Heather Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harvey, Illinois.
- Location
- 15600 South Honore Street, Harvey, Illinois 60426
- CMS Provider Number
- 145173
- Inspections on file
- 39
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Heather Health Care Center during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown did not receive ordered pressure ulcer prevention and treatment. One resident with multiple pressure ulcers and total dependence for repositioning had outdated sacral wound orders continued on the TAR, heel dressings that did not match physician orders, no heel offloading devices in use, and a LALM that was set to an incorrect high weight, later found unplugged and off while the resident remained in bed. Staff, including an RN and wound care nurse, were unable to confirm or adjust the correct LALM settings, and the wound care director reported preventive measures that were not in place during observation. Another resident with significant comorbidities and high skin risk had a stage 2 buttock wound observed without treatment, despite orders for buttock skin care and scheduled skin checks; the CNA could not clearly describe the wound, and the wound care director was initially unaware of any current buttock wound. Facility policies required identification and treatment of pressure injuries and outlined LALM set-up responsibilities but did not specify who ensured correct LALM settings, contributing to inconsistent implementation of wound care and prevention.
The facility failed to follow its feeding policy, provide needed feeding assistance, ensure meals and supplements were within reach, and accurately document meal intake for two residents with dementia, cancer, hemiplegia, and documented weight loss. One resident, assessed as needing total assistance with a pureed diet and supplements, had numerous undocumented or 0–25% meal intakes, and was observed receiving only supplemental ice cream and juice while the plated meal remained covered and largely untouched. Another resident, requiring supervision or assistance with a mechanical soft diet and supplements, had multiple undocumented meals and was observed with an untouched lunch tray placed out of reach more than an hour after meal service, with the assigned CNA acknowledging the resident needed feeding help and had not been fed.
Failure to supervise a resident with schizophrenia, anxiety, depression, and a history of self-harm and exit-seeking led to a serious incident. Staff documented pacing, sadness, and statements about wanting to leave and harm himself, but the resident accessed a fire extinguisher, broke a second-floor window, and jumped out without staff knowledge, sustaining a severe left tibia fracture.
Infection prevention and control failures occurred when the facility did not complete contact tracing, promptly test exposed residents and staff, or implement isolation measures as required after COVID-19 cases were identified. A resident returned from the hospital with COVID-19 after a fall, another resident developed respiratory symptoms and later tested positive, and a CNA also tested positive. Staff were observed removing PPE inside isolation rooms and one housekeeper entered a droplet-isolation room without the proper PPE, while the facility’s own policy required immediate testing, contact tracing, and correct PPE use.
The facility failed to provide timely incontinence and toileting care at least every two hours for four dependent residents. One resident with severe cognitive impairment was observed walking with visibly wet clothing, and multiple residents who were dependent or required maximum assistance for toileting were not checked during an extended observation period. When care was eventually provided, one resident’s brief was heavily saturated despite dry outer clothing and a skin indentation was noted, another resident was found with a saturated brief while requiring a mechanical lift and two staff, and a fourth resident was discovered sitting in urine with saturated clothing and sling. The DON confirmed that staff are expected to check and change residents every two hours and as needed.
Call light cords were not kept within reach for 6 residents reviewed. A resident lying in bed, another resident in bed with a very short cord, and several other residents had cords on the floor, behind a nightstand, or routed through the bedframe so they were not accessible. The DON stated call lights should be within resident reach at all times, and the facility policy states the same.
Advance directive orders were not documented in the physician orders for a resident with a DNR. Social Services and the DON described admission processes for identifying and recording advance directives, but the resident’s record showed a DNR on the social services assessment while the face sheet, care plan, and POS lacked the required code status order.
A resident with multiple chronic conditions had a head injury event after his forehead touched the floor from a wheelchair. A skull X-ray showed that a nondisplaced fracture was not excluded and that CT was clearly and strongly recommended, but the RN did not properly notify the NP/physician of the results or document the monitoring orders. The NP later stated she had not been informed of the X-ray findings, and the DON said the RN should have notified the physician.
Failure to notify the physician and provide medications when a resident left AMA. A cognitively intact resident with DM2, bipolar disorder, HTN, asthma, and wound care needs left after being educated on the risks and benefits of continued treatment, but the record did not document physician or NP notification. The assigned nurse said she did not notify the physician or give any meds, and social service staff said nurses were responsible for notifying the physician and providing 2 weeks of medications.
A resident’s ordered enoxaparin injections were not available for administration as prescribed. The MAR and progress notes showed missed doses because the medication was awaiting pharmacy supply, and the resident reported the facility runs out of his blood thinners and he sometimes goes without them for a day or two. An LPN said she did not give the dose, had ordered the wrong medication, and cited an insurance issue, while the DON said she was unaware of the problem.
Medication storage and labeling were not followed when a nurse found one resident’s opened insulin pen not dated and another resident’s unopened insulin pen left on the med cart instead of being refrigerated. The nurse stated that opened insulin should be dated and that unopened insulin pens should remain refrigerated until use. The facility policy required refrigerated meds to be kept in a locked refrigerator and residents’ meds to be stored and labeled according to legal requirements.
Stained lounge chairs in the resident TV room were observed on a locked unit, with multiple old dried stains, discoloration, dirt, and other marks on the cushions and armrests. A nurse said residents sit in the chairs and watch TV, and the DON said some stains appeared consistent with dried urine and others with spills; she also said she would not sit in either chair. The Housekeeping Director said she had taken pictures of the dirty chairs a week earlier, but could not report where the picture was, who received it, or what the resolution was. A resident was later observed sitting in one of the stained chairs.
