Helia Southbelt Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Belleville, Illinois.
- Location
- 101 South Belt West, Belleville, Illinois 62220
- CMS Provider Number
- 145241
- Inspections on file
- 55
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Helia Southbelt Healthcare during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow required food handling and storage practices, including a dietary aide plating meals from a steam table without a visible hairnet and multiple boxes of food items stored directly on the dry storage room floor instead of on shelves at least six inches above the floor. The dietary manager acknowledged the boxes had not been put away after delivery due to short staffing and confirmed the facility does not use clear hairnets, contradicting the aide’s claim. Facility policies require hair coverings to be worn at all times in the kitchen and food and supplies to be stored off the floor, and the administrator stated he expects dietary staff to comply with these policies for all residents.
A resident with severe cognitive impairment, tracheostomy status, and acute respiratory failure decannulated herself, had unsuccessful trach replacement attempts, and was transitioned to nasal cannula, and also received wound care that generated an external bill. The family member, listed as emergency contact and POA, reported not being informed of the resident’s wound or that the resident had been removing her trach tube, learning of the wound only after receiving a bill. The DON and ADON were unsure whether the family or physician had been notified of these changes, despite a facility policy requiring immediate notification of the resident, physician, and representative for significant changes in condition or status.
A resident with severe cognitive impairment, anxiety, dementia, tracheostomy status, and a history of grabbing and pulling at medical devices repeatedly removed her trach collar and other respiratory equipment, and ultimately decannulated herself. Progress notes documented multiple episodes of pulling off the trach collar and vent mask, causing skin tears and repeated disruption of respiratory support, while staff primarily continued to monitor and reposition her. Although staff used an abdominal binder for the G-tube and kept items out of reach, there were no documented care plan interventions specifically addressing her ongoing behavior of pulling at the tracheostomy tube, despite facility policy requiring identification of non-pharmacologic interventions for problematic behaviors.
A resident with nicotine dependence and a history of non-compliance repeatedly smoked in non-designated areas, including his room and hallways, despite being assessed as an unsafe smoker. Staff frequently found ashes, smelled smoke, and observed the resident with cigarettes and lighters, which were supposed to be secured per facility policy. The facility's ongoing awareness and repeated education did not prevent the resident from continuing to smoke in unauthorized areas, resulting in a deficiency related to accident hazards.
A resident with cognitive impairment and a history of substance abuse and hallucinations, identified as at risk for abuse, was involved in a physical altercation with another resident outside the facility. The incident escalated to physical contact before staff intervened, indicating a failure to prevent resident-to-resident abuse despite existing policies and risk identification.
A resident dependent on staff for transfers and requiring a mechanical lift did not consistently receive timely assistance due to ongoing issues with lift availability and dead batteries. Staff and the ombudsman confirmed that mechanical lifts were often not working, leading to delays in care and unmet resident needs, with no facility policy in place for battery maintenance.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A resident with severe cognitive impairment developed a skin tear on her ankle, and while treatment was initiated and documented, there was no evidence that the responsible party was notified of the wound's deterioration or new treatment orders. Family members discovered the wound during a visit, and staff could not confirm or document timely notification, contrary to facility policy.
A resident with multiple chronic conditions did not receive her scheduled morning medications as required, after an LPN left the medications in her room and later removed them without ensuring ingestion or consulting the physician about late administration. The MAR was inaccurately signed as if the medications were given, contrary to facility policy requiring direct observation and immediate documentation.
A resident with quadriplegia experienced verbal and physical abuse by staff at an LTC facility. A nurse removed a wound dressing after a verbal exchange, and a respiratory therapist threatened the resident during suctioning. Both staff members were terminated following the incidents.
A facility failed to provide adequate incontinent care for three residents, leading to a deficiency. One resident, cognitively intact, was not properly cleansed or dried after toileting. Another, severely cognitively impaired, was cleaned with the same portion of a towel for different areas and not dried. A third resident, with a history of UTIs and Alzheimer's, was also inadequately cleansed and not dried. The facility's policy requires separate washcloths and thorough drying, which was not followed.
A resident with glaucoma did not receive their prescribed Latanoprost eye drops as the facility failed to document and administer them according to professional standards. Despite the MAR indicating administration, the pharmacy records showed no refills for April and November, leading to a discrepancy. LPNs believed the medication was available, but the DON noted the lack of refills, highlighting a failure in medication administration policy adherence.
Two residents at a facility experienced falls due to inadequate fall precautions and failure to use a gait belt during transfers. One resident, who was cognitively impaired, was transferred without a gait belt, resulting in a fall. Another resident, also at risk for falls, did not receive timely interventions after a fall, leading to a broken nose. The facility did not adhere to its Falls Management Policy, resulting in deficiencies in care.
A resident with dementia and heart failure missed a medical appointment due to the facility's failure to provide timely transportation. The transportation schedule book was missing, leading to overcrowded schedules and missed appointments. The facility had only one van, and the resident's appointment was the third to be rescheduled, resulting in the doctor refusing to see them.
