Joliet Living & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 2230 Mcdonough, Joliet, Illinois 60436
- CMS Provider Number
- 14E247
- Inspections on file
- 29
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Joliet Living & Rehab Center during CMS and state inspections, most recent first.
A resident with a history of paranoid schizophrenia, bipolar disorder, and PTSD reported that staff conducted a random search of his room and jacket pocket without his presence or permission. A grievance documented his concern about the unaccompanied search, and the Psychosocial Rehabilitation Services Coordinator confirmed she performed the room check alone while the resident was not present. This action conflicted with the facility’s own inspection policy, which requires the resident to be present during room searches and to personally turn out their own pockets.
The facility implemented new house rules that prohibited residents from visiting other residents’ rooms if they lived on different wings, directing them instead to visit only in the dining room and providing no alternative space for private visits. This change conflicted with the facility’s own Resident Rights document, which states that residents have the right to private visits unless limited by a physician. Multiple residents, including those with anxiety, depression, and chronic migraine headaches, reported that they could no longer have private time with friends or intimate partners, felt their rights were violated, and described feeling depressed, anxious, and like prisoners due to the loss of privacy. The Administrator confirmed the rule was added to address resident smoking in rooms and that most residents had signed the new agreement.
Two residents with behavioral health diagnoses were involved in a verbal and physical altercation after repeated complaints about one resident's disruptive behavior were not addressed by staff. Despite awareness of the issue, no interventions or care plan updates were made, resulting in both residents sustaining injuries and requiring hospital evaluation.
The facility did not identify water systems requiring Legionella control measures or assess the risk of hazardous conditions as outlined in its water management program. Staff could only provide water flushing logs and a general policy, with no documented risk assessment or system identification, affecting all 88 residents.
Several cognitively intact residents reported and were observed to have room windows without screens, leading to concerns about insects and other objects entering when windows were open. The Maintenance Director confirmed the absence of screens throughout the facility, and the Administrator stated there was no policy requiring window screens, with past screens having been removed or damaged and not replaced.
The facility did not provide written notification of its bed-hold and return policy to residents or their representatives before hospital transfers, as required by policy. This deficiency was identified for four residents with complex medical and psychiatric needs who were hospitalized for various acute events, with no documentation of the required notification found in their records.
Two residents with psychiatric conditions were involved in a physical altercation after one began punching the other, leading to retaliation and injury. Staff and witnesses confirmed a pattern of aggressive and intrusive behavior by one resident, and both individuals required hospital evaluation following the incident.
Two residents with severe mental illness did not receive the necessary behavioral health services as outlined in their PASRR assessments and care plans. Both attended only minimal group sessions, with no evidence of participation in key rehabilitative programs or one-on-one interventions, and the facility failed to document refusals or efforts to provide required behavioral health care.
A resident with multiple diagnoses and intact cognition had a large piece of plywood covering a hole in the wall next to their bed for about a year after accidentally kicking the wall. Despite being told the wall would be repaired, the fix was overlooked by maintenance staff, and the plywood remained in place for 14 months, contrary to facility policy requiring timely repairs and maintenance.
Three residents with psychiatric diagnoses and cognitive intactness were involved in incidents where one resident was sexually abused by another after consuming alcohol, and subsequently physically assaulted her boyfriend, believing he allowed the abuse. The facility failed to prevent these instances of sexual and physical abuse, contrary to its stated abuse prevention policy.
A resident with multiple medical conditions and a need for assistance with ADLs did not receive timely podiatry care, resulting in long, discolored, and curled toenails. Despite being on the podiatry list and requesting care, the resident was not seen by the podiatrist as scheduled, and there was no documentation of refusal or alternative arrangements for foot care, contrary to facility policy.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact and required supervision for ADLs, was denied a second cup of coffee by a CNA despite there being no facility rule limiting coffee servings. The resident observed another individual receiving a second cup and was not informed of any restrictions, leading to feelings of frustration and being singled out. Staff and administration confirmed that no such rule existed and that residents were generally allowed additional coffee.