Two residents with known histories of aggression engaged in a verbal and physical altercation after one attempted to obtain juice from a cart, resulting in one resident sustaining a swollen, bruised, and lacerated eye. Staff were not present to prevent or immediately intervene in the incident, and the facility's initial abuse investigation inaccurately reported that no physical contact had occurred.
Multiple residents reported and surveyors observed unsanitary conditions, unrepaired damage, and lack of basic amenities such as working televisions in their rooms. Issues included stained linens, broken furniture, holes in walls, water damage, persistent odors, and inadequate housekeeping, with maintenance requests left unresolved for extended periods. Residents with complex medical and psychiatric needs were affected, and staff interviews revealed inconsistent monitoring and communication regarding room conditions.
Staff failed to administer scheduled medications on time for several residents, with an LPN giving medications hours after the scheduled time and inaccurately documenting administration in the MAR. Residents receiving medications for seizures, blood pressure, and diabetes expressed concern about the delays. The DON confirmed that such delays are not acceptable and that facility policy requires medications to be given within one hour of the scheduled time.
Two residents with significant medical needs were unable to access their call lights because the cords were not within reach, contrary to their care plans and facility policy. One resident reported a broken call light cord for a week, and staff were aware of the issue. Another resident was observed with the call light cord out of reach, and a CNA confirmed it should have been accessible.
A facility failed to provide post-surgical wound care according to a physician's orders for a resident with a left foot wound. The wound care coordinator did not apply collagen powder and antibiotic ointment as prescribed, despite the resident's medical history and specific wound care instructions. The facility's policies require adherence to physician orders, which was not followed in this instance.
A resident suffered fractured ribs after a CNA failed to use a gait belt during a transfer, resulting in a fall. The resident, who requires substantial assistance, experienced leg spasms during the transfer, and the CNA attempted to lower the resident to the floor without proper equipment. The incident was not immediately reported, and the resident was sent to the hospital after later complaining of pain. Facility policies require the use of a gait belt during transfers, but this was not adhered to, leading to the injury.
A resident with a history of falls and rib fractures experienced a fall during a transfer, but the physician was not notified until six hours later when the resident reported new pain. The staff initially failed to recognize the incident as a fall, leading to a delay in appropriate medical evaluation. The facility lacked a post-fall policy, contributing to the miscommunication and delay in reporting.
A resident fell in the bathroom due to improperly installed toilet handlebars and a sink that detached from the wall. The resident, who was cognitively intact and at risk of falling due to medical conditions, was found on the floor with back pain. Staff interviews confirmed the broken fixtures, and the incident was documented as a fall caused by the bathroom basin detaching from the wall.
A visually and cognitively impaired male resident was physically assaulted by another male resident with a known history of aggression. Despite the vulnerable resident's need for supervision, there was no care plan addressing the aggressive resident's behavior. The incident occurred in the early morning, leading to the injured resident's hospitalization. Staff, including an LPN and CNA, were unaware of the altercation until the injured resident was found. Initial reports mischaracterized the incident, but further investigation revealed the assault. The facility's lack of monitoring and intervention for the aggressive resident, combined with the decision to house both residents together, contributed to the failure to protect the vulnerable resident.
A resident with Schizophrenia, Schizoaffective Disorder, Dementia, and Atherosclerotic Heart Disease eloped from a secured Memory Care Unit. The resident, known for previous elopement history, left unnoticed and was later found in a local hospital after crossing a busy street. Staff members, including an LPN and a CNA, were unaware of the resident's elopement risk, citing her compliance and non-disruptive behavior as factors.
The facility failed to provide necessary care for a resident with chest pain who eloped and was hospitalized, and did not monitor another resident's escalating aggressive behavior, resulting in an assault. Both incidents highlight deficiencies in monitoring and addressing residents' changes in condition and behavior.
A resident with a history of Schizophrenia, Dementia, and Atherosclerotic Heart Disease reported severe chest pain but did not receive appropriate care, leading to her elopement from the facility and subsequent hospitalization. The facility failed to follow its pain management and change of condition policies, resulting in the resident seeking emergency medical attention on her own.
The facility failed to protect a cognitively impaired resident from physical abuse by another aggressive resident, did not adequately supervise a resident at risk for elopement, and failed to conduct a pain assessment for a resident with chest pain. These deficiencies highlight significant lapses in resident care and supervision.
