Landmark Of Lincoln Park Rehabilitation And Nursin
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 735 West Diversey, Chicago, Illinois 60614
- CMS Provider Number
- 145654
- Inspections on file
- 46
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Landmark Of Lincoln Park Rehabilitation And Nursin during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
A resident with significant mobility and self-care deficits, but intact cognition, was care planned to require substantial assistance with personal hygiene, including nail care and shaving. Over time, CNAs documented long toenails and nail bed issues, and a podiatry note later described elongated, dystrophic toenails with painful onychomycosis. Staff reported the resident’s toenails were long and aching, fingernails extended beyond the skin with dried black material the resident identified as stool, and that the resident repeatedly requested nail trimming. The resident also reported going about two months without being shaved despite requests, and was observed with a long, unshaven beard and mustache; staff described his facial hair as long, thick, and grizzly, and cited broken clippers and ineffective disposable razors. An observation also found the resident lying on a yellowish, unclean fitted sheet with dark particles, and a CNA acknowledged it did not appear changed and that the resident had been in bed for a prolonged period, demonstrating a failure to provide required ADL assistance.
A resident with a history of emphysema and prior smoking had conflicting nicotine-related information between hospital records, facility assessments, and the face sheet. Hospital documentation and a CT lung screening indicated nicotine dependence in remission, while the facility’s social history recorded no nicotine/tobacco history or current use, and the medical record listed an active nicotine dependence diagnosis with inconsistent onset dates. The resident, who reported having quit smoking and was concerned about assisted living acceptance, identified the discrepancy. The MDS coordinator and DON reported that diagnoses are entered from hospital records and updated when aware of new information, but they were not aware of all outside appointments and records, leading to the nicotine diagnosis being coded as dependence instead of remission and resulting in an incomplete and inaccurate medical record.
A CNA physically abused a resident with severe cognitive impairment by pulling the resident's ear and forcibly removing him from a chair, resulting in bruising and a scratch. The abuse was discovered after staff noticed injuries and behavioral changes, leading to a review of surveillance footage that confirmed the incident. The CNA had no prior history of abuse and had completed required training.
Surveyors found expired milk cartons in the walk-in cooler and a wet sanitation cloth left on the food preparation counter instead of in the sanitizing solution, contrary to facility policy. These lapses in food safety and sanitation procedures had the potential to affect all residents receiving food from the kitchen.
The facility did not keep outside garbage dumpsters properly closed, resulting in overfilled containers with partially open lids. Multiple departments contributed to the issue, and staff were unsure who was responsible for leaving the dumpsters open, despite facility policy requiring dumpsters to remain closed and the area kept clean. This affected all residents in the facility.
Two residents with confirmed COVID-19 were not provided with trash receptacles for PPE disposal in their rooms, leading staff to discard used PPE in hallway trash cans. One resident used both a shared bathroom and a communal rehab bathroom despite orders for a dedicated bathroom, with no signage or clear cleaning schedules in place. Another resident on isolation was observed leaving their room, interacting with others, and using a cloth mask instead of a required disposable mask, contrary to facility policy. These failures were confirmed by staff and management, and were not in line with infection control protocols.
Surveyors found that the lint trap in the dryer used for residents' personal laundry was not being emptied, resulting in a large buildup of lint. Staff confirmed there was no log or procedure for cleaning this lint trap, and it was not being checked regularly, despite facility policy requiring lint screens to be cleaned and documented after every two loads. This failure created an unsafe environment and a fire hazard potentially affecting all residents.
Several dependent residents did not receive timely oral hygiene or incontinence care as required by their care plans and facility policy. Two residents were observed with significant dental debris and reported a lack of staff assistance with mouth care, while two others, both paraplegic and always incontinent, experienced prolonged waits for incontinence care, sometimes exceeding an hour. Staff interviews confirmed that care was not consistently provided every two hours as required.
A resident with multiple risk factors for pressure ulcers was found in bed on a non-functioning low air loss mattress, despite physician orders and care plan interventions requiring its use. The LALM was observed to be almost flat with the power off, and the ADON confirmed it was not working at the time, resulting in a failure to provide appropriate pressure ulcer prevention.
Surveyors found that several residents requiring oxygen therapy did not have their equipment properly contained, labeled, or dated, with tubing often left unbagged or touching the floor. Required oxygen-in-use signage was missing in some rooms, and at least one resident received oxygen at a higher flow rate than ordered by the physician. These deficiencies occurred despite clear care plans and facility policies, affecting residents with significant respiratory and medical needs.
Surveyors found that medications, including insulin and eye drops, were not properly labeled with open dates, some were not refrigerated as required, and expired medications were not discarded. Temperature logs for medication refrigerators had missing entries, and staff did not consistently monitor temperatures as required, especially when vaccines were present. These failures affected multiple residents and had the potential to impact all residents on the affected floor.
Several residents' personal refrigerators lacked required temperature log sheets and thermometers, with staff failing to consistently document daily temperature checks as required by facility policy. Interviews confirmed that staff were responsible for these tasks, but the procedures were not followed, affecting residents with various medical conditions.
Two residents with significant physical and cognitive impairments were unable to access their call lights, as required by their care plans. In both cases, the call lights were found out of reach, despite facility policy and staff job descriptions mandating that call lights be kept within easy reach to allow residents to request assistance.
A resident with multiple psychiatric diagnoses received an increased dose of Venlafaxine HCL ER without documented clinical rationale or physician justification. The DON could not provide evidence of an IDT meeting or behavioral interventions prior to the dosage change, contrary to facility policy requiring assessment and documentation for psychotropic medication adjustments.
Three residents with limited mobility and contractures did not receive required range of motion (ROM) exercises or restorative devices as specified in their care plans and physician orders. Staff confirmed that necessary splints and palm protectors were unavailable and that temporary alternatives were not used. Two residents reported not receiving ROM exercises, and staff cited outdated lists and time constraints as reasons for missed care. Facility policies and job descriptions require these interventions, but they were not consistently provided.
Surveyors found that controlled medications were not double locked, completed medications were not returned to the pharmacy, and shift-to-shift count sheets were missing outgoing nurse signatures. These failures involved a resident with completed Lorazepam orders and two residents receiving other controlled substances, with staff acknowledging the lapses in required storage and documentation practices.
