Heartland Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Casey, Illinois.
- Location
- 410 Northwest Third, Casey, Illinois 62420
- CMS Provider Number
- 145416
- Inspections on file
- 31
- Latest survey
- October 20, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heartland Nursing & Rehab during CMS and state inspections, most recent first.
The facility did not maintain full mechanical lifts in safe working order, as several lifts were found to be nonfunctional, with broken emergency releases and makeshift repairs such as adhesive tape. Staff and residents reported frequent problems, and maintenance did not perform routine checks or receive work orders for these issues, resulting in continued use of unsafe equipment for multiple residents requiring lift assistance.
A resident who required a full mechanical lift for transfers, as documented in the care plan due to a right femur fracture, was transferred using a sit-to-stand lift by a CNA when the appropriate lift was not working. The resident expressed concern during the transfer, and staff confirmed that no updated therapy recommendations had been made to change the transfer method. The facility's policy for assessing and documenting transfer needs was not followed.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient safeguards and oversight by the facility.
A resident with dementia and multiple comorbidities, identified as a fall risk, did not have required fall prevention interventions in place, including non-skid strips, non-slip wheelchair material, and protective leggings and sleeves. The nurse call device was also out of reach. This lack of adherence to the care plan and physician orders resulted in an unwitnessed fall with multiple injuries.
The facility failed to employ a qualified director of food and nutrition services, impacting all 42 residents. The Dietary Manager lacked necessary certifications, holding only a cooking sanitation certificate. The facility used a Registered Dietician one day per month, and the previous Certified Dietary Manager was on leave and not returning. Issues with palatability, sanitation, and meal service were noted.
The facility failed to prevent potential food contamination by improperly storing a measuring scoop in a bulk sugar bin and keeping a broken spatula in a utensil drawer. These deficiencies could affect all 42 residents.
The facility failed to maintain an effective infection prevention and control program, lacking a comprehensive policy and documentation for trending monthly infections. The DON, also the Infection Preventionist, did not maintain a complete infection log, with records only for October and November 2024, and none for employees. No Quality Assurance process was in place for recurring infections, and no infection trending was completed, potentially affecting all 42 residents.
The facility failed to implement an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. The DON admitted that there were no antibiotic protocols or monitoring systems in place. The existing policy, dated 2/7/23, had not been updated annually, potentially affecting all 42 residents.
The facility failed to address grievances from residents and inform them about the grievance process. Residents reported dissatisfaction with meal options and lack of snacks at bedtime. The Dietary Manager acknowledged issues with meal service, and the survey book was found hidden and outdated. The grievance policy was not effectively communicated or implemented.
The facility failed to maintain sanitary conditions for respiratory care equipment for four residents, leading to deficiencies in infection control practices. A resident with COPD had undated oxygen tubing improperly stored, while another with pneumonia used a dirty suction catheter. A third resident's request for less frequent tubing changes was not documented or communicated regarding infection risks, and a fourth resident's oxygen equipment was not changed as required. These issues indicate a failure to adhere to the facility's policy on respiratory equipment sanitation.
The facility failed to contact physicians for unaddressed pharmacist recommendations and did not document physician responses, affecting several residents. For example, a resident on long-term antipsychotic medication lacked an AIMS assessment, and another was prescribed Seroquel without an approved diagnosis. Additionally, a resident's medication review suggested dose reductions due to falls, but the physician's response was delayed and undocumented. The facility did not adhere to its policy requiring regular AIMS assessments.
The facility failed to conduct necessary assessments and maintain accurate documentation for residents on psychotropic medications. Residents with conditions such as Alzheimer's, Dementia, and Major Depression were prescribed medications like Olanzapine, Sertraline, and Quetiapine without required quarterly assessments or attempts at gradual dose reductions. PRN orders lacked specified durations, and AIMS assessments were not completed as per policy, highlighting significant lapses in medication management.
The facility failed to maintain resident dignity by not covering urinary catheter bags for two residents. A resident's catheter bag was observed uncovered, exposing urine, and a caregiver reported inconsistent coverage of another resident's bag. The DON expressed disapproval of the practice, and the facility's policy requires catheter bags to be covered.