Multiple incidents occurred in which residents engaged in physical altercations following staff discussions about resident behavior within earshot of others and insufficient supervision during smoke breaks. These events led to residents confronting and physically assaulting each other, in violation of the facility's policy prohibiting abuse.
A resident with multiple medical conditions did not receive a Nurse Practitioner's ordered Basic Metabolic Panel (BMP) lab test, despite the order being confirmed by an RN. The facility lacked documentation that the test was completed, even though prior labs showed abnormal sodium and bilirubin levels. The resident was later hospitalized with further abnormal lab findings, and staff confirmed the test should have been done according to facility policy.
Two residents, both diagnosed with schizoaffective disorder and generalized anxiety disorder, were involved in a physical altercation when one resident slapped the other in a shared bathroom. The incident occurred due to a misunderstanding, as the resident who slapped perceived an insult. Despite the facility's abuse policy, the altercation was not prevented, highlighting a deficiency in protecting residents from abuse.
The facility failed to maintain cleanliness in the food preparation area and equipment storage, affecting all 92 residents. Staff were observed with improper hair restraints and inadequate hand hygiene. The kitchen had dust-covered vents, stained pans, and dusty storage racks. Facility policies on safe food preparation and cleaning schedules were not followed.
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies such as difficult-to-open bathroom doors, insufficient water pressure in showers, broken drawers, peeling paint, and wobbly toilets. These issues had been reported by residents but remained unresolved for extended periods, affecting their quality of life.
The facility failed to invite four residents to their care plan meetings, despite their cognitive abilities being intact or moderately impaired. Observations, interviews, and record reviews confirmed the absence of documentation for care plan meetings or invitations for these residents. The facility's policies require the development of a person-centered care plan with resident participation, but this was not adhered to, as evidenced by the lack of invitations and documentation.
The facility failed to prevent a resident from accessing unprescribed medications and did not adequately monitor smoking residents. One resident was found with five different pills, and multiple residents reported insufficient supervision during smoking breaks, contrary to facility policy.
The facility failed to maintain dignity and privacy for two residents with intact cognition. Staff entered rooms without waiting for permission, administered incontinence briefs in public areas, and shared dressers exposed personal belongings. The DON acknowledged these concerns, emphasizing the need for staff to knock and wait for permission before entering and to avoid public distribution of incontinence briefs.
The facility failed to maintain proper documentation for Advanced Directives for three residents, resulting in discrepancies between the residents' wishes and their medical records. The facility's policy mandates congruent documentation and timely updates, which were not followed.
The facility failed to follow physician orders for one resident by administering an incorrect dosage of Tylenol and did not monitor another resident's blood glucose levels despite her being on diabetic medications. The Director of Nursing confirmed these deficiencies, highlighting the need for proper medication administration and monitoring.
The facility failed to update the EMR to include a resident's medical diagnoses. The DON confirmed that the admitting nurse is responsible for entering the diagnoses and the MDS Coordinator should have reviewed them. The facility did not have a policy or procedure guide for updating resident records.
Resident Rights Violated During Unaccompanied Room and Belongings Search
Penalty
Summary
The facility failed to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions when staff conducted a room search without the resident’s presence or permission. The affected resident is an adult male with a history of paranoid schizophrenia, bipolar disorder, and post‑traumatic stress disorder, admitted on June 1, 2023. On interview, the resident reported that his room was searched randomly, that he was not present, and that he had not given permission for the search; he also stated that his jacket, which was lying on his bed, had its pocket searched. A grievance form dated April 20, 2026 documented the resident’s concern about his room being searched without him present. During interview, the Psychosocial Rehabilitation Services Coordinator acknowledged that she performed a random room check of this resident’s room on April 20, 2026, did so alone, and confirmed the resident was not present during the search. The facility’s Inspection Policy states that residents must be present during room searches and that residents’ pockets may only be checked by the resident turning their own pockets inside out, which was not followed in this instance. This sequence of events, including the staff member’s admission and the documented grievance, demonstrates that the facility did not adhere to its own policy or to resident rights regarding privacy and personal possessions during the room and clothing search for this resident.