Two residents with histories of behavioral issues and susceptibility to abuse were involved in a verbal and physical altercation, during which one threw water on the other and both exchanged offensive language. The incident was witnessed by an LPN, reported to the administrator, and resulted in police involvement. The facility failed to ensure the right of these residents to be free from abuse, as required by its abuse prevention policy.
Two residents experienced physical and verbal abuse from another resident with moderate cognitive impairment and a history of aggressive behavior. One resident was pushed and sustained a minor injury, while another was punched in the eye and verbally threatened after a dispute over loud television volume. Staff intervened in both cases, but the incidents highlight a failure to prevent and protect residents from abuse.
The facility failed to respond to nurse call activations promptly, affecting three residents. Resident Council Meeting Minutes and resident interviews revealed ongoing issues with CNAs not answering call lights and being rude. On one occasion, a surveyor observed a call light going unanswered for an extended period, despite staff being aware of it. The facility's policy requires prompt responses, which were not followed, leading to the deficiency.
Two cognitively intact residents engaged in a physical altercation over a disagreement, resulting in minor injuries. Staff intervened promptly, and both residents were sent for psychiatric evaluations. Despite the incident, both residents felt safe and declined police involvement.
A resident with a history of mental health disorders reported being punched by another resident, R1, in a LTC facility. Despite no visible injuries, the incident was considered physical abuse by witnesses. Staff confirmed the altercation, and R1 was sent for psychiatric evaluation. The facility failed to follow its abuse prevention policy, as R1 lacked an abuse care plan despite a history of aggressive behavior.
A former receptionist at an LTC facility verbally abused a resident by using profanity when the resident shared a security code. The incident was witnessed by another resident and reported to the administrator. Despite the resident feeling safe, staff members agreed that the behavior constituted verbal abuse. The facility's investigation could not substantiate the abuse claim, but it was determined that the receptionist's communication was inappropriate.
A resident with progressive systemic sclerosis did not receive her scheduled Tramadol medication for pain management due to lapses in communication and procedure among nursing staff and pharmacy. The resident, who is cognitively intact, experienced significant pain and discomfort without the medication. The RN was unable to find Tramadol in the medication cart and offered Tylenol instead, which the resident accepted despite its ineffectiveness. The DON later retrieved Tramadol from the emergency medication system after system issues. The resident's medication administration record confirmed the lapse, and the nurse practitioner was unaware of the situation.
Two residents engaged in a physical altercation over a bathroom dispute, resulting in one resident sustaining a foot fracture. Despite complaints of pain, the injury was not promptly addressed by the facility staff. The incident was witnessed by multiple staff members, but effective intervention was lacking, highlighting a deficiency in the facility's abuse prevention and response measures.
The facility failed to maintain a safe environment and adhere to professional standards, resulting in injuries to two residents. One resident experienced a delayed diagnosis of a foot fracture after an altercation, while another suffered a knee fracture with delayed assessment and notification. The facility did not follow its policies for immediate assessment and physician notification, leading to deficiencies identified by surveyors.
A resident with a history of self-harm and aggressive behavior was inadequately supervised, resulting in a nasal fracture after hitting himself in the face. Despite being in a supervised area, staff failed to prevent the incident, and monitoring was inconsistent. The facility's policies for handling behavioral emergencies were not effectively implemented, contributing to the deficiency.
A resident was found with lidocaine patches applied without proper orders or documentation. The patches were observed on both knees, with one dated incorrectly and the other undated. The LPNs involved were unaware of the patches, and the Director of Nursing confirmed there was no active order until a later date. Facility policy requires medications to be administered and documented according to physician orders, which was not adhered to in this instance.
The facility failed to conduct timely criminal background checks for new residents, impacting their safety and well-being. Several residents, including those with mental health conditions, were affected due to delays in the Criminal History Information Response Process (CHIRP) and fingerprinting. Staff interviews revealed confusion over responsibilities, and facility policies on abuse prevention were not followed, highlighting significant procedural gaps.
The facility failed to complete timely Health Care Worker Background Checks, as evidenced by an employee hired in 1998 whose work eligibility was still 'Not Yet Determined' over 20 years later. The Regional HR Director acknowledged the oversight, which contradicts facility policies requiring background checks before employment. This deficiency potentially affects all 137 residents.
The facility failed to post accurate and timely daily nursing staffing information, affecting all 137 residents. The outdated posting was observed multiple times, and the updated version still contained inaccuracies, such as an incorrect census and lack of specific unit details. The receptionist responsible for posting was absent, leading to the oversight.
The facility failed to adequately monitor food storage temperatures, potentially affecting all residents. A review of the Milk Cooler refrigerator temperature log revealed missing recordings for several shifts. The Dietary Manager confirmed the importance of tracking temperatures to prevent milk spoilage, as per facility policy.
A facility failed to ensure proper PPE disposal by a laundry aide who reused a gown throughout a shift, contrary to infection control guidelines. Additionally, a resident requiring enhanced barrier precautions due to a gastrostomy tube and indwelling catheter did not have the necessary precaution sign posted on their door. These deficiencies in PPE use and signage could increase the risk of spreading infections.
A facility failed to assess a resident's ability to self-administer medication, leaving a tube of topical medication on the resident's bedside table without a care plan or physician's order. The resident had a severely impaired mental status, and the Director of Nursing noted the risk of other residents accessing the medication. Facility policy requires an interdisciplinary assessment and physician's order for self-administration, which were not completed.
The facility failed to maintain a homelike environment for several residents, with issues such as holes and cracks in walls, peeling faux wood on a bed footboard, and chipped paint. These conditions were acknowledged by staff as not contributing to a homelike environment. Residents involved were cognitively intact, with some having significant medical diagnoses.
The facility failed to set low air loss mattresses to the correct weight settings for four residents, compromising pressure ulcer prevention. Observations showed that the mattresses were set higher than the residents' actual weights, which could affect circulation and pressure relief. Despite having care plans that included pressure-reducing mattresses, the incorrect settings were confirmed by staff, highlighting a significant oversight in care.
A resident's dignity was compromised when personal medical information was left uncovered in their room, visible to others. Signs detailing dietary and aspiration precautions were posted by an SLP to ensure staff compliance but were not covered, violating HIPAA and dignity standards. The resident had a history of dysphagia and required a mechanically altered diet.