Failure to Follow Wound Care Orders and Proper LALM Use for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for two residents with high risk for skin breakdown and existing wounds. For one resident with dementia, prior stroke, type II diabetes, and multiple documented pressure ulcers (sacrum stage 3, right buttock stage 2, left elbow unstageable, and bilateral heel stage 3), the facility did not consistently follow physician orders, did not correctly transcribe updated wound treatment orders, and did not ensure proper use and settings of a low air loss mattress (LALM). The resident’s care plan and physician wound assessment identified high risk for skin impairment, dependence on staff for repositioning, and the need for a LALM, turning every two hours, heel offloading, and specific wound treatments. However, the April Treatment Administration Record showed that an outdated sacral wound treatment order continued to be used after a new order was written, resulting in incorrect treatment being applied for several days. Surveyor observations showed that this resident was lying on a LALM that appeared firm and non-fluctuating, with the control unit crammed between the mattress and footboard, adding pressure to the mattress. The LALM weight setting was at 550 lbs, while nursing staff stated the resident weighed under 200 lbs, and a later note on the device listed the resident’s weight as 105.2. Staff, including the assigned RN and the wound care nurse, were unable to confirm or adjust the correct setting at the time of observation, and the LALM was later found turned off while the resident remained in bed, with the device unplugged. The resident’s heels were not elevated, heel protectors or booties were not in use, and heel dressings did not match the ordered treatment (they were not secured with foam dressings as ordered). The left heel was necrotic with surrounding red, bleeding skin, and the right heel skin appeared sheared off. The wound care director stated that preventive measures such as pillows or heel lifts were being used, but these were not in place during surveyor observations. For a second resident with altered mental status, multiple malignancies, hemiplegia, adult failure to thrive, and high risk for skin breakdown, the facility failed to identify and manage a buttock wound in accordance with its policies and physician orders. The care plan and physician orders included skin checks twice weekly, a wound consult, Betadine treatment to the left elbow, and a medicated paste to the buttocks for skin conditions. A recent physician wound assessment documented a left elbow wound, but did not mention a buttock wound. During observation, the resident was found lying on her back, and removal of the incontinence brief revealed a small circular open area (stage 2) on the right buttock without any wound treatment in place. The CNA assigned to the resident described the buttock area as looking like it was healing but could not clearly describe the wound. The wound care director initially stated that the resident did not have a buttock wound and that only a left forearm wound from IV infiltrate was being followed, and further indicated that staff were supposed to notify her, the family, and the physician when a wound is present and obtain an order. The facility’s pressure injury and skin alteration policy required identification of pressure injuries and implementation of preventive measures and appropriate treatment through individualized care plans, but weekly skin assessments were not being done by facility staff, with reliance instead on weekly physician visits and miscellaneous notes. The facility’s low air loss mattress policy assigned responsibility for identifying residents needing a LALM to the DON or designee and for set-up to maintenance or housekeeping supervisors, but did not specify who was responsible for ensuring correct LALM settings. Staff interviews showed that the RN and wound care nurse were unsure of the correct LALM settings for the resident and did not adjust the incorrect 550-lb setting when it was identified. The medical director stated that if a LALM is on the wrong setting or not working while in use, it does not work as intended and residents have the potential to develop a wound, and that failure to implement ordered wound treatments or apply treatments as ordered can reduce the potential for wound improvement. Overall, the survey findings document failures to follow policies and physician orders, failures in communication and notification to the wound care director, and failures to implement and maintain preventive interventions and treatments for pressure ulcers for both residents.
Failure to Provide Feeding Assistance, Accessible Meals, and Accurate Intake Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow its feeding policy, provide required feeding assistance, ensure meals and supplements were within residents’ reach, and accurately document meal intake for two dependent residents. For one resident with obesity, dementia, prior stroke, and poor oral intake, the care plan and nutrition assessment identified a need for total assistance with meals and nutritional supplements, including a no added salt, pureed diet, supplemental ice cream twice daily, and a high-calorie drink with meals. Despite this, meal intake records for March and April showed numerous blank entries where no intake was documented and many entries recorded as 0 (0–25% intake). The DON confirmed that blank entries meant CNAs did not chart for that shift. Survey observations showed that this resident could not be interviewed, did not feed herself, and required staff assistance. An RN stated staff assist the resident with feeding, but during observation the RN was only feeding the resident supplemental ice cream and juice while the plated pureed meal remained covered and largely untouched, with mashed potatoes and vegetables not offered and only one apparent bite taken from the meat. When asked why the plated meal was not fed, the RN stated the resident only wanted a couple of spoonfuls and said no more, and made no attempt to offer the rest of the meal. The resident’s weight records showed a decrease from 124.8 pounds to 105.3 pounds in one month, a 15.6% loss. For a second resident with altered mental status, multiple cancers, adult failure to thrive, hemiplegia, and hemiparesis, assessments and the care plan indicated the resident required supervision or touching assistance with eating, nutritional support due to weight loss and failure to thrive, and assistance with meals as needed. Orders included a mechanical soft diet and nutritional supplements with meals. Nutrition assessment documented significant weight loss of 7.9% in one month, with variable intakes and a need for limited to total assistance. Meal intake documentation for March contained multiple blank entries where meals were not documented. During observation, this resident’s lunch tray was placed near the foot of the bed, out of reach, with all items appearing untouched more than an hour after meal service. The resident reported not receiving assistance with lunch, and the assigned CNA, seated at the nurse’s station, acknowledged the resident required feeding assistance but was unsure who had fed the resident. Later, the CNA inspected the tray and stated staff had not come around to feed the resident and confirmed the tray was placed away from the bed. Staff interviews further confirmed that the resident generally could not feed herself and that assigned floor CNAs were responsible for feeding residents needing assistance.
Failure to Supervise Resident With Self-Harm and Exit-Seeking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident with schizophrenia, anxiety, depression, and a documented history of self-harming and exit-seeking behavior. The resident’s records included statements that he had self-harmed in the past by hitting himself and had thoughts of harming himself. His baseline care plan did not document schizophrenia, anxiety, depression, or the history of self-harming behavior, and an elopement risk assessment documented that he was not at risk for elopement. The resident later told staff he wanted to leave, and staff documented pacing, carrying a coat and bag, and appearing sad. A CNA reported feeling uneasy about the resident’s pacing and believed he needed more monitoring. A nurse later documented that the resident paced the unit throughout the night, wore a coat, and had a bag on his shoulder. The resident was also described as wanting to leave the facility and, during one interaction with staff, stated he wanted to harm himself before later saying he was joking. The resident accessed a fire extinguisher from his unit, walked past the nursing station to the second-floor dining room, broke a window with the extinguisher, and jumped out of the window without staff knowledge. He landed face down outside the facility and sustained a severe left leg fracture involving the distal tibia. Surveyor review also found that the fire extinguisher case on the resident’s hallway had been altered and that the resident’s elopement information was not present in the unit elopement binder.
