La Bella Of Morrison
Inspection history, citations, penalties and survey trends for this long-term care facility in Morrison, Illinois.
- Location
- 500 North Jackson Street, Morrison, Illinois 61270
- CMS Provider Number
- 146084
- Inspections on file
- 27
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at La Bella Of Morrison during CMS and state inspections, most recent first.
The facility failed to maintain a functional call system for three residents on one hallway, resulting in non‑working call lights in bedrooms and bathrooms and, in one case, the complete absence of a call light. One resident, care planned to use a call light, instead received a drum she could not effectively use, requiring her to yell or wait for staff checks. Another resident with a traumatic brain injury and convulsions reported having no call light or alternative device and having to walk to the nurses’ station for help. A third resident with diabetes and anxiety also reported a non‑functioning call light and no alternative call system, stating he had to search for staff. The Administrator and a CNA confirmed the south hallway call lights had been inoperative for an extended period, and the acting Maintenance Director acknowledged awareness of the problem and the importance of a working call system.
The facility failed to complete and document required initial and weekly wound assessments for two residents with significant lower extremity wounds and amputations. One resident on hospice with bilateral frostbite-related foot wounds did not have a complete wound assessment on admission, and no weekly assessments were documented for several weeks. Another resident with bilateral lower extremity surgical amputation sites had a care plan requiring weekly wound measurements and detailed documentation, but assessments were missed on multiple consecutive weeks without any record of refusal. These practices did not follow the facility’s wound management and documentation policies, which require admission and weekly assessments with specific wound measurements and characteristics.
A cognitively intact resident who was independent in self-care and mobility received an involuntary discharge notice for non-payment, while the ombudsman was actively assisting with an appeal and hearing. The resident chose to leave and was discharged home before the planned discharge date, but the facility did not notify the ombudsman of this discharge. The ombudsman learned of the discharge from an APS worker and confirmed that no discharge notice had been received, and the administrator acknowledged that required notification to the ombudsman, as outlined in facility policy, had not been provided.
Two residents were not safely transferred according to their assessed needs and facility policy, resulting in injuries requiring emergent hospital evaluation. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance was transferred by a single CNA unfamiliar with her status, leading to a leg laceration when her leg likely caught on the wheelchair during a hurried transfer. Another resident with cognitive impairment, right-sided paralysis, and a fall history, who required a gait belt and one-person assist, was stood from the toilet without a gait belt and left unsupported when the CNA turned away, causing a fall with head impact and leg pain.
A resident was admitted from a hospital with discharge orders and a POLST indicating DNR status, and a POA document identified a healthcare representative. Despite this, a physician order listed the resident as Full Code, and the admission care plan omitted any reference to advance directives. The POA reported being told that the facility could not honor the POLST until the medical director signed it, even though the DON later confirmed that a physician-signed POLST should be honored without additional signatures. The facility’s policy requiring advance directives to be copied, charted, and communicated on admission was not followed, resulting in the resident’s DNR wishes not being implemented.
Two residents who were cognitively impaired and dependent on staff for toileting and incontinence care were not provided timely incontinence care consistent with their assessments, care plans, and facility policy. One resident’s brief was last changed early in the morning and was not changed again for over five hours while the resident remained in common areas and then in her room, after which she was found incontinent of urine with reddened buttocks. Another resident, care planned for q2h checks and assistance, was observed with a stool odor in the room and was found to have a brief unchanged since the night shift, containing a large amount of liquid stool and with bright pink buttocks. The DON stated residents needing assistance are to receive toileting and incontinence care every two hours and as needed.
A resident sustained a sutured left lower leg laceration and was discharged with orders for daily wound cleansing and specific dressings each day shift. Review of the TAR and interviews showed that daily wound treatments and dressing changes were not provided on multiple days, and the resident’s private caregiver reported that dressings were not changed on at least two of those days and that she frequently had to request dressing changes. On observation, the leg dressing was undated, appeared dirty, and had yellow drainage, and there was no documentation of wound care for the prior day. The DON later added initials to previously blank TAR entries for two dates, then admitted she had not performed the wound care and had documented after the fact because she had been told not to leave charting blank, contrary to the facility’s wound treatment policy and documentation expectations.
A resident with diabetes had physician orders for blood glucose checks before meals and at bedtime, scheduled insulin doses with meals, and Reglan to be given before meals. On an observed morning, the resident had already eaten part of breakfast and stated he was done when an LPN checked the blood glucose after the meal, then administered Humulin R and Reglan more than two hours past the ordered times and after the meal, instead of before as ordered. The DON stated that medications are considered late if given more than one hour after the scheduled time and that blood sugars should be checked prior to eating, and facility policies required adherence to physician orders and correct timing for blood glucose monitoring, insulin, and medication administration.