A resident with a diagnosis of Cerebral Infarction and Aphasia was not provided with necessary communication devices as outlined in their care plan. Despite the resident's primary language being Spanish, the facility did not utilize communication aids, relying instead on Spanish-speaking housekeeping staff for translation. This oversight led to increased frustration for the resident, as confirmed by the resident's family and the responsible LPN.
A facility failed to follow its policy for changing a midline catheter dressing for a resident. The dressing, applied to the resident's left arm, was not changed for a week, leading to redness around the chlorohexidine patch, which could indicate infection. The RN confirmed the dressing had not been changed since application, and the DON stated that dressings should be changed weekly and monitored for infection signs. The facility's policy requires dressing changes 24 hours after insertion, every 5-7 days, or if compromised.
The facility failed to follow infection control practices for respiratory care equipment for two residents. A nebulizer mask was not stored in a plastic bag when not in use, and a nasal cannula was not changed weekly as required. Both residents had chronic conditions and moderately impaired cognitive status. These lapses were contrary to the facility's policies for infection control.
A resident with a complex medical history reported a fall to a CNA, who informed the assigned nurse. The nurse did not perform a comprehensive assessment or document the incident as required by the facility's policy. The resident's electronic health record lacked necessary documentation, and no incident report was completed by the night shift nurse.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Provide Adequate Nail Care and Shaving for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically nail care and shaving, for one cognitively intact resident who required substantial/maximal assistance with personal hygiene. The resident had multiple medical diagnoses, including hemiplegia, gait abnormalities, muscle weakness, and a history of falls, and was care planned as having a self-care deficit requiring assistance with all ADLs. The facility’s own A.M. care policy required cleaning under fingernails and maintaining nails at a smooth, safe length, and the resident rights policy affirmed the right to a dignified existence and accommodation of individual needs. Documentation and staff interviews showed that the resident’s toenails and fingernails were not maintained appropriately over time. CNA skin/shower worksheets on multiple dates documented long toenails and nail bed issues, and a foot and ankle clinic note later described elongated, dystrophic toenails with subungual debris and pain on palpation, with onychomycosis affecting all toenails. CNAs reported that the resident’s toenails were long and causing aching, and that podiatry services were dependent on being placed on a list. One CNA stated that when the resident returned from the hospital, the fingernails were beyond the skin with a lot of black dried material under them, which the resident identified as stool, and that the resident repeatedly requested fingernail clipping. The resident also did not receive consistent shaving and facial hair care despite requesting it. The resident reported it had probably been two months since staff had shaved him, despite asking aides to do so, and was observed with a long, unshaven beard and mustache. Staff interviews confirmed that the resident’s facial hair was long, thick, grizzly, and not well maintained, and that clippers were broken and disposable razors were reported as ineffective. A hospital social worker and a physical therapist raised concerns about the resident’s hygiene, including long facial hair, fingernails, and poor foot condition. During an observation, the fitted sheet under the resident was yellowish and unclean with multiple small dark particles, and a CNA acknowledged it did not appear to have been changed and that it had been a while since the resident had been out of bed. These observations and statements demonstrate that the facility did not consistently provide the personal hygiene assistance required by the resident’s condition and care plan.
Inaccurate Documentation of Nicotine Dependence Status in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one cognitively intact resident with a history of centrilobular emphysema and other chronic conditions. Hospital admission records documented the resident’s social history as a current cigarette smoker on some days, and a later CT chest lung screening documented nicotine dependence, cigarettes, in remission. However, the facility’s social history and assessment recorded no history of nicotine/tobacco use and no current use of smoking products. The resident’s face sheet and diagnosis list initially reflected nicotine dependence, unspecified and uncomplicated, rather than nicotine dependence in remission, and at one point showed differing onset dates and diagnosis descriptions for nicotine dependence. The resident, who reported having stopped smoking months earlier and expressed concern that an active nicotine dependence diagnosis would affect acceptance into assisted living, identified the coding issue and requested correction. The MDS coordinator stated that diagnoses are typically entered from hospital records at admission and updated when aware of new information, but acknowledged not knowing about the resident’s additional hospital visit and CT results, and that the nicotine diagnosis had been entered as dependence instead of remission. The DON reported that the resident makes her own appointments and provides records to medical records staff, and that multiple outside physicians with differing diagnoses contributed to confusion. The former nurse practitioner stated that diagnoses should be carried over from the hospital stay and updated to manage new problems, but the nicotine-related diagnosis in the facility record was not accurately aligned with the resident’s remission status, resulting in an incomplete and inaccurate medical record.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A certified nursing assistant (CNA) physically abused a resident with severe cognitive impairment in the facility's dining room. The CNA was observed on video grabbing and pulling the resident's ear, forcibly removing the resident from a chair, causing the resident to fall to the ground, and then picking the resident up and pushing him out of the dining room. The incident resulted in the resident sustaining bruising on both upper arms and a scratch on the ear. The resident, who has a history of dementia, cognitive communication deficit, and other neurological and psychiatric conditions, was at high risk for confusion and wandering. The abuse was not immediately witnessed by other staff, but signs of injury were noted over the following days. A CNA noticed a scratch and bleeding on the resident's ear, and a registered nurse trimmed the resident's nails, suspecting self-inflicted injury. The next day, bruising was observed on the resident's arms during a shower, and the nurse was informed. The resident initially stated he had bumped into a wall, but later reported that a man had touched or hit him, and subsequently refused to enter the dining room. These behavioral changes and physical findings prompted further investigation by facility management. Upon review of surveillance footage, the manager and administrator confirmed the abusive actions of the CNA. The CNA was not assigned to the resident but was responsible for monitoring the dining room. Staff interviews revealed no prior concerns or incidents involving the CNA, and the CNA had previously completed abuse prevention training. The abuse was substantiated through the facility's investigation, which included medical record review, staff statements, and direct observation of the video evidence.