A resident with glaucoma did not receive their prescribed Latanoprost 0.005% eye drops for two months due to the facility's failure to refill and deliver the medication. The pharmacy did not refill the prescription, and the nursing staff did not notify the pharmacy for refills, leading to a lapse in administration as per the physician's orders.
A resident with glaucoma had inconsistent documentation of Latanoprost eye drop administration. The MAR indicated daily administration, but pharmacy records showed no refills. LPNs claimed the medication was available, but the DON noted discrepancies, highlighting a failure to maintain accurate medical records.
A resident with hemiplegia and depression was reportedly slapped by a CNA during care, leading to the CNA's termination. The incident was witnessed by another CNA, who confirmed the resident's account. The facility's investigation found inconsistencies in the CNA's story, while the resident's account remained consistent.
A resident with complex medical needs was not permitted to return to the facility after hospitalization, exceeding the bed-hold policy. Despite the facility's policy to readmit residents, the resident was discharged due to being out for over 30 days and an investigation involving a threat by his ex-wife. There was no documentation of unmet needs or communication with the resident or family about the discharge, leading to a deficiency in the facility's actions.
A resident with obstructive sleep apnea and other health conditions was not provided with a BiPAP machine at bedtime as ordered. Observations showed the resident sleeping without the device, despite a physician's order for its nightly use. The care plan lacked documentation for the BiPAP, and the facility's policy emphasizes the importance of these devices for respiratory care.
The facility failed to update its facility-wide assessment to reflect current resident acuity levels and population, including a new specialty area for ventilator/tracheostomy care. This oversight, confirmed by the Administrator, affects all 104 residents.
The facility failed to prevent abuse among residents and inappropriate staff behavior. A resident with dementia repeatedly abused another resident, resulting in injuries. Additionally, a CNA was reported for kissing residents without consent, and another staff member made inappropriate comments and offered alcohol to a resident. These incidents highlight deficiencies in the facility's care and supervision protocols.
The facility failed to provide adequate activities for four residents with cognitive impairments, despite their care plans indicating preferences for group and independent activities. Observations showed these residents were often left without engagement, such as sitting idly or sleeping in common areas. The Activity Director mentioned offering sensory groups, but issues like a missing TV remote hindered activity provision. The Social Service Director noted challenges in redirecting residents, highlighting the facility's failure to meet activity needs.
The facility failed to maintain safe food temperatures for therapeutic diets, affecting several residents. Residents reported consistently cold breakfast food, and observations during lunch service showed mechanical soft beef tips served at 110°F, below the safe holding temperature. The issue was noted in Resident Council Meeting Minutes, indicating a recurring problem.
A facility failed to provide physician-ordered wound care for a resident with a chronic ulcer and open wound on the buttock. The resident, who is cognitively intact, reported inconsistent dressing changes, particularly at night, leading to periods without proper wound coverage. An LPN acknowledged issues with night shift treatments, while the DON was unaware of these concerns. The facility's Wound Management Program emphasizes skin integrity management.
A resident with multiple medical conditions experienced an undesirable weight loss, leading to a physician's order to increase tube feeding from 40ml/hr to 50ml/hr. Despite this, observations showed the feeding continued at the incorrect rate. Staff interviews confirmed the order change, highlighting a failure to adhere to the facility's tube feeding policy.
The facility failed to implement fall interventions for several residents, leading to multiple falls and injuries. A resident with Alzheimer's experienced falls due to missing interventions like a canoe mattress and reminder signs. Another resident with hemiplegia fell in a cluttered room without proper footwear. A cognitively impaired resident lacked non-slip socks, and a resident with a fractured humerus had no floor mat. These deficiencies highlight a systemic issue in following care plans.
A resident with Type 2 Diabetes was not provided insulin for the first five days of admission, leading to a significant medication error. The resident's discharge paperwork indicated the need for sliding scale insulin, but no diabetic medication was ordered during this period. Blood sugar levels ranged from 138 to 397, and the oversight was acknowledged by an LPN and a pharmacist.
The facility failed to maintain proper food temperatures during meal service, affecting all 114 residents. Observations revealed that food temperatures were not consistently checked or recorded, and the warming cart was not functioning properly. Residents reported receiving cold meals, and staff acknowledged the issue. The facility's meal service process was inefficient, contributing to delays and inappropriate food temperatures.
A resident with severe cognitive impairment missed nine doses of his prescribed Glaucoma medication, Brimonidine/Timolol, due to discrepancies in medication administration and availability. The medication was supposed to be kept at the bedside for self-administration, but this was not always feasible given the resident's condition. The facility's DON acknowledged the issue, and both a covering Primary Care Physician and a pharmacist confirmed that this constitutes a significant medication error.
