Integrity Hc Of Marion
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Illinois.
- Location
- 1301 East Deyoung, Marion, Illinois 62959
- CMS Provider Number
- 145863
- Inspections on file
- 42
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Integrity Hc Of Marion during CMS and state inspections, most recent first.
A resident with complex cardiac and respiratory conditions had diuretics discontinued by cardiology and a BNP test ordered. The resulting BNP level was critically elevated and flagged as "High High." An LPN received the result, sent it to the physician via secure messaging, did not obtain any orders, was unsure if a phone call was successfully made, and did not notify the cardiologist. The physician later stated he did not see the message until the next morning, did not receive a call from the facility, and did not issue orders. Leadership and other nursing staff reported that critical labs are expected to be called directly to the physician, consistent with the facility’s change-in-condition policy, but no separate lab policy was produced.
Surveyors found that multiple residents did not have water pitchers or drinking cups at their bedside on repeated observations, despite staff, including CNAs, the DON, and the Administrator, stating that residents should have constant access to fluids unless on fluid restriction or thickened liquids. Staff confirmed there were no such restrictions for these residents and could not explain the absence of water, and there was no written hydration maintenance policy in place.
A resident was found asleep with a medicine cup containing multiple unidentified tablets left on the overbed table, and later one pill remained in the cup when the resident was awake and oriented and reported she had fallen asleep before taking the medications. An LPN acknowledged he had left the medications at the bedside without confirming they were taken, and both the DON and Administrator stated that medications should not be left at the bedside due to safety concerns. The facility’s medication administration policy requires that medications be administered within one hour of the prescribed time, that resident identity be verified, and that medications not be prepared until the resident is present and ready to take them.
The facility failed to respond to call lights in a timely manner for multiple residents, including one who returned from a hospital stay to find a wet bed and waited an extended period after a family member activated the call light for assistance. Several residents filed grievances reporting long delays in call light response, including reports that call lights took over 30 minutes to be answered, that staff turned off call lights without returning, and that a resident soiled herself after a call light allegedly went unanswered for several hours. A family member reported unsuccessful attempts to reach the Administrator about these concerns. The acting DON and the Administrator both stated that call lights should be answered as quickly as possible, but neither specified a firm time standard, and both acknowledged that the facility did not have a call light policy.
A resident who was cognitively intact returned from the hospital and was moved to a different room for isolation that had not been cleaned after the prior occupant left. The resident and a family member reported dirty beds, dirt on the floor, used oxygen tubing on a chair, food crumbs on an adjacent bed, a cupcake left on the overbed table, and a toilet with brown stains resembling feces. The Housekeeping Supervisor and facility leadership acknowledged that rooms are expected to be cleaned daily and before a new resident is placed, but a miscommunication among housekeeping staff led to the room not being cleaned prior to the resident’s admission.
The facility did not serve meals at scheduled times, resulting in residents waiting extended periods for food, with some not receiving trays until staff intervened. Staff interviews confirmed that meal delays were common, often due to staffing shortages, and nursing staff expressed concern for diabetic residents needing timely meals with insulin. Residents were observed eating snacks to compensate for late meals, and posted meal times were not consistently followed.
A resident with multiple medical conditions was subjected to verbal abuse and profanity by a dietary aide after requesting an alternative meal. The incident was reported to nursing and dietary management, but the administrator, who was also the Abuse Coordinator, did not investigate or report the event as abuse, instead treating it as a customer service issue. Facility policy defined such language as verbal abuse, but the required procedures were not followed.
A resident with multiple medical conditions and intact cognition reported being verbally abused by a dietary aide, who used profane language and refused a food request. Staff, including an LPN and the dietary manager, were made aware and collected statements, but the administrator, acting as Abuse Coordinator, did not report the incident to the State Agency or law enforcement as required, instead treating it as a customer service issue. Facility policy for reporting and documenting abuse allegations was not followed.
A resident with multiple health conditions reported that a dietary staff member used profane language and refused to prepare a requested meal. Multiple staff corroborated the incident, but the administrator, despite being the abuse coordinator, did not conduct a formal investigation or report the event as required by facility policy. The lack of a thorough investigation and proper documentation led to a deficiency finding.
Three dependent residents with significant cognitive and physical impairments did not receive timely incontinence care or repositioning as required, with staff and resident interviews confirming that care was missed due to disruptions such as late meal service. Facility policy required care every two hours, but this was not consistently provided.
A resident with significant mobility limitations and multiple health conditions was not provided with required pressure-relieving devices or repositioned as per facility policy, resulting in the development of a pressure injury. Staff failed to accurately assess the resident's risk and did not implement necessary interventions, despite clear indications of high risk for skin breakdown.
A resident with intellectual disabilities, schizophrenia, and a documented risk for wandering eloped from the facility after exhibiting exit-seeking behavior. Despite a care plan noting elopement risk, the resident was not wearing an electronic monitoring device and was able to leave undetected. Staff initiated a search and notified police after discovering the resident missing, and the resident was later found safe at a family member's home.
Surveyors found that the dry food storage area was contaminated with mouse droppings and evidence of rodent entry, including a hole in the wall and debris, despite previous pest control efforts. The facility lacked a specific dry storage policy, and 94 residents were present at the time.
Multiple residents and staff reported and observed mice and evidence of rodent activity throughout the facility, including in resident rooms and food storage areas. Mouse droppings, open food, and structural access points were noted, and staff acknowledged the widespread presence of mice. The facility's pest control measures were ineffective in preventing or eliminating the infestation.
A resident who required pain management did not receive safe and appropriate interventions, resulting in a deficiency related to inadequate pain management services.
Multiple residents with varying medical conditions did not have accessible or adequately refreshed water in their rooms, with some unable to reach their pitchers and others reporting that water was only provided upon request or not refreshed regularly. Staff interviews confirmed inconsistent practices in passing water, and the facility lacked a policy to ensure hydration needs were met.
A working call system was not available in each resident's bathroom and bathing area, as observed during the survey. This deficiency was noted based on the lack of required equipment to allow residents to request assistance in these areas.
A resident with a recent right femur fracture and mobility deficits was unable to access a functioning call light system and had to rely on a bell that was not within reach, resulting in delayed assistance. Staff confirmed the call system had been down for several days, and bells were used as a substitute, but these were not always accessible or effective in alerting staff to residents' needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident admitted for short-term IV antibiotics, who was also a federal inmate, was kept under constant guard, handcuffed to the bed, and denied access to personal property, visitors, facility activities, and communication such as telephone use. The facility did not have policies or a care plan addressing these restrictions, resulting in a failure to protect and promote the resident's rights to dignity, self-determination, and communication.
A resident with multiple comorbidities developed unstageable ulcers on both heels that were not properly identified, assessed, or treated according to physician orders. There were significant lapses in wound documentation, delayed implementation of heel protection, and missed opportunities for infection management. The resident's condition worsened, leading to hospitalization for sepsis and gangrene, surgical debridement, and eventual death from septic shock.
A resident with multiple chronic pain conditions experienced ongoing severe pain that was not adequately managed, despite having several pain medications ordered. Pain assessments were inconsistently documented, and staff often relied on casual conversations or chart reviews rather than thorough evaluations. The resident reported daily pain that interfered with mobility and activities, while staff expressed limited options for further pain control and were sometimes unaware of the resident's diagnoses. The facility did not follow its own pain management policy, resulting in unmanaged pain and decreased quality of life.
Multiple residents who required assistance with daily activities experienced significant delays in call light responses, especially on weekends, due to insufficient staffing. Staff interviews and schedule reviews confirmed that CNAs and nurses were often assigned to cover large numbers of residents alone, making it difficult to provide timely care. The DON acknowledged the lack of a call light policy and agreed that current response times were not acceptable.
Surveyors identified failures in food storage and sanitation, including a large ice buildup in the freezer causing food to fall onto the floor, improper handling of drinking glasses by a dietary aide after touching multiple surfaces, and use of a sanitizer solution below required strength by another aide who was unaware of proper levels. These issues had the potential to affect all 96 residents in the facility.
