Landmark At 95th Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1010 West 95th Street, Chicago, Illinois 60643
- CMS Provider Number
- 145914
- Inspections on file
- 69
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 66
Citation history
Health deficiencies cited at Landmark At 95th Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A cognitively intact resident with multiple chronic conditions reported that a CNA did not adequately clean him after a bowel movement and later returned alone to his room, despite a buddy system being in place. During a subsequent verbal altercation, which the resident recorded, the CNA mocked the resident’s mention of recording and stated she could easily get another job while the resident would still be lying in bed, and refused the resident’s repeated requests to leave the room. The CNA later confirmed making these statements and acknowledged she should have left when asked. This conduct met the facility’s policy definition of verbal abuse, constituting a failure to ensure the resident was free from verbal abuse by staff.
Two residents with significant lower extremity wounds did not receive consistent, ordered wound care or timely wound assessments. One resident with a BKA and multiple comorbidities had MD orders for daily stump care that were not documented for several days, went 14 days between wound assessments, and later reported increased drainage before being sent to the hospital, where records noted a week of worsening drainage and a right heel stage 2 pressure injury with daily dressing orders that were not entered at the facility until much later. Another resident with chronic lower leg ulcers was admitted with documented skin integrity issues to both legs, but no wound care orders were entered for 8 days, during which the resident reported that dressings were not changed despite repeated requests. The DON and MD both stated that admission and return-from-hospital orders should be transcribed and followed, and that wounds should be addressed immediately and treated per physician orders.
A visually impaired resident with multiple chronic conditions, including legal blindness, was found with two unsecured pills on the bedside table within easy reach, despite not being assessed for self-administration of medications. The resident reported being unable to see well and could not identify the pills. An RN later identified the pills as Lubiprostone and Trazodone, both scheduled for nighttime administration, after comparing them to medications in the cart. Facility policy required medications and biologicals to be stored safely, securely, and properly, but this was not followed in this instance.
Surveyors found that the facility failed to follow its Enhanced Barrier Precautions (EBP) policy for two residents requiring infection control measures. One resident with multiple serious diagnoses, including a dehisced amputation stump and a history of sepsis, was care planned for EBP, yet the Wound Care Coordinator performed wound care without a gown and admitted not knowing what EBP was. Another resident with an indwelling urinary catheter and a pressure sore had no EBP signage on the door despite the presence of a catheter and pressure injury. The DON confirmed that EBP signage and PPE use should have been in place for these residents, while facility policy requires gowns and gloves during high-contact care such as wound care for residents with wounds or devices.
Surveyors found that a soiled utility room on the second floor had a broken door left partially open, overflowing trash on the floor and in the sink, a biohazard box in the sink, and visibly dirty floors, potentially affecting 72 residents on that unit. A housekeeping aide stated that housekeeping is responsible for cleaning soiled utility rooms but said he did not clean them because he believed floor technicians should do so, while the housekeeping director confirmed housekeeping must clean and organize the room daily and floor technicians are only responsible for floor care. The maintenance director reported repeatedly repairing the door after prior citations and stated that staff had been breaking the door to gain access, even though the room contains a linen chute that should remain locked for safety, and the housekeeping director’s job description assigns responsibility for cleaning schedules, supervision, and hazard recognition and removal.
A resident with severe cognitive impairment, multiple cardiovascular conditions, and on anticoagulation had a care plan requiring appropriate, stable, non-slip footwear during ambulation and transfers. While ambulating with a walker near the nurses’ station, the resident was allowed to walk wearing slide shoes, which staff later acknowledged were not appropriate. The resident lost balance, fell backward, and struck the head, leading to hospital evaluation where imaging revealed a subdural hematoma and subarachnoid hemorrhage. Staff interviews and documentation confirmed that the resident’s footwear at the time of the fall did not meet the care-planned standard for safe, traction-providing footwear.
The facility failed to properly report an injury of unknown origin for a resident to the state surveying agency as required. When surveyors requested Facility Reported Incidents (FRIs) for the prior months, the Administrator provided a few incidents that had been emailed to an incorrect state agency address, and review showed no confirmation of receipt. The Administrator later acknowledged that her email to the agency had been returned as undeliverable and that a second email sent by the DON contained no attached FRI, with only blank emails documented. Record review confirmed that no FRI for the resident’s injury, and no other FRIs from the facility for an extended period, had been received by the state agency, while the facility’s abuse policy requires prompt reporting of incidents and injuries of unknown origin.
The facility failed to maintain functional laundry equipment, leaving only one working washer and two non-functioning washers, along with an out-of-order dryer, which significantly reduced laundry capacity for linens and residents’ personal clothing. A RN and an LPN reported ongoing resident complaints about laundry after a washer broke, and the Housekeeping Director confirmed that only one machine was handling both linens and personal clothes, with frequent need to order extra linens. The Maintenance Director described long-standing, poorly maintained machines with rust, holes, and a jammed door trapping linens inside, and acknowledged that only a fraction of the normal wash capacity was available. Several residents, including one with bed sores and another with chronic diarrhea, reported not having enough clean linens, having unchanged sheets, needing to hold onto their own towels, or paying outside services to wash their clothes due to the lack of facility-provided laundry.
Surveyors found that clean linen supplies were insufficient on multiple units, with nearly empty linen carts and clean utility room shelves, while staff reported late or inadequate deliveries from laundry and acknowledged ongoing complaints about linen shortages. Several residents described having to wait for linen, keeping towels with them to ensure availability, seeing staff hide or alter towels due to lack of supplies, and wearing or storing unwashed clothing because washers were broken. One resident with paraplegia and stage 4 pressure ulcers reported not having clean sheets despite his condition, and another with chronic diarrhea stated that CNAs cited broken washers and that he had to pay for outside laundry yet still returned to dirty clothes. The housekeeping and maintenance directors confirmed that only one of three washers and two of three dryers were functional, that older machines were in disrepair, and that linen had to be frequently ordered, while only a small number of gowns and limited linens were observed in the laundry area and office.
A resident with paraplegia and multiple stage 4 pressure injuries reported that daily ordered wound care was not performed on several days, despite large, heavily draining wounds. Review of the care plan showed orders for pressure ulcer treatment per physician orders, and the wound care coordinator/LPN confirmed that staff nurses are responsible for wound care and documentation on the TAR when the wound nurse is not present. The January TAR documented multiple missed wound care treatments, contrary to facility guidelines requiring necessary treatment and services for pressure injuries to promote healing and prevent infection.
A cognitively impaired resident with multiple comorbidities, unsteady gait, and documented need for supervision experienced a decline in mobility over several days, including left leg weakness, inability to use the left leg during transfer, and ambulation with a non-baseline shuffled gait. The resident was provided a wheelchair and educated on its use, but there was no documentation of ongoing non-compliance or additional interventions despite continued gait abnormalities. The resident later reported left leg pain and was sent to the hospital, where imaging showed a left femoral neck fracture; the resident could not recall how the injury occurred, and records showed no community pass during this period. Separately, two other residents assessed as high fall risk, with care plans requiring supervision, fall precautions, and a safe environment, were observed sitting in geri-chairs in a dining room unsupervised, even though a CNA was assigned to monitor that area at set intervals. These events demonstrate failures in supervision and monitoring for residents at high risk for falls and injury.
The facility failed to provide adequate nurse and CNA staffing on one unit, resulting in delayed medication administration and untimely ADL care for multiple residents. With a census of 40 residents, only one LPN and initially two CNAs were assigned, despite internal expectations for two nurses and three to four CNAs at that census. The sole LPN managing two med carts did not begin 9AM medications until late in the morning and was still passing them after midday, while another LPN from a different floor had to assist after completing her own med pass. CNAs reported each caring for about 20 residents, prioritizing breakfast service over routine care, which delayed incontinence care, showers, and getting residents out of bed. A resident requiring substantial/maximal assistance for ADLs remained in bed well past breakfast, and another resident with quadriplegia who requested to get up mid-morning was not assisted out of bed until after lunch. The administrator confirmed there was no written staffing policy.
A resident with multiple chronic conditions, who was cognitively intact and able to express needs, reported that his call light remained on for more than two hours while he waited for his urinal to be emptied and for water, despite multiple calls to the receptionist. The receptionist confirmed he had called about a delayed response and notified a nurse, who later acknowledged the resident told her he had been waiting over an hour with his call light on. The CNA assigned to the resident stated she did not see or hear the call light because she was seated at the opposite end of the hallway and only responded after being informed by the nurse, at which time the resident again reported a wait of more than two hours. Another resident reported delays in call light response and showers due to lack of staff, and staff interviews, including with the DON, confirmed that call lights are expected to be answered within 15 minutes, although short staffing sometimes affects timeliness, contrary to facility policy requiring prompt response.
Two residents did not receive medications as ordered when staff failed to administer and document drugs within the facility’s required time frames. One cognitively intact resident with orthostatic hypotension and end-stage renal disease reported late and missed doses, and records showed Midodrine and other morning medications given several hours after their scheduled times, with incomplete BP documentation despite an order to hold Midodrine for elevated systolic BP. Another resident with cerebrovascular disease and hypertension received 9:00 AM medications, including Aspirin, Amlodipine, and Vitamin D3, more than two hours late while an LPN reported being the only nurse passing medications to 39 residents. The DON confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time and in accordance with physician orders.
Surveyors found that the facility did not fully implement its infection control policies for two residents on special precautions. One resident with ESRD and a central venous dialysis access had physician orders and a care plan for Enhanced Barrier Precautions, but no EBP signage was posted at the room entrance despite facility policy requiring it. Another resident on contact precautions for ESBL urine had appropriate door signage, yet a visitor entered and remained in the room without any PPE, and a CNA provided lunch assistance wearing only gloves and no gown, contrary to the posted requirement for both. At the time of review, this second resident’s EHR also lacked a physician order and care plan for contact precautions, despite facility policies requiring both.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this finding.
A resident reported feeling exposed and violated when a male individual entered the shower room while she was showering, and the room lacked privacy curtains. Although the resident communicated her concerns to staff, including the DON and Social Service Director, no documentation of the incident or the resident's feelings was entered into her medical record, resulting in incomplete and inaccurate recordkeeping.
Two shower rooms used by 117 residents were found with holes in the ceilings and peeling paint, with one room closed for remodeling and the other still in use despite visible damage. A resident with multiple medical conditions reported discomfort due to water leaks and deteriorating conditions, and staff confirmed ongoing maintenance issues related to moisture and faulty shower valves.
A resident with behavioral issues struck another resident with a glass bottle, causing an open wound, after staff failed to provide adequate supervision in a common area. Staff admitted they could not see all residents from their positions and were distracted by phone use, leading to the incident and resulting in physical and emotional harm to the injured resident.