Restriction of In-Room Visitation and Loss of Resident Privacy Rights
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to private visits and a dignified existence when it implemented new house rules restricting in-room visitation between residents from different wings. The facility’s written Resident Rights document states that residents have the right to private visits unless limited by a physician for medical reasons. However, effective January 23, 2026, the facility implemented a new House Rules and Behavior Expectations agreement, including a rule that residents are prohibited from going onto another unit or floor where they do not reside and directing them to use the dining room if they wish to visit a co-resident. The Administrator confirmed that this rule was added to make it easier to identify residents who were smoking in their rooms and that it was implemented permanently, with 80 of 92 residents signing the new agreement. The Administrator also acknowledged that there is currently no place where residents from different wings can visit privately. Multiple residents reported that this new rule removed their ability to have private visits in their rooms, particularly with significant others and friends who live on different wings. One resident stated she could no longer have her boyfriend or friends in her room and that they could not be intimate due to lack of privacy. Another resident reported that the rule violated his rights, increased his depression, and that he does not like leaving his room. Other residents described the rules as unconstitutional, said they could no longer play video games with friends in private, and reported feeling annoyed, depressed, anxious, and like prisoners because they could not have private time with friends or partners. One resident with chronic migraine headaches stated she prefers to stay in her room and now has limited time with her boyfriend because she does not like to go to the dining area. Staff confirmed that the new rule prohibiting residents from entering rooms on other wings had recently started and that residents were complaining about it.
Failure to Implement Interventions Following Behavioral Complaints Led to Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse by not implementing interventions in response to repeated behavioral concerns and a resident complaint. One resident, with a history of mood disorder, depression, anxiety, and chronic pain, exhibited verbally threatening behaviors almost daily and demonstrated depressive moods. Another resident, diagnosed with schizoaffective disorder, PTSD, anxiety disorder, and bipolar disorder, also experienced depressive moods. Despite ongoing complaints from residents and staff about one resident's behavior of placing meal trays on another table, no interventions or care strategies were documented or implemented to address the issue. An altercation occurred during dinner when one resident struck another after being verbally provoked, resulting in both sustaining injuries that required first aid and hospital evaluation. Multiple interviews confirmed that staff were aware of the ongoing behavioral issue and resident complaints but failed to act or document any interventions. The facility's abuse prevention policy requires timely response to consumer concerns, but records showed no evidence of such actions prior to the incident.
Failure to Implement Comprehensive Water Management and Legionella Risk Assessment
Penalty
Summary
The facility failed to follow its own water management program by not identifying building water systems that require Legionella control measures and not assessing the level of risk posed by hazardous conditions in those systems. During the survey, the facility was unable to provide documentation or evidence of a risk assessment or identification of specific water systems at risk for Legionella, as required by their policy. The only information provided consisted of a log for water flushing in unoccupied rooms, a general water management program policy, and screenshots of water flushing logs. The policy referenced a diagram (Figure A) for system identification, but no such diagram was attached or available. Interviews with the Administrator, Maintenance Director, and Regional Maintenance confirmed that no additional documentation or assessment existed beyond the flushing logs and policy. The staff stated that the water flushing logs constituted their assessment, but there was no written or otherwise documented evaluation of the facility's water systems or the risks associated with Legionella. This deficiency affected all 88 residents residing in the facility, as indicated by the facility census.