Surveyors found that several residents with complex medical conditions were served ham portions smaller than the 3 ounces specified by the dietician-approved dietary spreadsheet. Staff confirmed the portions were insufficient and that the facility had the means to provide the correct amount. Ongoing concerns were also documented regarding inconsistent food portions and meal ticket errors, particularly during dinner and weekends.
Several residents received lunch trays with ham served below the required hot holding temperature, as confirmed by thermometer readings and resident complaints that the food was not hot. The dietary manager served the food without reheating, contrary to facility policy that mandates hot foods be held at 136°F or above until served.
Four residents with orders for mechanical soft diets were served food items, such as large pieces of cauliflower, that did not meet their prescribed texture requirements, and one resident did not receive a required PB&J sandwich. These residents had complex medical conditions requiring dietary modifications, but the facility did not consistently follow physician orders or care plans, as confirmed by meal observations and ongoing resident council concerns about meal service accuracy and consistency.
Multiple residents who were dependent on staff for assistance with toileting, hygiene, and mobility experienced significant delays in call light response, with some waiting over an hour for help. Staff and residents attributed these delays to inadequate staffing, especially on weekends and when only one CNA was assigned to large hallways. The DON confirmed there was no call light policy and acknowledged that current response times were not acceptable.
Two residents were admitted without having advance directives or POLST forms formulated or offered as required by facility policy. One resident with severe cognitive impairment had no documentation of code status or advance directives in the EHR or care plan, and staff could not identify the resident's wishes in an emergency. Another resident, who was cognitively intact, had a care plan indicating full code status but lacked a documented advance directive or POLST form until after surveyor inquiry.
A resident with severe cognitive impairment reported being hit by another resident known for combative behavior and wandering. Another cognitively intact resident witnessed the incident and called for help. Staff were aware of the situation but did not document or report the allegation of abuse to the Administrator as required, resulting in a delayed investigation.
Two residents with significant medical needs were transferred to the hospital, but neither they nor their representatives received a copy of the facility's bed hold policy as required at the time of transfer. Documentation in the medical records and nurse's notes did not show that this notification was provided during their hospitalizations.
A resident with multiple mental health diagnoses did not have a current PASSR Level 2 screening in place after the previous short-term approval expired. The required screening was missed due to staff oversight, despite the resident's ongoing mental health needs documented in the care plan and assessments.
Three residents with cognitive and physical impairments did not receive necessary assistance with meal setup and eating, resulting in their inability to access or consume their food until staff intervention occurred. Staff failed to remove lids, open condiments, or provide encouragement as required by facility policy and resident care plans.
A resident with multiple diagnoses, who was cognitively intact, was found storing discontinued medications at the bedside after an LPN attempted to administer a medication that had already been discontinued. The resident, not authorized to self-administer, kept the pills in a medication cup after identifying the error. Facility policy requires only licensed staff to administer medications and prohibits self-administration without proper authorization, but these procedures were not followed, resulting in the deficiency.
A resident with multiple medical conditions and moderate cognitive impairment did not receive a required meal and was served a meal intended for another resident, resulting in meal service errors and another resident missing their lunch. Ongoing concerns about incorrect meal tickets and inconsistent portions were also documented by the resident council.
Three residents did not receive meals in accordance with their documented dietary preferences and restrictions, including being served disliked or restricted items such as apple juice, cauliflower, and drinks with ice. Residents expressed dissatisfaction, and facility records showed ongoing concerns about dietary tickets not being properly followed, despite policies requiring identification of food preferences.
Two residents with orders for adaptive eating utensils, including built-up and weighted utensils, did not consistently receive the required equipment during meals. Both residents, who had complex medical conditions such as dementia, Parkinson's disease, and muscle weakness, were observed receiving regular utensils instead of the prescribed adaptive devices. Dietary staff acknowledged that kitchen staff are responsible for ensuring adaptive equipment is provided, and facility records indicated ongoing issues with meal tickets being read incorrectly.
A resident with a history of self-inflicted burns was inadequately supervised, resulting in second-degree burns from hot water. Despite being dependent on staff for assistance, the resident was given hot water in a pitcher, leading to an accident. The facility's policy required adjusting interventions based on resident needs, which was not effectively implemented, contributing to the incident.
A resident was mistakenly given another resident's medications due to a nurse's failure to use two identifiers for proper identification. The nurse did not notify the physician about the unavailability of the resident's prescribed medication for restless leg syndrome. The facility's policy requires using two identifiers, which was not followed in this case.
A resident at high risk for falls due to multiple health conditions experienced falls because the facility failed to implement care plan interventions, such as placing fall mats at the bedside. Despite documented incidents of falls and injuries, staff were unaware of the missing fall mats, leading to a deficiency identified by surveyors.
The facility failed to provide prescribed dietary supplements and double portions for several residents, including one with severe cognitive impairment. Observations showed that meal trays lacked required portions and supplements, and the dietary staff did not communicate effectively to ensure dietary orders were followed. This issue was noted for multiple residents, indicating a systemic problem.
The facility failed to label insulin with open dates for four residents, leading to a deficiency in medication management. Insulin vials for residents with conditions like type 2 diabetes were found open without dates, confirmed by an LPN who stated insulins should be dated and discarded after 30 days if not. The DON expected staff to label insulin but was unsure of the facility's policy. The facility's policy required proper storage and noted insulin expires 28 days after opening.
The facility failed to adhere to its recipes for pureed diets, affecting 13 residents. The Dietary Manager prepared pureed pasta salad and cheeseburgers using unmeasured amounts of water and thickening agents, contrary to the specified recipes. The Registered Dietitian confirmed that staff were expected to follow these recipes to meet residents' dietary needs.
A resident with multiple diagnoses, including Parkinson's Disease and Type 2 Diabetes, did not receive prescribed daily wound care for scalp and facial wounds as per physician's orders. The Treatment Administration Record showed missed treatments, and both the Wound Care Physician and DON were unaware of the inconsistency in care.
A resident with a history of falls and gait/balance problems fell while getting off a transit bus, resulting in a left patellar fracture. The facility failed to ensure the resident used a walker, did not perform a full body assessment or notify the physician immediately after the incident, and did not send the resident to the ER until the following day when her pain worsened.
Failure to Timely Notify Physician of Critical BNP Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a physician of a critical laboratory value for one resident. The resident was admitted with multiple diagnoses including acute on chronic systolic congestive heart failure, COPD, chronic respiratory failure with hypoxia, peripheral vascular disease, obesity class 2, difficulty walking, anxiety, major depressive disorder, osteoarthritis, hypo-osmolality, and hyponatremia. On 4/3/26, cardiology discontinued the resident’s Lasix and Bumex and ordered a complete metabolic panel and BNP test, with instructions for an office follow-up in one week. The BNP result, received by the facility’s lab on 4/9/26 at 9:06 AM, was 761, flagged as a “High High” (HH) critical value, with a normal range of 1–100. A progress note documented that late on 4/9/26, an LPN notified the physician via a secure messaging application. In interview, the LPN stated she received the lab value while on break, sent a secure message to the physician after seeing he was active on the application, did not receive any orders in response, and was unsure whether she successfully attempted a phone call; she also did not notify the cardiologist who ordered the test. The physician reported he received the critical lab notification via secure messaging at 11:24 PM on 4/9/26 but did not see the lab until the next morning and did not respond with any orders, and he stated he did not receive a call from the facility about the critical lab. The regional clinical nurse and DON both stated that critical labs should always be called to the physician, and other LPNs described their usual practice as immediately calling, faxing, and/or using secure messaging for critical labs. The facility’s “Change in Condition” policy required notifying the attending or on-call physician when there is a need to significantly alter medical treatment or a significant change in condition; a specific lab policy was requested but not provided.