Expired Milk and Improper Sanitation Cloth Storage in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety and sanitation practices in the kitchen. Specifically, two 8-ounce cartons of skim milk with expired dates and one additional carton with a different expired date were found in the walk-in cooler. The dietary manager from the corporate office confirmed that dietary aides were responsible for checking and discarding expired food items but had not done so in this instance. Additionally, a wet kitchen sanitation cloth was found left on the food preparation counter rather than being stored in the sanitizing solution as required by facility policy. Facility documentation and policies reviewed by surveyors indicated that all towels must be returned to the sanitation bucket after use and that food products must be rotated and discarded by their expiration dates. The observed failures to discard expired milk and to properly store the sanitation cloth were not in accordance with these established procedures and had the potential to affect all 150 residents receiving food from the kitchen.
Improper Disposal and Management of Garbage Dumpsters
Penalty
Summary
The facility failed to ensure that outside garbage waste dumpsters were properly closed with lids, as required by facility policy, to prevent pest infestation and foul odor. Observations revealed that two out of three dumpsters were overfilled with garbage and had lids left partially open. Staff interviews indicated that multiple departments, including dietary and housekeeping, contributed to the use of these dumpsters, and there was uncertainty regarding who was responsible for leaving the lids open. The facility's policy specifies that dumpsters must be kept closed at all times and the surrounding area clean, with instructions to contact the garbage service if dumpsters become full. At the time of the deficiency, 150 residents were residing in the facility.
Failure to Implement Infection Control Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to follow infection control protocols for residents on transmission-based precautions for COVID-19. Specifically, two residents with confirmed COVID-19 diagnoses were not provided with trash receptacles in their rooms for the disposal of personal protective equipment (PPE), as required by facility policy. Staff, including CNAs, RNs, and housekeeping, reported that there was no designated place to discard used PPE in these rooms, leading them to dispose of PPE in hallway trash cans. Management and the infection preventionist confirmed that isolation rooms should have dedicated trash receptacles for PPE, but these were not present. Additionally, the facility did not maintain proper contact and droplet isolation for COVID-19 positive residents. One resident was observed using both their own bathroom, which was shared with other residents, and a communal rehab bathroom, contrary to orders and facility policy that called for a dedicated bathroom. There were no signs posted to redirect the resident to the appropriate bathroom, and staff were unaware of the cleaning schedules for these shared spaces. The infection preventionist and DON acknowledged the risk of infection spread due to improper bathroom use and lack of cleaning oversight. Furthermore, another resident on isolation for COVID-19 was observed leaving their room, interacting with other residents, and using a cloth mask instead of a required disposable mask. This resident was seen smoking outside near others and attending resident council while removing their mask and coughing. Staff confirmed that the resident was not supposed to be off isolation and should have been using a surgical mask and maintaining distance from others. These lapses in infection control protocols were observed and confirmed by multiple staff members, and were not in accordance with the facility's own policies and CDC guidelines.
Failure to Maintain Lint Trap in Residents' Personal Dryer Creates Fire Hazard
Penalty
Summary
The facility failed to ensure the lint compartment and filter of the dryer used for residents' personal laundry were emptied, resulting in a significant buildup of lint. During a tour of the laundry area, surveyors observed a large accumulation of lint in the lint trap/screen compartment of the residents' personal use dryer. The Housekeeping/Laundry Director confirmed that there was no log sheet or established procedure for cleaning the lint trap/screen for this dryer, and stated uncertainty about who checks it when not present. The Housekeeper/Laundry Aide also reported that laundry aides do not check or log the lint trap/screen for the residents' personal dryer, only for the main dryers, and had never checked it during their shifts. Facility policy requires that all dryer lint screens be cleaned by laundry staff after every two loads and documented on a daily cleaning form. Job descriptions for both the Laundry Aide and Director of Housekeeping specify responsibilities for safe equipment use and adherence to facility policies and procedures. Despite these requirements, the lack of a cleaning schedule, documentation, and staff awareness regarding the residents' personal dryer led to the deficiency, creating an unsafe environment and a fire hazard with the potential to affect all 150 residents.
Failure to Provide Timely Oral and Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents who were dependent on staff for care, specifically in the areas of oral hygiene and timely incontinence care. Observations revealed that two residents had visible accumulations of brown sediments on their teeth, indicating a lack of oral care. One of these residents was unable to communicate due to cognitive impairment, while the other, who was cognitively intact, reported that staff had not assisted with mouth care for an extended period. Both residents had care plans indicating the need for staff assistance with oral hygiene due to self-care deficits related to their medical conditions. In addition, two other residents who were paraplegic and always incontinent reported and were observed to experience delays in receiving incontinence care. One resident stated that incontinence care was typically provided only twice daily, resulting in prolonged periods spent in wet undergarments while seated in a wheelchair. Another resident was found in bed with a strong odor of urine and feces, having activated the call light for assistance approximately five minutes prior to being attended to. This resident reported that wait times for incontinence care could exceed one hour, and staff interviews confirmed that care was not consistently provided every two hours as required by facility policy. The affected residents had significant medical histories, including hemiplegia, paraplegia, neuromuscular dysfunction of the bladder, and other conditions resulting in self-care deficits. Facility policies and job descriptions for CNAs, LPNs, and the DON outlined the expectation for regular oral care and incontinence care every two hours or as needed, but these standards were not met for the residents reviewed. The deficiencies were identified through direct observation, resident interviews, record reviews, and staff interviews.