Failure to Provide Window Screens in Resident Rooms
Penalty
Summary
The facility failed to provide window screens in resident rooms, resulting in a lack of a safe, clean, and comfortable environment for residents. Multiple cognitively intact residents reported that their room windows did not have screens, and observations confirmed the absence of screens, as well as the presence of warped or damaged screens in several rooms. Residents expressed concerns about insects and other objects entering their rooms when windows were open for ventilation. In one instance, a resident reported that a maintenance staff member installed a wooden block to prevent the window from opening fully due to safety concerns, but did not address the missing screen despite being informed about it. Another resident's window screen was found lying outside on the grass, broken and ripped, and had not been replaced for over two weeks. The Maintenance Director confirmed that, to his knowledge, none of the facility's windows had screens since he began working there three years prior. The Administrator stated there was no facility policy regarding window screens and indicated that screens had previously been removed or damaged by residents, leading to the decision not to reinstall them. These actions and inactions resulted in the ongoing absence of window screens in resident rooms, despite residents' requests and concerns.
Failure to Provide Written Bed-Hold Policy Prior to Hospitalization
Penalty
Summary
The facility failed to provide written notification of its bed-hold and return policy to residents or their representatives prior to hospitalization, as required by its own policy. This deficiency was identified through record review and interviews, which revealed that four residents who were transferred to the hospital for various medical and behavioral reasons did not receive the required written documentation. The residents involved had complex medical and psychiatric diagnoses, including diabetes, schizoaffective disorder, bipolar disorder, PTSD, and intellectual disabilities. Each resident experienced an acute event necessitating hospital transfer, such as rib fractures with pneumothorax, abnormal diagnostic results, urinary tract infection, escalating aggressive behavior, or self-harm attempts. Despite multiple hospitalizations and clear documentation of the events leading to each transfer, there was no evidence in the residents' records that the facility provided the mandated written bed-hold and return policy prior to their departure. The facility administrator confirmed during the survey that the bed-hold forms were not being completed for residents transferred to the hospital, even though the facility's policy required this notification. The deficiency was found in all four cases reviewed for hospitalization in the sample.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with psychiatric diagnoses. One resident, who is cognitively intact and diagnosed with paranoid schizophrenia, was seated next to another resident with moderately impaired cognition, unspecified schizophrenia, and a history of aggressive and abusive behavior. While watching a movie in the dining/day room, the resident with a history of aggression began lightly punching the other resident's arm, escalating to harder punches. The recipient of the punches did not initially report the behavior, as it was consistent with the aggressor's known conduct, but eventually retaliated by grabbing the aggressor's hand and kneeing him in the abdomen. This resulted in the aggressor losing balance and falling to the floor. Multiple staff interviews confirmed that the aggressive resident had a pattern of socially inappropriate and intrusive behavior, including touching others without consent. Staff present at the time witnessed the escalation and responded after the physical altercation had already occurred. Both residents sustained injuries and were sent to the hospital for evaluation. The incident highlights a failure to adequately supervise and intervene to prevent physical abuse between residents, particularly given the known behavioral history of one of the individuals involved.
Failure to Provide Required Behavioral Health Services to Residents with SMI
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with severe mental illness (SMI), as required by their PASRR Level II recommendations and care plans. Both residents had diagnoses including schizoaffective disorder and schizophrenia, and their PASRR assessments specified the need for rehabilitative supports such as life skills programs, psychotherapy, and regular meetings with mental health professionals. Despite these documented needs, the facility did not ensure that the recommended behavioral health services were consistently offered or provided. For the first resident, documentation showed only two group sessions attended over a five-month period, totaling one hour of behavioral health services. The resident was not listed as a participant in key groups such as symptom management, home and self-care, or social skills, despite being assessed as able to benefit from them. Facility staff stated that the resident refused both group and one-on-one sessions, but there was no documentation of these refusals or of efforts to offer one-on-one interventions as required by the care plan and PASRR recommendations. The second resident also had a history of SMI and substance use, with PASRR recommendations for multiple rehabilitative services and psychotherapy. This resident attended only three money management group sessions and one sexual health group session over several months, with no participation in other recommended groups. Staff confirmed that the resident refused additional groups and one-on-one sessions, but again, there was no documentation of refusals or of attempts to provide individualized behavioral health interventions. Both cases demonstrate a lack of implementation and documentation of required behavioral health services for residents with SMI.