A resident sustained a left ankle fracture after being rammed and run over by another resident using an electric wheelchair during a verbal altercation. Staff did not immediately assess the injured resident or document pain complaints prior to a subsequent fall, and the aggressive resident continued to have access to the injured resident's area despite a history of behavioral issues.
Two residents were involved in a physical altercation due to the facility's failure to implement preventive interventions and provide adequate supervision. One resident, with severe mental impairment, displayed aggressive behavior and wandered into other residents' rooms, while the other resident, with intact cognition, reported feeling threatened. The facility's abuse prevention program was not effectively implemented, leading to injuries for both residents.
The facility failed to ensure call lights were within reach for three residents, leading to a deficiency in accommodating their needs. A resident with severe cognitive impairment and requiring assistance for transfers was found with the call light on the floor, out of reach, despite staff presence. Another resident, dependent on staff for transfers, also had the call light out of reach, which was only corrected after surveyor intervention. A third resident, with moderate cognitive impairment, was left without call light access while alone in a wheelchair. The facility's policy requires call lights to be accessible, which was not followed.
A resident with a history of falls and altered mental status fell from bed, but the facility delayed notifying the physician for over 7 hours. The resident was eventually sent to the ER after family insistence and was admitted for pulmonary thrombosis. The facility's policy required immediate notification of the physician, which was not followed.
The facility failed to develop timely and comprehensive care plans for two residents. One resident, admitted with a history of falling, had a care plan addressing fall risk initiated 1.5 years late. Another resident's care plan omitted their history of alcohol and cocaine abuse, despite being admitted with these diagnoses. The facility's policy requires comprehensive assessments and care plans upon admission, which was not followed.
The facility failed to update care plans for two residents at risk for falls. One resident experienced an unwitnessed fall that was not included in their care plan, which had an outdated goal target date. Another resident's care plan was not updated due to no recorded falls, despite being at risk. The Care Plan Coordinator acknowledged the oversight, citing staffing issues and lack of fall history as reasons for the deficiencies.
The facility failed to implement fall prevention measures for three residents, leading to inadequate supervision and intervention. A resident with severe cognitive impairment and high fall risk was found with the call light out of reach, contrary to care plan instructions. Another resident experienced an unwitnessed fall and lacked required non-slip material in the wheelchair. A third resident, with severe impairment, also had the call light out of reach, violating the facility's fall prevention program.
A facility failed to prevent abuse when a resident with a history of bipolar disorder entered another resident's room, leading to a physical altercation. The resident claimed to have been pushed to the floor, resulting in a hospital visit, although no acute injuries were found. The facility's abuse prevention policy was not effectively enforced, allowing the incident to occur.
A physical altercation occurred between two residents in the dining room, where one resident intervened in a verbal dispute between another resident and staff, leading to a physical confrontation. The facility failed to provide adequate supervision during mealtime, as required by their policy, resulting in a deficiency in preventing resident abuse.
An LPN in a facility was observed preparing medications for two residents simultaneously, contrary to policy, and failed to identify a pill that fell during preparation. Additionally, the LPN administered a blood pressure medication to a resident despite their blood pressure being below the physician's specified parameters. The ADON confirmed these actions were against facility policy, which mandates medications be administered as prescribed and vital signs monitored before administration.
A facility failed to develop comprehensive care plans for three dependent residents, omitting necessary interventions for ADLs such as eating, bathing, toileting, and transfers. The MDS Coordinator was unaware of their responsibility for ADL care plans, and the facility lacked a Restorative Nurse, contributing to the oversight.
The facility failed to maintain adequate staffing levels and care planning, resulting in insufficient care for residents. On the first floor, a nurse and three CNAs were responsible for 30 residents, leading to inadequate monitoring of a urinary catheter and a resident being left in a saturated brief. On the third floor, staffing was also insufficient for 52 residents, many with Alzheimer's, resulting in a resident being left in a soiled brief for over three hours. The facility lacked a formal staffing policy and proper care planning for ADLs.
The facility failed to maintain essential equipment and infrastructure, resulting in a ceiling leak on the third floor. Despite being reported months earlier, the issue persisted due to a malfunctioning actuator and unpaid HVAC services. The maintenance program was not followed, with inspections and repairs not documented or conducted timely, affecting 145 residents.
The facility failed to maintain a clean and hazard-free environment, affecting residents on the 1st and 3rd floors. A resident with Alzheimer's disease had a dirty room with food debris and a removed baseboard. Dining areas were not cleaned timely, with food debris and spills observed. Despite having six housekeepers, cleaning procedures were not followed, leading to these deficiencies.
A facility failed to transfer a resident in a timely manner and did not include discharge planning in the resident's care plan upon admission. Despite the family's requests for transfer to other facilities, the facility did not adequately document follow-ups on transfer referrals, resulting in delays. The discharge care plan was only initiated months after admission, contrary to the facility's policy.
The facility failed to provide timely ADL care to two residents, as observed by the Illinois Department of Public Health. One resident with Alzheimer's disease was found in a saturated incontinence brief, and another resident with vascular dementia was found with a soiled brief, indicating neglect in routine checks. The facility's policies on ADL and incontinence care were not followed, as staff confirmed delays in attending to the residents' needs.
A resident with chronic kidney disease and other health issues experienced a severe decline in condition due to the facility's failure to monitor changes, address critical lab results, and schedule necessary medical consultations. Despite documented weight gain and edema, the facility did not take appropriate action, leading to the resident's emergency hospitalization for severe health complications.
The facility failed to provide adequate ADL care, specifically incontinence care, to residents dependent on staff assistance. One resident with paraplegia was left in urine and feces overnight, worsening a wound. Another resident with hemiplegia reported being soaked in urine for hours, leading to itching and distress. A third resident with reduced mobility was found in a soiled state, indicating neglect by the night shift. The facility's policy of two-hourly incontinence checks was not followed, as confirmed by staff observations and resident council complaints.
A facility failed to provide adequate wound care and incontinence management for three residents, leading to worsening conditions. One resident's pressure ulcer was not treated for several days due to a conflict with the wound care nurse, while another resident's sacral wound increased in size due to exposure to urine and feces. A third resident developed moisture-associated dermatitis from prolonged exposure to soiled conditions. The facility did not adhere to its policy of daily skin assessments and timely wound dressing changes.
A facility failed to provide adequate linen and towels due to malfunctioning washing machines, leaving residents in unsanitary conditions. Residents reported being left in soiled states for extended periods, and CNAs confirmed the shortage of clean laundry. The facility's laundry operations were hindered by broken equipment, impacting all 150 residents.
The facility failed to properly contain and cover waste containers, potentially affecting all 156 residents. A surveyor and the Maintenance Director observed an uncovered dumpster and an overflowing trash can in the facility's dumpster area and back parking lot. The Maintenance Director acknowledged the issue, noting that the containers were for construction waste and should have been picked up by the city. The facility's policy requires that trash not accumulate to the point where lids cannot fit tightly and that dumpster lids remain closed.
The facility failed to prevent a resident with a history of alcohol abuse from accessing and consuming alcohol, despite being on narcotic pain medication with a warning against alcohol use. Additionally, another resident was found with razors in their possession, posing a safety risk, and the facility lacked a policy for razor disposal.
The facility failed to manage and document respiratory care equipment properly for several residents. One resident's nebulizer mask and tubing were not dated or contained, and there was no oxygen order documented. Another resident received oxygen without a physician's order, and a third resident's respiratory devices were uncontained, risking infection. Additionally, a resident's oxygen tubing and humidifier bottle were not dated, contrary to facility policy.
The facility did not post the daily nursing staffing information, potentially affecting all 156 residents. The outdated staffing information was observed at the receptionist desk, and the new receptionist was unaware of the posting requirement. The Staffing Coordinator mentioned that either the Transportation Coordinator or the DON is responsible for posting the staffing information in her absence.
The facility failed to monitor and maintain personal refrigerators for residents, affecting four individuals. Deficiencies included missing temperature logs and thermometers, and inadequate cleaning. Observations showed confusion among staff about responsibilities, leading to improper maintenance. Residents' refrigerators were found dirty, with doors ajar, and lacking temperature checks, contrary to facility policy.
A facility failed to follow proper hand hygiene and PPE protocols, leading to potential infection risks. An LPN did not sanitize hands before and after glove use during a blood glucose test, and a CNA did not perform hand hygiene between assisting residents during meal service. Additionally, a resident's room lacked an Enhanced Barrier Precautions sign and PPE bin, which was later corrected. The involved residents had severe cognitive impairments and multiple health issues, necessitating strict infection control measures.
The facility failed to maintain resident dignity by not covering a resident's urinary bag and not providing proper one-to-one feeding assistance. A resident's urinary drainage bag was exposed, and despite requests, a privacy bag was not provided. Additionally, a CNA was observed feeding a resident while standing and engaging with others, contrary to the facility's policy for one-to-one feeding. The residents involved had conditions like dementia and dysphagia, requiring specific care interventions.
The facility failed to ensure call devices were within reach for three residents, affecting their ability to call for assistance. One resident's call device was on the floor, obstructed by floor mats, while another's was wrapped around a bed rail, and a third's was hanging from the wall. Staff acknowledged these issues, which contravened the facility's policy requiring accessible call lights.
The facility failed to support the rights of two residents to engage in consensual sexual activities, despite having care plans in place. Staff repeatedly intervened, citing privacy concerns in shared rooms, and there was a lack of clear communication and understanding among staff regarding the residents' rights to intimacy.
A resident's code status was not documented in the electronic medical record, despite being indicated in the care plan as FULL CODE. The facility's policy requires code status documentation, but it was missing from the resident's profile and orders, leading to a deficiency noted by surveyors.
The facility failed to provide adequate nail care for two residents, who were observed with long fingernails and a brownish-gray substance underneath. Both residents require assistance with ADLs, including personal hygiene, as per their care plans. Despite facility policies and staff responsibilities, the deficiency was noted due to a lapse in executing these duties.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a CNA. The resident, who has end stage renal disease, COPD, depression, hypotension, and constipation, reported that during the night a CNA applied cream over feces on his buttocks and did not clean him adequately after a bowel movement. The resident complained to the nurse and later activated his call light, stating he still felt dirty and smelled feces. When the CNA returned to the room alone, despite the resident being on a buddy system, the resident and CNA engaged in a verbal disagreement. The resident stated that the CNA used profanity, refused multiple requests to leave the room, and argued with him. The resident recorded the interaction, which captured the CNA mocking his statement about being recorded and saying she was not afraid of losing her job. The recording and interviews documented that when the resident told the CNA she should be scared of losing her job, the CNA responded that she could get another job and that he would still be lying in bed, and she remained in the room arguing instead of leaving when asked. The resident reported that he did not want the CNA to care for him anymore but stated he felt safe and did not want to move to another facility. The CNA acknowledged telling the resident she could get another job and that he would still be there, and admitted she should have left the room when he asked instead of continuing the argument. The facility’s abuse prevention policy defines verbal abuse as the use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. The staff member’s conduct toward the resident met this definition of verbal abuse.
