments. For instance, one resident's quarterly MDS ARD was on July 24, 2024, but the assessment was completed on September 19, 2024, which should have been completed by August 7, 2024. Another resident's quarterly MDS ARD was on August 21, 2024, but the assessment was completed on September 30, 2024, which should have been completed by September 4, 2024. The LPN attributed the delays to personal illness, which may have contributed to not locking the assessments within the required timeframe. This failure to complete assessments on time could potentially affect the care provided to the residents.
Failure to Ensure RN Certification of MDS Assessments
Penalty
Summary
The facility failed to ensure that each Minimum Data Set (MDS) assessment was certified as complete by a registered nurse (RN) for seven residents out of 26 reviewed. The assessments for these residents were instead signed by an LPN, identified as V17, who has been working in the facility for two years as the MDS/Care Plan coordinator. The MDS assessments are crucial for determining residents' activities of daily living, cognitive function, urinary/bowel function, current diagnosis, medication use, skilled therapy, and any falls. The State Operations Manual requires that each resident's assessment be coordinated by and certified as complete by an RN, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for residents, which is a violation of their policy. This deficiency was identified during interviews and record reviews, where it was found that care plans were missing for several residents regarding their code status and medication use. For instance, one resident with severe cognitive impairment had no care plan addressing their full code status, while another resident with intact cognition had no care plan for their DNR status. Additionally, a resident with intact cognition and multiple diagnoses, including heart disease and diabetes, also lacked a care plan for their full code status. Another resident with moderate cognitive impairment and on psychotropic medications had no care plan for their medication use or code status. Furthermore, a resident with a history of seizures and anoxic brain damage reported not receiving their anticonvulsant medication for four days, and it was confirmed that there was no care plan addressing their anticonvulsant medication use. The facility's policy mandates that care plans should be developed by the interdisciplinary team in conjunction with the resident and their family, and should include measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to this policy, as evidenced by the lack of care plans for the residents reviewed.
Unlocked Crash Cart Poses Safety Hazard
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the security of emergency supplies in the crash cart, which was observed to be unlocked and accessible in the hallway near the front lobby and nurses' station. The unlocked crash cart contained items such as intravenous (IV) line kits, needles of various sizes, oxygen tubing, and IV fluid bags. This oversight was identified during an observation on the morning of October 8, 2024. Interviews with two registered nurses revealed that the night shift nurse is responsible for checking the crash cart, and both nurses acknowledged that the cart should be locked but were unaware of how long it had been unlocked. They also recognized the potential safety risk if residents accessed the needles. The Director of Nursing (DON) confirmed that the crash cart should be locked when not in use, but admitted that the facility currently lacks a functional lock for it. The DON mentioned that a temporary lock was attempted but failed, and the Assistant Administrator is in the process of ordering a new lock. The facility's policy mandates that the crash cart be locked at all times to ensure supplies are available during emergencies and checked daily to verify the lock's integrity. The deficiency potentially affects 19 ambulatory residents who could access the cart's contents, posing a safety hazard.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to perform monthly medication regimen reviews (MRR) for four residents who were on psychotropic medications. The Director of Nursing (DON) acknowledged that the MRR should be conducted monthly by a licensed pharmacist to assess the effectiveness, adverse reactions, and safety of the medications. However, the facility was unable to provide any MRR documentation for the residents in question, including one resident with multiple diagnoses such as Bipolar disorder, Major depressive disorder, and Anoxic brain damage. This resident was on medications like Fluoxetine and Valproic Acid, yet the only MRR available was dated several months prior. The surveyor's review of the electronic health records for the other residents revealed that no MRRs were documented for their psychotropic medications, despite active orders for drugs like Alprazolam, Haloperidol, and Paroxetine. The facility's policy on psychotropic drugs, which mandates medication reviews upon admission, was not adhered to, and the facility could not provide the policy when requested. The DON, who started working at the facility recently, confirmed the importance of MRRs for ensuring medication safety and effectiveness but admitted that the reviews had not been conducted as required.