Failure to Ensure Functioning Pressure-Relieving Mattress for At-Risk Resident
Penalty
Summary
A resident identified as being at risk for pressure ulcers was observed in bed with a low air loss mattress (LALM) that was not functioning, as the mattress was almost flat and the power was off. The Assistant Director of Nursing confirmed that the machine was not working due to the power being off and indicated that the mattress would not function unless the power was turned on. The resident's care plan and physician orders specified the use of a pressure-reducing mattress as an intervention for pressure ulcer prevention, and the facility's guidelines require adherence to such interventions for residents at risk. The resident's medical history included diagnoses such as protein calorie malnutrition, venous insufficiency, dementia, muscle wasting and atrophy, poly-osteoarthritis, and dermatitis, all of which increase the risk for pressure ulcers. The resident was assessed as being at risk for pressure ulcers, and the care plan included the use of a pressure-reducing mattress. Despite these documented needs and interventions, the required equipment was not operational while the resident was in bed, constituting a failure to provide appropriate pressure ulcer prevention as ordered.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors observed multiple failures in the provision of respiratory care for six residents requiring oxygen therapy. Oxygen equipment, including nasal cannulas and tubing, was found not properly contained, labeled, or dated in several resident rooms. In some cases, oxygen tubing was left hanging on tanks or concentrators, touching the floor, or not stored in a clean manner, contrary to facility policy and infection control standards. Additionally, oxygen equipment was not consistently bagged when not in use, and there was a lack of labeling to indicate when tubing was last changed, despite physician orders and facility protocols requiring weekly changes and proper documentation. Further deficiencies included the absence of required signage indicating oxygen was in use in resident rooms, as observed with one resident receiving oxygen therapy without any visible warning sign. Staff interviews confirmed that signage should have been present and that its absence was an oversight. In another instance, a resident's oxygen concentrator was set at a higher flow rate than prescribed by the physician, with both the resident and a registered nurse acknowledging the discrepancy. This failure to follow physician orders for oxygen flow rates was noted as a direct deviation from the resident's care plan and medical orders. The residents affected had significant medical histories, including chronic obstructive pulmonary disease, emphysema, acute respiratory failure, and other serious conditions requiring careful respiratory management. Documentation reviewed by surveyors showed that care plans and physician orders specified the need for monitoring, proper storage, and regular changing of oxygen equipment. Despite these directives, staff did not consistently adhere to established protocols, resulting in lapses in safe and appropriate respiratory care for all six residents reviewed.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices. During observations, it was found that several multi-dose medications, such as Latanoprost and Fluticasone nasal spray, were not labeled with open dates, making it unclear how long they had been in use. Additionally, artificial tears for two residents were found with open dates that exceeded the recommended 30-day usage period. These lapses in labeling and timely discarding of medications could result in the administration of expired drugs. Unopened insulin pens requiring refrigeration were found stored in the medication cart instead of the refrigerator, contrary to pharmacy auxiliary labels and facility policy. Staff interviews confirmed that unopened insulin should be refrigerated, and that failure to do so could compromise medication integrity. Furthermore, the daily refrigerator temperature logs on the 3rd floor had missing entries, and staff acknowledged that temperature checks were not consistently performed as required. This inconsistency in monitoring could affect the safety and efficacy of temperature-sensitive medications stored for all residents on the floor. Vaccines were also found stored in the refrigerator, but temperature monitoring was only performed once daily instead of the expected twice daily when vaccines are present. Staff were unclear about the correct monitoring frequency, indicating a lack of adherence to established protocols. The facility's own policies require medications to be stored according to manufacturer recommendations, with proper labeling and timely removal of outdated drugs, but these procedures were not consistently followed for the residents involved.
Failure to Monitor and Document Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of personal refrigerators used by residents for food storage. Observations revealed that several residents' personal refrigerators were missing required temperature log sheets and thermometers. Specifically, one resident's refrigerator had multiple days with missing temperature checks and staff initials, while another resident's refrigerator had no documentation of temperature checks at all. Additional refrigerators were found without log sheets or thermometers, and in some cases, residents were unaware of the missing items or stated that staff were responsible for maintaining them. Interviews with staff, including the Director of Nursing (DON) and Housekeeping Director, confirmed that facility policy requires daily temperature checks and documentation for each resident's personal refrigerator. Staff are expected to record the temperature and their initials on a log sheet every shift, and each refrigerator should be equipped with a thermometer. The purpose of these checks is to ensure that food is stored at safe temperatures to prevent spoilage and potential illness. However, the observed lack of documentation and missing equipment indicated that these procedures were not consistently followed. The residents affected by these deficiencies had various medical conditions, including weakness, abnormalities of gait and mobility, repeated falls, diabetes, and other chronic illnesses. Some residents were cognitively intact and able to report on the situation, while others were unable to participate in interviews due to altered mental status. Despite the presence of food in the refrigerators, there were no immediate concerns about the condition of the food itself, but the absence of required monitoring and documentation represented a failure to comply with facility policy and safe food storage practices.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents as required by their care plans. One resident, who is blind and has multiple diagnoses including encephalopathy, weakness, and reduced mobility, was observed trying to locate his call light, which was found out of reach between the siderail and the floor. The resident expressed difficulty in finding the call light, and his care plan specifically required that the call light be kept within reach due to his self-care deficits and moderate cognitive impairment. Another resident, who was lying on a low air loss mattress and has a history of falls, osteoarthritis, and cognitive impairment, was unable to locate the call device. The call device was found stuck on the headboard and not within the resident's reach. The care plan for this resident also required that the call light be placed within reach due to fall risk and decreased safety awareness. Facility policy and CNA job descriptions further specify that call lights should be kept within easy reach of residents, but these procedures were not followed in these instances.
Lack of Clinical Justification for Psychotropic Medication Increase
Penalty
Summary
The facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication for a resident diagnosed with multiple psychiatric conditions, including depression, schizoaffective disorder/bipolar type, major depressive disorder, alcoholism-dependence/withdrawal, and anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 15. The physician order sheet documented an increase in Venlafaxine HCL ER from 225 mg to 300 mg daily, but there was no corresponding progress note or documentation from the interdisciplinary team (IDT) or physician explaining the need for this dosage increase or describing any behavioral interventions considered prior to the change. Review of the medication administration records confirmed that the resident received the increased dosage as ordered. The Director of Nursing (DON) was unable to provide documentation of an IDT meeting or clinical justification for the medication change. The facility's policy requires that psychotropic drug use be based on comprehensive assessment and that gradual dose reductions and behavioral interventions be implemented unless contraindicated, with dosage reductions attempted per CMS guidelines unless clinically contraindicated. These requirements were not met in this instance.