Failure to Provide and Document Ordered Wound Care and Timely Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care treatments, timely wound assessments, and physician notification for residents with significant wounds. One resident with a left below-knee amputation (BKA) and multiple serious medical diagnoses, including dehiscence of amputation stump, bacteremia, sepsis, pulmonary hypertension, PTSD, and heart failure, had care plans identifying increased risk for impaired skin integrity and the need for wound care per MD orders and weekly skin checks. A physician order dated 02/24/26 directed daily wound care to the left BKA stump, but the Treatment Administration Record showed no documentation of treatments on 02/24/26, 02/25/26, and 02/26/26. The same resident’s wound assessments were documented on 02/24/26 and then not again until 14 days later on 03/10/26. A progress note for this resident on 03/12/26 documented that during rounds the resident complained of phantom pain, and assessment revealed below-knee wound dehiscence, after which the physician and NP were called and the resident was sent to the ER. Hospital records dated 03/13/26 stated the resident was sent from the nursing home due to increased drainage from the left BKA wound for the past week, with concern for infection, and that the resident reported drainage had started about a week earlier and became increasingly difficult to manage. Discharge records from 03/24/26 documented a left BKA wound dehiscence with infection status post above-knee amputation revision, and also identified a right heel stage 2 pressure injury present on admission with orders to cover with alginate and bordered foam and change daily. On 04/03/26, the Wound Care Coordinator was observed cleansing and dressing the right heel wound and stated she had just discovered it and would apply a treatment of her recommendation until the wound care doctor saw the resident. Review of physician orders showed no order for the right heel wound until 04/03/26, despite the hospital discharge documentation of an active right heel wound and associated orders on 03/24/26. Another resident with diagnoses including peripheral vascular disease, venous insufficiency, lymphedema, and a non-pressure chronic ulcer of the right lower leg was admitted on 02/26/26. A progress note on the admission date documented chronic embolism and thrombosis of the lower extremity and a non-pressure chronic ulcer to the left lower leg, and indicated the physician was notified and orders were to be continued. The care plan dated 02/26/26 identified alterations in skin integrity to both lower legs and directed that treatment be provided per MD order. However, review of physician orders showed that initial wound care orders for this resident were not entered until 03/09/26, leaving an 8‑day period after admission with no wound orders. The resident stated she had been in the facility for over a week without having her wounds changed and that when she asked nurses to change the dressings, she was told there was no one available who could do it. The DON stated that nurses are expected to document everything they do, that residents are admitted with orders from the discharging facility which should be transcribed on admission, and that a resident should not be in the facility with an open wound and no orders. The facility’s physician confirmed he was not aware that these residents had not received wound care treatment and stated that it is the standard of care and his expectation that physician orders are carried out and that wounds should be addressed on the day of admission and followed with an appropriate treatment plan.
Medications Left Unsecured at Bedside of Visually Impaired Resident
Penalty
Summary
The facility failed to ensure medications were securely stored and not left at the bedside of a visually impaired resident, contrary to professional standards and facility policy. A resident with diagnoses including multiple sclerosis, generalized anxiety, insomnia, chronic idiopathic constipation, legal blindness, and conductive hearing loss was observed with two pills on the bedside table within easy reach. The resident stated she could not see well, could not see the surveyor’s identification badge, and requested that the surveyor write her name in large print with a marker because she could not see regular pen writing. The resident’s assessments did not include any self-administration of medication assessment, and the DON later stated that a resident with vision impairment such as blindness would not be approved to self-administer medications. During the observation, the surveyor noted one white, round, scored pill and one oval, clear, light orange pill at the bedside. When the RN was asked, she stated the resident had not received any pills from her that day. The RN accompanied the surveyor to the room, asked the resident what the pills were, and the resident replied that she did not know. The RN removed the pills and compared them to medications in the cart, identifying the orange pill as Lubiprostone 24 mcg and the white pill as Trazodone 50 mg, both scheduled for administration at night. Review of the medication administration record showed Trazodone scheduled daily at 9:00 p.m. and Lubiprostone scheduled twice daily at 9:00 a.m. and 5:00 p.m., though the surveyor was unable to determine on which day the medications had been left at the bedside. The facility’s policy on medication storage stated that medications and biologicals are to be stored safely, securely, and properly.
Failure to Implement Enhanced Barrier Precautions for Wound Care and Indwelling Device
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for residents requiring wound care and with indwelling devices. One resident (R1), who had diagnoses including dehiscence of an amputation stump, bacteremia, sepsis, acquired absence of the left leg, pulmonary hypertension, post-traumatic stress disorder, and heart failure, was care planned for EBP due to wounds or skin openings requiring dressings. Despite this, during an observation of wound care, the Wound Care Coordinator (V3) performed wound care on R1 without wearing a gown, and V3 stated she did not know what EBP was and did not think a gown was needed while providing wound care. The resident’s care plan documented that EBP was to be followed, including use of appropriate PPE such as gowns and gloves during wound care, but this was not implemented during the observed care. The facility also failed to identify and implement EBP for another resident (R4) who had an indwelling urinary catheter and a pressure sore. During observation, there was no EBP signage on R4’s door, and the urinary catheter drainage tubing and an air pump at the foot of the bed were visible; R4 reported having a catheter due to urinary retention and a sore on the buttocks. The DON (V2) confirmed that R4 had been in the room since admission, acknowledged that there was no EBP sign on the door, and stated that R4 should have had such a sign. The facility’s own policy on Guidelines for Enhanced Barrier Precautions, revised 12/2022, states that residents with wounds are at high risk for acquiring or spreading multidrug-resistant organisms and that gowns and gloves are to be used during high-contact resident care activities such as wound care, and that EBP is generally in place for the duration of the resident’s stay or until resolution of the wound or discontinuation of the device. These observations and statements show that EBP was not consistently implemented for two residents reviewed for infection control.
Failure to Maintain Safe and Sanitary Soiled Utility Room Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary functional environment in the second-floor soiled utility room, potentially affecting all 72 residents on that unit. During a tour of the second floor, the surveyor observed that the soiled utility room door was broken, could not be closed, and was standing partially open. Inside the room, there was overflowing garbage on the floor, garbage in the sink, a biohazard box placed in the sink, and floors with visible black debris and dirt. The room also contained access to the second-floor linen chute, which the Maintenance Director stated should be locked at all times for safety. When interviewed, a housekeeping aide stated that housekeeping is responsible for cleaning the soiled utility rooms but reported that he personally did not clean them because he believed floor technicians should be responsible for ensuring the soiled utility rooms are clean. He also acknowledged that it is unsafe and unsanitary for the soiled utility room to go without being cleaned. The Housekeeping Director confirmed that the housekeeping department is responsible for daily cleaning of the soiled utility room, including removing trash, sweeping, and organizing, while floor technicians are responsible for waxing and keeping floors free of dirt and debris. The Maintenance Director reported that he had repaired the second-floor soiled utility door several times after citations from the state agency for the door not being locked, and that staff continued to break down the door when they could not access the room. The facility’s job description for the Director of Housekeeping documented responsibility for ensuring cleaning schedules are followed, supervising housekeeping personnel, and recognizing, removing, and reporting potential hazards, as well as ensuring housekeeping personnel follow established safety regulations.
Failure to Ensure Appropriate Footwear Resulting in Fall and Intracranial Hemorrhage
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for falls wore appropriate footwear to prevent accidents. The resident was an older adult with diagnoses including pulmonary embolism with acute cor pulmonale, essential hypertension, coronary artery disease with stent, dementia, and other conditions. The resident’s MDS documented a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan, initiated in January 2026 and revised in February 2026, specifically included an intervention to ensure the resident wore appropriate footwear that provided stability and good traction when ambulating, mobilizing in a wheelchair, and during transfers. On the day of the incident, the resident was ambulating with a walker in a supervised area near the nurses’ station, walking toward the dining room. Staff statements and nursing documentation indicate that the resident abruptly stood up or was walking with the walker, lost balance, and fell backwards. The LPN on duty reported hearing the walker, then seeing the resident on the floor, and documented that the resident appeared to have hit her head. The LPN and other staff confirmed that the resident was wearing slide shoes at the time of the fall, described as open-toed, backless footwear with a strap across the top of the foot. The LPN acknowledged that slides were the resident’s preferred footwear but stated that, honestly, this was not appropriate footwear for the resident. Following the fall, the resident, who was on blood thinners (Eliquis), was sent to the hospital for evaluation. Hospital records document that the resident presented after a mechanical fall with head impact, reporting headache, neck pain, and wrist bruising. Imaging studies, including CT and MRI of the brain, identified a tiny left frontal, parietal, temporal, and occipital subdural hematoma and a small focus of subarachnoid hemorrhage in the left posterior frontal lobe. The nurse practitioner and restorative nurse both indicated that proper footwear for a resident of this age and condition should include closed-toe/heel shoes or non-skid socks with grip, and that slide footwear was not appropriate. The facility’s fall guidelines required incidents and accidents to be identified, reported, investigated, and used for QAPI trending, but the failure to ensure the resident wore appropriate, care-planned footwear directly preceded the fall and resulting intracranial bleeding.
Failure to Properly Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely and properly report an injury of unknown origin for one resident (R7) to the state surveying agency, as required by regulation and the facility’s Abuse Prevention Program policy. Surveyors requested Facility Reported Incidents (FRIs) for the prior three months and were provided only three incidents dated 12/02/25, 12/16/25, and 01/14/26. During review, surveyors observed that these incidents had not been submitted to the correct state agency email address. The Administrator (V1) stated she became aware of R7’s incident from the DON (V2) and believed she had reported it to the state agency via email on 12/16/25, the same day it was reported to her. When asked to provide confirmation of successful submission, V1 was unable to access her email initially and later reported she had not received confirmation because the email was returned as undeliverable. Further review showed that V1 also asserted that V2 had emailed R7’s incident to the state agency, but the only documentation produced to the surveyor were scanned emails showing time stamps of blank emails (one undeliverable and one sent to the correct address) with no FRI attached. When the surveyor requested that V1 forward the original email with the attached reportable incident, this was not provided. Record review confirmed that no FRI for R7 had been received by the state agency and that no FRIs from the facility had been received since 12/03/25. V1, who had been Administrator since 08/2024, stated she was unaware she had been using an incorrect email address and acknowledged that she never received confirmation of successful submissions. V1 also reported using an incorrect fax number for the state agency. The facility’s Abuse Prevention Program policy requires all personnel to promptly report any incident or suspected incident of abuse, mistreatment, neglect, including injuries of unknown origin, but this did not occur for R7’s injury of unknown origin.