Infection Prevention and Control Failures with COVID-19 Exposure
Penalty
Summary
The facility failed to follow its infection prevention and control program by not conducting contact tracing, not immediately testing exposed residents and staff, not implementing isolation orders promptly, and by allowing PPE to be doffed inside isolation rooms before staff exited. The report states that two residents and one CNA tested positive for COVID-19, and that these events resulted in resident and staff exposure to COVID-19. Facility documentation also states that the infection prevention and control program is intended to prevent the development and transmission of communicable diseases and infections. One resident was admitted with diagnoses including ataxia, major depressive disorder, type II diabetes, and hypertension. After a fall, the resident returned from the hospital with a diagnosis of COVID-19. The resident had been on unit XYZ, was ambulatory on the unit, attended outpatient group therapy, and ate in the common dining room. The infection preventionist stated that the resident’s roommate was tested, but no other residents on the unit were tested as close contacts, despite the resident’s movement and participation in shared activities. The facility policy required contact tracing for a single new COVID-19 case and testing of close contacts on day 1, day 3, and day 5. Another resident had coughing, wheezing, phlegm, shortness of breath, and later was sent to the emergency room, where COVID-19 was confirmed. The resident’s record did not document testing for acute respiratory viruses before hospitalization, and the infection preventionist stated there had been no acute respiratory testing prior to the hospital transfer. Facility policy required immediate collection of respiratory specimens when illness began and initiation of contact and droplet precautions with a rapid antigen test for COVID-19 when a resident showed signs of acute respiratory illness. The infection preventionist also stated that the facility did not consider itself in outbreak status even after three COVID-19 cases were identified within 72 hours. During observations, staff were seen removing PPE inside the isolation room rather than as close to the exit as possible. In one instance, a trash receptacle was positioned between the beds in a two-bed room, requiring staff to walk past the resident and move the privacy curtain before exiting. In another observation, a housekeeper entered a room on droplet isolation wearing only a surgical mask, gown, and gloves, without an N-95 or face shield, and doffed PPE in the doorway. Staff interviews confirmed that PPE was being removed in the room and that the trash can placement contributed to that practice. The report states the facility had 155 residents.
Failure to Provide Timely Incontinence and Toileting Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinence care and assistance with toileting at least every two hours for four residents who were dependent or required maximum staff assistance for ADLs. One resident with severe cognitive impairment and dependent on staff for toileting was observed ambulating in the halls with sweatpants visibly wet in the buttocks, groin, and upper thighs. Continuous observations conducted over several hours on the same unit showed that this resident, along with three others who were either dependent or required maximum assistance for toileting, were not checked by staff for incontinence care during the observation period. Another resident with severe cognitive impairment and dependent on staff for toileting was left waiting in the hallway, during which a CNA walked past and remarked that she was not rushing before later providing care. When care was finally given, the resident’s pants were dry but the brief was heavily saturated with urine, and a linear indentation was noted on the proximal left leg, which the CNA attributed to sitting in the wheelchair. A third resident, requiring maximum assistance for toileting and not assisting with care, was found with a saturated brief when transferred to bed with a mechanical lift and two staff. A fourth resident, dependent on staff for toileting, was found with a small puddle of urine and a deep indentation on the chair cushion; the sling and clothing were saturated and dripping urine during transfer to bed. The DON stated that staff should be checking and changing residents every two hours and as needed.
Call Light Cords Not Within Residents’ Reach
Penalty
Summary
The facility failed to follow its call light policy and ensure call light cords were within reach for 6 residents out of 10 reviewed for call light accessibility. On 3/3/26, R161 was observed lying in bed with the call light cord on the floor next to the wall, R144 was observed lying in bed with a call light cord that was twenty inches in length and not within reach, R121 was observed lying in bed with the call light cord dangling on the floor, R78 was observed lying in bed with the call light cord on the floor behind the nightstand, R81 was observed sitting in a wheelchair with the call light cord dangling through the bedframe at the head of the bed on the opposite side and not within reach, and R74 was observed lying in bed with the call light cord dangling on the floor. On 3/6/26, the DON stated that call lights should be placed within resident's reach at all times. The facility's call light policy dated 09/2020 states that call lights are to be placed within resident reach at all times.
Advance Directive Orders Not Documented
Penalty
Summary
The facility failed to follow its advance directives policy and did not ensure that one resident’s wishes for advance directives were documented in the physician orders. R2 had a uniform DNR advance directive dated 1/25/26, and the initial social services assessment dated 2/5/26 documented that R2 was DNR. However, R2’s face sheet contained no documentation regarding advance directives, there was no documentation that an advance directives care plan was initiated, and R2’s POS did not include an order for code status or advance directive. During interviews, Social Services stated that residents are asked about advance directives on admission and that if a resident is admitted with a POLST, it is documented on the initial social services assessment and uploaded into the electronic medical record. The DON stated that the nurse is expected to ask the resident and/or representative about advance directives as part of the admission checklist, review code status with the physician, obtain an order, and enter it into the physician orders section of the electronic medical record. The facility’s policy stated that the resident will have a code status order entered in physician orders in accordance with advance directives on file, and that Social Services will assess for pre-existing advance directives, upload copies into the electronic medical record, and document them in the care plan.
