Lacon Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Lacon, Illinois.
- Location
- 401 9th Street, Lacon, Illinois 61540
- CMS Provider Number
- 146123
- Inspections on file
- 28
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Lacon Rehab And Nursing during CMS and state inspections, most recent first.
Two residents were not provided meal options that accommodated their food dislikes, despite a facility policy stating that resident likes and dislikes would be considered for substitutions. One resident ate a fish entrée he disliked only by covering it with tartar sauce and reported that the only alternative offered was a peanut butter and jelly sandwich, which he also disliked, and he was not offered a substitute for a dessert he did not eat. Another resident, who also disliked fish, skipped the facility meal and obtained outside food instead. The Dietary Manager reported there was no anytime menu and that available substitutes were limited to peanut butter and jelly or possibly a cheese sandwich, which were acknowledged as not nutritionally equivalent to the main meal.
The facility failed to follow its own policy requiring all transported food to be covered and maintained at proper temperatures, contributing to ongoing complaints about cold and poorly executed meals. During an observed lunch service, plated meals were transported from the kitchen to the dining room uncovered and placed on tables before residents arrived, with no warming plates used. A resident later found his fish only slightly warm and reported that this occurs frequently, while two other residents’ plates sat uncovered for an extended period before being removed. Staff acknowledged that plates are usually covered and that covers were available, and the Dietary Manager confirmed both the requirement to cover transported food and the presence of repeated complaints about cold food.
Surveyors found that multiple residents were living in rooms that were not clean, well-maintained, or safely equipped. One resident’s bathroom sink was inoperable with a black, slimy ring and torn wallpaper on the walls. Another resident’s call light was reportedly always on due to a short, leaving them without a reliable way to summon help, and their bathroom had a strong urine odor and a large puddle of yellowish liquid on the floor that remained wet later in the day. A third resident’s toilet had dried bowel movement on the seat, rim, and front of the bowl, with urine odor extending into the hallway and visible splatter on enabler bars, despite a housekeeper stating the room had been cleaned. Nursing staff reported that housekeeping was expected to clean rooms and bathrooms daily and as needed, and to address issues such as the soiled floor.
The facility failed to maintain adequate heating and hot water, and did not effectively implement its emergency protocols during extreme cold. On one wing, hallway and room temperatures were documented as low as the mid-50s°F, while residents and staff reported that it had been cold there for an extended period. A resident with spinal stenosis, chronic severe pain, and opioid use reported that the persistent cold increased back spasms and pain and prevented comfort, while other residents reported that the cold worsened breathing and pain. The DON could not explain why residents were not relocated to warmer rooms or why additional heat sources were not obtained, and the Administrator’s account of temperature checks conflicted with later low readings. In addition, one side of the building had no true hot water for weeks, with residents reporting they had to go to the other side for showers and staff using kettles for basic hygiene, while measured water temperatures on the affected side were near cold and the other side only lukewarm. Leadership acknowledged ongoing mixing valve problems and that the affected side had been without hot water for about a month.
The facility failed to develop and implement required discharge care plan interventions for four of five residents reviewed for discharge planning. Policy required a post-discharge plan addressing care preferences, access and payment for services, coordination among caregivers, specific discharge needs (e.g., ADLs, self-medication, diet, dressings, therapy), referrals, and preparation for discharge, as well as measurable objectives and timetables. One resident reported discharge was not discussed until an involuntary discharge notice was issued, and others stated no one had discussed discharge with them, with one relying on family to explore home health independently. In each of these cases, the EMR and care plans lacked any documented discharge plan or interventions. The MDS Director/RN stated discharge planning should begin on admission and identified the Social Service Director as responsible for the discharge portion of the care plan, and the Social Service Director admitted she had fallen behind and confirmed the absence of discharge plans for these residents.
The facility failed to maintain its boiler in working order, causing indoor temperatures to fall into the mid to upper 50s Fahrenheit, despite policies requiring regular maintenance of heating systems and safe, comfortable temperature levels. On the day of the deficiency, a seam in the boiler had broken, leaving the building without heat, and staff confirmed the low temperatures. Multiple residents were observed wearing winter coats, stocking caps, and several blankets while in bed or seated in common areas, and a family member reported that a resident’s room was very cold and that the resident’s head was cold to the touch upon arrival. The census records showed that 60 residents were present at the time, all with the potential to be affected by the lack of adequate heat.
The facility failed to maintain adequate heating, hot water, functional call systems, and building repairs, resulting in cold rooms, lack of hot water, and unsafe, unsanitary conditions. Water temperatures were appropriate on one hall but only in the mid‑70s°F on another, with the Maintenance Director citing unresolved mixing valve and boiler issues. Several bathrooms lacked running water, had clogged sinks and toilets, wet and stained bath blankets on the floor, black slimy material in toilets, and suspected mold-like areas, while ceiling tiles in a main hallway were stained and associated with a mildew odor. Multiple residents were observed bundled in coats, blankets, and shawls, reporting that their rooms were cold and that prior complaints to staff went unanswered; one resident’s room temperature was documented at 63°F. Call systems were unreliable or absent, including cords with exposed wires, call lights that only worked while held down, call lights that stayed on continuously or activated spontaneously, and a resident resorting to a handheld bell for assistance. Staff confirmed long‑standing issues with water temperature and call lights and reported heating water in an electric tea pot at the nurses’ station for bathing and hygiene.
Surveyors found that the facility's dishwasher was not properly monitored for required sanitizing temperatures, with staff using incorrect test strips and unable to provide temperature logs or appropriate testing materials. Both dietary and maintenance staff were unfamiliar with proper procedures and responsibilities, resulting in a failure to ensure dishes were sanitized according to facility policy for all residents.
Water temperatures in several resident rooms were found to exceed the facility's policy limit, with one resident reporting that the water was sometimes too hot. The Maintenance Director confirmed that routine water temperature checks had not been conducted as required.