Improper Food Handling and Storage Practices in Dietary Services
Penalty
Summary
Surveyors identified that the facility failed to store and prepare food in a manner that prevents potential contamination for all residents. During breakfast service, a dietary aide (V6) was observed plating food from the steam table without wearing a hairnet, despite initially stating she was wearing one. Later, the dietary manager (V4) clarified that the facility does not purchase clear hairnets and that the hairnets used have thin black webbing, indicating V6 was not in compliance with the requirement to wear a visible hair covering. In the dry storage room, surveyors observed several stacks of food and supply boxes, including bread, brown sugar, dry cereal, apple juice, potato chips, jelly, syrup, and non-dairy creamer, stored directly on the floor rather than on shelves at least six inches above the floor as required by facility policy. V4 stated these boxes had been delivered the previous day and had not been put away due to short staffing. The administrator (V1) stated he expects all dietary staff to wear hairnets in the kitchen and to store food according to policy. Facility policies revised January 2012 require the kitchen to be maintained in a clean and sanitary condition with hairnets or hair coverings worn at all times, and food and supplies to be stored six inches above the floor on clean racks or shelves. The daily census documented 94 residents living in the facility at the time of the survey.
Failure to Notify Representative and Physician of Significant Change in Condition and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative and physician of significant changes in condition and treatment. The resident had multiple serious diagnoses, including intracerebral hemorrhage, unspecified dementia, tracheostomy status, and acute respiratory failure, and had a BIMS score of 00 indicating severe cognitive impairment. The resident’s care plan identified a risk for respiratory difficulties related to respiratory failure and included an intervention to notify the physician of any changes. Progress notes documented that the resident decannulated herself, respiratory therapy attempted three times to replace the tracheostomy, the stoma closed quickly, and the resident was then placed on 3 L/min nasal cannula with continued monitoring. The facility’s policy on change in condition required immediate notification of the resident, physician, and resident representative when there is a significant change in physical, mental, or psychosocial status. The resident’s family member, who was listed as emergency contact and power of attorney, reported that after the resident’s death they received a bill from a wound care company for treatment and removal of something from a wound, but the family had not been notified of any wounds or related treatment. The family member also stated they were not notified that the resident had been removing her tracheostomy tube and described the communication as horrible. The DON and ADON both stated they were unsure if the family or physician had been notified of any changes in the resident’s condition. One LPN reported not being familiar with the resident but stated she generally notifies families of changes, while another LPN stated the resident had a history of pulling at her tracheostomy tube and other devices and that after the resident extubated herself and was placed on oxygen and moved to another hallway, she (the LPN) always notified the family and physician of changes. However, there was no documentation or confirmation that the resident’s representative and physician were notified of the decannulation event or the wound care, leading to the cited failure to follow the facility’s notification policy.
Failure to Implement Preventative Measures for Resident Repeatedly Removing Tracheostomy Tube
Penalty
Summary
The deficiency involves the facility’s failure to implement preventative measures for a resident with a known history of attempting self-extubation of a tracheostomy tube. The resident was an 84-year-old female with diagnoses including intracerebral hemorrhage, anxiety disorder, unspecified dementia, tracheostomy status, acute respiratory failure, depression, hypertension, atrial fibrillation, and type 2 diabetes. On admission, she had a tracheostomy with ventilatory support, severe cognitive impairment per MDS (BIMS score of 00), left-sided weakness from a prior stroke, and a history of grabbing and pulling at items within reach, including her gastrostomy tube. Her care plan identified anxiety and risk for respiratory complications related to respiratory failure, but there were no documented interventions addressing her behavior of pulling at the tracheostomy tube. Progress notes show repeated episodes of the resident removing or attempting to remove respiratory equipment. On the evening of admission, documentation indicated she pulled off her trach collar three times, with RT noting they would continue to monitor. The following morning, staff documented that she was extremely restless, had to be repositioned multiple times, and tried multiple times to remove the vent mask, causing two skin tears on her upper right chest. Later that same morning, it was documented that she had pulled herself off the trach collar four times and emptied the humidity water bottle twice, with staff moving the O2 tank and water bottle to the foot of the bed and continuing to monitor while her O2 saturation remained in the mid-90s. Subsequent documentation shows that the resident ultimately decannulated herself, with RT unsuccessfully attempting three times to replace the trach before the stoma closed, after which she was placed on nasal cannula oxygen. Notes also indicate she continued to remove her nasal cannula, though her oxygen saturations generally remained within normal limits. Interviews with the DON, MDS/Care Plan Coordinator, and an LPN confirmed that the resident had a history of pulling at her tracheostomy tube, feeding tube, and other items, and that she was very anxious. The LPN reported that an abdominal binder was used over the G-tube site and items were kept out of her reach, but stated there was nothing they could do to keep her from pulling at the tracheostomy tube and that it was inevitable she would pull it out. Despite the facility’s Problematic Behavior Management Clinical Protocol requiring identification and implementation of non-pharmacologic interventions for problematic behaviors and assessment of whether a resident is a danger to themselves, there was no documentation of specific preventative interventions for the resident’s repeated attempts to remove her tracheostomy tube.