Failure to Ensure Bedside Access to Drinking Water for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to drinking water at their bedside, as observed for four residents out of five reviewed for access to drinking water. On multiple observations over several days, surveyors noted that these residents did not have water pitchers or drinking cups on or near their overbed tables. On 3/31, two residents were observed with only empty cups containing drops of clear liquid, and two other residents had no pitchers or cups at all. On 4/1, repeat observations showed that none of the four residents had water pitchers or cups at their bedside. On 4/6, the same four residents again had no water pitchers or drinking cups at bedside. Multiple CNAs interviewed stated that all residents should have access to drinking water at their bedside unless they are on a fluid restriction or require thickened liquids, and one CNA reported she could not think of any resident who should not have access to water in their room. CNAs working on the hall where the four residents resided confirmed that these residents were not on fluid restrictions or thickened liquids and could give no reason for the absence of water pitchers or cups. The DON verified during room checks that the four residents did not have water pitchers or cups at bedside and later stated there was no reason they should not have had water. The DON and the Administrator both stated that residents should always have or have constant access to fluids, and that water is expected to be passed regularly, but there was no written policy for hydration maintenance in place at the facility.
Medications Left Unsecured at Bedside and Not Verified as Administered
Penalty
Summary
The deficiency involves the facility’s failure to secure medications at the bedside for one resident, contrary to facility policy and safe medication administration practices. On 4/2/26 at 9:58 AM, the resident (R22) was observed sleeping soundly in bed, responding only with a moan or grunt and not easily awakened, with a medicine cup containing 7–8 tablets of unknown medications left on the overbed table. The resident did not awaken while the surveyor was in the room. Later that day at 12:02 PM, when the resident was alert and oriented to person, place, and time, she stated it was her fault that the medications were left at the bedside, explaining that the nurse had brought them in while she was awake but she fell back asleep before taking them. At that time, the surveyor observed one unidentified pill remaining in the medication cup, and the resident stated she was going to take it shortly. On 4/2/26 at 4:37 PM, the LPN (V28) acknowledged he was the nurse responsible for administering the resident’s medications and admitted it was not safe or appropriate to leave the medications at the bedside without verifying administration before leaving the room. On 4/7/26, the DON (V2) stated that the nurse should not have left the medications at the bedside without ensuring they were administered, citing safety reasons including the possibility of another demented resident wandering into the room and swallowing the medications or the intended resident hoarding and taking them all at once. The Administrator (V1) similarly stated that medications should not be left at the bedside at all, also citing safety concerns such as demented residents wandering in and ingesting the medications or the resident hoarding and taking too many at once. The facility’s medication administration policy, revised December 2012, specifies that medications must be administered within one hour of their prescribed time, that the resident’s identity must be verified before administration, and that medications cannot be prepared for administration until the resident is present and ready to take them.
Failure to Respond Timely to Resident Call Lights and Lack of Call Light Policy
Penalty
Summary
The deficiency involves the facility’s failure to answer resident call lights in a timely manner for six residents, affecting their right to a dignified existence, self-determination, communication, and exercise of rights. One cognitively intact resident (BIMS score 13) reported that upon returning from a hospital stay and being moved to a new room, his bed sheets and mattress were wet; his daughter activated the call light to request fresh linens, and he recalled that it took well over 15 minutes for staff to respond. The daughter stated she timed the response using her phone, initiating the call light at 8:20 p.m. and noting that staff did not respond until 9:00 p.m., and she identified the specific date this occurred. She also reported unsuccessful attempts to reach the Administrator about concerns with call light response times, describing repeated “phone tag” and eventually discontinuing her efforts. Additional evidence of delayed call light response was documented through multiple resident grievance forms. One resident reported that it took a long time for staff to answer call lights on the night shift, while another stated that CNAs were not answering her call light in an appropriate amount of time. Another resident reported that nursing staff were not timely in answering his call light, and a further grievance documented that a resident’s call light took over 30 minutes to be answered and that when staff did come, they turned the call light off and did not return to address the issue. In another case, a resident’s POA complained that the resident had soiled herself because her call light had not been answered in four hours. When interviewed, the Regional Director of Clinical Operations/Acting DON stated he had not received recent complaints about call light response times, believed call lights should be answered as quickly as possible, and considered 15 minutes an appropriate maximum, while acknowledging the facility had no call light policy. The Administrator similarly reported not being aware of complaints, stated call lights should be answered as quickly as possible depending on circumstances, and confirmed there was no facility call light policy.
Resident Placed in Unclean Room Following Hospital Return
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment when a newly admitted resident was placed into a room that had not been cleaned after the prior occupant left. The resident, who was cognitively intact with a BIMS score of 13, reported that upon returning from a hospitalization and being moved to a different room for isolation, the beds in the new room were dirty and did not appear to have been cleaned. The resident’s family member corroborated this, stating that the room did not appear to have been cleaned or sanitized, noting dirt on the floor, used oxygen tubing on a chair, a cupcake in a container on the overbed table, and food crumbs on the empty bed next to the resident. The family member also reported that the private bathroom toilet appeared unclean, with brown stains resembling feces on the porcelain bowl. The Housekeeping Supervisor stated that resident rooms are supposed to be cleaned daily, including wiping high-touch surfaces with sanitizer, sweeping and mopping floors, emptying trash, and cleaning lavatories and toilets, and that mattresses and bed frames are cleaned twice weekly on shower days. She explained that due to a miscommunication, the housekeeper responsible for the room believed there was more time to clean it, went to lunch, and by the time they returned, the resident had already been placed in the room, which had not been cleaned between the prior resident’s discharge and the new resident’s admission. The Regional Director of Clinical Services/Acting DON and the Administrator both stated that rooms should be cleaned daily and that the room should have been cleaned before the resident was placed there, with the Administrator acknowledging there had been a complaint about this specific room not being cleaned prior to the resident’s return from the hospital. An undated “Deep Cleaning a Room” checklist describes extensive cleaning steps but does not change the fact that the room was not cleaned before the resident’s placement.
Failure to Serve Meals Timely and Consistently to Residents
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner, as required to meet residents' needs, preferences, and requests. Multiple residents reported and were observed experiencing significant delays in meal service, with some meals being served well past the scheduled times. On several occasions, residents were seen waiting in the dining room for extended periods before receiving their meals, and some resorted to eating snacks such as chips due to hunger. Staff interviews confirmed that meal delays were a recurring issue, often attributed to staffing shortages and operational challenges in the kitchen. The facility's posted meal times were not consistently adhered to, with documented instances of lunch and supper being served over an hour late. Additionally, there were instances where residents did not receive their trays at all until staff intervention occurred. One resident was observed preparing to leave the dining room without supper, believing she would not receive a tray, until a staff member intervened to provide her meal. Another resident was also reported to have not received a tray until prompted by staff. Nursing staff expressed concerns about the impact of these delays, particularly for diabetic residents who require timely meals in relation to insulin administration. The deficiency was substantiated through direct observation, resident and staff interviews, and review of facility records.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including osteomyelitis, type 2 diabetes with skin complications, traumatic amputation, hyperlipidemia, bipolar disorder, and hypertension, was subjected to verbal abuse by a dietary aide/cook. The resident, who was cognitively intact, requested a grilled cheese sandwich as an alternative meal. The dietary aide responded with profanity, refused to prepare the sandwich, and dismissed the resident's request in a derogatory manner. Multiple staff statements corroborated that the aide used inappropriate language and refused service to the resident, and that similar issues had occurred with this staff member previously. The incident was promptly reported by the resident to a nurse, who then notified the dietary manager and the administrator. The dietary manager collected statements from those involved and sent the staff member home. However, the administrator, who also served as the facility's Abuse Coordinator, did not report the incident as abuse, instead categorizing it as a customer service issue. No formal investigation into whether the incident constituted verbal abuse was conducted by the administrator, despite being notified of the situation and receiving documentation from the dietary manager and nursing staff. Facility policy defined verbal abuse as the use of disparaging or derogatory language toward residents. The administrator acknowledged being aware of the incident and the staff member's conduct but did not review the collected statements or initiate an abuse investigation. The lack of appropriate response and failure to report the incident as required by policy resulted in the facility not ensuring the resident was free from verbal abuse and intimidation.