A resident admitted with Alzheimer's dementia and high risk for pressure injuries had a coccyx pressure ulcer identified at admission, but wound treatment orders were not obtained until nearly two weeks later. The delay occurred because the resident was not seen by the wound care provider as scheduled, resulting in a lapse in timely wound care.
A resident with full cognitive capacity was repeatedly gotten out of bed for meals against her wishes, resulting in emotional distress. Despite the facility's policy supporting resident choice, staff followed instructions to get her up, disregarding her expressed preferences. Leadership later confirmed that residents should not be forced to get up if they do not want to.
Surveyors found that the outdoor trash dumpster was missing two lids, with trash piled above the top and no surrounding security, allowing potential access by pests or animals. The Dietary Manager confirmed the dumpster should be kept closed and secured, in accordance with facility policy.
Medications and treatment supplies were left unsecured in a resident's room, contrary to facility policy, while multiple residents with cognitive impairment and wandering behaviors were able to enter another resident's room repeatedly. One such intrusion resulted in a resident being injured when a confused resident fell onto her, and no follow-up or investigation was documented by staff.
Staff failed to consistently follow infection control protocols, including proper use of PPE and hand hygiene, when caring for residents on contact precautions for ESBL and VRE and during wound care procedures. An LPN and other staff entered isolation rooms without required gowns, did not perform hand hygiene before or after glove use, and handled shared medication carts and supplies, increasing the risk of cross-contamination.
Two residents receiving psychotropic medications did not have specific behaviors or non-pharmacological interventions documented prior to medication administration. For one, the MAR only showed check marks without detailed progress notes, and the care plan behaviors did not match those recorded. For the other, behavior monitoring was noted but lacked specifics, and progress notes described combative behaviors without documentation of attempted interventions.
A resident was placed on contact isolation due to an active infection, with visible signage and a physician order in place. However, the care plan was not updated to reflect the new isolation precautions, despite facility policy requiring care plan revisions when a resident's condition changes.
A resident with a history of depression and recent bereavement expressed suicidal ideation, leading a psych NP via telehealth to order a hospital evaluation. Facility staff failed to document any physical or behavioral assessment, did not record vital signs or details of the resident's statements, and did not update the care plan or provide required follow-up monitoring. The DON confirmed that documentation and monitoring were inadequate following the incident.
The facility failed to ensure residents retained their personal items, affecting all 54 residents. Complaints were made about missing items and slow clothing returns due to a broken washing machine. The Housekeeping Supervisor noted understaffing and issues with marking resident clothing, leading to confusion and items being placed on a missing items rack.
The facility did not ensure that prior survey investigations were accessible or that signs were posted to inform residents and families of their availability. During a survey, it was found that Resident Council Members were unaware of the state investigations, and no notices or binders were visible. The Activity Director located the binder hidden behind the guest sign-in book, and the Administrator confirmed the lack of notification signs.
The facility failed to maintain a safe kitchen environment, with deficiencies in the dishwasher sanitation system and unsanitary conditions. The dishwasher's rinse cycle did not reach the required temperature, and there were leaks from a hole in the exhaust fan. Additionally, the steam table was unclean, and water pooled on the floor due to dishwasher splashes. These issues could affect all 54 residents.
A facility failed to implement enhanced barrier precautions (EBP) for a resident as ordered. The EBP policy required gowns and gloves during high-contact care activities, with signage on the door. However, no EBP sign or PPE was available outside the resident's door, and an LPN was unaware of the EBP order.
The facility failed to implement an effective antibiotic stewardship program, lacking documentation and monitoring of antibiotic use and infections. A resident hospitalized for severe infections was not properly documented in the facility's logs, and the DON acknowledged the tracking system's incompleteness.
The facility failed to follow its elopement policy and did not document the testing of elopement devices for residents at high risk for wandering. Residents with severe cognitive impairments were not consistently monitored, and some were found without proper elopement devices. Additionally, residents at high risk for falls were observed unsupervised, despite care plans requiring frequent rounding and supervision. Staff acknowledged these lapses, indicating a failure to implement safety protocols effectively.
The facility failed to monitor refrigerator and freezer temperatures as required, compromising the safe storage of medications. Temperature records were incomplete for the refrigerator/freezer in the Saint [NAME] Linen Room and the Saint [NAME]'s Medication Room, affecting the storage of medications like Basaglar, Insulin Lispro, Tresiba, Humalog, and Tuberculin Purified Protein. This deficiency could impact the health of residents relying on these medications.
A facility failed to provide a resident and their representative with a written notice of transfer to a hospital. The resident's medical record lacked evidence of such notification, and the facility administrator confirmed the oversight.
A facility failed to provide a resident or their representative with a copy of the bed hold policy upon the resident's transfer to a hospital. The resident's medical record lacked documentation of written notice regarding the policy. This was confirmed by the facility's administrator during an interview.
A facility failed to update a resident's care plan to include bilateral lower extremity edema and daily weight monitoring, despite the resident's diagnoses of congestive heart failure and the presence of a left ventricular assist device. The care plan did not reflect these critical needs, and there were significant gaps in the documentation of daily weights, contrary to the physician's orders. The DON acknowledged the oversight, noting the necessity for the care plan to specify daily weight monitoring and the protocol for contacting the cardiovascular team.
The facility failed to obtain daily weights for two residents, one on diuretic therapy and another with a Left Ventricular Assist Device, as per physician orders. Additionally, the facility did not ensure Hospice care plans were available and updated in residents' records, with one resident's plan not specific to the services needed and another's records inaccessible due to electronic documentation by Hospice staff.
A facility failed to create a person-centered dementia care plan for a resident with dementia and agitation. The care plan only included monitoring for changes and task segmentation, lacking individualized interventions. The Care Plan Coordinator confirmed the absence of person-centered strategies, contrary to the facility's dementia care policy.