Failure to Maintain Functional Laundry Equipment Resulting in Linen Shortages
Penalty
Summary
The facility failed to maintain laundry equipment in good working condition, resulting in inadequate availability of clean linens and personal clothing for residents. Staff interviews revealed that the facility’s washing machines had been malfunctioning over several months. A RN reported that residents had been complaining about their laundry after a washing machine broke approximately two weeks prior to the survey. An LPN stated that a new washing machine had recently been installed and was being used for both linens and residents’ clothing, and that during this period residents voiced concerns about their clothing not being washed and returned. The Ombudsman Residents’ Rights document cited in the record notes that residents have the right to keep and wear their own clothing. The Housekeeping Director stated that both linens and residents’ personal clothes are washed in the facility and that, when the machines needed repair, clothes and linens were sent to another facility. She reported that three months earlier only one washer was working while another was being repaired, and that one washer was designated for personal clothes and the other for facility linens. She also stated that she frequently had to order additional linens from an outside vendor because there were not enough linens available, and that some residents were hoarding linens in their rooms. At the time of the survey, she reported that a single washing machine was being used for both linens and personal clothing, and that there was a significant difference in capacity and workflow when all machines were functioning. The Maintenance Director reported that there were three washing machines, but two were not working. One washer had been newly installed after it broke three months earlier, and after that installation the other two washers failed and required repair. The two non-functioning washers were observed in poor condition with rust-like structures and holes, and one contained linens that could not be removed because the door would not open. The facility therefore had only 60 pounds of washing capacity in use instead of the 200 pounds available when all three machines were operational. One of three dryers was also out of order. Multiple residents reported a lack of linens: one resident with bed sores stated that his fitted sheet had not been changed and that he had informed the Administrator he had no linen; another newly admitted resident reported hearing concerns about linen shortages and having to wait for linen; another resident kept a clean towel on her chest to ensure she would have one for care; and a resident with daily diarrhea reported that CNAs often said they had no linen because the washers were broken, leading him to pay an outside service to wash his clothes. Invoices and orders showed that parts for washers and dryers had been ordered over preceding months, and the facility’s laundry policy stated that laundry equipment would be inspected and serviced by Maintenance per preventive maintenance procedures.
Inadequate Clean Linen Supply Due to Laundry Equipment Failures and Poor Linen Management
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate clean linens for multiple residents, resulting in limited access to necessary bedding and personal care items. During observations on several floors, surveyors noted that linen carts and clean utility room shelves were sparsely stocked or empty, particularly on the first and second floors. On the first floor, only a small number of gowns, wash cloths, sheets, underpads, and towels were available on a single linen cart, and the clean utility room cart had no linen. A registered nurse reported that laundry usually delivers linen late in the morning and that residents had been complaining about not having enough linen. On the second floor, one linen cart was completely empty and the others had minimal linen, and the clean utility room cart was also empty, despite staff stating that laundry had delivered linen. Residents reported direct impact from the linen shortage. One recently admitted resident stated she had heard concerns about lack of linen and sometimes had to wait for linen to be provided. Another resident was observed keeping a clean towel folded on her chest in bed, explaining that if she did not keep it with her, she would not have a towel for her care; this resident also reported witnessing staff hide linen for later use and cut larger towels into smaller wash cloths due to insufficient supplies. A resident with paraplegia and documented pressure ulcers of the sacral region and right hip (stage 4) stated there was no linen available, that staff cited washer problems, and that his fitted sheet had not yet been changed while he was washing himself up. He reported telling the administrator he had no linen despite having bed sores and being told linen was coming from another company, but no linen arrived. Additional information from staff and another resident further described ongoing linen and laundry capacity issues. Resident council minutes noted concerns about residents and staff hoarding linen. The housekeeping director stated that both linens and personal clothes are washed in-house, that washers had been down and clothes and linens had been sent to another facility, and that linen had to be ordered frequently because there was not enough. She also reported that currently a single working washer was being used for both linens and personal clothes. The maintenance director confirmed that of three washers, only one 60‑lb capacity machine was operational, with the other two older machines out of order and in poor condition, and one dryer also out of order. In the laundry area, only five gowns were observed on shelves, and additional wrapped linens in the housekeeping director’s office did not include gowns. Another resident with irritable bowel syndrome and frequent diarrhea reported that CNAs told him they had no linen because the washers were broken, that he had resorted to paying for outside laundry due to backed‑up dirty clothes, and that he continued to wear dirty clothes upon return because his clothing remained unwashed.
Failure to Consistently Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement physician-ordered pressure ulcer treatments for a cognitively intact resident with multiple stage 4 pressure injuries. The resident, who has paraplegia and pressure ulcers of the sacral region and right hip, reported that on several days the ordered wound care was not performed, despite orders for daily dressing changes due to large, heavily draining stage 4 wounds. The resident stated that he waited for staff to come at any time during the day, did not call to remind the nurse, and sometimes fell asleep while waiting, resulting in days passing without the treatment being done. Record review confirmed that the resident’s comprehensive care plan and current care plan included pressure ulcer treatments per physician orders, with goals for the wounds to remain free of signs and symptoms of infection and to continue healing without complications. The wound care coordinator/LPN stated that wound care is documented on the Treatment Administration Record (TAR) and that staff nurses are responsible for completing wound care when the wound care nurse is not working. The January TAR showed multiple dates on which the resident’s wound care treatments were not administered as ordered. Facility guidelines state that residents with pressure ulcers are to receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.
Failure to Adequately Supervise High-Risk Residents Resulting in Unwitnessed Femur Fracture and Unattended High-Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent accidents for three residents, including one who sustained a left femoral fracture. One resident had multiple diagnoses including essential hypertension, type 2 diabetes with neuropathy, cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, muscle wasting, weakness, unsteadiness on feet, and unspecified convulsions. This resident’s MDS showed significant cognitive impairment with a BIMS score of 6/15 and documented need for supervision with ADLs and mobility. The resident’s care plan stated that a safe environment was to be maintained and that staff should anticipate and meet needs and provide a safe environment. A community survival skills assessment documented that the resident did not appear capable of unsupervised outside pass privileges. On 12/11/2025, staff identified a change in this resident’s condition related to mobility and gait. The restorative nurse received a report that the resident was experiencing increased unsteadiness in gait. Upon assessment, the resident reported that his left knee sometimes gave out. A wheelchair and urinal were provided, and the resident was educated on safe wheelchair use and encouraged to request staff assistance. A change in condition note by an LPN the same day documented that the resident needed two-person assistance to bed due to left leg weakness, later proceeded to walk without staff after resting, and that his gait was not at baseline, though it showed some improvement. Another note documented that the resident was later seen leaning on the bathroom door, unable to use his left leg during transfer, and that he walked into the dining area for dinner with a shuffled gait that was not baseline. The care plan and progress notes from 12/11/2025 to 12/16/2025 did not document any ongoing non-compliance with wheelchair use or additional interventions related to his increased unsteadiness. On 12/16/2025, the LPN documented that the resident complained of left leg pain starting at the groin and radiating down the thigh, with pain on movement but not on light touch, and the resident was sent to the hospital for evaluation. Hospital records showed a left basicervical femoral neck fracture, and the resident was described as a very poor historian, alert and oriented x1, unable to explain why he was brought to the ED, and unable to recall the mechanism or timing of injury. The hospital record noted that no information was provided from the nursing home and that family could not be reached. The social services director stated that the resident did not go into the community independently and that any community pass would be documented; review of progress notes and the Resident Community Access Tracking Tool for December 2025 showed no documentation that the resident went out on community pass. Despite the resident’s impaired cognition, unsteady gait, and documented change in condition, there was no clear documentation of how the fracture occurred while the resident was in the facility. The deficiency also includes inadequate supervision of two additional residents who were both assessed as high fall risk. On observation, two residents were seen sitting in geri-chairs in the second-floor dining room unsupervised and unattended. Their fall risk assessments documented high fall risk scores (13 and 12), and their care plans included impaired cognition, history of falls, muscle weakness, dementia, impaired decision-making, and the need for cueing, reorientation, supervision, fall precautions, and maintenance of a safe environment with fall interventions in place. An LPN stated that CNAs take turns monitoring residents in the dining room at 30-minute intervals to ensure residents do not fall, injure themselves, choke, or get into physical altercations, and that a specific CNA was assigned to monitor the dining room during the time of observation. Despite this assignment and the facility’s policies on standard supervision and incidents/accidents/falls, the two high-risk residents were left in the dining room without staff present, demonstrating a failure to provide the supervision and monitoring required by their assessed needs and care plans.