The facility did not develop or document discharge plans in the care plans or electronic medical records for two residents with complex medical needs. Both residents were unaware of their discharge plans, and staff confirmed that required discharge planning was missing, despite facility policy mandating comprehensive, person-centered discharge documentation.
Two residents in the facility suffered from inadequate pressure ulcer care due to failures in implementing necessary interventions and treatments. One resident was found on a deflated air mattress without heel protection, leading to a stage 3 pressure injury. Another resident's stage 2 pressure wound worsened to stage 3 without documented treatment. The facility did not follow its policy for assessing and treating skin alterations, resulting in inadequate care.
The facility failed to ensure a safe, clean, and comfortable environment, with deficiencies in the resident shower room and lack of hot water in bathrooms. The shower room had an uncovered drain, missing tiles, and exposed wood, while residents reported consistently cold water in their bathrooms. Staff acknowledged these issues, which were confirmed by temperature measurements and resident feedback.
The facility failed to maintain safe water temperatures and ensure call light accessibility. Hot water in resident areas exceeded the policy limit, and a resident at high fall risk had an unreachable call light. The Maintenance Director did not conduct additional checks or contact another plumber after identifying the issue. Staff confirmed call lights should be within reach, highlighting a lack of supervision and safety measures.
The facility failed to assess and authorize two residents to self-administer medications. One resident was found with lidocaine patches and an inhaler without proper orders, while another resident used an inhaler for shortness of breath without authorization. The facility's policy requires an assessment, physician's order, and care plan for self-administration, which were not completed for these residents.
A cognitively impaired female resident with autistic disorder and Down syndrome was observed wearing a restraint vest without a physician's order or a completed restraint assessment since admission. Staff provided conflicting accounts of the resident's ability to remove the harness, and the Director of Nursing confirmed the lack of assessment. The facility did not provide a restraint policy during the survey.
A facility failed to include necessary interventions for a chest harness restraint in a resident's care plan. The resident was observed using the harness multiple times, but no assessment had been completed since admission. The DON acknowledged the need for a restraint in the care plan, yet it was missing.
A facility failed to trim the nails of a resident with a hand contracture, resulting in indentations in the resident's palm. Despite the resident not refusing hygiene assistance, the nails remained untrimmed over consecutive days. Staff acknowledged the need for nail trimming, which is usually done during showers, but the facility's policy on grooming was not followed.
A resident with a history of lower extremity edema and congestive heart failure did not have elastic bandages applied as required by physician orders and care plan. Observations showed the resident without the bandages on multiple occasions, and staff interviews revealed a lack of awareness and adherence to the care plan. The resident's condition necessitates the use of these bandages to manage edema and circulation.
A facility failed to include a stop date in a psychotropic medication order for a resident with generalized anxiety disorder. The order for Lorazepam Oral Concentrate did not specify a duration, contrary to the facility's policy requiring PRN orders to be limited to 14 days. This was confirmed by the administrator.
The facility failed to assess and offer pneumococcal immunizations to two residents upon admission. The Director of Nursing acknowledged that the admitting nurse is responsible for screening and administering vaccines, but this process was not followed. The facility's policy requires assessment and offering of the vaccine upon admission, which was not adhered to.
The facility did not post daily staffing information for 35 residents as required. Staffing details were kept in a binder at the nurse's station, but not displayed near the front door for visitors. The CNA Supervisor was unaware of the requirement to visibly post staffing information.
The facility failed to test its water system for Legionella and did not prevent water from becoming sedentary in an unoccupied area. Maintenance staff were unsure if a water system assessment had been conducted, and there was no evidence of Legionella testing. Observations revealed a therapeutic bathtub with a continual slow drip and a long brown stain, and the facility's policies and procedures for Legionella management were not followed.
The facility failed to have a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The DON, who was identified as the IP, did not have the required certification. The Administrator acknowledged the requirement and mentioned that the DON was in the process of obtaining certification but was not currently certified. The facility's job description for the IP role specified that the individual must have completed specialty training in infection prevention and control through accredited continuing education such as the CDC or APIC.
The facility failed to update a resident's advanced directives as requested. Despite the resident opting to become a DNAR and signing the POLST form, the form lacked necessary signatures and was not processed correctly, leaving the resident still considered a full code.
The facility failed to ensure a resident received necessary post-amputation care, including follow-up with her surgeon, obtaining a properly fitted shrinker, and assisting in the process to obtain a prosthetic leg. The resident reported significant delays and improper fittings, and staff were unaware of the specific orders for her care.