The facility failed to implement fall prevention measures for two high-risk residents. One resident, with a history of falls, was not provided with a double cord call light and fell during a transfer without a gait belt. Another resident lacked non-skid strips in front of her recliner, as required by her care plan, increasing her fall risk. These deficiencies highlight a lack of adherence to the facility's fall prevention policies.
Failure to Provide Adequate Menu Substitutions Based on Resident Dislikes
Penalty
Summary
The facility failed to implement menus that addressed residents’ dislikes, despite a substitutions policy stating that residents’ likes and dislikes will be considered when making substitutions. One resident was observed at lunch with baked fish, broccoli, hash brown casserole, and baked apples; he stated he does not like fish and used three packets of tartar sauce to mask the taste so he could eat it, reporting that if he did not eat the fish he would not get anything else. He further stated that the only substitute offered is a peanut butter and jelly sandwich, which he also does not like and does not consider an appropriate substitute for the main meal, and he was not offered any substitute for the baked apples he disliked and left uneaten. Another resident’s lunch tray with fish was left on the dining room table while she was absent; staff later stated she had food delivered because she does not like fish, and the resident confirmed she does not like fish and therefore ordered outside food instead of eating the facility meal. The Dietary Manager stated that the facility does not offer an anytime menu and that the only substitutes available are a peanut butter and jelly sandwich or possibly a cheese sandwich, and verified that these substitutes are not equal in nutritional value.
Uncovered and Poorly Temperature-Controlled Meals During Transport and Service
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring all food transported from the kitchen to other parts of the building to be covered and maintained at proper temperatures. The facility’s Transportation of Food policy, revised 11/5/19, states that all food must be covered during transportation and that food must maintain proper temperatures while being transported. Resident Council Meeting Minutes from two separate meetings document multiple complaints about meal execution, including burnt or overcooked items, cold food, undercooked or soggy eggs/omelets, and cold or late meals. On the observed lunch meal service, a cart with already-plated meals was taken from the kitchen to the dining room without any covers or warming plates to protect the main meal. The plates were set on the table uncovered before the residents were present. One resident arrived at the table and found his fish only slightly warm, stating that this happens all the time and that there was no one in the dining room to reheat the meal. Two other residents’ plates remained uncovered on the table for an extended period until a staff member removed them, with the staff member acknowledging that plates are usually covered but not knowing why they were not covered that day. The Dietary Manager confirmed that all transported food is supposed to be covered, that covers were available next to the service line, that no warming plates are used, and that there have been complaints about cold food.
Failure to Maintain Clean, Repaired Environment and Functional Call System
Penalty
Summary
Surveyors identified failures to maintain the building in good repair and cleanliness and to ensure a functional call system for multiple residents. For one resident, the bathroom sink had no running water, with a sign posted instructing not to turn on the water, and the sink bowl had a black, slimy ring. The wallpaper inside the door was ripped from the ceiling to about three feet from the floor in a section approximately two feet wide, with another large piece missing near the heating vent. The Assistant Maintenance Director confirmed that the sink was not working and the wallpaper was peeled off the walls. Another resident was observed sleeping in bed with the call light activated while a CNA in the hallway stated that this resident’s call light was always on due to a short or similar issue and suggested the resident should have a handheld bell, which could not be located. When asked how the resident would request help if they fell, the CNA stated she did not know. The same resident’s bathroom had a strong urine odor and a large puddle of yellowish liquid in front of the toilet with footprints leading from the toilet to the bed; later in the day the floor remained wet with paper towels covering the puddle and the odor unchanged. A third resident’s toilet had dry bowel movement on the seat, around the top rim, and down the front of the bowl, with a strong urine smell extending into the hallway and visible yellow and brown splatter on the enabler bars. A housekeeper reported she had finished cleaning that room and described her duties as emptying garbage, cleaning floors, and dropping off paper products, while the toilet and bathroom remained unchanged. A RN stated that housekeeping was supposed to enter the room several times a day to empty garbage and that rooms, including bathrooms, were to be fully cleaned daily and as needed, and verified that housekeeping should have cleaned the floor in the other resident’s room.
Inadequate Heating, Emergency Protocol Failures, and Prolonged Hot Water Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe, comfortable indoor temperatures and to follow its emergency protocols during periods of extreme cold, as well as its failure to provide adequate hot water throughout the building. The facility’s own Homelike Environment and Cold Weather policies require maintaining comfortable and safe temperature levels, conducting regular maintenance and inspections of heating systems, and routinely monitoring indoor temperatures when outdoor temperatures fall below 65°F. Despite these policies, surveyors observed on 1/29/26 that the St. [NAME] wing (100 Hall) was chilly, with hallway thermostats reading 64–65°F and multiple room thermostats between 62–68°F. When the Maintenance Director used a temperature gun, hallway and room air temperatures on that wing ranged from 54–63°F. Staff interviews confirmed that the wing had been cold for an extended period, with staff wearing fleece jackets and stating they could not recall when it had not been cold on that wing. Residents reported ongoing cold conditions and associated discomfort. One resident in room 117, with diagnoses including spinal stenosis, diabetes with foot ulcer, morbid obesity, and restless legs syndrome, and documented as cognitively intact with frequent severe pain and chronic lower back pain requiring opioid medication, stated that it had been cold in his room since earlier in the month and that being cold all the time made him tense, increased his back spasms and pain, and prevented him from getting comfortable. Another resident in room 106-1 stated it was always cold on the wing and that it affected his breathing. A resident in room 118 reported that the constant cold made her tense and increased her pain. The Director of Nursing could not explain why residents had not been moved to open rooms on a warmer hall or why additional heating sources had not been obtained, and stated she was not part of those conversations with corporate while the Administrator was on vacation. The Administrator later acknowledged that staff had contacted her around 2:00 a.m. when temperatures began dropping, and that the Maintenance Director had checked temperatures and reported higher readings than those later observed by surveyors, indicating a lack of effective implementation of the facility’s emergency protocol as temperatures continued to fluctuate and remain low. The deficiency also includes the facility’s failure to provide adequate hot water to the entire building, particularly on the St. [NAME] side. Residents and staff reported that there had been hot water issues for weeks, with residents from the affected side needing to come to the other side to shower, and staff using kettles to warm water for face, hands, armpits, and perineal care. On 1/30/26, surveyors measured hot water temperatures and found zero hot water on the St. [NAME] wings, with room readings as low as 15.4°F, while the other side of the building had lukewarm water in the 86.7–93.7°F range. The Administrator stated that not all mixing valves had been replaced on the St. [NAME] wings and that this side of the building had been without hot water since a prior complaint survey on 1/12/26. Multiple residents confirmed that there had been no hot water on their side for about a month. The Maintenance Director and Regional Maintenance Director stated that the St. [NAME] side had been with and without hot water throughout the month, describing the problem as intermittent and related to mixing valves in the main system, the main shower, and individual room showers, with several room mixing valves identified as broken.