Failure to Notify Physician of Skull X-Ray Results
Penalty
Summary
The facility failed to notify the physician of diagnostic test results for R159 that indicated the need for further evaluation. R159’s record showed diagnoses including type 2 diabetes, hypertension, anemia, acromegaly, a personal history of transient ischemic attack and cerebral infarction without residual effects, and unspecified osteoarthritis. After R159 was observed leaning over in a wheelchair and his forehead touched the floor without him falling out of the wheelchair, staff documented that he denied pain and had no injury, bruising, swelling, or redness to the forehead. The nurse informed the NP, DON, and plenary guardian, and the resident was placed on neuro checks while awaiting a stat skull X-ray. The radiology report for the skull X-ray stated there was no definite displaced or depressed calvarial fracture by plain film, but a nondisplaced fracture was not excluded, head trauma/injury was not evaluated by plain film, intracranial pathology was not evaluated by plain film, and CT was clearly and strongly recommended. The RN documented that the report was relayed to the NP, but the NP later stated she was not informed of the X-ray results and would have ordered hospital transfer for further evaluation. The RN stated he was notified of the results, said he informed the NP, and acknowledged he did not document the NP’s orders to monitor the resident for changes or send him to the hospital if changes occurred; he also stated he did not complete neuro checks. The DON stated the RN should have notified the physician of the X-ray results, and the facility policy required the resident physician, physician on call, NP, and responsible party to be kept informed of changes in condition.
Failure to Notify Physician and Provide Medications When Resident Left AMA
Penalty
Summary
The facility failed to follow its against medical advice policy when a resident left the facility against medical advice and the physician was not notified. The resident was admitted with diagnoses including type II diabetes with foot ulcer, asthma, bipolar disorder, hypertension, and asthma, and a brief interview for mental status dated 12/11/25 documented a score of 13/15, indicating the resident was cognitively intact. The resident’s progress note dated 3/3/26 documented that he left AMA after being educated on the risks and benefits of continued treatment and verbalizing understanding, but the record did not document any notification to the physician or nurse practitioner regarding the departure. The resident’s physician orders included sertraline, Depakote, Seroquel, lisinopril-hydrochlorothiazide, metformin, gabapentin, and daily wound treatments to the toes. A nurse stated she was assigned to the resident on the day he left AMA, did not call or notify the physician, and did not give the resident any medications upon discharge. Social service staff stated they completed AMA paperwork and did not notify any physicians, and one staff member said nurses were responsible for notifying the physician and providing 2 weeks of medications. The DON stated staff should inform the doctor, document the notification in the progress notes, and provide a couple days of medications when residents leave against advice.
Enoxaparin Not Available for Ordered Doses
Penalty
Summary
The facility failed to ensure Enoxaparin Solution Injection Solution Prefilled Syringe, ordered as 0.4 mL subcutaneously twice daily for chronic embolism and thrombosis of an unspecified deep vein of the lower extremity, was available for administration as prescribed for one resident. The resident’s physician order sheet documented the medication order, and the MAR for 3/1/26 through 3/31/26 showed the medication with code 9 on 3/4/26 at 6:00 a.m. and 4:00 p.m., and on 3/5/26 at 6:00 a.m., indicating follow-up needed. Electronic medication progress notes documented that the medication was not available and was awaiting supply from the pharmacy because it was being reordered. During interview, the resident stated the facility runs out of his blood thinners at times and that he goes without the prescribed blood thinner for a day or two periodically; he also said he did not receive the morning dose because the facility had run out. Observation of the medication cart showed the resident’s Enoxaparin was not in stock, on hand, or available. The LPN stated she did not administer the morning dose, initially said she had to order it, then verified she had ordered the wrong medication, pantoprazole. She also stated the medication did not arrive because of an ongoing insurance issue and denied informing the DON. The DON later stated she was unaware the resident had any problems receiving the blood thinner and said she expected nurses to ensure ordered medications are on hand for administration as prescribed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to follow its medication storage policy by keeping medications on the medication cart that were not stored or labeled correctly. During a medication cart audit with a nurse, R3’s insulin glargine subcutaneous solution pen-injector was found opened, used, and not dated. The nurse stated that the insulin should have been dated after opening and that insulin is good for 28 to 30 days after opening. R5’s insulin aspart with niacinamide was also observed on the medication cart even though it was new, unopened, and unused; the pharmacy bag documented that it should be refrigerated until opened, and the nurse stated that unopened insulin pens should be refrigerated until they are opened or used. The facility policy stated that medications requiring refrigeration are to be stored in a locked refrigerator accessible only to licensed staff and that residents’ medications are to be stored and labeled according to legal requirements.