A facility failed to request a PASARR Level II Screening for a resident with Schizoaffective Disorder who was receiving antipsychotic medication. The resident's medical records indicated the disorder as a diagnosis during the stay, and observations showed symptoms consistent with the disorder. The facility's President of Clinical Operations confirmed the absence of a PASARR II request and acknowledged the lack of a policy for admissions regarding PASARR screenings.
A facility failed to document a discharge summary for a resident with multiple medical conditions, including Acute Kidney Failure and Heart Failure. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. The Director of Nurses confirmed the absence of this documentation, which is crucial for ensuring continuity of care.
A resident with a urinary tract infection did not receive complete doses of prescribed antibiotics due to a failure in medication administration. The resident's MAR showed missing doses, leading to a subsequent infection confirmed by urinalysis. The DON acknowledged the error, noting the potential impact on treatment efficacy.
A resident with a history of tobacco use and other medical conditions was observed smoking unsupervised, despite the care plan indicating supervision was required. The resident kept smoking materials in her room and smoked alone, contrary to documented interventions. Facility staff confirmed the care plan did not match the resident's actual smoking practices, leading to a deficiency in ensuring a safe environment.
A resident experienced a 7.24% weight loss within two weeks of admission, but the facility failed to notify the physician or develop a care plan. The resident, with severe protein-calorie malnutrition and NPO status, was at high risk for weight loss due to multiple health issues. Despite the facility's policy requiring notification for significant weight changes, no new interventions were implemented.
A facility failed to monitor and obtain physician orders for a resident with a gastrostomy tube. The resident, diagnosed with dysphagia and severe protein-calorie malnutrition, was on NPO status and required enteral feeding. Despite this, the resident self-administered feedings and medications without orders for self-administration or staff monitoring. The DON confirmed the lack of orders and documentation for site maintenance or monitoring.
A facility failed to administer medications on time for a resident, with medications scheduled for 8:00 AM not prepared until 10:17 AM. An LPN cited being occupied with another resident's surgery as the reason for the delay. Other LPNs confirmed that late medication administration was common due to staffing challenges. The DON acknowledged that medications should be on time, and the facility's policy requires timely administration, but the MAR did not reflect actual administration times.
The facility failed to obtain physician's orders for supplemental oxygen for three residents, including those with chronic respiratory conditions. Observations revealed that two residents were using oxygen without documented orders, and all three lacked orders specifying when to change oxygen equipment, contrary to facility policy. The DON acknowledged the oversight due to a recent computer program change.
Failure to Maintain Safe and Operable Mechanical Lifts
Penalty
Summary
The facility failed to maintain full mechanical lifts in safe and operable condition, affecting all eight residents reviewed who required the use of these lifts. Multiple residents reported that the full mechanical lifts were not functioning properly, with issues such as the lifts only lowering and not raising, and the emergency release mechanisms being broken. Staff confirmed that one lift had gray adhesive tape around the gear box housing, which had been present for at least three years, and that the emergency release had also been nonfunctional for a significant period. Staff had to use alternative equipment or borrow lifts from other areas due to these malfunctions. The maintenance director stated that no work orders had been received for the lifts and that there were no routine checks performed on the equipment. Upon inspection, the maintenance director confirmed that one lift would not raise and both lifts had nonfunctional emergency releases. Facility policy required that lifts be tested for proper function, including the emergency release, and that non-working lifts be removed from service until repaired. However, these procedures were not followed, and the lifts remained in use despite ongoing mechanical issues.