Removal Plan
- In-service all staff members present on the facility's Comprehensive Emergency Manual Policy by the Administrator and Human Resources.
- In-service the Maintenance Director on the facility's Cold Weather Policy by the Administrator.
- Notify the Medical Director of the Immediate Jeopardy and update on the plan by the Administrator.
- Move residents on the affected wing to available rooms on the same wing; offer remaining residents a transfer to another facility or warmer parts of the building; provide extra blankets and warm beverages to residents who choose to stay.
- Immediately assess identified residents by the DON and Nurse Practitioner to ensure needs are met and comfort is maintained; assess all other residents by nursing staff and outside physicians.
- Assess the air handler, determine the cause of fluctuating temperatures, install new blower fans into the air handler, and complete repairs to ensure adequate hot air circulation.
- Monitor temperatures in each resident room on the affected unit every hour.
- Initiate shift-by-shift temperature monitoring and continue until extreme cold weather has abated as determined by the QAPI committee.
- Assess and continuously monitor all residents remaining on the affected unit for pain, respiratory comfort, and general comfort until heat is fully stabilized; implement interventions to address identified distress or pain and monitor effectiveness.
- Install temporary flannel window coverings to reduce heat loss in rooms on the affected wing.
- Educate all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather Policy; educate staff unavailable prior to their next scheduled shift.
- Develop and implement a plan to monitor preventative maintenance for the heating system, including regular audits of maintenance logs by the Administrator to ensure HVAC inspections and radiator filter cleanings are completed; review results during scheduled QAA meetings; continue audits.
- Implement a mandatory education schedule ensuring all staff are educated on the facility emergency policies and procedures; make training a permanent part of orientation for all new hires and conduct annually for all existing staff by Human Resources.
Failure to Develop and Implement Discharge Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive discharge care plan interventions for four of five residents reviewed for discharge planning. Facility policy on discharge care planning requires that, when a resident is discharged, a post-discharge plan be provided to the resident and/or representative, including the resident and family’s preferences for care, how services will be accessed and paid for, coordination of care among multiple caregivers, identification of specific needs at discharge (such as ADLs, self-administration of medications, diet, sterile dressings, and therapy), appropriate referrals by social services, and preparation for discharge. The comprehensive care plan policy also requires an individualized plan with measurable objectives and timetables to meet each resident’s medical, nursing, mental, and psychological needs. Despite these policies, the electronic medical records for four residents admitted for care did not contain discharge plans or related interventions. One resident reported that discharge plans were not discussed until an involuntary discharge notice was given, and his current care plan lacked any discharge planning or interventions. Another resident’s record similarly showed no documented discharge plan or interventions. A third resident, who stated he would be going home after completing therapy, reported that no one had discussed discharge plans with him, that his family was independently looking into home health services, and that discharge was never addressed during his care plan meeting; his care plan also lacked discharge planning or interventions. A fourth resident was admitted and later discharged home without any documented discharge plan or interventions in the care plan. The Minimum Data Set Director/RN stated that discharge planning is supposed to be initiated upon admission and that the Social Service Director is responsible for documenting the discharge portion of the care plan. The Social Service Director acknowledged being responsible for discharge care planning, stated she had fallen behind, and confirmed that these four residents did not have discharge plans on their care plans.
Failure to Maintain Boiler Resulting in Inadequate Indoor Temperatures
Penalty
Summary
The facility failed to maintain the boiler in working order to provide adequate heat, resulting in indoor temperatures ranging from 56.0°F to 58.0°F throughout the building. The facility’s own Homelike Environment/Maintenance policy, revised 12/1/25, requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior with safe temperature levels, and its Cold Weather policy, revised 11/24/25, requires regular building maintenance and inspection, including maintenance of heating and air conditioning systems and thermostats. On 1/18/26 at 1:00 p.m., the maintenance staff (V3) confirmed that a seam had broken in the boiler, leaving the facility without heat and temperatures in the mid to upper fifties, and the Administrator (V1) verified at 1:30 p.m. that the heat was out in the facility. On 1/18/26 at 1:30 p.m., residents were observed bundled in multiple layers of clothing and blankets due to the cold environment: one resident was in bed with several blankets and a stocking cap, and that resident’s family member reported the room was very cold and that the resident’s head was cold to the touch when she arrived and he was not yet wearing a cap; another resident remained in her room wearing a winter coat and several blankets; and a third resident sat in the front hall wearing a winter coat, stocking cap, and several blankets on his lap, stating that it was very cold in the facility. The Administrator later confirmed that the census on 1/18/26 was 60 residents, as documented on the Daily Census sheet dated 1/17/26, indicating that all 60 residents had the potential to be affected by the lack of heat.