The facility failed to implement pressure ulcer interventions and identify pressure injuries before they progressed to stage 2 for two residents. One resident's stage 2 pressure wound was not identified until it had been present for more than four days, and another resident was observed without a pressure-relieving device despite having a stage 2 pressure wound and orders for a pressure relief cushion.
The facility failed to ensure proper catheter care for a resident, leading to deficiencies such as improper cleaning techniques and incorrect placement of the catheter drainage bag. The CNAs involved were unaware of the correct procedures, and the resident's care plan lacked specific interventions to prevent these issues.
Failure to Maintain Functional Call System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system in resident rooms, bathrooms, and bathing areas for three residents on the south hallway. One resident’s admission record showed she was elderly and care planned to have her call light within reach and to be encouraged to use it for assistance. On observation, her bed and bathroom call lights were not working, and she confirmed this, stating staff had given her a drum to signal for help. She reported she was unable to use the drum effectively, and when she attempted to use it, no audible sound could be heard at her door. She stated that when she needed help, she had to yell or wait for staff to check on her. Her daughter‑in‑law confirmed that the resident was not physically capable of making a loud sound with the drum and that the call light system had not worked since admission. A second resident, with diagnoses including traumatic brain injury and convulsions, was observed in bed with no call light present in the room and a non‑functioning call light in the bathroom. This resident stated she did not have a call light and had to walk to the nurses’ desk to find staff when she needed help, and that no alternative call system such as a noise maker had been provided. A third resident, diagnosed with diabetes and anxiety, reported his call light was not working and that staff had not provided an alternative call system; he stated he had to look for staff when he needed assistance, and no noise maker was observed in his room. The Administrator stated the call light system on the south hallway had not been working for about two weeks. A CNA reported that call lights on the south hallway were not working and that the facility had provided drums as noise makers, while the acting Maintenance Director stated he became aware of the call light system problem the previous week and acknowledged the importance of a working call system so residents can contact staff.
Failure to Complete Initial and Weekly Wound Assessments per Facility Policy
Penalty
Summary
The facility failed to complete required initial and weekly wound assessments for residents with significant lower extremity wounds, contrary to its own wound management and documentation policies. One resident was admitted with multiple serious diagnoses including COPD, severe calorie malnutrition, gangrene, chronic respiratory failure, and was on hospice services with moderate cognitive impairment and extensive care needs. A skin check completed on the admission date documented only a right heel issue without measurements and did not include the left foot wound. The next available wound assessment, dated nearly a month later, documented large eschar-covered wounds on both feet attributed to frostbite, with measurements and a palliative care plan, but there were no wound assessments documented upon admission for the bilateral lower extremity wounds and no weekly assessments for several consecutive weeks following admission. Another resident, admitted with chronic CHF, severe protein-calorie malnutrition, multiple lower extremity amputations, and a cardiac pacemaker, had a care plan requiring weekly wound treatment documentation for bilateral lower extremity surgical sites, including detailed measurements and wound characteristics. The record showed weekly wound assessments were completed on one date in late February and then not again until late March, with no weekly assessments documented on four intervening weeks for the right and left stump wounds. The resident’s medical record contained no evidence of refusal of wound assessments, and the resident reported that a wound doctor and another individual came to measure the wounds only occasionally. The facility’s written policies required wound assessments on admission, weekly, and as needed with specific elements such as wound type, location, measurements, tissue type, peri-wound condition, drainage, odor, and pain, which were not consistently documented for these residents.
Failure to Notify Ombudsman of Resident Discharge After Involuntary Discharge Notice
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the ombudsman of a resident’s discharge following an involuntary discharge notice for non-payment. The resident was admitted on an unspecified date and was documented as cognitively intact on a 3/3/26 assessment, with independence in self-care (with supervision) and mobility. On 2/13/26, the Administrator issued the resident an involuntary discharge notice due to non-payment, with a planned discharge date of 3/16/26. The ombudsman reported that she was actively working with the resident on the involuntary discharge case, including filing an appeal and arranging a hearing, and had obtained representation for the resident and notified the facility of these actions. Despite the pending appeal and scheduled hearing, the resident discharged to home on 3/11/26, which the Administrator stated was the resident’s choice. The ombudsman stated that she learned of the discharge from an APS care worker’s message and that, as of 3/19/26, the facility had not sent any discharge notification to her office. The Administrator acknowledged that either she or social services should have notified the ombudsman of the resident’s discharge and confirmed, after reviewing email communications, that no such notification had been sent. This failure occurred despite the facility’s transfer and discharge policy dated 10/13/25, which requires that notice of transfer or discharge, including any updated information, be provided to the resident, the resident’s representative if appropriate, and the ombudsman as soon as practicable, and that the facility maintain evidence that the notice was sent to the ombudsman.