Failure to Prevent Unauthorized Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure that a resident only smoked in designated, safe areas and that tobacco and smoking supplies were kept in secure locations, as required by facility policy. The resident, who was cognitively intact and independently ambulatory, had a history of type 2 diabetes mellitus, cerebral infarction, and nicotine dependence. Despite being assessed as a potentially unsafe smoker and having a care plan indicating non-compliance with smoking protocols, the resident repeatedly smoked in his room and other non-designated areas. Multiple staff members, including the administrator, DON, nurse manager, CNAs, and RNs, reported finding ashes, smelling smoke, and observing the resident with cigarettes and lighters in his room and hallways. Progress notes documented several instances where the resident's room and bathroom smelled of smoke, ashes were found, and the resident was caught with smoking materials. The facility's smoking policy required that smoking materials be secured at the nurses' station and prohibited smoking in resident rooms, allowing it only in designated outdoor areas. Despite repeated education and reminders from staff, the resident continued to access and use tobacco products in unauthorized areas, sometimes obtaining cigarettes and lighters from outside the facility or visitors. The facility was aware of the ongoing issue, as documented in interviews and progress notes, but the non-compliance persisted, resulting in a failure to maintain a safe environment free from accident hazards related to smoking.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with a history of psychoactive substance abuse, bilateral blindness, and hallucinations, who was identified as moderately cognitively impaired and at risk for abuse or neglect, was involved in a physical altercation with another resident. The incident occurred outside the facility, where an argument escalated, resulting in one resident being hit in the groin and subsequently slapped in the face by the other. Staff members, including a CNA and two LPNs, witnessed or were informed of the altercation and intervened to separate and assess the residents. The event was documented in the resident's progress notes and reported to facility administration and the police. The facility's abuse prevention policy emphasizes the establishment of a resident-sensitive and secure environment to prevent abuse and neglect. Despite this policy, the incident demonstrates a failure to prevent resident-to-resident abuse, as the altercation occurred and physical contact was made before staff intervention. The involved resident's care plan had previously identified them as being at risk for abuse or neglect, yet the measures in place were insufficient to prevent the incident.
Failure to Ensure Timely Assistance with Mechanical Lift Transfers Due to Equipment Issues
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including severe obesity, osteoarthritis, and limited mobility, did not consistently receive required assistance with transfers using a mechanical lift. The resident was dependent on staff for transfers and had a care plan specifying the use of a mechanical lift. However, both the resident and staff reported ongoing issues with the availability and functionality of the mechanical lifts, particularly due to dead batteries and a lack of working equipment. The resident described having to wait an hour and a half to be transferred to bed because the lift was not charged, resulting in distress and unmet care needs. Staff interviews confirmed that problems with mechanical lifts had persisted for months, with frequent difficulties finding a working lift and delays in obtaining new batteries. The ombudsman and staff corroborated that the issue was ongoing and affected residents' ability to be transferred as needed. The facility administrator acknowledged there was no policy regarding battery maintenance for the equipment. Facility policies required the use of mechanical lifts for residents with limited mobility and emphasized residents' rights to dignity and timely care, but these were not consistently upheld due to equipment failures and lack of procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's condition at the time, are not provided in the report.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident with a history of dementia, chronic kidney disease, and Alzheimer's disease. The resident was admitted with significant cognitive impairment and communication deficits, requiring staff to communicate with family to determine the best approach for care. On a specific date, the resident developed a skin tear on her right ankle, and treatment orders were initiated and documented in the Medication Administration Record. However, there was no documentation that the resident's Power of Attorney (POA) was notified of the wound's deterioration or the new treatment orders, despite the facility's policy requiring such notification and documentation. Interviews with staff and the resident's family member revealed inconsistencies regarding when and if the POA was informed about the change in the resident's condition. The family member discovered the wound during a visit and was not previously informed about its presence or the treatment being provided. Staff members were unable to confirm the exact date of notification, and the Director of Nursing and Administrator acknowledged the lack of documentation regarding notification of the POA. The facility's policy mandates that changes in condition be reported and documented promptly, but this was not followed in this instance.
Failure to Ensure Complete Medication Administration and Accurate Documentation
Penalty
Summary
The facility failed to ensure that medications were completely administered and accurately documented for one resident. The resident, who was cognitively intact and had diagnoses including adrenocortical insufficiency, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and hypertension, was care planned for non-compliant behavior related to medication administration. On the day in question, the resident's Medication Administration Record (MAR) indicated that all morning medications were administered and signed off by an LPN, but the resident did not actually take the medications at the scheduled time. According to progress notes and interviews, the LPN left the resident's medications in her room, intending for her to take them on her own. When the nurse returned later, the medications were still present, along with a pill from the previous night. The nurse then removed the medications, refused to allow the resident to take them late, and documented the situation in a progress note. The resident and her daughter both reported that the medications were not taken as scheduled and that the nurse did not ensure ingestion or consult the physician about late administration, despite the importance of the medications for the resident's conditions. Facility policy required that medications be administered at the time they are prepared, with the nurse observing ingestion and documenting administration immediately afterward. The nurse's actions did not comply with this policy, as medications were left at the bedside without an order, ingestion was not observed, and the MAR was signed as if the medications had been given. The nurse also did not consult the physician regarding the possibility of late administration, despite the resident's medical needs.