Failure to Maintain Adequate Heat, Hot Water, Call Systems, and Building Repairs
Penalty
Summary
The facility failed to provide adequate heating, hot water, and building maintenance, resulting in an environment that was not safe, clean, or comfortable for residents, staff, and the public. Facility policies on homelike environment, cold weather, and resident call bells required maintenance of safe temperature levels, regular inspection and maintenance of heating and air conditioning systems, and a functional call system accessible from resident beds, toilets, and bathing areas. During a tour with the Maintenance Director, water temperatures on one hall measured 110–116°F, while on another hall they were only 75–77°F. The Maintenance Director acknowledged an ongoing problem with a mixing valve on the affected hall and stated that it was supposed to have been fixed by a plumber but was not. Multiple bathrooms were in disrepair: one resident’s bathroom had chipped paint and missing drywall under the sink; two other rooms had no running water to sinks or toilets, wet and stained bath blankets on the floor under sinks, black slimy-looking substances in toilets, and a black mold-like area in front of a toilet. The Maintenance Director stated that the sink and toilet were clogged and he had not had a chance to fix them. Ceiling tiles across the front hallway were discolored with brown stains and a mildew smell was noted; the Maintenance Director attributed this to condensation leaking into the tiles when boilers were turned up and stated he was the only maintenance person and had difficulty keeping up with repairs. Residents reported and demonstrated discomfort and lack of access to required systems. One resident was observed sitting in his room wearing a jacket and wrapped in a blanket, stating it was always cold on the southeast side of the building and that it smelled moldy in the front where ceiling tiles appeared wet; the wall behind his chair had gouges with crumbling plaster on the floor. When this resident pressed his call light, it illuminated only while the button was held down, and the second bed’s call cord consisted of open wires with no call button. Another resident was observed wearing a long-sleeve shirt and coat, reporting that his room had been warm until a recent weekend, that he told staff it was too cold but received no response, and that he stayed in bed wrapped in covers. A third resident, dressed in warm clothing with a shawl and blanket, stated her room was cold; a wall clock in her room showed 63°F. Another resident was using a handheld bell to call for assistance, stating he had no call light, and he and other residents confirmed there was no hot water in their rooms. Staff verified that certain room call lights stayed on all day or activated by themselves, that water on one side of the building only became warm but not hot, and that they heated water in an electric tea pot at the nurses’ station for showers and washing. The Administrator confirmed that water and room temperatures were not at proper levels and that many repairs were needed, while the Maintenance Director confirmed ongoing problems with the mixing valve and boiler and that water temperatures on one side of the building were in the mid‑70s°F.
Dishwasher Sanitization Failure Due to Improper Monitoring and Lack of Staff Knowledge
Penalty
Summary
The facility failed to ensure that the dishwasher used for sanitizing dishes was operating in accordance with professional standards and facility policy. During the survey, staff used quaternary ammonia test strips on a high-temperature dishwasher, which is not the correct method for verifying hot water sanitization. The test strips did not register any sanitizer, and staff were unable to locate appropriate hot water test strips in the building. Additionally, the final rinse temperature was not displayed on the dishwasher, and there were no temperature logs available for review. The Dietary Manager and Maintenance Director were both unfamiliar with the proper procedures for monitoring and servicing the dishwasher, and neither knew who was responsible for its maintenance or which company serviced it. These failures affected all 56 residents in the facility, as the dishwasher was not properly monitored or tested to ensure it reached the required sanitizing temperature of at least 180 degrees Fahrenheit, as specified in the facility's policy. The lack of proper testing materials, absence of temperature logs, and staff's lack of knowledge regarding the dishwasher's operation and maintenance contributed to the deficiency in food service sanitation.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that water delivered to resident rooms was maintained at a safe and comfortable temperature, as required by facility policy. During an observation, water temperatures from bathroom sinks in multiple resident rooms were found to exceed the policy limit of 110 degrees Fahrenheit, with specific readings recorded for six residents. One resident reported that the water was sometimes too hot. The Maintenance Director acknowledged that water temperatures in resident areas should not exceed 110 degrees Fahrenheit and admitted that required water temperature checks had not been performed due to lack of time. The facility's policy, dated 12/30/2024, specifies that water temperatures in resident rooms should not exceed 110 degrees Fahrenheit.
Delayed Pressure Ulcer Treatment Orders for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's dementia, depression, and anxiety was admitted to the facility and identified as high risk for pressure injuries based on the Braden Scale. Upon admission, the resident had a pressure injury to the coccyx, which was documented as non-staged. The admission assessment indicated that the wound care company was notified and scheduled to see the resident on a future date. However, the resident was not seen by the wound care provider as planned, and no treatment orders were obtained at the time of admission. It was not until approximately 13 days after admission that a wound assessment was completed by the wound care physician, and specific treatment orders were initiated. During this period, the resident's wound care was delayed, as confirmed by interviews with the Director of Nursing and Assistant Director of Nursing, who acknowledged that wound treatment should be obtained as soon as a wound is discovered. Facility policy requires prompt identification and treatment of pressure ulcers, but this was not followed in the resident's case.
Resident Denied Right to Self-Determination Regarding Daily Routine
Penalty
Summary
A cognitively intact resident, as evidenced by a BIMS score of 15/15, was observed in emotional distress and crying in the dining room, expressing that she did not want to be out of bed and felt as though she was being punished. The resident reported pain, discomfort from the light, and stated that her repeated requests to return to bed were ignored by staff, who would say they would get help but did not return. The facility's policy affirms residents' rights to self-determination, including choices about daily routines and care. Interviews with staff revealed that a CNA acknowledged the resident's desire to remain in bed but stated that nurses instructed her to get the resident up for meals. An LPN confirmed the resident's ability to make her own care decisions but expressed personal opinions about the resident's dietary and activity choices, suggesting she should not always be allowed to decide for herself. Facility leadership, including the Administrator and Social Service Director, confirmed that residents should not be gotten up against their wishes, and the CNA involved believed she was following proper procedure until educated otherwise.