Medication Labeling and Expiration Management Deficiency
Penalty
Summary
The facility failed to properly label and manage medications, specifically multi-dose inhalers and expired medications, for four residents. During an inspection of the medication cart, it was observed that inhalers for four residents were not labeled with the date they were opened. These inhalers included Breo, Incruse, Advair, and Fluticasone Furoate, each of which has specific discard timelines after opening to ensure medication potency and safety. The absence of opened dates on these inhalers indicates a failure to adhere to the facility's policy on medication storage and labeling, which requires such information to be documented. Additionally, the inspection revealed a bottle of house stock Famotidine with an expiration date that had already passed, yet it was still stored in the medication cart. The Director of Nursing confirmed that all medications, including over-the-counter ones, should be discarded by their expiration date and should not be stored or administered past this date. This oversight in medication management and labeling practices highlights a deficiency in the facility's adherence to its own policies and accepted professional principles for medication handling.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as prescribed by the physician for five residents, leading to discrepancies between the prescribed diets and what was actually served. For instance, Resident R10 was prescribed a No Concentrated Sweets (NCS) diet with pureed texture and thin liquids, but was observed receiving a mechanical soft diet with solid food items. The Dietary Manager, V13, admitted to receiving verbal changes from nursing staff without proper documentation, leading to incorrect diet cards being used. Resident R25, who was supposed to be on a renal diet due to a history of dialysis, was served a regular diet without dietary restrictions. The kitchen staff continued to serve meals based on outdated meal tickets, despite verbal communication that the renal diet was discontinued. However, the Registered Dietitian, V6, emphasized that diet orders should be followed as prescribed by the physician, and any changes should be documented and communicated properly. Additionally, Resident R5, who required nectar thickened liquids, was served thin liquids, while Resident R15, who required thin liquids, was served thickened liquids. These inconsistencies were due to a lack of communication and documentation between the nursing and dietary departments. The facility's policies on diet orders and tray pass were not adhered to, resulting in potential risks to the residents' health and safety.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as R12, who was part of a sample of 14 residents reviewed for call light accessibility. On multiple occasions, R12 was observed lying in bed without the call light within reach, despite a yellow sign above the bed indicating fall precautions, which included having the call light accessible. The call light was found on the roommate's side of the privacy curtain, with a string too short to reach R12's side. Both a Certified Nursing Assistant (V12) and a Registered Nurse (V5) confirmed the call light was out of reach and acknowledged the need for it to be accessible for the resident's safety. R12 has several diagnoses, including Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Alcohol Abuse, Gastro-Esophageal Reflux Disease, Unspecified Psychosis, Major Depressive Disorder, and Conversional Disorder with Seizures or Convulsions. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a high fall risk. The care plan for R12 included ensuring the call light was within reach due to the risk of falls related to gait and balance problems. The facility's policies on call lights and fall prevention also emphasized the importance of having the call light accessible to residents at all times.
Discrepancy in Advance Directives Documentation
Penalty
Summary
The facility failed to accurately document the advance directives code status for a resident, identified as R12, which led to a discrepancy between the resident's documented wishes and the information available to the nursing staff. R12, who has a severely impaired cognition with a BIMS score of 06 out of 15, was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. The POLST form signed by R12's surrogate, V10, indicated a Do Not Attempt Resuscitation (DNR) status with selective treatment, while the facility's records, including the face sheet and order summary report, incorrectly documented R12 as FULL CODE. This inconsistency was further compounded by the absence of a care plan for advance directives and/or code status in R12's records. Interviews with facility staff revealed that the code status should be consistent across all documentation to ensure the resident's preferences are respected. However, the Director of Nursing acknowledged the discrepancy and the potential for administering CPR against the resident's wishes due to conflicting information. The POLST form, which should have been accessible in the nursing station's Advance Directives binder, was missing, indicating a lapse in maintaining updated and accurate records. The facility's policy mandates that residents' code status be documented in their electronic health records at admission, but this was not adhered to in R12's case, leading to the deficiency identified by the surveyor.
Failure to Conduct Required PASARR Screenings
Penalty
Summary
The facility failed to adhere to its policies and procedures for the Preadmission Screening and Annual Resident Review (PASARR) process for two residents, R2 and R8, who required a Level 2 PASARR screening for mental disability and intellectual disability. For R2, the Minimum Data Set (MDS) indicated cognitive impairment, and the resident was admitted with a diagnosis of bipolar disorder. However, there was no documentation of a referral to the state-designated authority for a Level 2 PASARR evaluation. The Assistant Administrator, V2, could only provide a Level 1 PASARR screening dated several years prior and confirmed the absence of a Level 2 PASARR for R2. For R8, the admission record showed multiple diagnoses, including bipolar disorder and unspecified dementia, with intact cognition according to the MDS. Despite these conditions, no PASARR documentation was found in R8's health record. V2 stated that the facility relied on the hospital's social worker or discharge planner to check PASARR prior to admission and admitted that the facility did not verify PASARR before admitting residents. Consequently, the facility was unable to provide a PASARR evaluation for R8, which is contrary to their policy requiring screening prior to admission and upon any changes in status.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 14.29% error rate during the survey. This deficiency was observed in the medication administration for three residents. For one resident, a registered nurse was unable to administer the prescribed Fiasp insulin due to its unavailability in the medication cart or convenience box. The nurse documented that the insulin was not administered and was awaiting pharmacy delivery. Another resident did not receive the prescribed Flonase nasal spray during the morning medication pass, as observed by the surveyor. Additionally, a third resident did not receive the ordered dose of Levetiracetam solution, an anticonvulsant medication, because it was unavailable. The resident also received an incorrect dose of Aspirin, receiving 81 mg instead of the ordered 325 mg. The Director of Nursing stated that nurses should follow the 6 Rs of medication administration and adhere to physician orders, as outlined in the facility's Quality Assurance in Medication Administration policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. On one occasion, a registered nurse was unable to administer the prescribed insulin to a resident with Type 2 Diabetes Mellitus due to the unavailability of the medication. The resident's blood glucose level was checked, and it was determined that they required an insulin injection according to the sliding scale order. However, the insulin was not found in the medication cart or convenience box, and the nurse stated that the resident would not receive the insulin until the pharmacy delivered it later that day. In another instance, a registered nurse prepared morning medications for a resident with Anoxic Brain Damage and Cerebral Infarction but was unable to administer the prescribed anticonvulsant medication, Levetiracetam, because it was not available. The resident reported not receiving the medication for four days, which is prescribed for seizure activity. The medication was not signed off on the Medication Administration Record as given, and the nurse confirmed that a follow-up call was made to the pharmacy. The Director of Nursing acknowledged that medications must be administered according to physician orders and highlighted the potential for adverse reactions if high-alert medications like insulin and anticonvulsants are missed.