Failure to Provide Range of Motion Exercises and Restorative Devices
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate range of motion (ROM) exercises and apply restorative devices for three residents with limited mobility and contractures. One resident with contractures of both hands and quadriplegia was observed without hand protectors or splints in place, despite care plans and physician orders specifying the use of such devices. Staff confirmed that the required splints and palm protectors were not available, and temporary alternatives such as rolled towels were not implemented as directed. The restorative nurse acknowledged the lack of supplies and indicated that the administrator had been informed, but no interim measures were put in place. Another resident with left-sided weakness from a stroke reported that staff had not been providing ROM exercises for the affected limbs, expressing concern about developing contractures. A third resident also complained of not receiving ROM exercises for over two weeks. The restorative aide responsible for these residents stated that one of the residents was not on the current list for ROM exercises and admitted that the list was outdated. The aide also noted being unable to perform ROM exercises for all assigned residents due to time constraints and other duties, such as escorting residents or covering for staff absences. Record reviews for the affected residents showed documented diagnoses of contractures, hemiplegia, muscle weakness, and reduced mobility, with care plans and physician orders specifying the need for restorative interventions, including ROM exercises and the use of assistive devices. Facility policies and job descriptions for restorative staff and CNAs require the provision and documentation of ROM exercises and the use of restorative equipment to maintain or improve residents' mobility. Despite these requirements, the facility did not ensure that restorative care was consistently provided, and necessary devices were not available or used as ordered.
Failure to Secure and Account for Controlled Medications
Penalty
Summary
Surveyors identified several deficiencies related to the management of controlled medications. During an observation of the medication storage area, a nurse accessed a refrigerator containing controlled substances without a lock, despite the presence of Lorazepam for a resident whose medication order had already been completed. The nurse acknowledged that the refrigerator should have been locked due to the presence of controlled medications and found the lock on the floor, indicating it was not in use. Additionally, the completed Lorazepam medication, which should have been returned to the pharmacy after the order ended, was still present in the facility. Further review of medication administration records and interviews revealed that the facility failed to ensure proper documentation on the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. Specifically, there were missing signatures from outgoing nurses on two separate dates, which was confirmed by staff. The expectation, as stated by facility leadership, is that both incoming and outgoing nurses count and sign for controlled medications at each shift change to ensure accountability and accurate record-keeping. The residents affected by these deficiencies included individuals with diagnoses such as osteoarthritis, hypertension, seizure history, neuralgia, hemiplegia, low back pain, post-traumatic stress disorder, and sleep disorder. The facility’s policies and job descriptions require that controlled substances be double locked, properly disposed of or returned when no longer needed, and that accurate shift-to-shift counts and documentation be maintained. These requirements were not met, as evidenced by the unsecured storage, retention of completed medications, and incomplete shift count records.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by a verbal and physical altercation between them. One resident, a female with emphysema, hypothyroidism, and liver disease, and a history of conflictual behavior and susceptibility to abuse, was involved in a dispute with a male resident who has a vertebra fracture, neurogenic bowel, anxiety disorder, depressive disorder, and angina pectoris, and is also care planned as susceptible to abuse. During the incident, the male resident threw water on the female resident during a verbal altercation, and both exchanged derogatory and offensive language. The altercation was witnessed by an LPN, who separated the residents and reported the incident to the administrator/abuse prevention coordinator. The incident was also reported to the police. Both residents had documented histories of behavioral issues, including verbal threats, use of profanity, and difficulty coping with stress. The facility's abuse prevention policy prohibits and aims to prevent resident abuse, neglect, and mistreatment, but the altercation and subsequent investigation revealed that the facility did not ensure the right of these residents to be free from abuse. The incident was documented in progress notes and an abuse prevention investigation, with both residents expressing that they felt safe after the event, but the deficiency centers on the facility's failure to prevent the abusive interaction from occurring.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse, affecting two residents out of five reviewed. In one incident, a resident with moderate cognitive impairment and diagnoses including parkinsonism and weakness was pushed by another resident after a verbal disagreement in the hallway, resulting in a minor scrape to the elbow. Staff intervened and separated the residents, and the injured resident reported feeling safe afterward. In a separate incident, another resident with intact cognition and a history of chronic heart failure and mobility issues was punched in the eye by the same aggressor after requesting that the television volume be lowered late at night. The aggressor also yelled derogatory language and threatened further violence. Staff, including an LPN and a CNA, responded to the altercation, attempted to redirect the aggressor, and called for additional assistance when the aggressor became physically and verbally aggressive toward both staff and the other resident. The injured resident declined police involvement and reported no lasting distress. The aggressor resident had a history of major depressive disorder, aphasia, and hemiplegia, with documented moderate cognitive impairment. Care plans noted the resident's risk for abuse and socially inappropriate behaviors, including playing loud music and difficulty with interpersonal interactions. Despite these known risks and previous incidents, the facility did not effectively prevent further altercations, resulting in physical and verbal abuse between residents.
Failure to Respond to Nurse Call Lights in a Timely Manner
Penalty
Summary
The facility failed to meet the needs of residents by not responding to nurse call activations in a timely manner for three out of ten residents sampled. Resident Council Meeting Minutes from January and February 2025 highlighted ongoing issues with CNAs not responding to call lights, being rude, and not providing timely assistance, especially during meal times. Residents reported waiting for extended periods, sometimes up to two hours, for assistance after activating their call lights. Specific incidents included residents waiting for ADL care and remaining in soiled conditions due to delayed responses. On March 24, 2025, a surveyor observed a nurse call light activated on the 2nd floor, which went unanswered for an extended period. Despite being aware of the call light, both an LPN and a CNA failed to respond, citing being too busy. The facility's policy requires all staff to promptly and courteously respond to call lights, but this was not adhered to, leading to the deficiency. The lack of timely response to call lights was corroborated by resident statements and direct observations by the surveyor.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to ensure the right to be free of abuse for two residents, resulting in minor injuries. The incident involved two female residents, both with a BIMS score of 15/15, indicating they were cognitively intact. The first resident, with a history of Diabetes 2, Anxiety Disorder, Heart Disease, and Pyoderma Gangrenosum, and the second resident, with a history of Diabetes 2, Chronic Respiratory Failure, Peripheral Vascular Disease, and Congestive Heart Failure, engaged in a physical altercation. The altercation occurred during a disagreement over whether the door to their shared room should remain open while they were playing cards. The first resident sustained a superficial scratch on her forearm, while the second resident received a small mark under her eye. The incident was promptly addressed by staff, who intervened and separated the residents. Both residents were sent to the hospital for psychiatric evaluations, although they did not require treatment for injuries. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the physical contact between the residents. Despite the altercation, both residents expressed feeling safe in the facility and declined police involvement. The facility's failure to prevent the altercation constitutes a deficiency in protecting residents from abuse.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to follow its policy to ensure a resident is free from abuse, affecting one resident (R2) out of three reviewed for abuse. R2, who has a history of various medical conditions including epilepsy, cerebral infarction, and mental health disorders, reported being physically abused by another resident (R1) on 11/30/24. R2 stated that R1 punched him in the back without provocation as he was coming off the elevator. Although R2 did not sustain visible injuries, he expressed feeling abused by the incident. Multiple staff members and residents provided accounts of the incident. An LPN, who did not witness the event, responded to a Code PURPLE and found R1 agitated and wanting to smoke. The LPN was informed by a receptionist that R1 had hit R2. A social service director confirmed that R1 was sent to the hospital for psychiatric evaluation following the altercation. A CNA and another resident corroborated R2's account, stating that R1 deliberately hit R2. The facility's Director of Nursing and other staff members acknowledged the incident, with the DON noting that R1 made contact with R2 and was subsequently placed on 1:1 supervision until transferred to the hospital. The facility's policies on abuse prevention and residents' rights were not adequately followed, as evidenced by the lack of an abuse care plan for R1, who had a history of aggressive behavior. The facility's abuse prevention program defines abuse as the willful infliction of injury or harm, and the incident between R1 and R2 was considered physical abuse by several witnesses. Despite the facility's policy to prevent abuse, the incident occurred, highlighting a deficiency in the implementation of the facility's abuse prevention measures.