Failure to Timely Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident and a staff member to the State Agency and local law enforcement within the required 24-hour timeframe. The incident involved a resident with diagnoses including osteomyelitis, type 2 diabetes mellitus with skin complications, traumatic amputation of the right great toe, hyperlipidemia, bipolar disorder, and hypertension, who was cognitively intact. The resident requested a grilled cheese sandwich from a dietary aide, who responded with profane language and refused the request. Multiple staff members, including a nurse and the dietary manager, were made aware of the incident, and statements were collected from those involved and witnesses. Despite the facility's policy requiring immediate reporting of potential abuse, the administrator, who also served as the Abuse Coordinator, did not report the incident. The administrator was notified of the situation the night it occurred but considered it a customer service issue rather than verbal abuse, despite staff indicating otherwise. The dietary manager, who believed the incident constituted verbal abuse, was instructed by the administrator not to terminate the staff member for abuse to avoid mandatory reporting to public health authorities. The dietary manager ultimately resigned due to concerns about the handling of the situation. A review of facility records revealed that no report of the incident was made to the State Agency or law enforcement, and the required documentation was not present. The facility's abuse prevention policy outlines clear steps for reporting and investigating allegations of abuse, including immediate notification of authorities and documentation of actions taken. These procedures were not followed in this case, resulting in a failure to comply with regulatory requirements for reporting suspected abuse.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident verbal abuse involving a resident with multiple medical conditions, including osteomyelitis, diabetes with skin complications, traumatic amputation, hyperlipidemia, bipolar disorder, and hypertension. The resident, who was cognitively intact, reported that a dietary staff member used profane language and refused to prepare a requested meal. Multiple staff statements corroborated the resident's account, indicating that the staff member was insubordinate, used inappropriate language, and refused to fulfill meal requests. The incident was promptly reported to the dietary manager and administrator, and the staff member was sent home and subsequently terminated for various offenses, including inappropriate conduct toward a resident and sleeping on duty. Despite the immediate actions taken by the dietary manager, the administrator, who was also the facility's abuse coordinator, did not initiate or complete a formal investigation into the incident as required by the facility's Abuse Prevention Program Policy. The administrator acknowledged awareness of the incident but classified it as a customer service issue rather than potential verbal abuse, and did not review all relevant documentation or conduct interviews beyond reviewing employee discipline paperwork. There was no documentation of the incident in the facility's reportable abuse incidents, and the required investigation steps outlined in facility policy—such as interviewing all involved parties and reviewing the circumstances—were not followed. The lack of a thorough investigation was further highlighted by the dietary manager's resignation, citing an inability to address the abuse situation appropriately due to administrative direction. The administrator's decision not to classify the incident as abuse and not to report it to the state agency resulted in the facility failing to meet its obligation to promptly and aggressively investigate all reports and allegations of abuse, as outlined in its own policy. This deficiency was identified through interviews, record reviews, and the absence of required documentation and reporting.
Failure to Provide Timely Incontinence Care and Repositioning for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care and repositioning services for three dependent residents who required assistance with activities of daily living (ADLs). Observations and interviews revealed that these residents, all of whom had significant cognitive and physical impairments, were not repositioned or provided incontinence care as required. For example, two residents were observed sitting in the dining room for approximately three hours without being repositioned or toileted, despite being dependent on staff for these needs. One resident, who was always incontinent of bowel and bladder and dependent for all ADLs, was observed in her wheelchair throughout the day without being changed or repositioned from the time she was gotten up for breakfast until late afternoon. Both the resident and the CNAs confirmed that she had not been changed or laid down during this period. Staff interviews indicated that delays in meal service frequently disrupted the regular schedule for turning, repositioning, and providing incontinence care, resulting in residents not receiving care every two hours as expected. Multiple CNAs and supervisory staff acknowledged that the affected residents were incontinent and required assistance with turning and repositioning. Staff also stated that late meal service often interfered with their ability to maintain the required care schedule. The facility's policy required repositioning and skin care every two hours, but this standard was not met for the residents in question. The facility did not provide a policy specifically regarding ADL care to the surveyors.
Failure to Implement Pressure Ulcer Prevention Interventions for High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including chronic obstructive pulmonary disease, malnutrition, osteoporosis, cancer, and cognitive impairment, was identified as being at risk for pressure ulcer development. The resident was dependent on staff for all mobility and transfers and was incontinent of bowel and bladder. Despite these risk factors, the care plan did not include specific interventions for the use of pressure-relieving devices for the resident's chair or bed, even though the Minimum Data Set indicated such devices should be used. Braden assessments initially rated the resident as low risk, but this was later determined to be inaccurate given the resident's condition. During multiple observations, the resident was seen in a reclining wheelchair without a pressure-relieving cushion and was not repositioned for at least three consecutive hours, contrary to facility policy requiring repositioning every two hours. Staff interviews confirmed that pressure-relieving cushions were expected for all residents at risk, but the resident had not received one. Additionally, the resident was found to have red, blanchable areas on the coccyx and ankles, which progressed to a non-blanchable area with skin peeling over the coccyx, indicating the development of a pressure injury. Documentation review revealed that no new physician orders or treatments were in place for the coccyx area at the time of the deficiency, and the resident was still on a standard mattress rather than a pressure-reducing mattress. Staff acknowledged that the Braden assessment had been completed incorrectly and that the resident should have been classified as higher risk. The facility's policy required special mattresses and chair cushions for high-risk residents, but these interventions were not implemented prior to the development of the pressure injury.
Failure to Prevent Elopement of At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an elopement for a resident identified as being at risk for wandering and elopement. The resident had a history of intellectual disabilities, paranoid schizophrenia, anxiety, and difficulty walking. The resident's care plan documented impaired safety awareness and a pattern of sitting by exit doors, with interventions to identify and address wandering. Despite these risk factors, the resident was not wearing an electronic monitoring device at the time of the incident, as he had not previously attempted to leave the facility. On the day of the incident, staff observed the resident exhibiting increased restlessness and exit-seeking behavior, including packing belongings and expressing a desire to leave. The resident was last seen eating lunch in the dining room, after which staff noticed he was missing. A search of the facility was conducted, and when the resident could not be located, the police and the resident's power of attorney were notified. The resident was later found safe at a family member's house, having left the facility on his own without staff knowledge or intervention. Interviews with staff and family confirmed that the resident had never previously attempted to elope, although he had a pattern of preparing to leave and waiting for family. Staff reported that the wander guard system was operational, but the resident was not wearing a device. The incident revealed that the facility's supervision and monitoring were insufficient to prevent the resident's unsupervised exit, despite documented risk factors and recent changes in the resident's behavior.
Rodent Contamination Found in Food Storage Area
Penalty
Summary
Surveyors observed that the facility failed to maintain the dry food storage area free from contamination by rodents and rodent droppings. During inspection, a pile of small pieces of plaster or wood and a hole above it were found in the corner of the dry storage room, with several mouse droppings noted on shelves containing food items around the room's perimeter. The Administrator confirmed that although a pest control company had previously covered three holes believed to be entry points for mice, she was unaware that mice had chewed through one of the repairs. The Regional Clinical Director stated that the facility did not have a specific dry storage area policy. The facility's pest control policy indicated an ongoing program to keep the building free of insects and rodents. At the time of the survey, 94 residents were residing in the facility.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in multiple residents reporting sightings of mice in their rooms and evidence of rodent activity throughout the building. Several residents, all of whom were cognitively intact or had only moderate cognitive impairment, described seeing mice in their rooms, finding mouse droppings in personal belongings, and, in one case, having a mouse on a resident's bed. Observations confirmed the presence of mouse droppings in resident rooms, open food items accessible to pests, and mouse bait boxes in use. Staff interviews revealed that sightings of mice were common knowledge, and one CNA stated she did not report a mouse sighting because mice were present throughout the building. Further inspection of the facility revealed unsanitary conditions conducive to pest infestation, including food debris on floors, open snacks in resident rooms, and a dry storage area in the kitchen with mouse droppings and a hole chewed through the wall. The maintenance room door was found propped open to the outside, providing potential access for rodents. The pest control company had informed the facility that bait boxes would not be effective as long as food sources remained available to the mice. Facility records confirmed an ongoing pest control program, but the presence of rodents and evidence of their activity indicated the program was not effective in preventing or eliminating the infestation.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The deficiency was identified based on the facility's failure to provide necessary pain management interventions for a resident in need.