Failure to Repair Resident Room Wall in Timely Manner
Penalty
Summary
A deficiency was identified when a resident's room was not maintained in good repair, as required by facility policy. The resident, who was cognitively intact and had multiple diagnoses including schizoaffective disorder and obesity, had a large piece of plywood covering a hole in the wall next to his bed. The hole was created when the resident accidentally kicked the wall while sleeping, and the plywood had been in place for approximately a year. The resident reported that he was told the wall would be repaired, but no timeline was provided, and the repair was not completed. Interviews with facility staff confirmed that the plywood had been covering the hole for 14 months due to an oversight by the Maintenance Director. The Administrator acknowledged that the hole should have been fixed and that leaving plywood on the wall for such an extended period was inappropriate. Facility policy states that the Maintenance Department is responsible for keeping the building in good repair and free from hazards, but this was not followed in this instance.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect three residents from sexual and physical abuse. One resident, who was cognitively intact and had diagnoses including PTSD, schizoaffective disorder, anxiety, and borderline personality disorder, reported that another resident with similar psychiatric diagnoses and a history of substance use entered her room and touched her inappropriately by grabbing her breast. The incident occurred after the residents had consumed alcohol together. The resident responded by kicking the perpetrator and later reported the incident to facility staff, after which the police were called. Additionally, the same resident slapped her boyfriend, another resident, because she believed he allowed the inappropriate contact to occur. The boyfriend confirmed being slapped but denied injury or pain and declined police intervention. Both incidents were reported to the Illinois Department of Public Health. The facility's abuse policy states a commitment to protecting residents from abuse by anyone, but the events described demonstrate a failure to uphold this policy, resulting in residents being subjected to both sexual and physical abuse by peers.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium, did not receive appropriate podiatry care. The resident was cognitively intact and required supervision or assistance with activities of daily living. During observation, the resident was found to have long, black, and curled toenails on the left foot and long toenails on the right foot. The resident reported that the last podiatry visit for toenail clipping was six months prior and that, despite being on the list to see the podiatrist, was not seen during the most recent visit. The resident also stated that he had informed the program manager of his need for toenail care. Interviews with facility staff confirmed that the resident should have received podiatry care and that there was no documentation of the resident refusing services. The facility's records showed the resident was added to the podiatry list for toenail trimming, but there was no documentation of the resident being seen by the podiatrist as scheduled. The facility's policy requires podiatry services, including toenail trimming, to be made available to all residents, but this was not provided in this case.
Resident Denied Second Cup of Coffee Without Justification
Penalty
Summary
A resident with multiple diagnoses, including cocaine dependence with cocaine-induced anxiety disorder, major depressive disorder, COPD, cardiac arrhythmia, back pain, and suicidal ideations, was admitted to the facility and assessed as cognitively intact and requiring supervision with all ADLs. On the day in question, the resident requested a second cup of coffee during a meal service. The CNA serving coffee refused the request, instructing the resident to wait until all others had received their first cup. The resident expressed frustration, noting that he was not informed of any such rule and observed another resident receiving a second cup. The resident attempted to obtain a second cup through his roommate, but the CNA recognized the attempt and did not provide the coffee. Interviews with staff confirmed that there were no facility rules limiting residents to one cup of coffee, and the administrator stated there had been no issues with coffee supply or restrictions on second helpings. The Psychiatric Rehabilitation Services Coordinator noted that the resident was particularly distressed that day and that a second cup of coffee could have helped. Observations on a subsequent day showed residents freely receiving additional cups of coffee, and no rules regarding coffee service were posted. The incident resulted in the resident feeling singled out and denied a personal preference without justification.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving altercations between residents. In one incident, a resident with a history of cocaine dependence, major depressive disorder, and other medical conditions requested a second cup of coffee and was denied by a CNA, leading to a verbal exchange. The CNA later discussed the incident within earshot of other residents, who then confronted the resident in his room. This confrontation escalated into a physical altercation, with one resident striking another in the face. Staff interviews confirmed that the CNA's conversation was overheard by residents, which directly contributed to the escalation of the situation. Another incident involved two residents with cognitive impairments and multiple medical diagnoses who became involved in a physical altercation during a smoke break. One resident cut in line, leading to an argument and a physical push. Staff and other residents intervened to prevent further escalation, but the initial lack of supervision allowed the altercation to occur. Documentation and staff interviews confirmed that the altercation was witnessed and that the residents were able to physically engage before being separated. In both cases, the facility's failure to prevent staff from discussing resident-related issues in the presence of other residents, as well as insufficient supervision during high-risk times such as smoke breaks, contributed to the occurrence of physical abuse. The facility's own policy affirms the right of residents to be free from abuse, yet these incidents demonstrate lapses in maintaining a safe environment and protecting residents from harm.