Improper Transfer Method Used Due to Equipment Failure
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and dependent on staff for transfers due to a right femur fracture, was transferred using a sit-to-stand mechanical lift instead of the care plan-specified full mechanical lift. On the day in question, the full mechanical lift on the resident's hallway was not functioning, and maintenance staff were unavailable. The Certified Nursing Assistant (CNA) used the sit-to-stand lift to transfer the resident from the wheelchair to the bed, despite the resident expressing concern about falling. The resident's care plan and Minimum Data Set (MDS) indicated that a full mechanical lift was required for transfers, and there had been no documented change in transfer status from therapy staff. Interviews with facility staff confirmed that the resident's transfer status remained unchanged and that the use of the sit-to-stand lift was not approved for this resident. The CNA acknowledged submitting a work order for the broken lift but proceeded with the alternative transfer method without updated recommendations from therapy or changes to the care plan. The facility's policy requires ongoing assessment and documentation of transfer needs, which was not followed in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and accident prevention interventions as outlined in a resident's care plan and physician orders. The resident, who had diagnoses including dementia, major depression, hypertension, and osteoarthritis, was identified as a fall risk and required staff supervision and assistance for all activities of daily living. Despite physician orders and care plan interventions for non-skid strips in front of the recliner, non-slip material in the wheelchair seat, and the use of protective leggings and sleeves, these measures were not in place at the time of observation. The resident's nurse call device was also found out of reach, hanging from a light fixture several feet away from where the resident was seated. The resident experienced an unwitnessed fall from bed, resulting in multiple bruises, abrasions, and a head injury that required emergency department evaluation and treatment. Upon return to the facility, further injuries were noted, including additional bruising and surgical glue applied to wounds. Staff interviews confirmed that required fall prevention interventions were not consistently implemented, and the resident was not wearing the prescribed protective equipment. The lack of adherence to the care plan and physician orders directly contributed to the resident's fall and subsequent injuries.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a qualified director of food and nutrition services, affecting all 42 residents. The Dietary Manager, identified as V5, was observed supervising and directing food preparation and meal services without holding the necessary qualifications. V5 only possessed a cooking sanitation certificate from a national company and did not have a Certified Dietary Manager (CDM) certificate or a Certified Food Protection Professional (CFPP) certificate. Additionally, V5 did not meet the state requirements for a Director of Food Services or the definition of a Dietetic Service Supervisor, lacking a national dietetic school program graduation, relevant experience prior to 1990, or qualifying military experience. The facility utilized the services of a Registered Dietician on a consultant basis for only one day per month. The Regional Dietary Representative, V6, also lacked the necessary certifications but was enrolled in a Certified Dietary Manager course, with plans to enroll V5 after 30 days of employment. The facility's administrator, V1, acknowledged that the previous Certified Dietary Manager was on family medical leave and would not return, leading to V5's hiring. The report also noted issues with palatability, sanitation, lack of alternative menu items, lack of bedtime snacks, and potential contamination in the kitchen and meal services.
Kitchen Utensil Contamination Risk
Penalty
Summary
The facility failed to maintain kitchen utensils in a manner that prevents potential food contamination. During an observation, a metal, long handle measuring scoop was found inside a bulk sugar bin, with the handle in direct contact with and partially buried by the sugar. This was acknowledged by the Dietary Manager and the Regional Dietary Representative, who confirmed that the scoop should not be left in the sugar. Additionally, a silicone blade spatula with a broken corner was found in a kitchen utensil drawer. The broken spatula exposed granulated and rough internal material, which could potentially crumble off and contaminate food during preparation, and was not easily cleanable. These deficiencies have the potential to affect all 42 residents residing in the facility.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a comprehensive Infection Control Surveillance and Monitoring Policy. The facility did not provide documentation on how it trends monthly infections to prevent further spread throughout the facility. The Director of Nursing, who also serves as the Infection Preventionist, admitted to not maintaining a log for infections for residents, with records only available for October and November 2024, and none for employees. Additionally, there was no Quality Assurance process in place for recurring infections, and no trending of the facility's infections was completed. This deficiency has the potential to affect all 42 residents residing in the facility.
Lack of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. This deficiency was identified during an interview and record review, where the Director of Nursing (DON) admitted that the facility had not completed an Antibiotic Stewardship Program. There were no antibiotic protocols or systems in place to monitor antibiotic use among the residents. The existing policy, intended to monitor antibiotic use, was dated 2/7/23 and had not been updated annually. This oversight has the potential to impact all 42 residents residing in the facility.