Failure to Provide Accessible and Sufficient Hydration for Residents
Penalty
Summary
The facility failed to ensure that residents had access to water in their rooms, as required to maintain adequate hydration. Observations and interviews revealed that four residents did not have water readily available or accessible. One resident with cerebral palsy, acute kidney failure, diabetes, and hypertension was found unable to reach his water pitcher, which was placed out of reach on a table at the foot of his bed. Another resident with heart failure and cognitive communication deficit reported that his water was not refreshed for several days, was hot, and lacked ice, requiring him to get his own ice. A third resident with cerebral infarction and moderate cognitive deficit stated that he was not offered ice water and typically had to get it himself, sometimes finding no ice available. The fourth resident, who had a right femur fracture and was cognitively intact, reported that her water pitcher was only filled upon request and that she usually poured water from meal cups into her pitcher. Staff interviews confirmed that there were complaints from residents about not receiving ice or water, and that the responsibility for passing water was not consistently fulfilled. The Director of Nurses stated that staff should be passing ice water at the beginning of each shift, with meals, and as needed. However, the facility was unable to provide a policy regarding ensuring water availability in resident rooms, further contributing to the deficiency.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The absence of a working call system in these locations was directly noted during the survey, but no additional details about specific residents, their medical history, or their condition at the time were provided in the report.
Failure to Ensure Call Light Accessibility During Call System Outage
Penalty
Summary
A deficiency was identified when a resident with a right femur fracture, muscle weakness, and difficulty walking was found without access to a functioning call light system. The resident, who was cognitively intact and required assistance with transfers, was observed sitting on the edge of her bed, unable to reach a bell placed on the opposite side of the bed. She reported having to yell for assistance, with no staff responding until the surveyor intervened. The resident also stated that there was no working call system in her room or bathroom and recounted an incident where she was left on the commode for 30-45 minutes after calling for help. Staff interviews confirmed that the call system had been down for several days, and residents were provided with bells as an alternative means to request assistance. Staff reported that they attempted to ensure residents had their bells with them, including during bathroom visits, and conducted 15-minute checks. However, it was acknowledged that the bells were not always within reach and were less effective than the standard call system, making it more difficult to identify which resident needed help. The administrator confirmed the call system outage and stated that residents were expected to take the bells with them.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Protect and Promote Resident Rights for Incarcerated Individual
Penalty
Summary
A resident was admitted to the facility for a short-term stay to receive intravenous antibiotics following a recent hospital stay, with diagnoses including sepsis and the presence of a cardiac pacemaker. The resident was alert, oriented, and largely independent in self-care activities. The admission contract and care plan outlined the resident's rights, including dignity, self-determination, communication, and the ability to retain personal property. However, the care plan did not address the use of physical restraints, preferred activities, personal property, or communication rights. Upon admission, the resident, who was an inmate of the federal prison system, was placed under constant supervision by two armed federal prison guards and was handcuffed to the bed. The resident was not allowed to leave the room, participate in facility activities, have visitors, use the telephone, or possess personal property or clothing. The facility administrator stated that these restrictions were imposed by the federal prison system, but there was no contract or policy in place between the facility and the federal prison system regarding the care of inmates. The resident's admission contract did not include any restrictions on rights due to incarceration. Staff interviews and direct observation confirmed that the resident remained confined to the room, was not permitted to use the call light, and had no personal belongings. The federal prison captain confirmed that these restrictions were based on prison protocols, but could not provide documentation of these protocols. The facility did not have policies or protocols for admitting inmates for medical care, and previous inmate admissions had not involved such restrictive measures. The lack of a care plan addressing these restrictions and the absence of facility policies contributed to the failure to protect and promote the resident's rights.
Failure to Prevent and Treat Heel Ulcers Resulting in Sepsis and Death
Penalty
Summary
The facility failed to prevent the development of unstageable ulcers, properly identify and assess newly developed ulcers, consistently implement interventions to promote healing, and follow physician orders for wound care for a resident with multiple comorbidities, including Parkinson's disease, diabetes, and peripheral vascular disease. The resident was admitted without heel ulcers, but later developed full-thickness arterial wounds on both heels. Documentation shows that the right heel ulcer was first identified after the resident's daughter noticed blood on the sock, but there was no physician order for treatment of this wound for approximately two weeks. The left heel ulcer was not documented or assessed until it was identified by the wound specialist, and there was no record of when it first developed or how it was initially managed. Throughout the resident's stay, there were significant lapses in wound assessment and documentation. Weekly skin records and progress notes failed to consistently document the status of the heel ulcers, and there were missed assessments on several dates. The care plan did not include specific interventions such as heel offloading or heel protection, despite the resident's high risk for skin breakdown. Orders for heel protectors were not implemented until late in the course of the resident's decline. Additionally, wound care interventions, such as debridement and dressing changes, were inconsistently documented, and there was no evidence that wound cultures were obtained or that antibiotics were started in response to signs of infection, despite care goals indicating the presence of odor and infected tissue. The resident's condition deteriorated, with increasing lethargy, fever, and hypotension, eventually leading to hospitalization for sepsis, gangrene, and necrosis of the bone and surrounding tissue in both heels. Hospital records confirmed the presence of large, necrotic, foul-smelling ulcers with exposed bone and tendon, requiring surgical debridement. The resident was subsequently placed on hospice and died from cardiorespiratory failure due to septic shock. The survey identified Immediate Jeopardy due to the facility's failure to provide appropriate wound care and follow physician orders, resulting in severe harm and death.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple chronic pain-related diagnoses, including polyneuropathy, osteoarthritis, myalgia, lumbago with sciatica, and osteoporosis. The resident was cognitively intact and consistently reported daily severe pain that interfered with mobility and participation in daily activities. Despite having orders for acetaminophen, ibuprofen, gabapentin, and a lidocaine patch, the resident continued to experience significant pain, which was not adequately controlled by the prescribed medications. The resident reported that the pain was never as low as a zero or three on the pain scale, and at times rated it above ten, even after receiving pain medication. The resident also expressed that the gabapentin made her tired without providing much relief, and she was unable to use her walker due to the pain, resulting in increased wheelchair use and decreased activity. Pain assessments and documentation were inconsistent and incomplete. The Medication Administration Record (MAR) showed that pain levels were not documented for most days, and when documented, did not reflect the resident's reported pain experience. Staff interviews revealed that pain assessments were often conducted as casual conversations rather than thorough evaluations, and sometimes were completed by referencing the resident's chart rather than direct interaction. The Care Plan Coordinator admitted to not conducting in-depth pain assessments and not always asking the resident the required questions. Nursing staff acknowledged the resident's ongoing pain complaints but expressed a lack of options for further pain management, with one nurse stating there was nothing more that could be done and another unaware of the resident's diagnoses. The facility's pain management policy required prompt and accurate assessment and management of pain, including consistent documentation and monitoring as the fifth vital sign. However, the facility did not follow these procedures, resulting in the resident experiencing uncontrolled severe pain, decreased mobility, and reduced participation in daily activities. The physician was unaware that pain assessments were not being completed as required and expected staff to document pain consistently. The failure to adhere to the facility's pain management policy and to respond appropriately to the resident's pain complaints led to the identified deficiency.