Insufficient Nursing and CNA Staffing Leading to Delayed Medications and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the first floor to meet residents’ ADL needs in a timely manner and to administer medications as ordered. On the day of survey, the staffing coordinator stated that the first floor should be staffed with two nurses when there are 32 or more residents and three to four CNAs when the census is 40. The daily census for the first floor showed 40 residents, yet the daily assignment sheet listed only one nurse assigned to the unit. Observations confirmed that only one LPN was working on the first floor, and initially only two CNAs were present due to a CNA call-out, with a third CNA brought in later in the morning. The LPN assigned to the first floor reported that she was the only nurse scheduled for the 7AM–7PM shift and that she had to manage two medication carts. She stated she had not started passing 9AM medications by 10:50 AM and was still passing 9AM medications after noon, acknowledging that the medications were late due to staffing. Another LPN from the second floor came down after completing her own 9AM medication pass to assist with remaining medications and Accu-Chek readings for diabetic residents on the first floor. The Director of Nursing confirmed that medications are expected to be administered within one hour before or after the scheduled time and that insufficient staffing could cause delays in care, including medication administration. CNAs on the first floor described having to care for 40 residents with only two CNAs at the start of the shift, each responsible for about 20 residents, which they stated was not realistic compared to the usual 11–12 residents per CNA. They reported prioritizing breakfast service, including passing trays, feeding dependent residents, and collecting dirty trays, which delayed routine care such as two-hour checks, incontinence care, and showers. One CNA stated she still needed to provide a shower that would have been completed earlier if fully staffed. Residents corroborated delays in ADL care: one resident, with diagnoses including hemiplegia following cerebral infarction, cerebral palsy, neuromuscular bladder dysfunction, and documented need for substantial/maximal assistance with ADLs, reported that she was usually gotten out of bed before breakfast but remained in bed late in the day and attributed this to having only two CNAs instead of three. Another resident, with quadriplegia, extensive mobility and self-care limitations, and substantial/maximal assistance needs, stated he requested to get out of bed at 9:30 AM but was told staff could not assist due to only two CNAs working; he was not gotten out of bed until after lunch around 12:30 PM. The facility administrator reported there was no written staffing policy.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were answered in a timely manner, as required by its own policy and expectations. One resident with diagnoses including orthostatic hypotension, end-stage renal disease, and polyosteoarthritis, and who was cognitively intact, reported that his call light remained on for more than two hours one afternoon while he waited for his urinal to be emptied and for water. He stated that no one responded to his call light from approximately 4:20 PM until 6:45 PM, despite his calling the reception desk four times to request assistance. The receptionist confirmed that residents sometimes call the front desk when call lights are not answered timely and recalled that this resident had called her, reporting he had been waiting “a while” for his call light to be answered; she then went to the floor and informed the nurse, who said she would send someone. The nurse assigned to the resident that evening stated that when she entered the room to administer pain medication, the resident told her he had been waiting over an hour with his call light on and that no one had emptied his urinal. The CNA assigned to the resident that evening reported that she only became aware of the call light after being informed by the nurse; when she entered the room, the resident told her he had been waiting more than two hours for someone to answer his call light and needed water and his urinal emptied. The CNA stated she did not hear or see the call light because she was sitting at the end of the hallway on the opposite side of the resident’s room. Another resident reported that staff were sometimes delayed in answering call lights and providing showers due to lack of staff. The DON and staff interviews confirmed that anyone can and should answer call lights, that they are expected to be answered within 15 minutes, and that short staffing sometimes affects timeliness of care, contrary to the facility’s written policy requiring prompt response to activated call lights.
Failure to Administer Medications Within Ordered Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders and facility policy for two residents. One resident, cognitively intact with a BIMS score of 15 and diagnoses including orthostatic hypotension, end-stage renal disease, and polyosteoarthritis, reported not receiving scheduled morning medications at 6:00 AM on one day, instead receiving them at 8:00 AM, and also reported not receiving Eliquis, a multivitamin, and Midodrine on a prior date. Record review showed that Midodrine 10 mg ordered every eight hours with a 10:00 PM scheduled dose was not documented as administered until 5:19 AM the following day, more than seven hours late. The same resident’s Medication Administration Audit Report showed that on another day, Midodrine, Protonix, and Ferrous Sulfate ordered for 6:00 AM were documented as administered at approximately 8:00 AM. Nursing staff interviews revealed inconsistencies and issues related to medication availability and administration timing. One RN who worked the night shift denied giving Midodrine late and suggested that medications might not be administered if they were unavailable or not ordered. Another RN assigned to the resident on the evening shift documented that Midodrine was “on order” and stated it was not administered because the resident’s blood pressure was high, although there was no documentation of blood pressure readings in the progress notes for that date other than a single reading at 6:17 AM of 110/68. The facility’s blood pressure summary for that resident showed no additional readings for that day, and the progress note documented the Midodrine as on order without further clarification. A second resident, with diagnoses including cerebrovascular disease and essential hypertension and a BIMS score of 6 indicating cognitive impairment, also received medications outside the facility’s required time frame. During a medication pass observation, an LPN reported being alone to pass medications to 39 residents and stated she was not finished with the 9:00 AM medications. The LPN took this resident’s blood pressure at 11:14 AM and then prepared and administered the resident’s 9:00 AM medications (Aspirin, Amlodipine, and Vitamin D3) between 11:16 AM and 11:21 AM. The Medication Administration Audit Report showed these medications, ordered for 9:00 AM, were documented as administered at 11:18 AM, more than two hours late. The DON stated that medications are to be administered within one hour before or after the scheduled time and that nurses are expected to follow physician orders and facility policy, which requires medications to be given within 60 minutes of the scheduled time.
Failure to Post EBP Signage and Enforce PPE Use for Residents on Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not posting required Enhanced Barrier Precautions (EBP) signage and not ensuring proper use of personal protective equipment (PPE) for a resident on contact precautions. One resident with chronic conditions including COPD, end stage renal disease (ESRD), dependence on hemodialysis, and a central venous dialysis access in the right chest had physician orders and a care plan indicating the need for EBP due to the invasive dialysis access site. During observation, this resident was found resting in bed with a visible dialysis catheter dressing, but there was no EBP signage posted at the room entrance, contrary to the resident’s care plan and the facility’s EBP policy, which require door signage and PPE guidance for staff and visitors. A second resident, admitted with multiple diagnoses including ESRD, diabetes, liver disease, transplant-related conditions, MRSA infection, and C. difficile enterocolitis, was on contact precautions for ESBL in the urine, as later confirmed by the infection preventionist (IP) nurse. At the time of surveyor observation, there was contact precautions signage on the door instructing everyone to don gloves and gown before room entry. However, a visitor was observed inside the room sitting and talking with the resident without wearing any PPE, and a CNA was later observed entering the room and assisting the resident with lunch while wearing gloves but no gown, despite the posted requirement for both gloves and gown upon entry. Interviews with the IP nurse and the DON confirmed that residents on EBP should have door signage and accessible PPE, and that residents on contact precautions require a physician order, care plan, and use of gloves and gowns by staff and visitors when entering the room. Review of the second resident’s electronic health record with the IP nurse initially showed no physician order or care plan for contact precautions at the time of the observations. The facility’s written policies for EBP and infection control/isolation guidelines specify that appropriate PPE must be used, proper signage must be posted on resident room doors, and that contact precautions require gloves and gowns upon room entry and must be ordered by a physician and care planned, all of which were not fully implemented for the residents observed.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Document Resident Privacy Concern During Shower Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, resulting in a lack of documentation regarding a reported privacy violation during a shower. The resident, who was cognitively intact and able to clearly express her concerns, reported that while taking a shower, a male individual entered the shower room, leaving her feeling exposed and violated. The resident stated that she had previously complained about privacy issues, including staff not knocking before entering rooms, and specifically reported this incident to the nurse on duty and to the Social Service Director. The shower room in question did not have privacy curtains, and the resident expressed feeling unprotected and vulnerable as a result. Despite the resident's report and the acknowledgment by staff that the incident occurred and that the shower room lacked privacy curtains, there was no documentation of the incident or the resident's concerns in her medical record. The Social Service Director and the DON both indicated that they did not consider the event an incident requiring documentation, and only a general concern form and an in-service related to shower room safety were completed, neither of which addressed the specific privacy concerns raised by the resident. The lack of documentation and failure to record the resident's expressed feelings and the details of the event constituted a deficiency in maintaining accurate and complete resident records in accordance with professional standards.
Failure to Maintain Safe and Homelike Shower Room Environment
Penalty
Summary
The facility failed to provide a homelike environment by not maintaining the physical condition of two shower rooms, resulting in visible holes in the ceilings and peeling paint. During the survey, it was observed that one shower room on the third floor was closed for remodeling, while the other in the 3 North hallway, still in use, had a hole in the ceiling. On the second floor, a resident reported holes in the wall, peeling paint, and water dripping from the ceiling in the shower room, expressing discomfort with using the facility. The surveyor confirmed the presence of a hole and peeling paint in the 2-North shower room, which was actively being used for resident showers. A resident affected by these conditions was cognitively intact and had multiple medical diagnoses, including polyosteoarthritis, inguinal hernia, localized swelling, hyperlipidemia, and GERD. The Maintenance Director explained that ongoing issues with shower valves led to water leaks, steam, and moisture accumulation, causing the drywall to become soggy and buckle, resulting in holes and peeling paint. Facility records indicated that 117 residents were scheduled to use these shower rooms, and facility policies required immediate attention to areas needing repair, as well as maintaining a clean and attractive environment.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy to protect a resident from physical abuse by another resident. One resident, who had a history of behavioral issues including aggression and manipulative behavior, struck another resident in the face with a glass bottle, resulting in an open wound above the left eyebrow. The incident took place near the dining room, and staff were not positioned to adequately supervise all residents in the area, as confirmed by their own statements that they could not see all residents from where they were seated. The resident who was struck had significant medical conditions, including hemiplegia and severe cognitive impairment, and reported feeling scared and experiencing headaches after the incident. Multiple staff members, including CNAs and LPNs, acknowledged that residents are not supposed to hit each other and that such altercations are considered abuse. The staff also admitted to being distracted or not optimally positioned for supervision at the time of the incident, with some using their phones for charting or personal use, which further limited their ability to monitor resident interactions and prevent altercations. Documentation and interviews revealed that the facility's policies on supervision and abuse prevention were not effectively implemented. The incident was reported to the police, and the aggressor was sent to the hospital for psychiatric evaluation. However, the failure to provide adequate supervision and to prevent the altercation directly led to the physical abuse and injury of a resident, as well as emotional distress.