Failure to Prevent Abuse and Neglect of Resident
Penalty
Summary
The facility failed to prevent physical and verbal abuse for a resident diagnosed with quadriplegia and dependent on a ventilator. The resident, who had a perfect BIMS score indicating full mental capacity, reported an incident involving a nurse who, after completing a wound dressing, removed it and discarded it in the trash following a verbal exchange. The nurse's actions were witnessed by a CNA, and the incident was reported to the facility's administration, leading to the nurse's termination. Another incident involved the same resident and a respiratory therapist (RT). The resident alleged that the RT was rough during suctioning and made verbal threats after the resident threatened to have his family retaliate. The RT was overheard by a nurse making threats to choke the resident, and the situation escalated to the point where the RT was removed from the room by staff. The RT was subsequently terminated for his actions. The facility's administrator acknowledged that the incidents were likely due to frustration and noted that the resident often used words to provoke staff. Despite this, the administrator emphasized the importance of protecting residents and took action by terminating the involved staff members. The facility's abuse prevention policy aims to create a resident-sensitive and secure environment, but these incidents highlight a failure to uphold this standard.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide complete incontinent care to prevent urinary tract infections for three residents. Resident 3, who is cognitively intact and requires assistance with toileting, was not properly cleansed by the CNA, who failed to clean the labia and urethra and did not dry the resident after toileting. Resident 4, who is severely cognitively impaired and dependent on staff, was not properly cleansed as the CNA used the same portion of a towel to clean both the groin and rectal areas, and failed to dry the resident. Resident 5, who has a history of urinary tract infections and Alzheimer's Disease, was also not properly cleansed as the CNA used a soiled towel to clean the rectum and buttocks and did not dry the resident. The facility's policy on perineal care, dated July 2017, specifies that separate washcloths and water should be used for cleaning different areas, and that residents should be thoroughly dried after care. However, the CNAs involved did not adhere to these guidelines, as they reused towels for different areas and did not dry the residents. The Director of Nurses confirmed that Resident 5 did not have an indwelling urinary catheter, contrary to the documentation, and the Administrator acknowledged that the same section of a towel should not be used for all incontinent care and that residents should be dried after care.
Failure to Document and Administer Eye Drops as Prescribed
Penalty
Summary
The facility failed to ensure that a resident's prescription eye drops were documented as administered according to professional standards. The resident, who was diagnosed with glaucoma, had a physician's order for Latanoprost 0.005% eye drops to be administered in both eyes at bedtime. However, the facility's pharmacy records indicated that the eye drops were not refilled for the months of April and November 2024, despite the Medication Administration Record (MAR) documenting that the medication was administered on those days. Interviews with the pharmacy technician confirmed that the medication was not refilled or delivered during these months, suggesting a discrepancy between the MAR and the actual availability of the medication. Licensed Practical Nurses (LPNs) who documented the administration of the eye drops stated that they believed the medication was available and administered as per the physician's orders. The Director of Nurses (DON) also noted the lack of refills and expressed confusion over how the staff documented the administration of the eye drops without the pharmacy refilling them. The facility's Medication Administration Policy requires medications to be administered as prescribed and in accordance with good nursing principles, which was not adhered to in this case.
Failure to Implement Fall Precautions and Use Gait Belt
Penalty
Summary
The facility failed to ensure the use of a gait belt during a one-person transfer for a resident, R11, who was at high risk for falls. R11, who was severely cognitively impaired and required substantial assistance with transfers, was observed being transferred without a gait belt by a CNA. During the transfer, R11's feet slid, and the CNA fell on top of him, resulting in R11 hitting the bathroom wall. The CNA initially attempted to lift R11 without assistance and later called for help from another CNA and a Physical Therapy Assistant. The incident was not immediately reported as a fall, and the resident's Power of Attorney was misinformed about the nature of the incident. Another resident, R7, who was also at risk for falls due to cognitive impairments, experienced a fall that resulted in a broken nose. The care plan for R7 included modifying the wheelchair seat to prevent further falls, but this intervention was not implemented. Additionally, after a subsequent fall, the intervention of 15-minute safety checks was delayed by two days. The facility's Director of Nursing acknowledged that fall interventions should be implemented promptly after falls. The facility's Falls Management Policy emphasizes the importance of assessing and managing resident falls through prevention, investigation, and implementation of interventions. However, the facility failed to adhere to this policy by not implementing necessary fall precautions and interventions for both R11 and R7, leading to deficiencies in the care provided to these residents.
Failure to Provide Timely Transportation for Medical Appointments
Penalty
Summary
The facility failed to provide timely and reliable transportation for a resident, identified as R2, who was scheduled for a medical appointment. R2, who was admitted with diagnoses including dementia, heart failure, and weakness, required substantial assistance with mobility and used a wheelchair. The resident's appointment on November 18, 2024, was missed because the transportation was late due to another appointment running over time. This was the third time R2's appointment had to be rescheduled, and the doctor refused to see the resident when they arrived late. The transportation issues were compounded by the disappearance of the transportation schedule book, as stated by the transportation driver, V4. This led to multiple resident appointments being missed or rescheduled due to overcrowding of the schedule and limited transportation resources, with only one van available. The facility administrator, V1, acknowledged that the previous transportation driver was terminated, and the schedule went missing, resulting in missed appointments for R2. The facility's policy on resident rights emphasizes the importance of providing access to necessary services, which was not upheld in this instance.