Failure to Complete Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to follow a Nurse Practitioner's order to obtain a Basic Metabolic Panel (BMP) laboratory test for a resident who had multiple complex medical diagnoses, including schizoaffective disorder, UTI, abnormal gait, muscle weakness, heart failure, COPD, diabetes, and others. The order to check the BMP was placed on August 31 and confirmed by a Registered Nurse on September 2, but there is no documentation that the laboratory test was ever completed. The facility's own policy requires that laboratory and diagnostic testing be performed according to provider orders, with oversight and coordination by the Director of Nursing or designee, and that requisitions be completed and filed appropriately. The resident's previous laboratory results had already shown abnormal sodium and bilirubin levels. Later, the resident was sent to the hospital, where further testing revealed a significantly low sodium level and elevated bilirubin, leading to diagnoses of hyponatremia and acute kidney injury. Interviews with facility staff confirmed that the ordered BMP should have been completed, but it was not carried out as required.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, R1 and R2, which occurred on October 13, 2024. R1 reported to the Administrator that R2 slapped him when he entered the shared bathroom while R2 was using it. Both residents are diagnosed with schizoaffective disorder and generalized anxiety disorder, and are cognitively intact according to their respective MDS assessments. R1 also has Parkinson's disease and experiences delusional thoughts and maladaptive behaviors, while R2 has a history of aggressive behavior and ineffective coping mechanisms. The incident was reported to have occurred because R2 was surprised and upset by R1's entry into the bathroom, which R2 perceived as an insult. The facility's abuse policy, effective since March 2022, prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite this policy, the facility's investigation concluded that R2 did not intend to abuse R1, attributing the incident to R2's response to internal stimuli. The Administrator confirmed the incident and noted that R2 had no previous episodes of aggression or violence, while R1 is hard of hearing and hears voices, which can lead to annoyance. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from abuse, as outlined in their policy.