Verbal Abuse by Receptionist Towards Resident
Penalty
Summary
The facility failed to prevent verbal abuse by a staff member, specifically a former receptionist, towards a resident. The incident involved the receptionist, identified as V3, who allegedly used profanity towards a resident, R2, when R2 verbally shared the security code for the door with others. This interaction was witnessed by another resident, R4, who confirmed hearing the receptionist curse at R2. The incident was reported to the facility's administrator, V1, who apologized to R2. Despite the resident feeling safe and not experiencing physical or emotional distress, the use of profanity was considered verbal abuse by several staff members interviewed. The facility's investigation into the incident involved interviews with various staff members and residents. V5, another receptionist, and V7, a restorative aide, both acknowledged that swearing at a resident constitutes verbal abuse. V10, a CNA, did not recall the incident but agreed that such behavior is abusive. V2, the Director of Nursing, and V11, the Social Service Coordinator, both indicated that if the statement was made, it would be considered verbal abuse, regardless of the resident's feelings of safety. The administrator, V1, conducted an investigation and concluded that while the abuse could not be substantiated, the receptionist's communication was inappropriate and made R2 uncomfortable. The facility's policy on abuse prevention clearly prohibits verbal abuse, defining it as the use of disparaging or derogatory language towards residents. Despite the facility's inability to substantiate the abuse claim, the incident highlights a failure to protect the resident from verbal abuse, as defined by the facility's policy. The receptionist was suspended pending the investigation, and the facility's protocol was implemented, although the report does not detail specific corrective actions taken post-incident.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to provide a scheduled pain medication, Tramadol, per doctor's order for effective pain management for a resident diagnosed with progressive systemic sclerosis, Raynaud's syndrome, and other mobility issues. The resident, who is cognitively intact, reported experiencing significant pain and discomfort due to the lack of Tramadol, which was not administered on specific days. The resident expressed that without Tramadol, she was unable to get out of bed without experiencing a lot of pain and discomfort in her joints and body. On the day of the survey, a registered nurse (RN) was observed attempting to administer medications but found that the Tramadol was not available in the medication cart. The RN offered Tylenol as an alternative, which the resident accepted despite stating it would not be effective. The Director of Nursing (DON) later retrieved Tramadol from the emergency medication system after encountering issues with the system being offline. The resident's medication administration record confirmed that Tramadol was not administered on a specific date, and there was no documentation of the resident refusing the medication. The report highlights communication and procedural lapses among the nursing staff and pharmacy, leading to the resident not receiving her prescribed medication. The nurse practitioner was not aware of the medication lapse and indicated that the staff could have contacted the on-call provider for an emergency refill. The facility's documentation guidelines state that medications should be administered as prescribed, but the resident's care plan and medication records were not followed, resulting in the deficiency.
Failure to Protect Residents from Abuse and Address Injury
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse, resulting in one resident experiencing a right foot injury. The incident began with a verbal disagreement between the two residents over the use of the washroom in their shared room. One resident, who was eating lunch, became upset when the other resident used the bathroom with the door open. This led to a heated argument, during which the resident in the wheelchair felt threatened and physically engaged with the other resident, resulting in both residents falling to the floor. The resident in the wheelchair sustained a right foot injury during the altercation, which was later diagnosed as a subacute fracture of the distal right fourth metatarsal. Despite the resident's complaints of foot pain following the incident, the facility staff initially failed to address the injury adequately. The resident reported the pain to several nurses, but it was not until a week later that an LPN arranged for an X-ray, which confirmed the fracture. The resident's foot was swollen and painful, and the resident was unable to stand, which was a change from their previous ability to stand independently. Interviews with staff revealed that the altercation was witnessed by multiple staff members, including a Social Service Director and a Certified Nursing Assistant, who observed the residents arguing and physically engaging with each other. The facility's policy on abuse prevention emphasizes the importance of creating a safe environment and preventing abuse, yet the staff did not intervene effectively to prevent the altercation or address the resulting injury promptly. The facility's failure to protect the residents from abuse and to respond appropriately to the injury constitutes a deficiency in care.
Failure to Follow Professional Standards and Timely Report Injuries
Penalty
Summary
The facility failed to maintain a safe environment and follow professional standards of practice, resulting in injuries to two residents. One resident, R2, experienced new onset right foot pain after an altercation with another resident, R1, on 6/24/24. Despite R2's repeated complaints of pain, the facility delayed notifying the physician until 6/28/24, and an X-ray on 6/30/24 revealed a new healing subacute fracture of the distal right fourth metatarsal. The facility did not document any assessment or follow-up related to R2's right foot injury until the physician was notified. Another resident, R5, suffered a left knee fracture after an incident on 6/20/24, where R5's wheelchair collided with a brick wall. R5 later reported right knee pain after hitting it on a bedframe on 7/3/24, but the facility failed to promptly assess or notify the physician of this new injury. Despite R5's complaints and the physical therapist's recommendation for an X-ray, the facility did not take action until 7/10/24, when a CT scan revealed an acute inter-articular fracture of the right femoral condyle. The facility's policies require immediate assessment and notification of the physician for any incidents resulting in injury or significant changes in a resident's condition. However, in both cases, the facility did not adhere to these policies, leading to delays in diagnosis and treatment. The lack of timely communication and documentation contributed to the deficiencies identified by the surveyors.