Stained lounge chairs in resident TV room
Penalty
Summary
The facility failed to maintain a clean and homelike environment on one of three units reviewed when two lounge chairs in the television room on the third locked unit were observed with multiple old, dried stains on the seat cushions and armrests. On 3/4/26 at 10:09 a.m., surveyors observed two filthy lounge chairs with multiple dried irregular-shaped circles in the middle of the seat cushions, discoloration, dirt, and other stains covering the chairs and armrests in the resident television room. A nurse stated that residents sit in those chairs and watch television and that the chairs had been dirty for a long time. The Assistant Director of Nursing stated that the chairs had stains on the cushions and armrests, that some of the stains were consistent with dried urine and others with spills, and that she would not sit in either chair because of the multiple stains. The Housekeeping Director stated she had taken pictures of the dirty chairs a week earlier to see what could be done to clean them, but she could not report where the picture was, who she gave it to, or what the resolution was. At 10:30 a.m., a resident was observed sitting on one of the stained lounge chairs and refused to speak with the surveyor when asked about it.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse policy and did not protect residents from abuse, resulting in a physical altercation between two residents. Both residents involved had documented histories of verbal and physical aggression, as well as care plans identifying them as at risk for abusive behaviors. On the day of the incident, one resident attempted to obtain juice from a cart after lunch, which led to a verbal exchange with another resident. The situation escalated when one resident threw a cup of juice at the other, who then responded by striking the first resident in the face. Staff interviews and observations revealed that the altercation occurred in a common area near the dining room, with both residents in wheelchairs. Housekeeping staff witnessed the incident, while the assigned CNAs were providing care to other residents and did not hear the commotion. An LPN became aware of the situation only after hearing a disturbance and intervened after the physical contact had already occurred. The injured resident was observed with a swollen, bruised, and lacerated left eye following the incident. Both residents had care plans and risk assessments indicating a history of aggression and potential for abusive behavior. Despite these documented risks, staff were not present to prevent or immediately intervene in the altercation. The facility's initial abuse investigation report to the State Surveying Agency inaccurately noted that no physical contact had occurred, despite evidence and witness statements to the contrary. The facility's abuse policy affirms residents' rights to be free from abuse, but this policy was not effectively implemented in this instance.
Failure to Maintain Clean, Safe, and Comfortable Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by multiple observations of unsanitary and poorly maintained resident rooms. Residents reported and surveyors observed stained sheets, broken or missing furniture handles, holes in walls, non-functioning televisions, water damage, missing baseboards, and broken grab bars in shared bathrooms. Additionally, there were reports of excessive heat due to non-functioning windows, dust and grime on curtains, and persistent unpleasant odors such as urine. Maintenance logs confirmed that many of these issues had been outstanding for several months without resolution. Several residents, including those with complex medical and psychiatric histories such as schizophrenia, bipolar disorder, dementia, and heart failure, expressed dissatisfaction with the cleanliness and repair of their living spaces. Observations included holes in walls, chipped paint, stained pin boards, dirty floors, and buildup on radiator vents and bathroom vents. Residents also reported that maintenance was aware of these issues but had not addressed them, and that housekeeping was insufficient, with visible stains and residue remaining for multiple days. The facility's maintenance and housekeeping policies require prompt attention to repairs and regular cleaning, but interviews with staff revealed gaps in communication and follow-through. The maintenance manager relied on nurse logs and did not routinely inspect all resident rooms, focusing instead on common areas. There was also a lack of clarity regarding work orders, as seen in the case of a resident who waited three weeks for a television after being moved to a new room. The facility's failure to address these environmental deficiencies affected all nine residents reviewed for this issue.
Failure to Administer Scheduled Medications on Time
Penalty
Summary
Staff failed to administer scheduled medications on time for multiple residents, as observed and documented by surveyors. On the morning of 4/6/2025, an LPN was seen administering medications to several residents well past the scheduled 0900 time, with medication administration records (MAR) inaccurately reflecting that medications were given on time. Medication audits revealed actual administration times ranging from 10:40AM to 1:18PM, despite MAR entries indicating 0900. Residents affected included those receiving critical medications for conditions such as seizures, blood pressure, and diabetes. Two residents specifically voiced concerns about receiving their medications late, citing worries about seizure control and blood pressure management. The LPN acknowledged being behind schedule and confirmed she still had additional residents to medicate late into the medication pass. The Director of Nursing (DON) confirmed that late medication administration is unacceptable and that medications should be given within one hour of the scheduled time, as per facility policy. The DON also stated that nurses are regularly in-serviced on timely medication administration and can request assistance if running behind. Facility policy requires medications to be administered within one hour of the prescribed time unless otherwise specified by the physician.
Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were able to operate their call lights by not placing them within reach, as required by their care plans and facility policy. One resident, a male with multiple diagnoses including COPD, heart failure, hemiplegia, diabetes, hypertension, depression, end-stage renal disease on dialysis, and a history of falls, reported that his call light cord was broken and unusable while he was in bed. This condition had persisted for a week, and staff were aware of the issue. Observation confirmed the call light cord was disconnected and hanging from the bed. The resident's care plan specified that the call light should be within reach. Another male resident with diagnoses including diabetes, peripheral vascular disease, congestive heart failure, chronic kidney disease, bilateral below-knee amputations, adult failure to thrive, osteoarthritis, and shoulder impingement was observed in bed with the call light cord not within reach. A certified nursing assistant confirmed that the call light should be accessible to the resident. This resident's care plan also required the call light to be within reach. The facility's policy stated that call lights must be placed within resident reach at all times.