Failure to Provide Adequate Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple resident and staff interviews, record reviews, and direct observations. Several residents, all of whom were cognitively intact and dependent on staff for activities of daily living such as toileting, transferring, and personal hygiene, reported excessive wait times for call light responses, particularly on weekends. One resident described waiting over an hour for assistance on a Sunday, while another reported a 30-minute wait after activating the bathroom call light, followed by an additional 15-minute delay before being helped off the toilet. These delays were corroborated by staff interviews and direct observation of a resident's call light being ignored for an extended period while staff walked past the room. Staff interviews consistently indicated that staffing levels, especially on weekends and certain shifts, were insufficient to meet resident needs in a timely manner. CNAs and nurses reported working alone on halls with up to 30 residents, making it difficult to answer call lights promptly, complete required care tasks, and provide timely assistance with activities such as getting residents out of bed, passing supper trays, and performing two-person transfers. Staff described situations where they had to pull nurses away from medication administration to assist with resident care due to the lack of available CNAs. Multiple staff members stated that with only one CNA per hall, it was not feasible to meet all resident needs promptly, particularly during busy periods such as meal times and when families were visiting. Review of facility staffing schedules confirmed that on several occasions, including weekends and holidays, the number of CNAs and nurses scheduled was below the facility's stated expectations and insufficient to cover the resident population. The Director of Nursing acknowledged that the facility did not have a call light policy but expected call lights to be answered within 10 to 15 minutes, and agreed that 30-minute wait times were not timely. The facility's own assessment tool stated that staffing should be based on resident needs and acuity, but the documented schedules and staff accounts demonstrated that this standard was not consistently met, resulting in unmet resident needs and delayed care.
Deficiencies in Food Storage, Handling, and Sanitation
Penalty
Summary
Surveyors observed multiple failures in food storage, handling, and sanitation within the facility's dietary services. A large accumulation of ice was found on the freezer floor and on two boxes of food, with some individual ice creams having fallen out of their box onto the floor due to the ice. The Dietary Manager confirmed there was a leak in the freezer that worsened during storms and stated that short staffing and additional duties prevented timely cleanup. Additionally, a Dietary Aide was seen transferring glasses by the rim with gloved hands after touching various surfaces, including a milk carton, her shirt, the drink cart, health shakes, the ice scoop, and her face. Another Dietary Aide wiped a counter with a cloth from a sanitizer bucket and then began preparing sandwiches; the sanitizer solution was found to be less than 25 parts per million chlorine, and the aide was unaware of the required sanitizer level. These deficiencies had the potential to affect all 96 residents in the facility. No specific residents or their medical histories were mentioned in the report, but the documented census indicated 96 residents were present at the time of the survey.
Failure to Provide Dietician-Approved Food Portions and Consistent Meal Service
Penalty
Summary
The facility failed to provide food portions as directed by the dietary spreadsheet approved by the registered dietician for four residents out of a sample of seventeen reviewed for dining. Specifically, residents with complex medical histories, including diabetes, chronic kidney disease, dementia, malnutrition, and other conditions, were served ham portions that were less than the required 3 ounces specified on the dietary spreadsheet. The dietary manager weighed the ham and found it to be just under 2.75 ounces, and this amount was served to multiple residents. Staff confirmed that the correct portion should have been 3 ounces and acknowledged that the facility had equipment capable of slicing the ham to the appropriate size, but this was not done. Additionally, facility documentation and resident council forms indicated ongoing concerns about food service, including inconsistent portion sizes, meal tickets not being read properly, and residents receiving items they did not like. These issues were noted as recurring, particularly during dinner and weekends, and there were reports of insufficient food to complete meal service. These findings were based on interviews, observations, and record reviews conducted by surveyors.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable and safe temperature for four residents during meal service. On the day of the survey, the dietary manager measured the temperature of honey glazed ham before serving and found it to be 90 degrees Fahrenheit in three different locations, which is below the facility's policy requirement of 136 degrees or above for hot foods. Despite this, the ham was served to residents without any attempt to raise its temperature. Later, a tray refused by a resident was tested and the ham was found to be 83 degrees Fahrenheit. Multiple residents who received the ham during lunch expressed that the food was not hot, with comments indicating it was barely warm or not even warm. All affected residents were alert and oriented at the time of the meal. The facility's policy clearly states that hot foods must be held at 136 degrees or above until served, but this procedure was not followed, resulting in the deficiency.
Failure to Provide Food in Physician-Ordered Texture
Penalty
Summary
The facility failed to provide food in the appropriate texture as ordered by physicians for four residents who required mechanical soft diets. Despite having active orders and care plans specifying the need for mechanical soft or chopped food textures, these residents were served pieces of cauliflower that exceeded the recommended size for their dietary needs. In one instance, a resident also did not receive a prescribed PB&J sandwich with their meal. These actions were observed during meal service and were not in accordance with the dietary orders documented in the residents' records. The residents affected had significant medical histories, including conditions such as hemiplegia, dementia, Parkinson's disease, chronic obstructive pulmonary disease, and dysphagia. Their care plans and physician orders clearly indicated the need for modified diets, such as mechanical soft textures and specific food items to be provided at certain meals. The facility's own diet spreadsheet and policy required that food be prepared and served according to these orders, and that a tray identification system be used to ensure accuracy. Additional documentation from resident council forms indicated ongoing concerns about meal service, including reports that meal tickets were not being read properly, residents were receiving items they did not like, and portion sizes were inconsistent. These issues suggest that the facility's processes for preparing and serving meals according to individual dietary needs were not consistently followed, resulting in the observed deficiencies.
Failure to Timely Respond to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to answer call lights for residents needing assistance in a timely manner, impacting the dignity and care of three residents who were dependent on staff for toileting, personal hygiene, bed mobility, and transferring. One resident reported waiting over an hour for call lights to be answered on multiple occasions, particularly on weekends, and another described waiting 30 minutes after activating the bathroom call light, followed by an additional 15-minute wait before being assisted off the toilet. Observations confirmed that a resident's call light remained activated for over 20 minutes while multiple staff members walked past without responding. Residents expressed frustration with the long wait times and attributed the delays to insufficient staffing. Staff interviews corroborated these concerns, with a CNA and a registered nurse both stating that call lights were not answered promptly when staffing levels were low, particularly when only one CNA was assigned to a hallway with 30 residents. The Director of Nursing acknowledged the absence of a call light policy and stated that a 10 to 15-minute response time would be considered timely, but 30-minute waits were not acceptable. The lack of a formal policy and inadequate staffing contributed to the failure to meet residents' needs for timely assistance, as documented through resident interviews, staff statements, and direct observation.
Failure to Formulate or Offer Advance Directives Upon Admission
Penalty
Summary
The facility failed to formulate or offer to formulate an advance directive for two residents upon admission, as required by policy. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and metabolic encephalopathy, the admission record left the advanced directives section blank. Multiple staff members, including a registered nurse, social service assistant, and the DON, were unable to locate any documentation of an advance directive, POLST form, or code status in the resident's electronic health record or care plan. The absence of this documentation meant that staff would not know what type of care to provide in an emergency. A POLST form was later produced, but it was signed on the day of the survey, and the signature date was initially incorrect and had to be corrected in front of surveyors. For a second resident, who was mostly cognitively intact and had several chronic conditions, the care plan indicated full code status, but there was no copy of an advance directive or POLST form in the electronic health record at the time of review. The POLST form was only signed and dated after the surveyor's inquiry. Facility policy requires that residents be provided with information about advance directives upon admission, and that staff document the offer to assist and the resident's decision. In both cases, these steps were not completed as required.