Failure to Address Resident Grievances and Meal Service Issues
Penalty
Summary
The facility failed to adequately address grievances from residents and their families, as well as inform them about the grievance process and the location of the survey book. Four residents expressed that while they could voice complaints, no actions seemed to follow. They were unaware of how to file a grievance form, and the Activity Director, who took their complaints, did not document or follow up on these concerns. Additionally, the residents reported dissatisfaction with meal options and the lack of snacks at bedtime, noting that meals were often late and cold, and that they were not informed about an 'always available' menu. The Dietary Manager acknowledged issues with meal service, including cold and late meals, and stated that the 'always available' menu was not being utilized properly. The survey book, which should be accessible to residents, was found hidden behind decor and was not up to date, containing only surveys from 2022. The facility's grievance policy states that grievances should be directed to the Administrator, who is responsible for addressing them promptly, but this process was not being effectively communicated or implemented.
Deficiencies in Respiratory Equipment Sanitation
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for four residents, leading to deficiencies in infection control practices. Resident R34, diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, had undated oxygen tubing and nebulizer equipment improperly stored, confirmed by both the resident's daughter and the Director of Nurses. Resident R350, diagnosed with Pneumonia and Sepsis, was using a dirty oral suction catheter that was not covered, and the Director of Nurses confirmed it should have been cleaned and stored properly. Resident R4, who was using continuous oxygen therapy, had requested less frequent changes of his oxygen tubing, which was not documented or communicated to him regarding the infection control risks. The tubing and humidifier bottle were not changed weekly as per the physician's order. Resident R14, with diagnoses including Obstructive Sleep Apnea, had oxygen tubing and a water bottle that were not changed since the previous month, despite using oxygen nightly. These observations indicate a failure to adhere to the facility's policy on changing and storing respiratory equipment, leading to potential infection risks.
Failure to Address Pharmacist Recommendations and Document Physician Responses
Penalty
Summary
The facility failed to ensure that physicians were contacted for unaddressed pharmacist recommendations and did not maintain documented evidence of physician responses to these recommendations. This deficiency affected four residents who were reviewed for unnecessary medications. For instance, a pharmacist recommended an AIMS assessment for a resident on long-term antipsychotic medication, but there was no documented physician response or evidence of the assessment being conducted. Another resident was prescribed Seroquel without an approved diagnosis, and there was no physician response to the pharmacist's request for justification. Additionally, a resident's medication regimen review suggested dose reductions due to self-reported falls, but the physician did not respond timely and provided no documented reason for declining the recommendation. Another resident had multiple pharmacist recommendations for AIMS assessments, yet there was no evidence of these assessments being conducted or any physician response. The facility's policy required AIMS assessments before starting neuroleptic therapy and every six months thereafter, but this was not adhered to, and there was no policy provided regarding following pharmacy recommendations.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to conduct necessary assessments and maintain accurate documentation for residents receiving psychotropic medications. Specifically, the facility did not perform required quarterly psychotropic medication assessments or abnormal involuntary movement scale (AIMS) assessments for residents on antipsychotic medications. For instance, a resident with Alzheimer's Disease and Dementia was receiving Olanzapine and Sertraline without any documented attempts at gradual dose reduction or clinical contraindications for such reductions. Additionally, the resident's electronic medical record lacked any quarterly psychotropic medication assessments or AIMS assessments. Another resident with Major Depression was prescribed Bupropion, yet their electronic medical record did not include any required quarterly psychotropic medication assessments. The Director of Nursing acknowledged that these assessments should be completed quarterly, and AIMS assessments every six months, but they were not found in the records. Furthermore, a resident with Dementia and Irritability was prescribed Quetiapine and Lorazepam on a PRN basis without a specified stop date or duration, contrary to the facility's policy requiring PRN psychotropic medications to be limited to 14 days unless justified by a physician. The facility's failure to adhere to its own policies and regulatory requirements was further evidenced by another resident with Schizoaffective Disorder who did not have any AIMS assessments documented until prompted by the surveyors. Similarly, a resident with Dementia and Major Depression was prescribed Risperidone and Sertraline without any documented AIMS assessments or attempts at gradual dose reductions over the past year. The facility's policies clearly state that psychotropic medications should be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and review, which was not followed in these cases.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to protect the dignity of residents by not ensuring that urinary catheter collection bags were covered. This deficiency was observed in two residents, R22 and R33, who were part of a sample list of 26. On December 10, 2024, at 10:50 AM, R33's urinary catheter collection bag was seen under his wheelchair without any covering, exposing approximately 400 cc's of yellow urine. The Director of Nursing, V2, expressed disapproval of the exposed catheter bags, indicating a preference for them to be covered. Additionally, V7, a private caregiver for R22, reported that the staff inconsistently covered R22's catheter bag, leading to situations where R22's family had to search for a covering bag when taking R22 out of the facility. The facility's policy on Quality of Life - Dignity, dated 2001, mandates that residents be cared for in a manner that promotes dignity, explicitly stating that urinary catheter bags should be covered.