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide post-surgical wound care according to the current physician's orders for a resident who had undergone outpatient surgery for the excision of a bone spur on the left foot. The resident, who had a history of chronic kidney disease, hypertension, and other medical conditions, was observed with a painful wound on the left foot. The wound care physician had provided specific orders for wound care, including the use of antiseptic povidone-iodine solution, collagen powder, silver alginate, and antibiotic ointment, to be applied daily. On a particular day, the wound care coordinator performed wound care on the resident's left foot but did not follow the updated physician's orders. The coordinator cleansed the wound with antiseptic povidone-iodine and normal saline, applied silver alginate, and wrapped the wound with gauze, but failed to apply the collagen powder and antibiotic ointment as ordered. The coordinator later acknowledged misreading the order and not seeing the new treatment instructions on the treatment administration record. The facility's policies require that wound treatment be performed as per medical doctor orders and that medications and treatments be administered only upon clear and complete orders from an authorized prescriber. The assistant director of nursing confirmed that nurses are expected to follow physician orders precisely, and any changes to orders should be obtained from the physician. The failure to adhere to these orders was identified as a deficiency during the survey.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to utilize a gait belt during a transfer for a resident, identified as R2, who requires substantial or maximum assistance. This failure resulted in R2 suffering three fractured ribs after falling to the floor during the transfer. The incident was not immediately reported to the nurse, and R2 was sent to the hospital for further evaluation only after complaining of pain later in the day. Hospital records confirmed the diagnosis of closed fractures of multiple ribs. R2 reported that during the transfer, a CNA, identified as V8, attempted to transfer R2 from the bed to the wheelchair without using a gait belt. R2, who has limited mobility due to arthritis, stated that V8 refused to listen to instructions on how to properly transfer R2. During the transfer, R2 experienced leg spasms, and V8 attempted to lower R2 to the floor, resulting in a fall. V8 initially claimed that R2 requested to be set on the floor, but later admitted that a gait belt was not used during the transfer. Interviews with staff revealed inconsistencies in the reporting and handling of the incident. V8 and another CNA, V10, assisted R2 back into the wheelchair without using a gait belt. The incident was not reported to the nurse until R2 complained of pain hours later. The facility's policies require the use of a gait belt during transfers to ensure resident safety, but this protocol was not followed, leading to the injury.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility failed to notify a physician promptly after a resident, identified as R2, experienced a fall. R2, who has a history of falling, muscle weakness, and multiple rib fractures, fell during a transfer from bed to wheelchair. The incident occurred in the early morning hours, but the physician was not notified until approximately six hours later when R2 began complaining of new pain. The delay in notification was due to the staff's initial failure to recognize the incident as a fall. R2 reported that during the transfer, a CNA attempted to assist R2 without listening to R2's instructions, resulting in R2 being dropped to the floor. Despite R2's immediate lack of pain, R2 later experienced significant pain, leading to a hospital visit where multiple rib fractures were diagnosed. The staff involved, including CNAs and nurses, did not immediately report the incident as a fall, and there was confusion about whether the incident constituted a fall, which contributed to the delay in notifying the physician. The facility lacked a post-fall policy to guide staff on the necessary steps following a fall, which may have contributed to the miscommunication and delay in reporting. The Director of Nursing and the Nurse Practitioner both acknowledged that the incident should have been considered a fall and reported immediately. The care plan for R2 indicated a risk for injury and required assessment for injuries following a fall, but this was not adhered to promptly due to the staff's initial misjudgment of the situation.
Improperly Installed Bathroom Fixtures Lead to Resident Fall
Penalty
Summary
The facility failed to ensure that bathroom fixtures, specifically the toilet handlebars and sink, were properly installed to prevent accidents, leading to a fall incident involving a resident. The resident, who was cognitively intact with a BIMS score of 15, experienced a fall in the bathroom when the sink detached from the wall. The resident was found on the floor, complaining of back pain, with the sink on the floor nearby. The incident was documented as a fall, and the resident was subsequently transferred to a hospital with diagnoses including intractable back pain and lumbar radiculopathy. Interviews with staff revealed that the CNA on duty responded to the resident's call light and found the resident on the bathroom floor. The Building Manager confirmed that the sink and toilet rails were broken and required immediate repair. The Director of Nursing noted that there was no evidence of the resident dismantling the sink, and the incident was reported as a fall due to the bathroom basin detaching from the wall. The resident's care plan highlighted an increased risk of falling due to heart failure, hypertension, and reliance on a quad cane. The care plan included interventions such as encouraging the use of a cane and ensuring the call light was within reach. However, the failure to maintain the bathroom fixtures contributed to the resident's fall, indicating a lapse in the facility's maintenance and safety protocols.
Failure to Protect Resident from Physical Abuse Due to Inadequate Monitoring and Care Planning
Penalty
Summary
The facility failed to protect a cognitively and visually impaired resident (R1) from physical abuse by another resident (R2) with a known history of aggressive behavior. R1, a visually impaired male with severe cognitive impairment, was physically assaulted by R2, a male resident with intact cognition but a history of aggression and violence. Despite R1's vulnerability and documented need for supervision due to his visual impairment, there was no care plan addressing R2's aggressive behavior prior to the incident. R2's behavior, including aggression, agitation, and intimidating actions, was observed by staff and other residents, indicating a pattern of concerning behavior that was not adequately addressed. The incident occurred in the early hours of the morning, resulting in R1 being hospitalized with injuries consistent with physical assault. Staff members, including a Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA), were unaware of the altercation until R1 was found injured. The facility's response to the incident was initially framed as a fall by R1 and later as an unsubstantiated allegation of abuse by R2. However, subsequent investigations, including interviews with residents and staff, revealed a different narrative of R2 physically assaulting R1. The lack of appropriate monitoring and intervention for R2's escalating behavior, as well as the decision to place R1 and R2 in the same room despite R2's history of aggression, contributed to the failure to protect R1 from abuse. The facility's failure to address the risks associated with housing a vulnerable resident like R1 with a resident exhibiting aggressive behavior like R2 highlights systemic deficiencies in resident assessment, care planning, and monitoring. The incident underscores the importance of thorough risk assessments, individualized care planning, and vigilant monitoring to ensure the safety and well-being of residents in long-term care facilities. The lack of proactive measures to prevent abuse and address behavioral concerns among residents, particularly those with a history of aggression, led to a serious breach in resident safety and regulatory compliance.