Failure to Safely Transfer Residents and Use Required Gait Belts
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer residents in accordance with assessed needs and established procedures, resulting in resident injuries. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance for transfers and standing was transferred by a single CNA who was unfamiliar with the resident’s transfer status. During a wheelchair-to-bed transfer, the CNA attempted to stand the resident, who became frantic and panicked. The CNA, feeling anxious, hurried to complete the transfer instead of stopping to seek additional help or allowing the resident time to calm down. The resident’s leg likely became caught on the wheelchair leg during this process, causing a large skin laceration that required emergent hospital evaluation and repair with nine sutures. Another resident with impaired cognition, right-sided paralysis from a prior stroke, nonverbal status, and a history of falls had a care plan requiring use of a gait belt and one-person assistance for transfers, standing, and ambulation. While assisting this resident from the toilet, a CNA did not use a gait belt as required. After helping the resident to stand, the CNA turned away to remove gloves and wash hands, leaving the resident unsupported. During this time, the resident fell and struck her head on the sink, later complaining of right leg pain and requiring emergent hospital evaluation. The facility’s policy required the use of gait belts for residents who could not independently ambulate or transfer, and restorative staff confirmed that a gait belt was to be used for this resident.
Failure to Honor Resident’s Documented DNR Status
Penalty
Summary
The deficiency involves the facility’s failure to honor and implement a resident’s documented DNR (do not resuscitate) status as indicated on a valid POLST (Physician Orders for Life-Sustaining Treatment) form. The resident was admitted from a hospital with discharge orders clearly indicating DNR status, and a POLST form dated later in the month also documented the resident as DNR. The resident’s healthcare POA was identified in a POA document, and the POA stated that the facility had a signed POLST form but reported being told by facility staff that they could not honor it until the facility’s medical director signed off on the DNR. Despite these existing documents, a physician order entered shortly after admission listed the resident as Full Code. The admission care plan documented that the resident was cognitively impaired but did not include any information related to advance directives. The facility’s DON confirmed that if a resident has a POLST form signed by a physician, the facility is supposed to honor it and that the medical director’s additional signature is not required for validity. Upon reviewing the POLST, hospital discharge orders, and current admission orders, the DON acknowledged not knowing why the resident was listed as Full Code and stated the resident should be DNR. The facility’s own policy on Residents’ Rights Regarding Treatment and Advance Directives states that upon admission, existing advance directives are to be copied, placed in the chart, documented in the medical record, and communicated to staff, but this was not carried out for this resident’s DNR status.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting assistance to residents who were cognitively impaired and dependent on staff for these activities of daily living. One resident’s assessment showed cognitive impairment and dependence on staff for toileting and incontinence care. A private caregiver reported that staff did not toilet or change this resident’s brief unless prompted and that the resident would sit in the same brief for hours. On the survey day, the resident’s brief was last changed around 7:00 AM before being dressed and taken to breakfast. The resident remained in common areas and then in her room for several hours, during which time the private caregiver stated no staff offered toileting or incontinence care. When the resident was finally transferred to bed at 12:37 PM, staff confirmed the brief had not been changed since 7:00 AM, the resident was incontinent of urine, and her buttocks were red. Another resident’s assessment showed severe cognitive impairment, dependence on staff for toileting and incontinence care, and incontinence of stool and urine. The resident’s care plan directed staff to check the resident every two hours and assist with toileting as needed. On the survey day, the resident was observed seated in a wheelchair with an odor of stool in the room. A CNA stated the resident’s brief had last been changed by night staff sometime before 5:00 AM and that the resident was already up and dressed at the start of the CNA’s shift. When CNAs transferred the resident to bed and removed the brief, the resident was found incontinent of a large amount of liquid stool, and the buttocks appeared bright pink. The DON later stated that residents requiring assistance with toileting and/or incontinence care are to receive such care every two hours and as needed, and the facility’s incontinence policy indicated that all incontinent residents will receive appropriate treatment and services based on their comprehensive assessment.
Failure to Provide and Accurately Document Daily Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide daily wound treatments and dressing changes as ordered for a resident who sustained a left lower leg laceration requiring nine sutures after being injured during a transfer by facility staff. Hospital discharge instructions and a physician order dated 2/7/26 directed staff to cleanse the wound on the left lower extremity with wound cleanser and cover it with xeroform, maxorb, an abdominal pad, and kerlix dressing every day shift. Review of the February 2026 Treatment Administration Record (TAR) showed no documentation that wound treatments or dressing changes were provided on 2/11/26 or 2/12/26. The resident’s private caregiver reported that on those two days the dressing was not changed at all and stated that she had to ask staff every day to change the dressing. On subsequent observation, the resident was seen with a gauze dressing on the left lower leg that had no date and later appeared dirty with a moderate amount of yellow drainage, with the caregiver stating that no dressing change had been done the previous day. Review of the TAR on 2/24/26 showed no wound treatment or dressing change documented for 2/23/26. New entries had been added to the TAR indicating that the DON had provided wound care on 2/11/26 and 2/12/26, but in interview the DON admitted she had not performed the wound care on those dates and had entered her initials the previous night because she was told by corporate to never leave charting blank. The facility’s Wound Treatment Management policy required that wound treatments be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.