Failure to Refill and Deliver Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication, Latanoprost 0.005% eye drops, was refilled and delivered for administration as per the physician's orders. The resident, who was diagnosed with glaucoma, had a physician's order for the eye drops to be administered in both eyes at bedtime. However, the pharmacy did not refill or deliver the medication for the months of April 2024 and November 2024, leading to a lapse in administration. The Pharmacy Order Entry Technician confirmed that the prescription was not refilled or delivered during these months, and the Director of Nurses acknowledged that the nurses are responsible for notifying the pharmacy for medication refills. The facility's Medication Administration Policy requires medications to be administered as prescribed, but the failure to reorder the medication resulted in a deficiency in meeting the resident's pharmaceutical needs.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with glaucoma. The resident's Physician's Order Sheet (POS) indicated a prescription for Latanoprost eye drops to be administered at bedtime. However, the facility's pharmacy records showed that the medication was not refilled for the month of April 2024, despite the Medication Administration Record (MAR) documenting that the medication was administered daily. Similarly, in November 2024, the MAR showed inconsistent documentation, with some days marked as administered, some as therapeutic leave, and others left blank, despite the pharmacy not refilling the medication. Interviews with Licensed Practical Nurses (LPNs) revealed that they documented the administration of the medication based on its availability at the facility, contradicting the pharmacy's records. The Director of Nurses (DON) acknowledged the discrepancy, noting that the lack of refills should have prevented accurate documentation of administration. This inconsistency in documentation indicates a failure to maintain accurate medical records in accordance with professional standards, as required by the facility's Medication Administration Policy.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by a Certified Nursing Assistant (CNA). R2, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and depression, was reported to have been slapped by the CNA during an incident in the bathroom. The incident occurred when R2 was in her wheelchair, and the CNA allegedly became agitated, resulting in the CNA slapping R2. This was corroborated by another CNA who witnessed the event and reported that the CNA's claim of being slapped by R2 was false. The facility's investigation revealed inconsistencies in the CNA's account of the incident, while R2's account remained consistent. The facility's abuse prevention policy defines abuse as the willful infliction of injury or punishment causing physical harm or mental anguish. Despite the CNA's claim that R2 had slapped her, the evidence and witness statements supported R2's account of being slapped by the CNA. The facility's administrator decided to terminate the CNA's employment following the investigation.
Facility Fails to Permit Resident's Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as R5, to return to the nursing home after hospitalization, which exceeded the bed-hold policy. R5, a 48-year-old male with a complex medical history including acute respiratory failure, quadriplegia, and stage 4 wounds, was sent to the hospital at his request for wound care. Despite the facility's policy to readmit residents to the first available bed in a semi-private room after hospitalization, R5 was not allowed to return due to an ongoing investigation related to a threat involving his ex-wife. The facility's records and interviews reveal that R5 had been out of the facility for over 30 days, leading to his discharge based on the facility's policy. However, there was no documentation of a specific need that could not be met at the facility, nor were there attempts to meet those needs. Additionally, there was no physician documentation or communication with R5 or his family regarding the discharge or the bed-hold policy. The facility's staff, including the Administrator and Social Service Director, stated that R5 was discharged due to being out of the facility for over 30 days, but this reasoning was not familiar to the Ombudsman, who insisted that the facility had to take him back. Interviews with various staff members, including the Director of Nursing and the Admissions Coordinator, indicated that R5 had multiple complaints and refusals of care, and the facility had made several attempts to accommodate his needs. However, the facility cited an investigation involving R5 and his ex-wife as a reason for not allowing his return. The Social Worker and R5's mother expressed concerns about the facility's ability to meet R5's needs and the lack of communication regarding his discharge. The facility's actions and inactions led to a deficiency in permitting R5 to return after hospitalization, as required by their policy.
Failure to Apply BiPAP Machine as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required the use of a BiPAP machine at bedtime. Observations revealed that the resident, who has diagnoses including congestive heart failure, type II diabetes mellitus, and obstructive sleep apnea, was not wearing the BiPAP machine as ordered. The resident was observed sleeping without the device on multiple occasions, despite having a physician's order specifying its use nightly at bedtime with specific inspiratory and expiratory pressure settings. The resident's care plan did not include documentation regarding the use of the BiPAP machine, indicating a lack of proper care planning for the resident's respiratory needs. The facility's policy on CPAP/BiPAP support outlines the importance of using these devices to improve oxygenation and ensure resident comfort and safety. The administrator acknowledged that the night nurses and respiratory therapy staff are responsible for applying the machines, yet the deficiency occurred, highlighting a failure in adhering to the prescribed respiratory care protocol.