Failure to Prevent and Protect Resident from Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to prevent and protect a resident from resident-to-resident abuse, resulting in the resident sustaining a left ankle fracture. The incident began when the resident refused to lend a Bluetooth speaker to another resident, leading to a verbal altercation with a second resident who then used his electric wheelchair to ram into the first resident, knocking him to the floor and running over his leg. Staff intervened only after the second resident attempted to run over the resident again. The initial staff response was limited to asking if the resident was okay, and no immediate assessment or vital signs were taken at that time. The resident later reported pain in his foot to a nurse, but there was no documentation of a thorough assessment or physician notification prior to the resident experiencing a fall in his room due to increased pain. After the fall, emergency services were called, and the resident was diagnosed with a closed bimalleolar fracture of the left ankle. The documentation failed to show that the nurse recorded the resident's complaint of pain, the assessment performed, or the notification to the physician before the fall occurred. The resident's care plan indicated a low risk for aggression, while the second resident had a documented history of behavioral issues and aggression towards peers and staff. Despite this, the second resident continued to have access to the area where the injured resident was relocated, and there was no evidence of effective interventions to prevent further contact or abuse. The facility's policies and residents' rights documents emphasize the prohibition of abuse and the requirement to protect residents from harm, which was not upheld in this case.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. Resident 1 (R1) and Resident 2 (R2) were involved in an incident where R1 sustained a displaced fracture of the left 5th metacarpal, right shoulder deformity, and right eye discoloration, while R2 had a scratched forehead. Prior to the altercation, R1 had reported feeling threatened by R2, who had been displaying aggressive behavior and wandering into other residents' rooms. Despite these warning signs, the facility did not implement adequate preventive interventions or provide sufficient supervision to prevent the altercation. R2 had a history of severe mental impairment, as indicated by a BIMS score of 3, and was diagnosed with dementia, metabolic encephalopathy, and psychoactive substance abuse. R2's care plan noted behavioral symptoms related to severe mental illness, with interventions including psychiatric evaluation as needed. However, R2 continued to exhibit aggressive and disruptive behavior, including an incident where R2 was verbally aggressive and refused to leave another resident's room. Despite these behaviors, the facility did not take effective measures to prevent the altercation with R1. R1, who had a BIMS score of 13 indicating intact cognition, reported being assaulted by R2, who was his roommate at the time. R1's care plan highlighted his increased susceptibility to abuse and neglect, yet the facility failed to observe and address signs of fear and insecurity. The facility's abuse prevention program was not effectively implemented, as resident and family concerns were not adequately recorded, reviewed, or addressed, and random rounds to assess safety were not conducted. This lack of action and oversight contributed to the failure to protect R1 and R2 from the altercation.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident R4, with a severely impaired mental status and requiring moderate assistance for transfers, was observed with the call light on the floor and out of reach. Despite the presence of a Licensed Practical Nurse (LPN) at the bedside, the call light was not placed within reach, and the LPN did not initially acknowledge this as part of the fall prevention interventions. Similarly, Resident R7, who is dependent on staff for transfers and has a severe cognitive impairment, was found with the call light on the floor and out of reach. The Director of Nursing (DON) confirmed the call light's location and had to place it within reach after being prompted by the surveyor. Resident R3, with moderate cognitive impairment and requiring assistance for transfers, was found alone in her room without access to a call light while seated in a wheelchair. The Certified Nursing Assistant (CNA) assigned to R3 was unaware of the fall prevention interventions beyond the use of floor mats and did not provide the call light within reach before leaving the room. The facility's call light policy mandates that the call system be available and accessible to residents, which was not adhered to in these instances, resulting in a failure to accommodate the residents' needs and preferences effectively.
Delayed Notification of Physician After Resident Fall
Penalty
Summary
The facility failed to timely notify the Physician, Nurse Practitioner, and/or Medical Director of a change in condition for a resident who was reviewed for falls. The resident, who has a history of altered mental status and falls, experienced a fall from bed. The incident was witnessed by the roommate, and the resident was found on the floor by a CNA. Despite the fall, the resident denied pain and showed no signs of distress or injury at the time. The staff transferred the resident back to bed and educated her on using the call light for assistance. However, the facility did not immediately notify the physician as required by their policy. The progress notes indicate that the staff contacted the Medical Doctor but awaited a callback. It was not until approximately 7.75 hours later, when the resident's family insisted, that the Nurse Practitioner was contacted, and the resident was sent to the emergency room. The hospital later admitted the resident for pulmonary thrombosis. Interviews with the facility's physician and staff revealed that the physician expected to be notified immediately of such incidents, and the facility's policy required immediate notification of the physician, family, and nursing leadership after a fall. The delay in notification and subsequent actions led to the deficiency identified by the surveyors.
Failure to Develop Timely and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop timely and comprehensive care plans for two residents, R4 and R6, as required by their care planning policy. R4, who was admitted with a history of falling, was identified as high risk for falls on 6/13/23, yet the comprehensive care plan addressing this risk was not initiated until 1/21/25, approximately 1.5 years after admission. This delay in care planning indicates a significant oversight in addressing the resident's fall risk in a timely manner. Similarly, R6 was admitted with a history of alcohol and cocaine abuse, but the comprehensive care plan received on 1/28/25 did not include these diagnoses under the Focus section, despite the Care Plan Coordinator acknowledging the need for such information to be included. The facility's care planning policy mandates that comprehensive assessments and individualized care plans be completed upon admission and updated as needed, which was not adhered to in these cases.
Failure to Update Care Plans for Fall Risk Residents
Penalty
Summary
The facility failed to follow its policy procedures regarding the review and revision of comprehensive care plans for two residents who were at risk for falls. Resident R3 experienced an unwitnessed fall on 11/26/24, but this incident was not included in their care plan, which had an outdated goal target date of 8/11/24. Similarly, Resident R7's care plan, which identified them as at risk for falls, had an outdated goal target date of 11/12/24 and was not updated due to a lack of recorded falls. The Care Plan Coordinator, V15, acknowledged that the care plans were not updated as required, citing that R3's care plan was assigned to someone who had quit and that R7's care plan was not updated due to no history of falls. The facility's care planning policy mandates that care plans be reviewed and updated as needed with re-admissions, quarterly, annually, and with changes in condition, while the fall prevention program requires that care plans address each fall with appropriate interventions.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow its fall prevention policy and procedures, resulting in inadequate supervision and implementation of fall prevention interventions for three residents. Resident R4, who is at high risk for falls due to severe cognitive impairment and mobility issues, experienced a fall that was witnessed by a roommate but not by staff. Despite being identified as requiring partial/moderate assistance for transfers and bed mobility, R4's call light was found on the floor and out of reach, contrary to the care plan's intervention to keep it within reach. Resident R3, also at high risk for falls, had an unwitnessed fall while attempting to cover her daughter, who was not present. R3 requires assistance for transfers and is supposed to have a non-slip material in her wheelchair, but this was not in use during the surveyor's observation. Additionally, R3 was left unattended without access to a call light, and the CNA assigned to her was unaware of all required fall prevention interventions. Resident R7, with severe cognitive impairment and moderate fall risk, was found with the call light on the floor and out of reach. The facility's fall prevention program mandates that call lights be within reach at all times, but this was not adhered to. The facility's failure to ensure staff awareness and implementation of fall prevention interventions contributed to the deficiencies observed during the survey.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure to prevent abuse, resulting in a physical altercation between two residents. Resident 1, a male with multiple diagnoses including cerebral infarction and mood disorder, reported being pushed to the floor by Resident 2, who has a history of bipolar disorder and alcohol dependence. The incident occurred when Resident 2 entered Resident 1's room, allegedly to speak with Resident 1's roommate. A commotion ensued, leading to Resident 1 being on the floor and later complaining of back pain. Despite conflicting accounts from the involved residents, the facility's initial incident report confirmed a dispute, and both residents were sent to the hospital for evaluation. The hospital records indicated that Resident 1 did not sustain any fractures or acute injuries, contradicting his initial claim of a fractured back and ribs. The facility's abuse prevention policy explicitly states that abuse, including physical abuse by other residents, will not be tolerated. However, the incident report and interviews reveal that the facility did not effectively prevent the altercation or ensure the safety of Resident 1. The facility's failure to prevent this incident highlights a deficiency in their abuse prevention measures, as Resident 2 was able to enter Resident 1's room and engage in a physical confrontation.
Failure to Prevent Resident Abuse During Dining Room Altercation
Penalty
Summary
The facility failed to prevent an incident of physical abuse between two residents, R1 and R2, which occurred in the dining room. R2, who has a history of unspecified convulsions, bipolar disorder, and major depressive disorder, reported that R1 pushed her and scratched her face after she intervened in a verbal altercation between R1 and the staff. R1, who has diagnoses including conversion disorder with seizures and major depressive disorder, claimed that R2 grabbed his face, prompting him to push her away. Witnesses, including other residents and staff, provided varying accounts of the incident, with some noting that R1 was cursing at staff and R2 intervened, leading to a physical altercation. The facility's staff, including CNAs and the Director of Nursing, were not present during the entire incident, and their accounts were based on second-hand information. The staff failed to adequately supervise the residents during mealtime, as required by the facility's policy and procedure for standard supervision and monitoring. The incident was not immediately witnessed by staff, and there were discrepancies in the accounts regarding whether there were visible injuries on R1 and R2 following the altercation. The facility's abuse prevention program policy mandates the prevention of resident abuse, neglect, and mistreatment, but the staff's inaction in adequately supervising the residents and intervening in a timely manner contributed to the incident. The facility's incident report concluded that R1 was frustrated with staff and R2's intervention led to the physical altercation. Despite the facility's policy to prevent abuse, the lack of immediate staff intervention and supervision during the incident resulted in a failure to protect R2 from physical abuse by R1.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the residents' physician, leading to significant medication errors. During a survey, an LPN was observed preparing medications for two residents simultaneously, which is against the facility's policy. The LPN placed the medications for one resident aside and began preparing medications for another resident without administering the first set. When questioned, the LPN admitted to preparing medications for both residents at the same time and acknowledged the importance of following the rights of medication administration. Further observations revealed that the LPN was unable to identify a pill that fell onto the medication cart while preparing medications for a resident, indicating a lack of adherence to proper medication administration procedures. Additionally, the LPN administered a blood pressure medication to a resident whose blood pressure reading was below the physician's specified parameters for administration. The LPN did not follow the physician's order to hold the medication if the resident's systolic blood pressure was less than 110, which was documented in the resident's medication administration record. The Assistant Director of Nursing confirmed that it is unacceptable for nurses to prepare medications for more than one resident at a time, as it could lead to residents receiving the wrong medication and experiencing adverse reactions. The facility's policy mandates that medications be administered as prescribed and in accordance with good nursing principles. The policy also requires that vital signs be monitored before administering medications dependent on such measures, which was not adhered to in this instance.
Deficient Care Planning for Dependent Residents
Penalty
Summary
The facility failed to ensure that staff were aware of and followed facility policies, resulting in the lack of comprehensive care plans for three dependent residents. These residents required various levels of assistance with activities of daily living (ADLs), such as eating, bathing, toileting, and transfers, but their care plans did not include the necessary interventions. For instance, one resident with Alzheimer's disease and severe cognitive impairment required extensive assistance with most ADLs, yet their care plan omitted specific interventions for eating, bathing, toileting, and transfers. Another resident with paraplegia required supervision for eating and substantial assistance for toileting and transfers, but their care plan also lacked these details. A third resident, dependent on staff for eating, transfers, and toileting, had a care plan that excluded ADL care entirely. The surveyor's investigation revealed that the facility's interdisciplinary team, including the MDS Coordinator and Restorative Nurse, was responsible for developing and updating comprehensive care plans. However, the MDS Coordinator was unaware of their responsibility for ADL care plans until the surveyor's inquiry. Additionally, the facility did not have a Restorative Nurse at the time of the survey, which may have contributed to the oversight. The Director of Nursing confirmed the absence of a Restorative Nurse, highlighting a gap in the facility's staffing and care planning processes.