Improper Disposal and Securing of Outdoor Trash Dumpster
Penalty
Summary
Surveyors observed that the facility failed to ensure the outdoor trash dumpster was properly maintained according to facility policy. During an initial kitchen tour with the Dietary Manager, it was noted that the dumpster was missing two lids, and trash was piled above the top of the dumpster. The dumpster was not secured by any walls or access doors, and the open condition allowed for the possibility of pests or animals accessing discarded food and trash. The Dietary Manager confirmed that the dumpster should be kept closed and secured to prevent such access. Facility policy requires all garbage containers to have tight-fitting lids and to be kept covered when not in continuous use, as well as to store garbage in a manner inaccessible to vermin. At the time of the survey, 57 residents were documented as residing in the facility.
Failure to Secure Medications and Prevent Resident-to-Resident Intrusions
Penalty
Summary
The facility failed to store medications and treatment supplies in a secure environment, as observed with a bottle of Dakins solution and a tube of Therahoney left unattended in a resident's room. According to facility policy, such items should be locked away when not in use to prevent access by unauthorized individuals. Staff confirmed that these items should not have been left in the room, especially given the presence of multiple residents with wandering behaviors who could potentially access them. Additionally, the facility did not adequately address the issue of confused residents entering another resident's room. Two residents with documented cognitive impairments and high risk for wandering were observed entering the room of another resident on multiple occasions. The resident whose room was entered reported frequent disturbances, including one incident where a confused resident fell onto her, resulting in soreness and bruising. Despite these repeated intrusions, staff did not implement effective measures to prevent such occurrences. Furthermore, the facility failed to investigate and document follow-up care after the incident in which a confused resident fell onto another resident, causing physical discomfort. There was no evidence in the medical record of any assessment or follow-up regarding the injury, and the administrator was unable to provide information on steps taken to prevent further incidents or to investigate the reported injury. This lack of action left the affected resident without appropriate support or intervention following the event.
Failure to Follow Infection Control Protocols for PPE and Hand Hygiene
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies regarding the use of personal protective equipment (PPE) and hand hygiene in rooms under transmission-based precautions. In one instance, an LPN entered a resident's room, who was on contact precautions for ESBL in the urine, without donning a gown and without performing hand hygiene before putting on gloves. The LPN touched the resident and her environment, administered insulin, and then left the room with the insulin pen still in her gloved hand. The LPN then accessed the medication cart, removed the needle, and placed the insulin pen back with other residents' medications, removed her gloves, and failed to perform hand hygiene at any point during or after the process. The LPN later acknowledged that she should have worn a gown and performed hand hygiene as required by facility policy. Other staff, including a speech therapist and housekeeping staff, were observed not wearing the required PPE when entering rooms of residents on contact precautions for ESBL and VRE. The speech therapist stated she only wore gloves when seeing a roommate not on isolation and was unaware a gown was required. Housekeeping staff admitted to sometimes only wearing gloves, depending on how rushed they felt, despite being educated on the need for full PPE. The Assistant Director of Nursing confirmed that all staff, including therapy and housekeeping, are required to wear gloves and gowns when entering rooms of residents on contact precautions. Additionally, the Director of Nursing was observed performing wound care on a resident with pressure ulcers and skin impairment without performing hand hygiene between glove changes. The DON removed and replaced gloves multiple times during the procedure without washing or sanitizing hands, contrary to the facility's hand hygiene policy. The DON later confirmed that hand hygiene should have been performed between glove changes.
Failure to Document Behaviors and Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to properly track and document specific behaviors and non-pharmacological interventions prior to administering psychotropic medications for two residents. For one resident with a history of fetal alcohol syndrome, intellectual disabilities, and various behavioral issues, the care plan listed multiple behaviors, but the Medication Administration Record (MAR) only showed check marks or a code for behavior without corresponding progress notes detailing the specific behaviors or any non-pharmacological interventions attempted. The administrator confirmed that there was no documentation describing what behaviors occurred or what interventions were tried, and that the behaviors listed on the care plan did not match those recorded on the MAR. During the survey, this resident was observed to be pleasantly confused and interacted with staff and other residents without agitation or aggression. Another resident, admitted with severe unspecified dementia, agitation, anxiety disorder, and depression, was prescribed antipsychotic and antianxiety medications. The care plan indicated the use of these medications but did not specify the indications for use. The MARs for several months documented behavior monitoring but did not specify the behaviors or any non-pharmacological interventions. Progress notes for this resident recorded combative and resistive behaviors but did not document any attempted interventions during these behaviors or prior to administering psychotropic medications.
Failure to Update Care Plan for Contact Isolation Precautions
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was placed on contact isolation precautions due to an active infection with transmissible significant pathogens. Observation showed the resident's room door was closed, with contact isolation signage and a PPE cart present. The resident's electronic medical record included a physician order for contact isolation, specifying that the resident was to be isolated in the room without a roommate, and that all activities and services were to be brought to the resident. Despite these documented precautions and the visible implementation of isolation measures, the resident's care plan was not revised to reflect the new contact isolation status. The facility's policy requires care plans to be updated as changes in a resident's condition occur, but this was not done in this case. The administrator confirmed that the care plan should have been updated to include the contact isolation precautions.