Failure to Request PASARR Level II Screening for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) Level II Screening for a resident diagnosed with Schizoaffective Disorder who was receiving antipsychotic medication. The resident's medical diagnosis sheet, dated December 13, 2024, indicated that the primary medical diagnosis for admission was Interstitial Pulmonary Disease, with Schizoaffective Disorder listed as a diagnosis during the stay. The initial PASARR screening, completed on August 8, 2021, at a different facility, documented that the resident did not need a Level II screening at that time. Observations on December 12, 2024, showed the resident engaging in conversation with an imaginary person, indicating symptoms of Schizoaffective Disorder. The resident's physician's order sheet from December 2024 confirmed the use of Quetiapine Sulfate (Seroquel) for treating Schizoaffective Disorder, with the medication starting on July 1, 2024. The President of Clinical Operations confirmed the absence of a PASARR II request and acknowledged that the facility lacked a policy for admissions regarding PASARR screenings.
Failure to Document Discharge Summary
Penalty
Summary
The facility failed to document a comprehensive discharge summary for a resident, identified as R49, who was reviewed for discharge. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. This documentation is crucial for ensuring that necessary information is communicated to the resident and the receiving healthcare provider at the time of a planned discharge. The absence of this documentation was confirmed by the Director of Nurses, who acknowledged that there was no discharge summary available for R49. R49 had multiple medical diagnoses, including Acute Kidney Failure, Unsteadiness on feet, Reduced Mobility, Cognitive Communication Deficit, Depression, and Heart Failure. Despite these complex medical conditions, the electronic medical record for R49 did not contain the required discharge documentation. This oversight has the potential to affect the quality of care and continuity of care for the resident after leaving the facility, as critical information regarding the resident's course of illness, treatment, and current status was not communicated to the next care provider.
Incomplete Antibiotic Administration for UTI
Penalty
Summary
The facility failed to provide complete antibiotic doses for a urinary tract infection for a resident, identified as R42. On November 9, 2024, R42's nursing notes indicated an abnormal urine sample was sent for analysis. By November 12, 2024, a new order for Bactrim DS was received to be administered twice daily for five days. However, the Medication Administration Record (MAR) for November 2024 showed that the doses scheduled for November 16, 2024, were not documented as given, indicating a failure to complete the prescribed antibiotic course. Subsequently, on December 8, 2024, R42's family reported symptoms of abdominal pain and bladder pressure, prompting a new urinalysis. The results on December 11, 2024, confirmed a positive infection, leading to a new prescription for Augmentin due to ESBL resistance. The Director of Nursing acknowledged the error in transcription and administration, noting that the incomplete antibiotic course could have contributed to the untreated infection, which R42 was now being treated for.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to accurately assess and supervise a resident for smoking safety, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who has a right artificial shoulder joint, is dependent on renal dialysis, and uses tobacco, was documented in the care plan to be supervised while smoking, with smoking materials kept secured by staff. However, observations and interviews revealed that the resident kept smoking materials in her room and smoked unsupervised, contrary to the care plan interventions. On multiple occasions, the resident was observed smoking alone in the designated smoking area and stated that she was never accompanied by staff while smoking. The facility's staff, including the MDS/Care Plan Coordinator and the Director of Nurses, confirmed that the resident was capable of smoking independently and that the care plan did not reflect the actual practice. This discrepancy between the care plan and the resident's actions indicates a failure to provide adequate supervision and ensure the resident's safety while smoking.