Elopement Incident Involving Resident with Cognitive Impairment
Penalty
Summary
The deficiency identified in the report pertains to the failure of a long-term care facility to provide adequate supervision and monitoring for a resident assessed to be at risk for elopement. The resident in question, R5, a female with a complex medical history including diagnoses of Schizophrenia, Schizoaffective Disorder, Dementia, and Atherosclerotic Heart Disease, was known to be at risk for elopement due to cognitive impairment and previous history of elopement from a different nursing home. Despite being placed in a secured Memory Care Unit, R5 managed to elope from the facility unnoticed and unsupervised on the night of 04/06/24. The incident unfolded when a staff member observed the alarm on the back door sounding, prompting a Code Green for elopement. Despite efforts to conduct a headcount and search for the missing resident, R5 was found to have left the facility and was later discovered in a local hospital after crossing a busy street intersection without shoes and allegedly experiencing chest pain. Staff members involved in the incident, including a Licensed Practical Nurse (V4) and Certified Nurse Aide (V3), expressed unawareness of R5's history of elopement and highlighted her compliance and lack of disruptive behavior as contributing factors to the oversight.
Failure to Monitor and Address Changes in Condition and Behavior
Penalty
Summary
The facility failed to provide necessary care and treatment during a change in condition for a resident (R5) who complained of chest pain and subsequently eloped from the facility. R5, a female resident with a history of schizophrenia, schizoaffective disorder, dementia, and atherosclerotic heart disease, was admitted to the facility with a known risk of elopement. Despite this, the staff did not adequately monitor her, and she was able to leave the facility unnoticed. R5 was found wandering in traffic and was taken to the hospital, where she reported experiencing severe chest pain, shortness of breath, and left upper extremity pain. She stated that she had informed the nursing home staff of her symptoms but did not receive proper care, prompting her to leave the facility on her own to seek medical attention. The facility also failed to monitor and address the escalation of maladaptive behavior in another resident (R2). R2, a male resident with a history of schizoaffective disorder, anxiety disorder, encephalopathy, and hypertension, exhibited increased wandering, pacing, and aggressive behavior. Despite having a history of aggression and violence, there was no care plan in place to monitor R2's behavior prior to an incident on 03/17/2024, where R2 committed an assault. Staff interviews revealed that R2's aggressive behavior was known, but there were no documented interventions or increased monitoring to address his behavior. R2 continued to display aggressive and intimidating behaviors, making other residents and staff uncomfortable. The facility's failure to provide necessary care and treatment for R5's chest pain and to monitor R2's escalating behavior resulted in significant safety concerns. R5's elopement and subsequent hospitalization for chest pain, as well as R2's aggressive behavior and assault, highlight the facility's deficiencies in monitoring and addressing residents' changes in condition and behavior. The lack of appropriate interventions and monitoring for both residents led to serious incidents that could have been prevented with proper care and attention.
Failure to Conduct Pain Assessment and Provide Necessary Care
Penalty
Summary
The facility failed to conduct a proper pain assessment and provide necessary care and treatment for a resident (R5) who complained of severe chest pain. R5, a female resident with a history of Schizophrenia, Schizoaffective Disorder, Dementia, and Atherosclerotic Heart Disease, reported chest pain to the nursing staff but did not receive appropriate attention. Consequently, R5 eloped from the facility without shoes and went to the nearest emergency room for further evaluation and treatment. The hospital records confirmed that R5 had been experiencing chest pain for three days and had alerted the nursing home staff of her symptoms before deciding to leave the facility due to inadequate care. On the night of the incident, the alarm on the back door of the facility went off, and a Code Green for elopement was called. The staff conducted a headcount and discovered that R5 was missing. Shortly after, the hospital contacted the facility to inform them that R5 was in the emergency room. Interviews with the staff revealed that R5 had asked for a brief and a blanket earlier in the evening but did not explicitly mention chest pain to the LPN on duty. However, R5 later stated that she had informed the nurse about her chest pain, but he did not pay attention, prompting her to leave the facility. The facility's policies on pain management and change of condition were not followed, as the staff failed to assess R5's pain and notify the physician. The care plans for R5 included monitoring for pain and changes in cardiac status, but these interventions were not implemented. The facility's failure to address R5's chest pain and provide appropriate care led to her elopement and subsequent hospitalization for chest pain.
Multiple Failures in Resident Supervision and Care
Penalty
Summary
The facility failed to protect a cognitively and visually impaired resident's right to be free from physical abuse from another resident with a known history of aggressive behavior. The aggressive resident, who had a history of agitation and violence, was not adequately monitored, and no care plan was in place to address his aggressive behavior. This led to an incident where the aggressive resident physically assaulted the impaired resident, causing significant injuries. Staff were unaware of the aggressive resident's history and did not provide the necessary supervision or intervention to prevent the assault. The facility also failed to provide adequate supervision and monitoring for a resident assessed to be at risk for elopement. Despite being identified as an elopement risk, the resident was able to leave the facility unnoticed and unsupervised. The resident, who had a history of elopement and was cognitively impaired, left the facility due to unaddressed chest pain. The staff were unaware of the resident's elopement risk and did not follow the facility's elopement policy, which included procedures for monitoring and reporting. Additionally, the facility failed to conduct a pain assessment and provide necessary care and treatment for a resident complaining of chest pain and during a change in condition. The resident reported severe chest pain and other symptoms to the staff, but the staff did not take appropriate action to assess and address the pain. This lack of response led the resident to leave the facility and seek medical attention at a nearby hospital. The facility's failure to monitor and address the resident's pain and change in condition highlights a significant deficiency in the quality of care provided.
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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