Failure to Document and Monitor After Suicidal Ideation
Penalty
Summary
The facility failed to thoroughly document and monitor a resident after she verbalized suicidal ideation. According to the facility's policies, any staff member who becomes aware of a resident's intent to inflict self-harm is required to report the behavior to the Nursing Supervisor without delay, and the charge nurse or Nurse Supervisor must immediately assess the situation and determine necessary interventions. In this case, a resident with diagnoses including metabolic encephalopathy, anxiety, and major depressive disorder expressed suicidal ideation, stating she wanted to die by a specific date and did not want to live anymore. The psychiatric nurse practitioner, via telehealth, ordered the resident to be sent to the emergency room for evaluation, but there was no documentation of a physical or behavioral assessment, vital signs, or details of what the resident said to prompt the transfer. The nurse's notes only indicated the resident was sent to the hospital for being suicidal and later returned after being declared not suicidal, with no further documentation of assessments or follow-up. Additionally, the resident's care plan was not updated to reflect the suicidal ideation or to include new interventions or increased monitoring. The facility's documentation policy requires alert charting for incidents or changes in condition for at least 72 hours or until stable, but this was not completed. The Director of Nursing confirmed that follow-up alert charting should have been done and acknowledged the documentation was very poor in this case. The lack of thorough documentation and monitoring after the resident's expression of suicidal ideation constitutes the deficiency identified by the surveyors.
Failure to Ensure Residents Retain Personal Items
Penalty
Summary
The facility failed to ensure that residents retained their personal items, which has the potential to affect all 54 residents residing in the facility. During a resident council meeting, three residents complained about missing items and a slow response in returning clothes due to a broken washing machine that has not been repaired for over a year. The Resident Council Monthly Meeting minutes from October 2023 through June 2024 document ongoing complaints of missing clothes and slow return of clothing and items. The Housekeeping Supervisor stated that once a month, the Activity Director provides a form listing missing items, which the supervisor attempts to locate. However, the washing machine has been broken for over a year, and despite promises of parts arriving, the issue remains unresolved. The facility is understaffed in the laundry department, with only two staff members struggling to keep up with the workload. Resident clothing is often not properly marked with identifiers, leading to confusion and items being placed on a missing items rack. Observations confirmed that resident items were hanging on a rack and a bin labeled as missing items.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that prior survey investigations were accessible and that signs were posted to inform residents and families about the availability of these survey investigations. This deficiency was observed during a survey conducted on June 24, 25, and 26, 2024. Three Resident Council Members confirmed that they were unaware of the availability of state investigations for review. During observational tours, no posted notice or state survey inspection binder was visible. The Activity Director, upon inquiry, found the survey investigation binder hidden behind the guest sign-in book at the entrance, in a non-patient care area, making it inaccessible to residents and families. The Administrator acknowledged that signs were not posted to notify residents and families about the survey investigation binder's availability.
Deficiencies in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a safe kitchen environment, specifically in the operation and maintenance of the dishwasher sanitation system. The Dietary Manager admitted to not testing the dishwasher, relying solely on the temperature gauge, and was unable to explain the testing process. A Dietary Aide conducted a test strip through the dishwasher cycle, revealing that the rinse cycle only reached 143 degrees Fahrenheit, below the required temperature for proper sanitation. Despite daily testing claims, the rinse cycle consistently failed to meet the necessary temperature. Additionally, the dish room had multiple soaked ceiling tiles with a brown substance, and several ceiling lights were out. The Maintenance Director confirmed a hole in the dishwasher exhaust fan, causing leaks into the ceiling and near light fixtures, with no approval from Corporate to fix the issues. Further observations revealed unsanitary conditions, including a portable steam table with black crumbly substances and brown grease-like substances in its compartments, with no record of recent cleaning. A large pool of water was observed on the floor from the dishwasher room to the kitchen, attributed to splashes from the dishwasher pooling in a low spot, with the drainage system located on the opposite side of the room. These deficiencies have the potential to affect all 54 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as ordered for a resident who required such measures. The EBP policy, dated March 27, 2024, mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices to prevent the transmission of infectious organisms. On April 16, 2024, a physician's order specified that staff should wear gowns and gloves during direct patient contact with the resident, and signage should be posted on the door. However, on June 24, 2024, it was observed that there was no EBP sign posted at the resident's door, and no personal protective equipment was available outside the door. A Licensed Practical Nurse (LPN) admitted to being unaware of the order for enhanced barrier precautions.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of assessment and monitoring of residents for signs and symptoms of infections, and the absence of appropriate documentation for antibiotic usage. The facility's policy on Infection Control with Antibiotic Stewardship, dated January 2024, mandates the development of antibiotic use protocols and a system to monitor antibiotic use, including written documentation of clinical justification. However, the facility's Infection Control Logs for April and May 2024 were incomplete, lacking specific antibiotic usage details, justification for antibiotic use, and ongoing surveillance data for infections. A specific case involved a resident who was hospitalized from May 7 to May 28, 2024, for acute respiratory failure, hypotension, pneumonia, sepsis, and a urinary tract infection. Upon discharge, the resident was diagnosed with sepsis and MRSA infection, requiring isolation. The facility's Infection Control Monthly Log for May 2024 did not document the resident's infection details, such as the source and organisms. The Director of Nurses acknowledged the incompleteness of the Antibiotic Stewardship Tracking, which lacked a surveillance plan and justification for antibiotic use.
Failure to Monitor Elopement Devices and Supervise High-Risk Residents
Penalty
Summary
The facility failed to adhere to its elopement policy and did not document the testing of elopement devices for several residents identified as high risk for wandering or elopement. Specifically, residents with severe cognitive impairments and a history of wandering, such as those diagnosed with Alzheimer's Disease, were not consistently monitored. For instance, one resident's wander guard was not documented for placement or functionality in seven out of twenty-five opportunities, and another resident's wander guard was similarly neglected in eight out of twenty-five opportunities. Additionally, a resident identified as medium risk for elopement was not properly monitored, as evidenced by an incident where the resident set off an alarm and was later found without an elopement device secured to their person. The facility also failed to provide adequate supervision for residents at high risk for falls. Residents with severe cognitive impairments and physical weaknesses were observed unsupervised in various areas of the facility, despite care plans indicating the need for frequent rounding and supervision in high-visibility areas. One resident, who had a documented history of 19 unwitnessed falls, was repeatedly found unattended in common areas, contrary to their care plan's directives. Another resident, also at high risk for falls, was observed wandering without staff supervision, despite the care plan's requirement for increased monitoring. The Director of Nursing and other staff members acknowledged the lapses in documentation and supervision, confirming that the required checks and monitoring were not consistently performed. The facility's policies on fall reduction and elopement prevention were not effectively implemented, leading to multiple instances where residents were left vulnerable to potential accidents or elopement. These deficiencies highlight significant gaps in the facility's adherence to safety protocols and resident care plans.