Failure to Administer Insulin, Reglan, and Blood Glucose Monitoring at Ordered Times
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of pharmaceutical services related to medication and blood glucose administration for one resident with diabetes mellitus. The resident’s admission record documented a diagnosis of diabetes and physician orders for blood glucose (Accu-check) monitoring before meals and at bedtime, specifically at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. The resident also had orders for Humulin R insulin, 3 units SQ with meals at 7:30 AM, 12:00 PM, and 5:30 PM, and Reglan 10 mg to be given before meals at 6:30 AM, 11:30 AM, and 4:30 PM. The resident’s POA reported that staff were not checking the resident’s blood glucose levels as ordered and were administering medications late. On the morning observed, the resident was seated in the dining room with breakfast and had already consumed approximately 25% of the meal and stated to staff that he was done eating. At 8:33 AM, an LPN checked the resident’s blood glucose after he had eaten, obtaining a reading of 256, and then administered 3 units of Humulin R at 8:39 AM, more than two hours after the ordered 7:30 AM administration time. At 8:56 AM, the LPN administered 10 mg of Reglan, also more than two hours late and after the resident had eaten, contrary to the order for administration before meals. The DON confirmed that medications are to be given at the scheduled time per physician order, that medication is considered late if given more than one hour past the scheduled time, and that blood sugars are to be checked prior to eating. Facility policies on blood glucose monitoring, timely administration of insulin, and medication administration all required adherence to physician orders and correct timing, which was not followed in this case.
Failure to Document and Implement Discharge Planning in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a discharge planning process and include this process in the electronic medical record and comprehensive care plan for two of three residents reviewed for discharge planning. One resident expressed uncertainty about his discharge date and reported not being informed about his discharge plans, aside from being told he would be discharged. Staff interviews revealed that discharge planning was not documented in the electronic medical record or care plan, and communication about discharges was primarily through dashboard alerts. The care plan for this resident did not include any discharge planning, and there were no physician orders for discharge at the time of review. The facility's policy requires that the comprehensive, person-centered care plan contain the resident's goals for admission and desired outcomes aligned with discharge, with supporting documentation of the resident's intent to leave and documented discussions, which was not present in this case. Another resident also did not have a discharge plan documented in her care plan, despite her goal to return to the community being noted in the Minimum Data Set. She was unaware of her discharge plan and only knew she would be receiving cancer treatment. The care plan lacked any information related to discharge, and staff confirmed that a discharge plan should have been in place. Both residents had complex medical histories, including chronic conditions and recent treatments, but the required discharge planning and documentation were not completed as per facility policy.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement necessary interventions and treatments for pressure injuries for two residents, leading to a deficiency in care. Resident R33 was found with a deflated air mattress and without heel protection boots, which are essential for pressure relief. The air mattress was turned off, and the heel boots were not in use, contrary to the care plan. The Director of Nursing (V2) was unaware of the pressure injury until it was reported on 2/27/25, although it was initially noted on 2/17/25. The wound physician (V6) confirmed the injury as a stage 3 pressure injury, indicating it had been present for more than three days without appropriate treatment or pressure-relieving interventions. Resident R21 also experienced a lapse in care, as her stage 2 pressure wound progressed to a stage 3 wound without documented treatment. The Treatment Administration Record for January 2025 did not show any scheduled treatment for her pressure ulcer, and there were no orders for wound treatment from 1/23/25 to 2/5/25. The Director of Nursing (V2) acknowledged the oversight, noting that treatment orders were not entered into the system until the day after the wound physician's rounds. The facility's failure to adhere to its Assessment of Skin Alteration Policy, which mandates assessment and treatment of skin alterations as ordered by a physician, contributed to the worsening of pressure injuries for both residents. The lack of timely intervention and communication among staff members resulted in inadequate care and management of the residents' pressure injuries.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of the resident shower room and the lack of hot water in resident bathrooms. Observations revealed that the shower room had an uncovered drain, missing tiles, exposed wood framing, and tiles held in place with duct tape. A Certified Nursing Assistant reported that a wheelchair wheel got stuck in the drain, and a resident who had been at the facility for nine years expressed ongoing dissatisfaction with the shower room's condition. The facility's administrator acknowledged awareness of the issues, and the Resident Council Minutes from June 2024 indicated that updates to the shower room were needed. Additionally, the facility failed to provide hot water in resident bathrooms, with temperatures recorded significantly below acceptable levels. Residents reported that the water never got warm, even after running for extended periods. A staff member indicated that the north wing had issues with hot water, possibly due to a lack of a return circuit. Temperature measurements taken during the investigation confirmed that the hot water in several residents' bathrooms was consistently below 61 degrees Fahrenheit, failing to meet the residents' rights to a safe and comfortable environment.