Failure to Maintain Cleanliness in Food Preparation Area
Penalty
Summary
The facility failed to maintain cleanliness in the food preparation area and equipment storage, affecting all 92 residents. During an initial kitchen tour, it was observed that a cook was wearing a hair restraint improperly, with hair dangling to the earlobes, and did not change gloves or perform hand hygiene after retrieving additional vegetables from the cooler. Another dietary aide was also observed with hair dangling to the earlobes while preparing food. The air vent in the food preparation area was covered with black dust, and the floor behind the shelving had a black substance. During lunch service, five of the six pans used were stained with black grease, and the ceiling above the steam table had dust particles and food stains. The storage racks for clean equipment were covered with dust and cobwebs. A cook was also observed with an improperly covered beard while serving food from the steam table. The facility's policies on safe food preparation and handling, as well as cleaning schedules, were not followed. The policies required proper hand washing techniques and suitable hair restraints, which were not adhered to by the staff. The dietary manager confirmed that the vents above the stove are cleaned every six months by an outside company, but there was uncertainty about how to ensure full beard coverage for staff. The deficiencies in cleanliness and hygiene practices in the kitchen were evident, as staff continued to use dusty and stained equipment for food preparation and storage.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed and reported by residents. Resident R34 reported that his bathroom door was difficult to open and close, requiring significant physical effort, and had been in this condition for 3-4 months despite notifying the Maintenance Director. Similarly, R72, who shares the bathroom with R34, confirmed the issue and added that the doorknob was loose and missing screws, making it even more challenging to use the door. The Maintenance Director acknowledged being aware of the problem but had not yet addressed it adequately. Resident R53 reported that the water pressure in his shower was insufficient to rinse soap off his body, a problem that had persisted for six months since the shower head was replaced. Despite informing the Maintenance Director, the issue remained unresolved. Resident R193 expressed concerns about her room's condition, including a piece of gum stuck under her bedside table, a falling baseboard, and broken or missing drawers in her built-in closet. These issues had been reported to staff but had not been addressed, making her feel unsafe and uncomfortable in the facility. Residents R75, R42, R59, and R71 also reported various maintenance issues in their rooms, such as broken drawers, peeling paint, and wobbly toilets. These problems had been ongoing for extended periods, with some residents reporting issues that had persisted for years. The Maintenance Director admitted to being unaware of some of these concerns and acknowledged that the facility was not homelike for the residents when their rooms were in disrepair. The Administrator and Director of Nursing also recognized the deficiencies and agreed that the facility should provide a more homelike environment for its residents.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite four residents (R55, R65, R76, and R31) to their care plan meetings, despite their cognitive abilities being intact or moderately impaired. Observations and interviews revealed that these residents had never been invited to or attended any care plan meetings. Record reviews confirmed the absence of documentation for care plan meetings or invitations for these residents. Specifically, R55, R65, and R76, all with intact cognition, reported never being invited to care plan meetings, and their electronic health records corroborated this lack of documentation. R31, with moderate cognitive impairment, also reported not being invited to a care plan meeting in over a year, and there was no documentation to show his participation or invitation to any care plan meetings. The facility's Administrator and Director of Nursing confirmed the lack of documentation and stated that the facility had only recently started documenting residents' acceptance or refusal to participate in these meetings. The facility's Care Plan policy requires the interdisciplinary team to develop and implement a person-centered care plan in consultation with the resident and their representative, with appropriate documentation of any refusals to participate. The facility's Care Planning - Interdisciplinary Team (IDT) policy mandates the development of a comprehensive care plan within seven days of the resident's assessment, encouraging the participation of the resident, their family, and/or legal representative. However, the facility failed to adhere to this policy, as evidenced by the lack of invitations and documentation for the care plan meetings of the four residents reviewed. The Psych Rehab Services Director, responsible for inviting residents and their families to care plan meetings, also confirmed the absence of documentation for R31's participation or invitation to any care plan meetings. This deficiency highlights a significant lapse in the facility's adherence to its own policies and regulatory requirements for resident care planning and documentation.