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to notify a resident's physician of significant weight loss and did not develop a care plan to address the resident's risk for weight loss. The facility's policy requires notification of the dietician and primary care physician for any weight change of 5% or more, with a loss greater than 5% within one month considered severe. Despite this policy, the facility did not notify the physician or implement new interventions for a resident who experienced a 7.24% weight loss within two weeks of admission. The resident, diagnosed with dysphagia and gastrostomy status, was admitted with severe protein-calorie malnutrition and was NPO with orders for enteral feeding four times a day. The resident's weight decreased from 174 pounds to 161.4 pounds over a short period, indicating severe weight loss. The Director of Nurses confirmed the significant weight loss and acknowledged the lack of notification to the physician and absence of new interventions, despite the resident's high risk for weight loss due to multiple health issues, including recent cancer treatment and severe malnutrition.
Failure to Monitor and Obtain Orders for Gastrostomy Tube Care
Penalty
Summary
The facility failed to monitor and obtain a physician order for a resident with a gastrostomy tube, which is necessary for proper care and management. The resident, diagnosed with dysphagia and gastrostomy status, was on a physician-ordered NPO (Nothing by Mouth) status and required enteral feeding four times a day due to severe protein-calorie malnutrition. Despite this, the resident self-administered her feedings and medications through the gastrostomy tube without any physician orders for self-administration or staff monitoring of the gastrostomy site. The Director of Nurses confirmed the absence of orders for self-administration, site maintenance, or monitoring by staff, and there was no documentation of staff monitoring the gastrostomy site for abnormal signs or symptoms.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications in a timely manner for one resident, identified as R10, out of a sample of ten residents. R10's Medication Administration Record (MAR) indicated that several medications were scheduled for administration at 8:00 AM, including Ascorbic Acid, Cholecalciferol, Famotidine, Fluoxetine, Furosemide, Gabapentin, Phentermine, Potassium Chloride, Spiriva, Symbicort, Bupropion, Cranberry Tab, and MiraLAX. However, on the day of observation, these medications were not prepared until 10:17 AM by an LPN, who acknowledged that the medications were late due to being occupied with another resident's cataract surgery. The LPN admitted that the MAR was filled in prior to administration, which did not reflect the actual time the medications were given. Further interviews with other LPNs revealed that administering medications late was a regular occurrence, attributed to the size of the building and staffing challenges, such as being the only nurse on duty. The Director of Nursing (DON) confirmed that the facility had only 45 residents and that medications should be administered on time. The facility's policy, revised in December 2012, mandates that medications be administered safely, timely, and within one hour of the prescribed time. However, the MAR did not accurately document the actual administration times, indicating a systemic issue in medication administration practices.
Failure to Obtain Physician's Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen for three residents, leading to a deficiency in providing safe and appropriate respiratory care. Resident 5, diagnosed with Chronic Respiratory Failure, was observed using oxygen at three liters per minute without a documented physician's order. Similarly, Resident 6, who has Chronic Obstructive Pulmonary Disease (COPD) and other health issues, was also using oxygen at the same flow rate without a physician's order. Additionally, Resident 1, who has a documented order for oxygen use, did not have a specified order for when the oxygen tubing or humidification bottle should be changed. The Treatment Administration Records (TAR) for all three residents lacked documentation specifying when the oxygen tubing and humidification bottles should be changed, which is a requirement according to the facility's policy. The Director of Nursing confirmed the absence of these orders and attributed the oversight to a recent change in computer programs. The facility's policy on respiratory therapy and infection prevention, revised in November 2011, outlines specific procedures for maintaining oxygen equipment, which were not followed in these cases.
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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