Failure to Monitor Refrigerator/Freezer Temperatures for Medication Storage
Penalty
Summary
The facility failed to adequately monitor refrigerator and freezer temperatures, which is essential for the safe storage of medications. The policy requires that temperatures be recorded daily, with specific acceptable ranges for refrigerators and freezers. However, the temperature records for the refrigerator/freezer in the Saint [NAME] Linen Room showed a lack of monitoring for 25 out of 47 required times in June 2024. Additionally, the refrigerator/freezer in the Saint [NAME]'s Medication Room was not monitored 37 out of 62 times in May 2024 and 13 out of 50 times in June 2024. This lack of monitoring could potentially affect the safe storage of medications for multiple residents. During observations, it was noted that the refrigerator/freezer in the Saint [NAME]'s Medication Room contained several injectable pens and multidose vials that require refrigeration. These included medications such as Basaglar, Insulin Lispro, Tresiba, Humalog, and Tuberculin Purified Protein. The failure to consistently monitor and record temperatures as per the facility's policy could compromise the efficacy and safety of these medications, potentially affecting the health of the residents who rely on them.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a resident and their representative with a written notice of transfer. This deficiency was identified during a review of a resident's medical record, which documented a transfer to a local hospital. The record lacked evidence of a facility notification to the resident or their representative regarding the transfer or discharge. The facility administrator confirmed that no written notice was provided.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. The medical record of the resident, identified as R18, did not contain documentation of written notice regarding the facility's bed hold policy. This deficiency was confirmed during an interview with the facility's administrator, who acknowledged that neither the resident nor the representative received the necessary documentation or notice of transfer.
Failure to Update Care Plan for Edema and Daily Weights
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R212, to reflect the presence of bilateral lower extremity edema and the requirement for daily weight monitoring. The facility's policy mandates that care plans be revised as changes in a resident's condition dictate, yet this was not adhered to in the case of R212. The resident was admitted with multiple diagnoses, including congestive heart failure and edema in the lower extremities, which necessitated daily weight monitoring to manage the condition effectively. However, the care plan did not incorporate these critical aspects, leading to a deficiency in care planning. Additionally, there were significant gaps in the documentation of daily weights for R212, despite orders requiring daily monitoring due to the presence of a left ventricular assist device and the risk of heart failure. The Director of Nurses acknowledged the need for the care plan to specify the requirement for daily weights and the protocol to contact the cardiovascular team if there was a weight gain of five pounds. Despite staff claims of obtaining daily weights, several dates were missing from the records, indicating a failure in executing and documenting the prescribed care regimen.
Deficiencies in Weight Monitoring and Hospice Care Documentation
Penalty
Summary
The facility failed to obtain physician-ordered daily weights for two residents, one of whom was on diuretic therapy for edema and had specific orders to administer additional medication if a weight gain was observed. The resident's daily weight records showed numerous missing entries over several months, which was confirmed by the Director of Nurses. Another resident with a Left Ventricular Assist Device also had missing daily weight records, despite having a doctor's order to monitor weight gain closely and contact the cardiovascular team if a significant gain occurred. Additionally, the facility did not ensure that Hospice plans of care were available and updated in the residents' records. One resident's Hospice care plan was not specific to the services they should receive, and the updated plan was only received on the day of the survey. Another resident's Hospice records were not available for review, and the facility did not have access to the Hospice's electronic documentation. The LPN confirmed that the Hospice staff documented on their own software, and the facility lacked access to these records.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop a person-centered dementia care plan for a resident diagnosed with dementia with agitation. The facility's policy on dementia care, dated November 5, 2019, requires that residents with dementia receive appropriate treatment and services to maintain their highest practical well-being, including person-centered care that maximizes dignity, autonomy, and safety. However, the care plan for the resident, dated October 20, 2023, only included monitoring for changes in condition and task segmentation to support short-term memory deficits. The Care Plan Coordinator confirmed that the care plan lacked individualized person-centered interventions.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to ensure safe resident transfer and fall intervention implementation for two residents, R2 and R3, who were identified as high fall risks. R2, who has diagnoses including lack of coordination, unsteadiness on feet, and repeated falls, was found without the required double cord call light in her room, which was supposed to provide additional access points for requesting assistance. During a transfer from a wheelchair to a toilet, R2 fell because the CNA did not use a gait belt, contrary to the resident's care plan and facility policy. The CNA claimed R2 refused the gait belt, but R2 denied ever refusing it, indicating a miscommunication or misunderstanding of the resident's needs. R3, also a high fall risk with diagnoses of lack of coordination and muscle weakness, was observed standing in front of her recliner without non-skid strips on the floor, which were specified in her care plan as a fall prevention measure. The absence of these strips was confirmed by an LPN, who was initially unaware of their necessity. R3 was seen leaning forward and wobbly, further highlighting the risk posed by the missing non-skid strips. The facility's policies on fall reduction and gait belt transfers emphasize the importance of providing an environment free of accident hazards and using assistive devices to prevent falls. However, the observations and interviews revealed that these policies were not adequately implemented for R2 and R3, leading to unsafe conditions and a fall incident for R2.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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