Failure to Update Facility Assessment for Resident Acuity and Population
Penalty
Summary
The facility failed to complete an updated facility-wide assessment to accurately reflect the current resident acuity levels and population. This deficiency was identified during a review of the facility assessment dated from January 2023 through December 2023, which did not document the updated resident acuity and population necessary to develop an appropriate care plan. The facility recently added a new specialty area for ventilator/tracheostomy care and treatment, which was not included in the current resident population assessment. During an interview, the Administrator confirmed that the facility does not have an updated facility assessment. This oversight has the potential to affect all 104 residents residing in the facility, as documented by the Centers for Medicare and Medicaid Services form 671.
Failure to Prevent Abuse and Inappropriate Behavior in LTC Facility
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving resident-to-resident abuse and inappropriate staff behavior. Resident R34, who has a diagnosis of dementia and moderate cognitive impairment, was involved in several incidents of physical aggression towards resident R77, who also suffers from severe cognitive impairment and dementia. These incidents included hitting R77 with objects such as a wet floor sign and a broom, resulting in injuries like lacerations and cuts. Despite R34's documented history of harmful behavior and R77's wandering and impulsive tendencies, the facility did not effectively manage or prevent these interactions, leading to repeated abuse. In addition to resident-to-resident abuse, the facility also failed to prevent inappropriate behavior by staff members. CNA V21 was reported to have kissed residents R54 and R63 without their consent, which was considered odd and unprofessional behavior. R54, who is dependent on a ventilator, and R63, who has ALS, both reported feeling uncomfortable with the CNA's actions. Despite the lack of prior reports of inappropriate behavior by V21, the incidents were substantiated by other staff members and residents, indicating a failure in monitoring and managing staff conduct. Furthermore, the facility faced issues with another staff member, V20, who was reported to have made inappropriate comments and offered alcohol to resident R67. This behavior was reported by both the resident and his son, leading to the termination of V20. The facility's abuse prevention program policy outlines the need for identifying residents with increased vulnerability to abuse, yet the repeated incidents suggest a lack of effective implementation of these measures. The facility's failure to protect residents from abuse and inappropriate staff behavior highlights significant deficiencies in their care and supervision protocols.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities for four residents, each with varying degrees of cognitive impairment and specific activity preferences. Observations revealed that these residents were often left without engagement or stimulation, despite documented care plans indicating their enjoyment of both group and independent activities. For instance, one resident with moderate cognitive impairment and a preference for spiritual activities and socializing was observed sitting idly in the dining room and hallway without any activities. Another resident with severe cognitive impairment and behavioral issues was found sleeping in the dining room with no activities occurring. This resident's care plan highlighted a preference for music and social interaction, yet there was no evidence of such activities being provided. Similarly, a resident with moderate cognitive impairment and a history of enjoying games and church activities was observed sleeping in the dining room with no sound from the TV, indicating a lack of engagement. Additionally, a resident with severe cognitive impairment and a preference for reading and crafts was observed sleeping or facing away from the TV, with no activities taking place. The resident's daughter expressed a desire for more involvement in activities. The Activity Director mentioned offering sensory groups and outdoor activities but acknowledged issues such as a missing TV remote, which hindered activity provision. The Social Service Director noted challenges in redirecting residents with dementia, further highlighting the facility's failure to meet the residents' activity needs.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures for therapeutic diets, affecting seven residents who were reviewed for food procurement, storage, preparation, and service. During a group meeting, several cognitively intact residents reported that their breakfast food was consistently served cold. Additionally, observations during lunch service revealed that mechanical soft beef tips were served at 110 degrees Fahrenheit, which is below the safe holding temperature, to residents on mechanical soft diets. These residents included those with varying levels of cognitive impairment, as documented in their Minimum Data Sets and Physician Order Sheets. The facility's Resident Council Meeting Minutes from earlier in the year also documented complaints about cold food, indicating a recurring issue. Despite the facility's policy requiring hot food to be cooked or heated to temperatures above 165 degrees Fahrenheit, the observed temperatures during meal service did not meet these standards. The Dietary Manager acknowledged the issue of cold purees and mechanical soft foods, but the report does not detail any immediate corrective actions taken at the time of the deficiency.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the physician for a resident with a chronic non-pressure related ulcer and an open wound on the left buttock. The resident, who is cognitively intact, had a physician's order to cleanse the wound with normal saline, apply Silver Silvadene, collagen powder, and calcium alginate, and cover it with a dry dressing daily. However, the treatment was not completed on two specific dates, and there was no physician order to hold the dressing change on those dates. The resident expressed concerns about the inconsistency in dressing changes, stating that the dressing was changed during the day but not at night, leading to periods where the wound was left uncovered. The resident reported that the dressing had only been changed once in the past week, and if it became dirty during the day, the day shift refused to replace it. A Licensed Practical Nurse acknowledged that sometimes night shift treatments were not completed, and the Director of Nurses was unaware of any concerns regarding night shift treatment completion. The facility's Wound Management Program emphasizes the importance of managing resident skin integrity through prevention, assessment, and intervention.