Deficiencies in Water Temperature Monitoring and Call Light Accessibility
Penalty
Summary
The facility failed to ensure that water temperatures in resident care areas were monitored and maintained within safe limits, as well as failed to ensure a resident's call light was within reach. Observations revealed that the hot water temperature in a shared resident bathroom was measured at 121.5 degrees Fahrenheit, exceeding the facility's policy limit of 110 degrees Fahrenheit. The Maintenance Director, V9, acknowledged the high temperatures and stated that the hot water heater was turned down to 125 degrees Fahrenheit a week prior, but no further action was taken to address the issue. Despite identifying the problem, V9 did not conduct additional water temperature checks beyond the regular Friday rounds, nor did he contact another plumber after the initial one was unavailable. Additionally, a resident identified as R4, who was at high risk for falls due to dementia and required assistance with personal care, was found with her call light coiled and out of reach on the floor. This was contrary to the facility's Call Light Policy, which mandates that call lights be within reach and secured as needed. The Director of Nursing and a Certified Nursing Assistant confirmed that call lights should be accessible to residents. These deficiencies indicate a lack of adequate supervision and environmental safety measures to prevent accidents and ensure resident safety.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess, care plan, and obtain physician orders for two residents to self-administer medications. Resident 27, who is [AGE] years old, was found with a box of lidocaine patches and an inhaler in her bedside stand, which she used for pain and respiratory issues, respectively. Despite having an order for the lidocaine patch, there was no order for her to self-administer any medications. The Director of Nursing confirmed that no residents had orders or assessments to self-administer medications, and the facility could not provide a medication self-administration assessment for Resident 27. Similarly, Resident 22, a [AGE] year old cognitively intact resident with chronic obstructive pulmonary disease and congestive heart failure, was observed with an inhaler on her bedside table, which she used as needed for shortness of breath. Her physician order sheet included an order for an Albuterol Sulfate inhaler but did not authorize self-administration. The facility's policy requires an assessment, physician's order, and care plan for residents to self-administer medications, none of which were completed for Resident 22.
Failure to Assess Resident for Restraint Use
Penalty
Summary
The facility failed to ensure a resident was properly assessed for the use of a physical restraint. A cognitively impaired female resident with diagnoses of autistic disorder and Down syndrome was observed wearing a restraint vest while seated in a wheelchair near the nurse's station. The vest was secured with straps and clips, but there was no physician order for its use, nor was there a restraint assessment completed since the resident's admission. Staff members provided conflicting accounts of the resident's ability to remove the harness independently, with one CNA stating the resident could move the top straps over her head, while another CNA indicated that staff were responsible for undoing the harness. The Director of Nursing confirmed that no restraint assessment had been conducted since the resident's admission. The facility did not provide a restraint policy during the survey.
Failure to Include Restraint in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for a resident included necessary interventions for a chest harness restraint. This deficiency was identified during a survey where the resident was observed wearing a restraint harness while in her wheelchair on multiple occasions. Despite the use of the harness, the resident's medical record showed no assessment had been completed since her admission. Additionally, the Director of Nursing acknowledged that a restraint should be included in a resident's care plan, yet the current care plan for the resident lacked any focus area or interventions related to the restraint.
Failure to Trim Nails for Resident with Hand Contracture
Penalty
Summary
The facility failed to ensure proper grooming for a resident with a hand contracture, leading to a deficiency in providing activities of daily living (ADL) assistance. The resident, a male with a history of stroke affecting his left side, was observed with fingernails approximately 1/4 inch long, causing indentations in his palm due to the contracture. Despite the resident not refusing hygiene assistance, his nails remained untrimmed over consecutive days. A Certified Nursing Assistant and a Certified Nursing Supervisor both acknowledged the need for nail trimming, which is typically performed during a resident's shower. The resident's care plan indicated a need for ADL assistance, but the facility's policy on providing resident care, including grooming, was not adequately followed.