Inadequate Staffing and Care Planning in LTC Facility
Penalty
Summary
The facility failed to ensure adequate staffing levels and a written staffing policy, which led to insufficient care for residents. On the first floor, an agency registered nurse and three CNAs were responsible for 30 residents, with more than half requiring assistance. This staffing level was deemed inadequate, as evidenced by the failure to monitor a resident's indwelling urinary catheter, which resulted in sediment buildup and a confirmed urinary tract infection. Another resident, who required substantial assistance, was found with a moderately saturated incontinence brief, indicating a lack of timely care. On the third floor, the staffing was also insufficient, with four to five CNAs and two nurses for 52 residents, many of whom had Alzheimer's and required assistance. The CNAs reported that the staffing was not adequate to meet the residents' needs, as demonstrated by a resident being left in a soiled incontinence brief for over three hours. The facility's staffing coordinator confirmed that there were call-offs and late arrivals, which further exacerbated the staffing issues. Additionally, the facility lacked proper care planning for residents' activities of daily living (ADL). The MDS Coordinator was unaware of their responsibility for ADL care plans, resulting in incomplete care plans for residents requiring assistance with transfers, toileting, and eating. The facility also did not have a restorative nurse, and the administrator admitted that there was no formal staffing policy, relying instead on census and needs assessments.
Facility Maintenance Failures Lead to Ceiling Leak
Penalty
Summary
The facility failed to maintain essential equipment and infrastructure, leading to a deficiency that affected the safety and comfort of its residents. The Illinois Department of Public Health received an allegation regarding falling ceiling tiles on the third floor of the facility. Upon investigation, it was observed that ceiling tiles were missing, and water was leaking profusely from the ceiling, with a large trash can and wet towels placed to manage the water. The Director of Nursing acknowledged the issue, but it was not adequately addressed. The Maintenance Director confirmed that the problem was reported months earlier, and although the roof was sealed, the issue persisted due to a malfunctioning actuator tied to the air handling system. The facility's maintenance program was not followed as required, with inspections and repairs not documented or conducted timely. The HVAC contractor, responsible for checking the air handling systems, had not been paid for services since July, and invoices for necessary repairs were missing. The preventive maintenance program required daily inspections and immediate attention to repairs, but these protocols were not adhered to, resulting in unresolved issues and potential risks to the 145 residents in the facility.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for its residents, as observed during a survey conducted by the Illinois Department of Public Health. The survey revealed that the facility did not ensure timely cleaning of resident rooms and dining areas, which posed potential risks to the residents. Specifically, a resident on the 1st floor, who has Alzheimer's disease and requires assistance for daily activities, was found to have a dirty room with food debris and a removed baseboard lying on the floor. The housekeeping staff claimed that rooms are cleaned daily, but the presence of smashed food and other debris indicated otherwise. Additionally, the dining room on the 1st floor had food debris and dried spills on the floor, suggesting inadequate cleaning after meals. On the 3rd floor, similar issues were noted, with the dining room tables not cleared and the floor littered with trash and food debris, including large orange juice spills. A resident's room on the 3rd floor was also found to have dried spots of gastrostomy tube feeding and scattered debris on the floor. Despite having six housekeepers on duty, the facility's housekeeping director confirmed that the cleaning procedures were not followed as required. The general cleaning policies and procedures of the facility mandate thorough cleaning of resident rooms and dining areas, but these were not adhered to, leading to the observed deficiencies.
Failure to Timely Transfer Resident and Document Discharge Planning
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the transfer and discharge of residents, specifically in the case of a resident who was not transferred in a timely manner. The resident's comprehensive care plan did not include discharge planning upon admission, which is a requirement. Despite the family's repeated requests for the resident to be transferred to another facility, the facility did not document follow-ups on the transfer referrals adequately. The resident's family expressed a desire for the resident to be transferred to several different facilities, but the facility either did not document the follow-up or failed to secure a transfer due to issues such as insurance or bed availability. The facility's social services staff acknowledged that every resident should have a discharge care plan upon admission, yet the resident's discharge care plan was only initiated over three months after admission, following a surveyor's request. The facility's transfer and discharge policy emphasizes the resident's right to receive necessary care and participate in the development of their comprehensive care plan. However, the facility did not ensure that the resident's discharge care plan included an actual discharge plan, nor did it adequately follow up on transfer referrals, leading to a delay in the resident's transfer to another facility.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two dependent residents, R1 and R3, as observed by the Illinois Department of Public Health. R1, diagnosed with Alzheimer's disease and requiring substantial assistance for toileting and transfers, had a care plan that did not include these necessary supports. On observation, R1 was found in a moderately saturated incontinence brief, indicating a lack of timely care. Similarly, R3, who is dependent on staff for eating, transfers, and toileting, also had a care plan that excluded ADL care. R3 was found with a soiled incontinence brief, suggesting neglect in routine checks and changes. The facility's policies on ADL and incontinence care were not adhered to, as evidenced by the observations and staff interviews. The policy mandates that ADL care should be provided throughout the day and as needed, with incontinence checks every two hours. However, both R1 and R3 were not checked or changed for over three hours, contrary to the facility's stated procedures. Staff interviews confirmed the lapses in care, with CNAs acknowledging the delay in attending to the residents' needs.
Failure to Monitor and Address Resident's Deteriorating Condition
Penalty
Summary
The facility failed to monitor and recognize a change in condition for a resident with a known history of chronic kidney disease, chronic obstructive pulmonary disease, type II diabetes, chronic congestive heart failure, cardiomegaly, essential hypertension, and other health issues. The resident was admitted with these conditions and had specific care plan interventions, including monitoring and documenting edema and weight changes, and reporting these to a physician. Despite these interventions, the facility did not adequately monitor the resident's condition, as evidenced by the lack of action on significant weight gain and edema, which were not addressed by the nursing staff or physicians. The facility also failed to review and address diagnostic test results in a timely manner. Critical lab values indicating deteriorating renal function were not reviewed or acted upon promptly by the nurse practitioner or other medical staff. Additionally, an abdominal ultrasound showing a large amount of ascites was not communicated to the physician, and the resident's significant weight gain was not addressed by the medical staff, despite being documented in progress notes. This lack of communication and follow-up on critical test results contributed to the resident's worsening condition. Furthermore, the facility did not follow physician orders to schedule necessary nephrology, cardiology, and pulmonary consultant appointments. The appointment scheduler was aware of the orders but did not schedule the appointments, citing uncertainty about insurance as a possible reason. This failure to schedule essential consultations and tests delayed the resident's access to necessary medical care, ultimately resulting in the resident being sent to the emergency department with severe health issues, including massive volume overload, worsening kidney function, and respiratory failure.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to residents who are dependent on staff assistance, specifically incontinence care and personal hygiene. This deficiency affected three residents, resulting in significant discomfort and potential health risks. One resident, with a medical history of muscle wasting, paraplegia, and major depressive disorder, reported being left in urine and feces overnight, which aggravated a wound on their buttocks. The resident's care plan indicated a need for total assistance with ADLs, yet they experienced prolonged exposure to incontinence, leading to the wound not healing properly. Another resident, admitted with hemiplegia and hypertension, also reported being left in urine for an extended period, leading to itching and scratching. This resident expressed feelings of neglect and a lack of personal hygiene care, as they had not received a shower despite repeated requests. The resident's care plan similarly required total assistance with ADLs, highlighting a consistent failure in providing necessary care. A third resident, with a diagnosis of weakness and reduced mobility, was found in a similar state of neglect, with their incontinence care not being addressed throughout the night. The resident was left in a soiled state, causing discomfort and distress. Staff observations confirmed that the night shift failed to provide the necessary care, and the facility's policy on incontinence care, which mandates checks every two hours, was not adhered to. This pattern of neglect was further corroborated by previous resident council complaints about inadequate incontinence care and delayed response to call lights.
Inadequate Wound Care and Incontinence Management
Penalty
Summary
The facility failed to adhere to its skin condition assessment policy, resulting in inadequate wound care for three residents. One resident, who was admitted with multiple medical conditions including heart failure and reduced mobility, developed a stage II pressure ulcer on the left rear thigh. The wound care nurse attempted to treat the wound but was met with resistance from the resident, leading to a lapse in treatment from September 4 to September 9. During this period, the resident's wound care was not completed as prescribed, and the resident reported the issue to the facility's ombudsman, expressing concerns about a potential infection. Another resident, who was admitted with a stage four sacral wound, experienced an increase in wound size due to inadequate care. The resident reported being left in soiled conditions overnight, which led to the wound being exposed to urine and feces. This lack of timely incontinence care contributed to the deterioration of the wound, as observed by the surveyor and confirmed by the wound nurse practitioner. The resident's wound dressing was not maintained, and the staff failed to replace it promptly, exacerbating the resident's condition. A third resident developed moisture-associated dermatitis due to prolonged exposure to urine and feces. The resident was found in a soiled state, with the incontinence pad saturated and the skin showing signs of excoriation. The facility's staff did not provide timely incontinence care, leading to the development of skin issues. The facility's policy requires daily observation and documentation of skin conditions, but this was not consistently followed, resulting in the residents' wounds worsening or not healing as expected.
Laundry Deficiency Leads to Unsanitary Conditions
Penalty
Summary
The facility failed to provide adequate bed linen and bath towels for four residents, leading to unsanitary conditions and discomfort. Residents reported not having clean towels and linens, resulting in prolonged periods without being changed or cleaned. This issue was exacerbated by the facility's malfunctioning washing machines, which hindered the timely provision of clean laundry. The deficiency was observed through interviews and record reviews, revealing that residents were left in soiled conditions for extended periods. One resident reported being soaked with urine and feces overnight, while another expressed frustration over not receiving a shower due to the lack of clean linen. Certified Nurse Assistants confirmed the shortage of towels and linens, indicating that they often had to wait for laundry deliveries, which were insufficient to meet the needs of all residents. The facility's laundry operations were severely impacted by equipment failures, with only one small washer functioning. The laundry aide and supervisor highlighted the challenges in maintaining adequate linen supplies due to broken washing machines and clogged drains. Despite being aware of these issues, the facility had not taken timely action to repair the equipment or secure additional resources, leading to a widespread deficiency affecting all 150 residents.