Failure to Timely Report Peer-to-Peer Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of peer-to-peer abuse to the Administrator, as required by policy. One resident with severe cognitive impairment reported that another resident, who also has a history of adverse behaviors and severe cognitive deficits, entered her room and hit her. Another resident, who is cognitively intact, corroborated that the alleged aggressor entered the room and was physically aggressive. Staff interviews confirmed that the resident in question is known to be physically combative and has a pattern of wandering into other residents' rooms, sometimes becoming aggressive. Despite these reports and observations, there was no documentation in the residents' progress notes or in the facility's abuse/neglect allegation records regarding this specific incident of peer-to-peer aggression. Staff members, including CNAs and an LPN, were aware of the incident, with one LPN responding to a call for help and finding the alleged aggressor in the room. The LPN and a CNA both documented that the resident who was allegedly hit denied being struck but wanted the other resident removed from her bed. However, the incident was not reported to the Administrator until the surveyor brought it to their attention. The facility's Abuse Prevention Training Program requires that all allegations of potential abuse, neglect, or mistreatment be reported immediately to the Administrator. In this case, the failure to report the incident in a timely manner resulted in a delay in initiating an investigation and notifying the appropriate authorities, as required by facility policy and regulatory standards.
Failure to Provide Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives at the time of transfer to the hospital for two residents who were hospitalized. According to the facility's own bed hold policy, a copy of this policy is required to be given to residents at admission and each time they are transferred from the facility. For both residents reviewed, there was no documentation in the electronic health record or nurse's progress notes that the bed hold policy was provided to either the residents or their representatives during their respective hospitalizations. One resident had diagnoses including chronic obstructive pulmonary disease, dementia, and required moderate assistance with daily activities. This resident was able to communicate but was cognitively confused. The other resident had diagnoses such as metabolic encephalopathy, chronic obstructive pulmonary disease, and was dependent for all functional abilities, unable to participate in a mental status interview. In both cases, despite their significant medical needs and vulnerability, there was no evidence that the required bed hold policy notification was given at the time of their transfer to the hospital.
Failure to Maintain Current PASSR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a current Preadmission Screening and Resident Review (PASSR) Level 2 screening was in place for one resident with multiple mental health diagnoses, including schizoaffective disorder, agoraphobia with panic disorder, insomnia, major depressive disorder, and anxiety disorder. The resident's medical record showed a previous PASSR evaluation that granted short-term approval without specialized services, with an end date that had already passed. No updated PASSR screening was documented after the expiration of the previous approval. The resident's care plan and assessments indicated ongoing mental health needs, but the required PASSR process was not completed in a timely manner due to oversight, as the staff member responsible for requesting the screening was new and had not yet submitted the request.
Failure to Assist Residents with Meal Setup and Dietary Needs
Penalty
Summary
The facility failed to provide necessary assistance with meals and dietary needs for three residents who required help with activities of daily living, specifically during mealtimes. One resident with severe cognitive impairment, hemiplegia, rheumatoid arthritis, and other chronic conditions was observed unable to remove lids from her food containers or open condiment packets. Despite her attempts and visible struggle, she did not receive timely assistance until prompted by an inquiry to a staff member. Dietary staff later confirmed that due to her hand contractures, staff should have been removing lids and opening condiments when delivering her meals. Another resident with moderate cognitive impairment, multiple chronic illnesses, and documented difficulty chewing was observed struggling to remove lids from her dessert and ice cream. She was unable to open these items and eventually gave up, requesting assistance only after several minutes. Dietary staff confirmed that for residents assessed as needing tray setup, staff are expected to remove lids, open cartons, and ensure food is ready to eat, which was not done in this instance. A third resident, also with moderate cognitive impairment and a history of fractures, malnutrition, and muscle weakness, was observed sitting in front of her meal without having taken any bites. She was not encouraged or assisted by staff who walked by, and only began eating after the administrator personally intervened and provided assistance. The facility's policy requires that residents receive meal assistance according to their individual needs, which was not followed in these cases.
Failure to Remove Discontinued Medications and Prevent Improper Storage
Penalty
Summary
A deficiency occurred when a resident was found storing discontinued medications at their bedside, which had not been properly removed by nursing staff. The resident, who was cognitively intact and had diagnoses including alcohol dependence with withdrawal, chronic obstructive pulmonary edema, hypertension, anxiety disorder, and major depressive disorder, reported that a nurse had attempted to administer a discontinued medication. The resident identified the error, did not take the medication, but kept it in a medication cup on the bedside table. The resident also had another pill in the cup that had been discontinued months prior. There was no care plan or intervention documented that allowed the resident to self-administer medications. Interviews with the LPN involved revealed that she had mistakenly given the resident a discontinued medication, and was unaware of the presence of the other discontinued pill. The DON confirmed that one of the pills had been discontinued recently and the other several months ago. Facility policy requires that only licensed staff administer medications and that residents may only self-administer if specifically authorized by the care team and physician, which was not the case for this resident. The failure to remove discontinued medications and prevent their storage at the bedside, as well as the lack of proper documentation for self-administration, led to the deficiency.
Failure to Provide Correct and Timely Meals to Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including metabolic encephalopathy, vascular dementia, dysphagia, and muscle weakness, did not receive a meal as required. The resident, who had moderate cognitive impairment, was observed on one occasion expressing hunger and stating that she had been forgotten for a meal the previous night. Additionally, there was a documented lack of food intake for dinner on a specific date. During another observation, the resident was found with a lunch tray intended for another resident, and staff only realized the error after it was pointed out by a surveyor. The correct lunch tray was then delivered, but the incident resulted in another resident not receiving their meal in a timely manner. Facility records and resident council forms further documented ongoing concerns about meal service, including dietary tickets not being read properly, residents receiving incorrect or disliked food items, and inconsistent portion sizes, particularly at dinner. These issues were noted as recurring and unresolved, contributing to the failure to provide nourishing, palatable, and well-balanced meals that meet residents' dietary needs.
Failure to Follow Resident Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to accommodate the dietary preferences and restrictions of three residents as observed through meal service and review of dietary records. One resident with multiple diagnoses, including diabetes and dementia, had a physician order for a no added salt diet and was specifically noted to avoid apple juice. Despite this, the resident received apple juice on her breakfast tray and expressed her dislike for it. Another resident with chronic kidney disease and other conditions was served cauliflower, which was listed as an allergy on her dietary card, despite her repeated statements that she does not like it. The resident also commented on the temperature and quality of the food, indicating ongoing dissatisfaction. A third resident with dementia and psychiatric diagnoses received drinks with ice, contrary to her dietary card instructions specifying no ice. Additionally, facility documentation from resident council meetings indicated ongoing concerns about dietary tickets not being read properly, resulting in residents receiving food items they do not like or cannot have. The facility's policy requires identification of food preferences within 72 hours of admission, but these incidents demonstrate a failure to consistently follow documented dietary preferences and restrictions for multiple residents.
Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered for two residents with specific needs. One resident, with diagnoses including chronic kidney disease, dementia, failure to thrive, anemia, Alzheimer's disease, and weakness, had a physician's order and care plan indicating the use of built-up utensils. Despite this, the resident received regular utensils at both lunch and breakfast on multiple occasions, and reported not always receiving the larger silverware as required. Another resident, diagnosed with Parkinson's disease, femur fracture, irritable bowel syndrome, low back pain, muscle weakness, major depressive disorder, anxiety disorder, and weakness, had an active order for weighted utensils. This resident also received regular utensils instead of the prescribed adaptive equipment at several meals and stated that she does not always get the bigger silverware, though her sister wants her to use them. Dietary staff confirmed that kitchen staff are responsible for reading meal tickets and ensuring adaptive equipment is provided. Facility documentation also noted concerns about meal tickets being read incorrectly, resulting in residents not receiving appropriate items.