Failure to Apply Elastic Bandages for Resident with Edema
Penalty
Summary
The facility failed to ensure that elastic bandages, known as tubi grips, were applied to a resident with a history of lower extremity edema. This deficiency was observed in one of the twelve residents reviewed for quality of care. On multiple occasions, the resident was seen in the activity room without the required elastic wraps on her legs, despite having physician orders to wear them daily from her toes to her knees. The resident's care plan also specified the need for these bandages to manage her condition, which includes congestive heart failure and a history of cellulitis. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. A CNA assigned to the resident admitted to not applying the elastic bandages, stating she was unaware of the requirement. A Licensed Practical Nurse confirmed that the resident was supposed to wear the bandages to aid circulation and prevent edema. The Director of Nursing acknowledged the resident's history of edema and cellulitis, emphasizing the importance of the bandages in managing her condition, especially since the resident prefers to remain active and upright.
Failure to Include Duration in Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included a duration for one of the six residents reviewed for psychotropic medications. Specifically, a resident with a diagnosis of generalized anxiety disorder had a physician's order for Lorazepam Oral Concentrate 2 MG/ML to be administered 0.25 ml by mouth every 2 hours as needed for anxiety. This order, dated 1/13/25, did not include a stop date or duration, which is a requirement according to the facility's policy. The policy, dated 3/2025, mandates that PRN orders for psychotropic medications, excluding antipsychotics, should be limited to no more than 14 days. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that all psychotropic as-needed medications should have a stop date.
Failure to Assess and Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that residents were assessed and offered pneumococcal immunizations upon admission, as evidenced by the cases of two residents. Resident 15's admission record indicated no historical or current record of having had or being offered a pneumococcal immunization. Similarly, Resident 21's records showed no evidence of being assessed or offered the vaccine. The Director of Nursing/Infection Prevention Nurse acknowledged that the admitting nurse is responsible for screening residents for vaccination status and administering vaccines, but noted that the previous Director of Nursing failed to ensure this process was followed. The facility's policy, reviewed in January 2025, mandates that each resident be assessed for pneumococcal immunization upon admission and offered the vaccine, which was not adhered to in these cases.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing information for all 35 residents reviewed for staffing. During the survey conducted from March 3 to March 5, 2025, it was observed that there were no staffing postings near the front door on the entry table or bulletin boards. The facility's Long Term Care Facility Application for Medicare and Medicaid indicated a resident census of 35. On March 5, 2025, at 1:25 PM, the Certified Nursing Assistant (CNA) Supervisor stated that staffing information was kept in a binder at the nurse's station, which included monthly and daily schedules for nursing and CNA staff. The CNA Supervisor admitted that staffing was not posted near the front door for visitors to see and was unaware that it needed to be visibly posted.
Failure to Test Water System for Legionella and Prevent Water Stagnation
Penalty
Summary
The facility failed to ensure its water system was tested for Legionella and did not prevent water from becoming sedentary in an unoccupied area. The maintenance staff admitted to flushing toilets and running water weekly but was unsure if a water system assessment had been conducted to identify potential problem areas conducive to waterborne pathogen growth. There was no evidence of Legionella testing being done, and the Business Office Manager confirmed that the city only tested for chlorine and fluoride, not Legionella. Additionally, there were no logs to show any flushing or water temperature checks were done on the south hall, which had been unoccupied since 2018-2019. Observations revealed a large therapeutic bathtub with a lift system in a common bathroom near the north nurse's station, which had a continual slow dripping of water and a long brown stained area. Staff were observed toileting residents in the room, and the door was wide open when not in use. The south end of the facility, which was unoccupied, also had a large therapeutic soaking tub that was inoperable. Despite this, the maintenance staff confirmed that water did come from the faucet when turned on. The facility's Legionella Environmental Assessment Form and Management Procedure showed no evidence of maintenance, disinfecting, or monitoring of the tubs. The facility's policies and procedures for Legionella management were not followed. The Legionella Environmental Assessment Form completed by a Corporate Administrator inaccurately marked the presence of hot tubs, whirlpool, or hydrotherapy spas as not applicable. The facility's Legionella Management Procedure required staff to be informed of good practices and for approved contractors to undertake surveys and risk assessments, but there was no evidence of such actions being taken. The Illinois Compiled Statutes require facilities to develop a policy for testing water supply for Legionella bacteria, including a risk assessment, water management program, and documentation of results and corrective actions, none of which were evident in the facility's practices.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to have a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Director of Nursing (DON), who has been at the facility since January 29, 2024, was identified as the IP but did not have the required certification. The facility's application for Medicare and Medicaid indicated there were 28 residents. The Administrator acknowledged the requirement for a certified IP and mentioned that the DON was in the process of obtaining certification but was not currently certified. The facility's job description for the IP role specified that the individual must have completed specialty training in infection prevention and control through accredited continuing education such as the CDC or APIC. The facility's QAPI team roster also identified the DON as the IP.