Medication Mismanagement and Inadequate Smoking Supervision
Penalty
Summary
The facility failed to prevent a resident from accessing medications that were not prescribed to them and did not adequately monitor smoking residents. One resident, who had a history of self-harm and substance abuse, was found in possession of five different pills that were not prescribed to him. The facility's staff admitted that the medications should have been disposed of properly and that the resident should not have had access to them. This lapse in supervision could have led to serious health risks for the resident and others who missed their medications. Additionally, the facility did not properly monitor residents during smoking breaks. Multiple residents reported that staff were either not present or only monitored from inside the building, leaving lighters unattended and allowing residents to light their own cigarettes. This was against the facility's smoking policy, which required staff to be present and to light cigarettes for the residents. The lack of supervision during smoking breaks posed a significant safety hazard, especially for residents with cognitive impairments or those who were not safe smokers. The facility's staff acknowledged the deficiencies in both medication management and smoking supervision. The Director of Nursing and other staff members admitted that the current practices were not in line with the facility's policies and posed risks to the residents. The facility's failure to adhere to its own policies and ensure proper supervision contributed to the identified deficiencies.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain dignity and privacy for two residents, R17 and R71, whose cognition is intact. R17 reported that staff would knock on her door and enter without waiting for permission, which made her feel disrespected and invaded. This was observed when a CNA knocked while opening the door and entered R17's room without waiting for permission. Similarly, R71 reported that some staff would enter her room without knocking, especially at night, leaving her exposed. This was confirmed when a nurse entered R71's room without knocking to administer medication. Additionally, R71 expressed discomfort with staff giving her incontinence briefs in the dining hall and the shared dresser that allowed her roommate to see her belongings, causing her anxiety. The DON acknowledged these concerns, stating that staff should knock and wait for permission before entering and that residents should not receive incontinence briefs in public areas for dignity reasons. The facility's Resident Rights information and policies from the Illinois Department of Aging and the facility itself emphasize the residents' right to privacy and a dignified existence. The facility's policies, dated 3/2021 and 4/2020, respectively, state that residents have a right to privacy and should be treated with respect, kindness, and dignity. The observations and interviews indicate that the facility did not adhere to these policies, leading to the reported deficiencies in maintaining resident dignity and privacy.
Failure to Maintain Proper Documentation for Advanced Directives
Penalty
Summary
The facility failed to maintain proper documentation for Advanced Directives for three residents in a sample of 26. For one resident, the health records showed conflicting information between the Advanced Directives book and the electronic health record regarding the resident's code status. The Director of Nursing confirmed that staff would follow the electronic health record, which could result in actions against the resident's wishes. The facility's policy requires congruent documentation and periodic reviews, which were not adhered to in this case. Another resident did not have an Advanced Directive care plan or a POLST form uploaded into the electronic medical record upon admission. It was only after a significant delay that the POLST form was completed and uploaded. Similarly, a third resident did not have a code status order entered until much later after admission, and there was a discrepancy between the resident's stated wishes and the documentation. The facility's policy mandates that code status orders be obtained upon admission, which was not followed in these instances.
Failure to Follow Physician Orders and Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to follow physician orders for one resident and did not monitor another resident's blood glucose levels as required. For the first resident, who had diagnoses including spinal stenosis and muscle weakness, the physician had ordered 1000 mg of Tylenol for pain management. However, the nurse administered only 650 mg, substituting two 325 mg tablets for the prescribed 500 mg tablets. The resident reported that this discrepancy occurred frequently, and the Director of Nursing confirmed that the nurse should have administered the correct dosage as per the physician's order to manage the resident's pain effectively. For the second resident, who had multiple diagnoses including schizophrenia and congestive heart failure, the facility failed to monitor her blood glucose levels despite her being on diabetic medications. The resident reported that her blood sugar was not being checked daily, as it had been in her previous facility. The nurse confirmed that there were no orders for blood glucose monitoring or an A1C test, and the resident's electronic medical record did not include a diabetes diagnosis. The Director of Nursing acknowledged that the resident's blood sugar levels should be monitored to prevent potential complications, given her diabetic medication regimen.
Failure to Update Resident's Medical Diagnoses in EMR
Penalty
Summary
The facility failed to update the EMR to include a resident's medical diagnoses. The resident was admitted to the facility, but during a review of the medical record, no diagnoses were listed in the EMR. The Director of Nursing confirmed that the admitting nurse is responsible for entering the diagnoses and the MDS Coordinator should have reviewed them. The diagnoses list is typically obtained from the discharge summary or admission packet received from the hospital. The facility did not have a policy or procedure guide for updating resident records.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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