Failure to Administer Correct Tube Feeding Rate
Penalty
Summary
The facility failed to administer tube feeding at the rate ordered by the physician for a resident with multiple medical conditions, including Amyotrophic Lateral Sclerosis, Protein-Calorie Malnutrition, Gastrostomy Status, and Dysphagia. The resident, who relies on tube feeding for more than 51% of their nutrition, experienced an undesirable weight loss, prompting a dietician to recommend an increase in the tube feeding rate from 40ml/hr to 50ml/hr. This recommendation was documented in the resident's progress notes and a new physician order was issued to reflect the change. Despite the updated order, observations on multiple occasions revealed that the resident's tube feeding was still being administered at the previous rate of 40ml/hr instead of the prescribed 50ml/hr. Interviews with facility staff, including a registered nurse and the Director of Nurses, confirmed that the tube feeding order had been changed and that nurses are responsible for ensuring the correct rate is administered. The facility's tube feeding policy requires checking the physician's order to determine the correct type and rate of feeding, which was not adhered to in this case.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions as care planned for several residents, leading to multiple incidents of falls and injuries. Resident 1, who was admitted with diagnoses including Alzheimer's disease and dementia, experienced several falls due to the lack of implemented interventions such as a canoe mattress, reminder signs, and dycem in her wheelchair. Despite being cognitively intact, Resident 1 was found on the floor multiple times, resulting in injuries such as a hematoma and fractures, indicating that the care plan interventions were not in place or followed by the staff. Resident 2, with diagnoses including hemiplegia and heart disease, was also at risk for falls. The care plan required a clutter-free environment and proper footwear, but observations revealed a cluttered room and the resident ambulating barefoot. This lack of adherence to the care plan led to falls, resulting in injuries such as skin tears and a hematoma. The resident reported not receiving assistance with organizing her room or being educated on maintaining a clutter-free environment, further highlighting the facility's failure to implement necessary interventions. Resident 4, who is severely cognitively impaired, was found on the floor wearing regular socks instead of the non-slip socks required by the care plan. Similarly, Resident 5, with a history of falls and a diagnosis of a fractured humerus, did not have a floor mat beside her bed as documented in her care plan. These observations indicate a systemic issue within the facility where care plan interventions for fall prevention were not consistently implemented, leading to repeated falls and injuries among residents.
Failure to Administer Insulin to Diabetic Resident
Penalty
Summary
The facility failed to provide insulin for the first five days of admission for a resident with Type 2 Diabetes, resulting in a significant medication error. The resident, who was moderately cognitively impaired, was admitted to the facility from another state and was documented to have Type 2 Diabetes without complications. Upon admission, the resident's discharge paperwork from an out-of-state medical center indicated the need for sliding scale insulin. However, the facility did not order any diabetic medication from the time of admission until five days later. During this period, the resident's blood sugar levels ranged from 138 to 397, indicating a lack of proper diabetic management. The oversight was acknowledged by a Licensed Practical Nurse, who stated that the sliding scale was not sent over, and a pharmacist confirmed that not receiving the long-acting insulin was a significant medication error. The facility's policy required that the attending physician provide necessary information for immediate care, including medication orders, which was not adhered to in this case.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures during meal service, affecting all 114 residents. Observations revealed that food temperatures were not consistently checked or recorded before and during meal service. For instance, a cook was seen transferring food from the stove to the steam table without checking temperatures, and the temperature logbook had not been updated since February 2024. Additionally, the warming cart used for meal delivery was not functioning properly, and meals were delivered uncovered, leading to complaints from residents about cold food. Interviews with residents and staff highlighted ongoing issues with food temperature. Residents reported receiving cold meals, and staff acknowledged the problem, noting that food was often not hot enough when served. The dietary manager admitted to assuming that cooks were checking temperatures, but there was no documentation to confirm this. Furthermore, the facility's policy required food to be cooked above 165 degrees and chilled below 40 degrees, but these standards were not consistently met. The facility's meal service process was inefficient, contributing to the problem. Trays were not organized in order, causing delays in delivery as staff had to search for the correct tray for each resident. This inefficiency, combined with the lack of proper temperature checks and documentation, resulted in meals being served at inappropriate temperatures, as confirmed by a test tray that showed food temperatures well below the required levels.
Significant Medication Error Due to Missed Glaucoma Medication Doses
Penalty
Summary
The facility failed to ensure that medications were provided and administered correctly for a resident (R2) with severe cognitive impairment, resulting in a significant medication error. R2 missed nine doses of his prescribed Glaucoma medication, Brimonidine/Timolol, over a period of time. The resident's care plan did not document the need for Glaucoma medication, and there were discrepancies in the Medication Administration Records (MAR) for January, February, and March. The medication was supposed to be kept at the bedside for the resident to self-administer, but due to the resident's cognitive impairment, this was not always feasible. The facility's Director of Nursing (DON) acknowledged that the medication was not always available and that the family insisted on keeping it at the bedside, despite the resident's condition. The report includes statements from various staff members and pharmacists, indicating that the medication was sent to the facility multiple times, but there were still instances where the medication was not administered. The DON mentioned that the medication was out of stock during a weekend and that they used separate bottles of eye drops that were not expired but had been opened. The covering Primary Care Physician and a pharmacist both confirmed that missing doses in a skilled nursing facility is unacceptable and constitutes a significant medication error.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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