Failure to Provide Menu Variety for Pureed Diets
Penalty
Summary
The facility failed to provide and follow menus and recipes to ensure menu variety for residents on pureed diets. Observations and interviews revealed that the kitchen staff did not have recipes for pureed diet consistencies and did not follow any production sheets or spreadsheets. The cooks relied on their experience to prepare meals, leading to a lack of variety and consistency in the meals provided to residents on pureed diets. For instance, residents on pureed diets consistently received mashed potatoes at every meal instead of the pureed version of the regular menu items. The dietary manager and cooks admitted that the kitchen did not puree certain foods like spaghetti, rice, and cornbread, and instead substituted these with mashed potatoes. This practice resulted in residents on pureed diets receiving the same foods repeatedly, such as mashed potatoes and applesauce, which did not align with the planned menu. The registered dietitian confirmed that the menus were designed to ensure nutritional adequacy and variety, and that the cooks should follow the menus and recipes to prevent residents from receiving the same foods repeatedly. The report highlighted the cases of three residents with various medical conditions, including Parkinson's Disease, Dementia, and Dysphagia, who required mechanically altered, therapeutic diets. These residents were not receiving the intended variety in their meals, as the kitchen staff did not follow the standardized recipes and cycle menu policies. The lack of adherence to these guidelines raised concerns about the nutritional adequacy and variety of the meals provided to residents on pureed diets.
Failure to Label and Discard Spoiled Food in Resident's Refrigerator
Penalty
Summary
The facility failed to properly label and date food items in a resident's personal refrigerator and did not discard spoiled foods, which could potentially affect the resident's health. During an observation, a surveyor found that the refrigerator contained an opened container of turkey bologna with a sour smell, hotdogs with black spots and a green tint, and an opened container of almond milk without any labeling or dating. The resident, who has several medical conditions including Cachexia, Severe Protein-Calorie Malnutrition, and Type II Diabetes Mellitus, stated that they were unaware of the need to label and date food items and could not reach inside the refrigerator due to a lack of hand strength. The Dietary Manager acknowledged the responsibility to check the resident's personal refrigerators daily for temperature and expired foods but stated it was not their responsibility to date the items. The Registered Dietitian emphasized the importance of labeling and dating food items to prevent residents from consuming expired items, which could make them sick. The facility's policy requires food brought from outside to be labeled and dated, and staff are responsible for checking the resident's personal refrigerators daily for proper labeling and temperature recording.
Resident-to-Resident Physical Altercation in Dining Room
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in an incident where one resident became physically aggressive towards another. The incident involved a resident with moderate cognitive impairment and diagnoses including unspecified dementia and chronic obstructive pulmonary disease. During a meal in the dining room, this resident was allegedly hit on the head and had milk thrown in their face by another resident, who also had moderate cognitive impairment and a history of restlessness, agitation, and schizophrenia. The incident was witnessed by staff, who intervened and separated the residents, initiating one-on-one monitoring. A head-to-toe assessment was conducted on the affected resident, and no visible injuries were noted. The medical doctor and family were informed of the incident. Interviews with the involved residents and witnesses revealed that the aggressive resident became upset after being told not to take food from another resident's tray, leading to the physical altercation. Staff members, including a certified nursing assistant and the activity director, confirmed the sequence of events and noted that the aggressive resident had a history of taking items from others and displaying aggressive behavior. The facility's administrator, who is also the abuse coordinator, outlined the expected procedures for handling such incidents, including separating the residents and conducting assessments. The facility's abuse prevention policy emphasizes the residents' right to safety and freedom from abuse, neglect, or exploitation.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse for a resident with severe cognitive impairment. The resident, who has a history of dementia and other medical conditions, alleged that multiple staff members physically abused her over several months. During a visit to an ophthalmologist, the resident reported the abuse to her escort, who then informed the Director of Nursing (DON). However, the DON dismissed the allegations, attributing them to the resident's dementia and confusion, and did not initiate an investigation or report the incident to the appropriate authorities. The facility's Administrator was unaware of the abuse allegation until the day of the surveyor's visit and acknowledged that the incident was not reported to the Illinois Department of Public Health. The facility's incident reports from June to August 2024 did not include any documentation of the resident's abuse allegation. The facility's Abuse Prevention Program requires that any allegation or suspicion of abuse be documented and investigated, but this protocol was not followed in this case.
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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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