Improper Waste Container Management
Penalty
Summary
The facility failed to ensure that waste containers were properly contained and covered, which has the potential to affect all 156 residents residing in the facility. During an observation, a surveyor and the Maintenance Director noted that one of the dumpsters in the facility's dumpster area was uncovered. Although the dumpster was designated for recyclable items, it was acknowledged by the Maintenance Director that it should still be covered, and he proceeded to cover it with the lid. Further observation revealed an additional dumpster and garbage can in the back parking lot, both of which were not properly covered. The dumpster was uncovered, and the trash can lid could not be closed due to the amount of trash inside, which included food and drink waste. The Maintenance Director explained that these containers were for construction waste and suggested that the city had forgotten to pick them up. He affirmed that trash is picked up weekly and acknowledged that not covering trash containers can attract pests and rodents. The facility's waste disposal policy mandates that trash should not accumulate to the point where the lid cannot fit tightly and that dumpster lids should remain closed at all times.
Failure to Prevent Alcohol Access and Ensure Razor Safety
Penalty
Summary
The facility failed to prevent a resident with a history of alcohol abuse from obtaining and consuming alcohol, which is prohibited within the facility. The resident, who is cognitively intact and has a diagnosis of alcohol abuse, was observed with an open half-empty bottle of beer in their personal refrigerator, which also contained more full bottles of beer. Despite the facility's policy prohibiting alcohol, the resident was able to access and consume it, and the staff did not take immediate corrective action to prevent further consumption. The resident was also on narcotic pain medication, which has a black box warning against the concomitant use of alcohol due to the risk of severe adverse effects. Additionally, the facility failed to ensure the safe storage and disposal of razors, which were found in another resident's basin. This resident, who is also cognitively intact, had two razors in their possession, posing a risk of self-harm or harm to others. The facility lacked a specific policy for the disposal of razors, and the resident did not have a care plan addressing shaving or razor use. The Director of Nursing acknowledged the expectation for razors to be disposed of in sharps containers but confirmed the absence of a formal hazard policy regarding razors.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper management and documentation of respiratory care equipment for several residents. For one resident with acute and chronic respiratory failure, the nebulizer mask and tubing were not dated or contained, and there was no oxygen order documented. The Director of Nursing confirmed that such equipment should be dated and contained to prevent infection. Another resident with chronic obstructive pulmonary disease and other respiratory conditions was observed receiving oxygen without a documented physician's order, which is required to guide the administration of oxygen therapy. Additionally, a resident with lung issues was found with an incentive spirometer and peak flow meter uncontained, with mouthpieces touching potentially contaminated surfaces. The Licensed Practical Nurse acknowledged that these devices should be contained to prevent infection. The Director of Nursing also stated that respiratory equipment should be kept at the bedside and covered to avoid dust and infection. Another resident was observed using oxygen with tubing and a humidifier bottle that were not dated, contrary to the facility's policy that requires such equipment to be labeled with the date, time, and staff initials. The Licensed Practical Nurse admitted to not changing the equipment due to the presence of water in the bottle, despite the lack of a date. These deficiencies highlight lapses in the facility's adherence to its own policies regarding respiratory care equipment management.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information, which has the potential to affect all 156 residents residing in the facility. On July 14, 2024, the Director of Nursing confirmed the facility's census of 156 residents. Upon entrance to the facility at 9:00 am, the daily staff posting was observed at the receptionist desk, dated July 4, 2024, indicating it was not updated. The receptionist, who had just started the position a few days prior, acknowledged that she did not post the updated Daily Nurse Staffing Form. On July 15, 2024, the Staffing Coordinator stated that the Nurse Staffing is posted daily, and in her absence, either the Transportation Coordinator or the Director of Nursing is responsible for posting it.
Failure to Monitor and Maintain Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerators for residents, affecting four residents in the sample. The deficiencies included the absence of temperature logs and thermometers in personal refrigerators, as well as inadequate cleaning. For instance, a resident's refrigerator was observed to be dirty and missing a temperature log for July, with the resident stating that they clean it themselves and staff do not check it. Another resident's refrigerator had no temperature entries recorded for nearly two weeks, despite the facility's policy requiring daily temperature checks. The facility's policy mandates that all refrigerators have internal thermometers and that temperatures are recorded daily to prevent food spoilage. However, observations revealed that several residents' refrigerators lacked these essential components. Staff interviews indicated confusion about responsibilities, with some staff members believing that nurses or administrative staff were responsible for monitoring the refrigerators, while others thought it was the housekeeping staff's duty. This lack of clarity contributed to the failure in maintaining the refrigerators properly. Additionally, one resident's refrigerator was found with the door ajar and no temperature log or thermometer present. The resident mentioned that they adjust the temperature manually when it gets too warm, indicating a lack of staff oversight. Staff members were unsure about who was responsible for checking the refrigerator temperatures, further highlighting the facility's failure to adhere to its own policies regarding food safety and refrigerator maintenance.
Infection Control Deficiencies in Hand Hygiene and PPE Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, as observed during a blood glucose test on a resident. An LPN applied gloves without using hand sanitizer and subsequently touched the medication cart without sanitizing hands. The LPN acknowledged the oversight, citing infrequent attendance at infection control in-services as a possible reason for the lapse. The facility's hand hygiene policy mandates the use of a waterless alcohol-based agent before glove application and interaction with residents, which was not followed in this instance. Additionally, the facility did not initially post an Enhanced Barrier Precautions (EBP) isolation sign or place a PPE bin outside a resident's room, who was on EBP due to a wound. The oversight was corrected the following day, but the initial failure to provide clear instructions and necessary PPE outside the room posed a risk of infection spread. The resident in question had multiple diagnoses, including dementia and a stage 3 pressure injury, necessitating strict adherence to EBP protocols. The facility's policy requires signage and PPE availability to prevent the spread of multidrug-resistant organisms. During meal service, a CNA failed to perform hand hygiene between assisting multiple residents, increasing the risk of cross-contamination. The CNA moved between residents without sanitizing hands, despite the facility's policy requiring hand hygiene after assisting each resident. The DON confirmed that hand hygiene is essential to prevent contamination, especially when handling food and utensils for different residents. The residents involved had severe cognitive impairments, making them particularly vulnerable to infection risks.
Failure to Maintain Resident Dignity and Proper Feeding Assistance
Penalty
Summary
The facility failed to maintain the dignity of residents by not adequately covering a resident's indwelling catheter urinary bag and by not providing proper one-to-one feeding assistance. During observations, a resident's urinary drainage bag was visibly exposed, and the resident expressed a desire for a privacy bag, which had not been provided despite requests. This lack of privacy was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that all urinary drainage bags should be kept in privacy bags to ensure the resident's dignity. Additionally, the facility did not uphold the dignity of a resident during meal times. A Certified Nursing Assistant (CNA) was observed feeding a resident while standing, not maintaining eye contact, and engaging with other residents, which is against the facility's policy for one-to-one feeding. The CNA was seen moving between residents, feeding multiple individuals, and not focusing solely on the resident requiring one-to-one assistance. This behavior was contrary to the expectations set by the Director of Nursing (DON), who stated that staff should be seated at eye level with the resident and fully attentive during feeding. The residents involved had various medical conditions, including dementia, dysphagia, and reduced mobility, which necessitated specific care interventions. The facility's failure to adhere to its policies and procedures regarding resident dignity and feeding assistance was evident in the observations and interviews conducted. The facility's policies clearly state the importance of treating residents with dignity and respect, yet these incidents demonstrate a lapse in compliance with those standards.
Inaccessible Call Devices for Residents
Penalty
Summary
The facility failed to ensure that call devices were within reach for residents to use to call for staff assistance, affecting three residents. On July 14, 2024, a surveyor observed a resident seated in a wheelchair by the window with the call device on the floor between two beds, making it inaccessible due to floor mats. The resident confirmed the inability to reach the call device. A Licensed Practice Nurse acknowledged the issue and repositioned the call device within reach. The resident's care plan emphasized the need for the call light to be within reach, but the facility did not conduct a call light assessment. Additionally, two other residents were affected by similar issues. One resident's call light was wrapped around a bed rail, making it unreachable, and a Licensed Practical Nurse confirmed this. Another resident's call light was hanging from the wall, out of reach, and a Certified Nursing Assistant acknowledged the resident's inability to reach it. The facility's call light policy requires that call lights be accessible to residents at all times, but this was not adhered to in these cases.
Failure to Support Resident Intimacy Rights
Penalty
Summary
The facility failed to adhere to the care plans of two residents, R8 and R65, who were assessed and documented as having the right to engage in an intimate sexual relationship. Despite both residents having intact cognition and expressing their desire to exercise this right, staff repeatedly intervened and stopped them from engaging in consensual sexual activities. R65 reported that the staff stopped them approximately 15 times, even though the facility provided condoms and had care plans in place supporting their right to intimacy. Interviews with staff revealed inconsistencies in understanding and implementing the residents' rights to intimacy. While some staff members acknowledged the provision of condoms and the need for privacy, others expressed personal discomfort or lack of clarity on the policy, leading to the interruption of the residents' consensual activities. The Director of Nursing was unsure about how communication regarding residents' sexual activities was handled among staff, indicating a lack of clear guidance and education on the matter.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to document the code status for a resident, identified as R133, in the electronic medical record. This oversight was discovered during a survey, which included observation, interview, and record review. R133 has multiple diagnoses, including Nontraumatic Intracerebral Hemorrhage, Epilepsy, and Schizoaffective Disorder, and is rarely or never understood according to the Minimum Data Set (MDS). Despite the care plan indicating that R133 elected to be a FULL CODE, the electronic medical record and the Order Summary Report did not reflect any physician's order for advance directives, such as full code or DNR status. Additionally, the Admission Record Form for Advance Directive was left blank. The Director of Nursing acknowledged that the code status should be documented for every resident in the facility, both on the resident's profile screen and in the orders. The facility's policy on Advance Directives, dated January 17, 2017, outlines the procedure for advising residents or their legal representatives about their rights to establish an advance directive and ensuring these choices are incorporated into the resident's plan of care. However, this policy was not followed in the case of R133, leading to the deficiency noted by the surveyors.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for two residents, R18 and R41, as observed by surveyors. R18, who has diagnoses including hemiplegia, type 2 diabetes mellitus, dementia, and a contracture in the right hand, was found with long fingernails and a brownish-gray substance underneath them. R41, diagnosed with cerebrovascular disease, hemiplegia, and a contracture in the left elbow, was also observed with a similar substance under their fingernails. Both residents require assistance with activities of daily living (ADLs), including personal hygiene, as documented in their care plans. The facility's policy on ADLs, dated January 25, 2023, states that residents should receive routine daily care to promote hygiene and comfort. The job description for Certified Nursing Assistants (CNAs) includes providing nail hygiene. However, interviews with staff, including an LPN and the Director of Nursing, revealed that nail care is supposed to be provided on shower days and as needed, with nurses responsible for diabetic residents. Despite these protocols, the observations indicated a lapse in the execution of these duties, leading to the deficiency noted by the surveyors.
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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