Failure to Update Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure a resident's advanced directives were updated as requested. Resident R18, who was admitted to the facility on an unspecified date, had a Practitioner Order for Life-Sustaining Treatment (POLST) form dated 12/16/21 indicating he opted to be a full code. However, a new undated POLST form on the front of R18's chart showed he opted to become a Do Not Attempt Resuscitation (DNAR). This new form was signed by R18 but lacked a witness signature and the required signature by a healthcare practitioner. Despite R18 being cognitively intact and having expressed his wishes, the form was not properly processed, leaving him still considered a full code according to the April 2024 Physician Order Sheet (POS). The facility's policy requires that no order for DNAR be effective until the POLST form is signed by both the resident and the physician, which was not adhered to in this case. Interviews with staff revealed that the form had not been sent to the physician for signature, as confirmed by the Registered Nurse (RN) and the Director of Nursing (DON). The DON stated that the procedure on admission involves having residents fill out and sign the POLST form, which should then be sent out for the physician's signature. The failure to follow this procedure resulted in the resident's advanced directives not being updated as requested, thereby not honoring the resident's right to refuse treatment as per his wishes.
Failure to Provide Necessary Post-Amputation Care
Penalty
Summary
The facility failed to ensure a resident received necessary treatment and services for her amputated leg, including following up with her surgeon, obtaining a sleeve for her stump, and assisting in the process to prepare and obtain a prosthetic leg. The resident, who had been at the facility for 9 months following a house fire that resulted in numerous injuries including a left above-the-knee amputation, reported that it took 4.5 months to get a shrinker, which was too large and not measured properly. The resident also stated that she never followed up with the surgeon after being transferred to the facility, and the facility did not arrange for the necessary follow-up appointments or fittings for a prosthetic leg as indicated in her hospital discharge documents and physician orders. The Director of Nursing (DON) and Social Services staff were unaware of the orders for the resident's follow-up care and the need for a properly fitted shrinker. The facility's records did not show any follow-up appointments with the surgeon or any fitting of a sleeve for the resident's stump. The DON and Social Services staff acknowledged the importance of having the correct measurements for the shrinker to reduce swelling and prepare for a prosthetic leg but admitted to not being aware of the specific orders or the resident's needs. The facility also lacked a policy for quality of care, post-surgical care, or current standards of practice related to the care of a resident after an amputation, which contributed to the oversight in the resident's care.
Failure to Implement Pressure Ulcer Interventions and Identify Pressure Injuries
Penalty
Summary
The facility failed to ensure pressure injury interventions were in place as ordered and did not identify a pressure injury before it progressed to a stage 2 pressure injury for two residents. One resident, admitted to the facility and documented as being at risk for pressure injuries, had a stage 2 pressure wound to the sacrum that was not identified until it had been present for more than four days. The resident's treatment record did not show any skin checks ordered or completed, and the care plan required weekly skin checks, which were not documented. The RN and DON confirmed that the pressure injury should have been identified earlier and documented in the nursing progress notes. Another resident was observed in a wheelchair without a pressure-relieving device, despite having a stage 2 pressure wound and orders for a pressure relief cushion. The resident's care plan did not include interventions for offloading and repositioning, which were necessary to prevent the wound from worsening. The DON confirmed that the resident should have had a pressure relief cushion to relieve pressure and prevent the wound from getting worse. The facility's policy required additional interventions to be established and noted on the care plan when a pressure ulcer is identified, which was not done in this case.
Deficient Catheter Care Practices
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to several deficiencies. The resident was observed with a catheter drainage bag attached to the lower bed frame and without a secure device for the catheter tubing. During catheter care, a CNA used a wet washcloth to clean the resident's groin and vaginal area, then wiped down the catheter tubing without changing the washcloth, which is against proper infection control practices. Additionally, the catheter drainage bag was placed on the resident's bed during repositioning, which is not allowed for infection control reasons. The CNAs involved were unaware of these requirements. The Director of Nursing confirmed that the catheter drainage bag should not be on the bed and that the washcloth should be folded differently or changed before cleaning the catheter tubing. The resident had a history of multiple medical conditions, including neurogenic bladder and a wound infection requiring antibiotics. The care plan indicated catheter care every shift and weekly changes, but did not include specific interventions to prevent the observed deficiencies. The facility's catheter care policy did not specify the need to use a clean washcloth or turn an existing one before cleaning the tubing, and the catheter insertion policy required securing the catheter to the thigh, which was not done in this case.
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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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