Failure to Prevent Resident Burns from Hot Liquids
Penalty
Summary
The facility failed to adjust the type and frequency of interventions and the needed level of supervision for a resident with a history of self-inflicted burns with hot liquids. This deficiency resulted in the resident spilling hot water onto his groin, sustaining second-degree burns to nine percent of his body, causing pain and the need for increased pain medication, and requiring placement of an indwelling catheter to prevent urine from irritating the wounds. The resident, who has diagnoses including spinal stenosis with fusion of the lumbar spine, schizoaffective disorder, and diabetes type 2, was dependent on staff for transfers and required assistance for eating. The resident's care plan documented that he displayed adverse behaviors and had been educated to let staff get him hot water to prevent burns, but he continued to be non-compliant. On the day of the incident, the resident asked a Certified Nursing Assistant to heat water for him, which was returned in a pitcher. While attempting to remove the lid, the hot water spilled, causing burns. The resident had a history of similar incidents, and despite repeated education, he continued to handle hot liquids unsafely. The facility's policy required a systems approach to safety, adjusting interventions based on identified hazards and resident needs, which was not adequately implemented in this case. Interviews with staff revealed a lack of clarity about who provided the hot water and indicated that staff re-education was insufficient. The Assistant Director of Nurses and the Regional Nurse/Director of Nurses responded to the incident, but no staff member took responsibility for giving the resident the hot water. The facility's policy emphasized the need for resident supervision and adjusting interventions based on individual needs and environmental hazards, which was not effectively applied, leading to the resident's injury.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R1, who was admitted with diagnoses including a nondisplaced fracture of the lateral condyle of the right tibia, restless leg syndrome, and fibromyalgia. On the night of the incident, a registered nurse, V7, mistakenly administered medications intended for another resident, R2, to R1. The nurse did not use two identifiers to confirm the resident's identity, leading to R1 receiving Tylenol and Benadryl instead of her prescribed medication, Ropinirole, for restless leg syndrome. The nurse, V7, admitted to having R2's Medication Administration Record open and mistakenly addressed R1 as R2, to which R1 responded affirmatively. After the error was realized, R1 attempted to spit out the medications. The nurse did not notify the physician about the unavailability of R1's prescribed medication, Ropinirole, which had not yet arrived from the pharmacy. The nurse did not consider the situation an emergency and did not take further action to obtain the medication from the emergency kit or notify the physician. The facility's policy requires the use of two identifiers when administering medications, such as checking identification bands or photographs and calling the resident by name. The Director of Nursing and the Administrator both acknowledged that the nurse should have used two identifiers and notified the physician about the unavailable medication. The incident highlights a lapse in following established protocols for medication administration and communication with the physician regarding medication availability.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident identified as R2, who was at high risk for falls due to multiple health conditions, including Parkinson's disease, repeated falls, and difficulty walking. R2's care plan included specific interventions such as placing fall mats at the bedside and ensuring the bed was in the lowest position. However, during observations on multiple occasions, it was noted that the fall mats were not in place, and the bed was not consistently in the lowest position, which contributed to R2 experiencing falls. R2 had a history of falls, with documented incidents where the resident was found on the floor, resulting in injuries such as a bleeding head wound and a skin tear. Despite these incidents, the facility staff, including CNAs and the Director of Nurses, were unaware of why the fall mats were not consistently in place. This lack of adherence to the care plan interventions and inadequate supervision led to the deficiency identified by the surveyors.
Failure to Provide Prescribed Dietary Supplements and Portions
Penalty
Summary
The facility failed to provide supplements and double portions as ordered for six residents, including a resident with severe cognitive impairment and multiple diagnoses such as dementia and anxiety disorder. This resident was observed not receiving the prescribed double portions and supplements during meals, despite having a care plan that included specific dietary interventions to address weight loss risk. Observations revealed that the resident's meal trays lacked the required double portions and supplements, such as ice cream and fortified pudding, which were part of the dietary orders. Further investigation showed that during meal service, the dietary manager did not ensure that residents with orders for double portions received them. The dietary staff failed to communicate effectively with the cooks, resulting in the omission of special dietary needs from the meal trays. The registered dietitian and the director of nursing both expressed expectations that dietary orders should be followed, but the dietary manager admitted that no double portions were provided during the observed meal service. This lack of adherence to dietary orders was documented for multiple residents, indicating a systemic issue in the facility's dietary service.
Failure to Label Insulin with Open Dates
Penalty
Summary
The facility failed to properly label insulin with open dates for four residents, leading to a deficiency in medication labeling and storage. During an observation, it was found that insulin vials for residents with various medical conditions, including type 2 diabetes mellitus, were open without any indication of the opening date. This included insulin lispro and insulin glargine for residents with chronic conditions such as chronic obstructive pulmonary disease, peripheral vascular disease, and chronic respiratory failure. The lack of labeling was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that all insulins should be dated when opened and discarded after 30 days if the open date is not recorded. The Director of Nursing (DON) was also interviewed and stated that staff were expected to label all insulin with an open date, although he was unsure about the specific facility policy regarding insulin labeling and storage. The facility's policy from December 2018 indicated that staff should ensure multi-dose vials are stored according to the manufacturer's suggested conditions. Additionally, an undated Insulin Reference Chart from the facility documented that insulin lispro and insulin glargine expire 28 days after opening. This oversight in labeling insulin vials with open dates led to a deficiency in the facility's medication management practices.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to provide pureed diets according to its established recipes for 13 residents out of a sample of 20 reviewed for dietary needs. During an observation, the Dietary Manager (V6) was seen preparing pureed pasta salad and cheeseburgers without following the facility's recipes. Specifically, V6 added unmeasured amounts of ice water and a thickening agent to the pasta salad and used water and brown gravy instead of the specified beef broth for the cheeseburgers. These actions were contrary to the facility's recipes, which required specific liquids other than water to achieve the correct consistency. The Registered Dietitian (V12) confirmed that dietary staff were expected to adhere to the recipes when preparing mechanically altered foods. The facility's policy and recipes clearly outlined the procedures for preparing pureed diets, including the use of specific liquids to achieve the desired consistency. Despite these guidelines, the dietary staff did not follow the recipes, resulting in a failure to meet the nutritional needs of the residents who required pureed diets.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to adhere to the physician's orders for the treatment of scalp and facial wounds for a resident diagnosed with Parkinson's Disease, Adult Failure to Thrive, and Type 2 Diabetes. The resident's treatment plan included the application of an antimicrobial gel and calcium alginate gauze with a bordered dressing to the left face and scalp wounds daily. However, the Treatment Administration Record for July 2024 showed that the treatments were not administered on three specific dates, indicating a lapse in the prescribed care. During an observation, the resident was found to have dressings on the scalp and face that were not changed as frequently as ordered, and the resident was unsure of the dressing change schedule. The Wound Care Physician confirmed that the treatments were intended to be performed daily to prevent secondary infection, but was unaware of the inconsistency in care. The Director of Nursing also acknowledged that the wound care was supposed to be conducted daily during the night shift but was unaware of the lapses in treatment.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to develop and implement appropriate fall interventions for a resident (R2) who had a history of falls and was at risk due to conditions such as CVA, TIA, and gait/balance problems. Despite being educated to use a walker, R2 refused to use it, and the facility did not ensure she had one available. On 3/28/24, R2 fell while getting off a transit bus, resulting in a left patellar fracture. The facility's staff did not perform a full body assessment or notify the physician immediately after the incident, and R2 was not sent to the ER until the following day when her pain worsened. R2's care plan included interventions to educate her to use a walker at all times and on outings, but these were ineffective as R2 consistently refused to use the walker. The facility lost track of R2's walker, and it was possibly being used by another resident. Therapy services were not involved in assessing R2 for a walker until after the fall on 3/28/24. The facility's failure to ensure R2 had and used a walker, and to perform a timely and thorough assessment after the fall, contributed to the deficiency. Interviews with staff revealed that R2 had a history of falls and was known to refuse using a walker. Despite this, the facility did not take additional measures to ensure her safety. The Director of Nurses and the Administrator acknowledged that R2 had a walker upon readmission, but it was not used or tracked properly. The facility's fall management policy was not effectively implemented, leading to R2's repeated falls and subsequent injury.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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