Inadequate Supervision Leads to Resident Self-Harm
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident with a history of unsafe and self-harmful behaviors, resulting in the resident sustaining a nasal fracture. The resident, identified as R3, had multiple diagnoses including schizoaffective disorder, depressive type, and a history of physically aggressive behavior. On 6/17/2024, R3 was observed hitting himself in the face in the dining room, which led to a nasal fracture. Despite being in a supervised area, the staff present did not prevent the self-harm incident. The incident was not immediately addressed, as discoloration on R3's face was only noticed two days later on 6/19/2024, prompting a call to the doctor and subsequent x-rays that confirmed the fracture. Staff interviews revealed inconsistencies in monitoring R3, with some staff unsure if R3 was being monitored at the time of the incident. The facility's policy required notification of the resident's physician and representative in case of significant changes in the resident's condition, but it is unclear if this was done promptly. The facility's guidelines for handling behavioral emergencies emphasize early recognition and intervention, but these were not effectively implemented in R3's case. The documentation showed that 15-minute checks were initiated only after the incident, indicating a lapse in proactive supervision. The lack of consistent monitoring and immediate intervention contributed to the resident's injury, highlighting a deficiency in the facility's supervision and safety protocols for residents with known self-harm behaviors.
Failure to Comply with Medication Administration Standards
Penalty
Summary
The facility failed to provide medication in compliance with standards of professional practice and facility policy for a resident, identified as R5. On 7/9/2024, R5 was observed with a lidocaine patch on the right knee dated 7/7/2024 and another patch on the left knee without a date. R5 mentioned that the patches had been on for a few days. A Licensed Practical Nurse (LPN), V4, was unaware of the patches and confirmed there was no order for lidocaine patches for R5. The Director of Nursing (DON), V2, later confirmed that there was no active order for lidocaine patches until 7/8/2024, and the nurse had incorrectly documented the application date. Additionally, there was no documentation of the lidocaine patch application until 7/9/2024. On 7/11/2024, R5 was observed with two lidocaine patches on the right knee, both undated, contrary to the order for one patch. Another LPN, V3, acknowledged the lack of documentation and communication regarding the patches. The DON provided documentation of a lidocaine patch application on 7/11/2024, but it was noted that the order was for only one patch. V10, an LPN who worked with R5 on 7/8/2024, stated that she did not apply the patches and was unaware of their presence. The facility's policy requires medications to be administered and documented according to physician orders, which was not followed in this case.
Failure to Conduct Timely Background Checks for New Residents
Penalty
Summary
The facility failed to perform timely criminal background checks for new residents, which is a critical step in preventing abuse and ensuring the safety of all residents. Specifically, the facility did not complete the Criminal History Information Response Process (CHIRP) within the required 24 hours of admission for several residents, nor did they obtain fingerprint orders within 72 hours when a preliminary criminal history search indicated a potential issue. This deficiency affected multiple residents, including those with serious mental health conditions such as schizoaffective disorder, bipolar disorder, and dementia. Interviews with facility staff revealed a lack of clarity and coordination in the process of conducting these background checks. The Administrator expressed hope that residents were isolated until CHIRP results were received, while the Admissions Director and Social Services Director provided conflicting accounts of their responsibilities. The Admissions Director stated that CHIRP is conducted upon admission, but the Social Services Director indicated that they were responsible for further checks and fingerprinting, which were not completed in a timely manner. The facility's policies on abuse prevention and resident rights emphasize the importance of protecting residents from abuse and ensuring a safe environment. However, the failure to adhere to these policies and complete necessary background checks in a timely manner demonstrates a significant oversight. The lack of documentation for some residents further highlights the gaps in the facility's procedures, which could potentially affect the safety and well-being of all residents.
Incomplete Background Checks Pose Risk to Residents
Penalty
Summary
The facility failed to ensure that Health Care Worker Background Checks were thoroughly completed and conducted in a timely manner, which is crucial for preventing abuse. This deficiency was identified during a survey where it was found that the background check for an employee, a cook hired in 1998, was not completed until over 20 years after their hire date. The Illinois Department of Public Health's Health Care Worker Registry indicated that the employee's work eligibility was 'Not Yet Determined,' and no further action, such as fingerprinting, was taken to resolve this status. The Regional Human Resource Director acknowledged the oversight and could not provide an explanation for why the previous Human Resource Director did not address the issue. The facility's policies, including the Abuse Prevention Program and the Facility Assessment Tool, require that criminal history checks and healthcare work registry checks be completed before a new employee starts working. However, these procedures were not followed in this case, as evidenced by the incomplete background check for the cook. The facility's job description for the Human Resource Director outlines the responsibility for ensuring all new hire paperwork, including background checks, is complete, but this responsibility was not fulfilled, leading to a potential risk for all 137 residents in the facility.
Failure to Post Accurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information accurately and in a timely manner, which has the potential to affect all 137 residents residing in the facility. On multiple occasions, the surveyor observed that the daily nursing staffing information posted near the receptionist area was outdated, showing a date of 5/17/24 instead of the current date. The Director of Nursing acknowledged the issue and replaced the outdated posting with a current one. However, the updated posting still contained inaccuracies, such as an incorrect resident census and lack of specific unit information. The receptionist, who is responsible for posting the daily staffing information, was not present on the day the deficiency was noted and was unsure why the information had not been updated since 5/17/24.
Failure to Monitor Food Storage Temperatures
Penalty
Summary
The facility failed to maintain adequate monitoring of food storage temperatures, which has the potential to affect all residents. During an observation and record review, it was noted that the Milk Cooler refrigerator temperature log for May 2024 lacked temperature recordings for both the AM and PM shifts on specific dates. The Dietary Manager confirmed that the temperature log should have been completed twice daily and acknowledged the importance of tracking the cooler's temperature to prevent milk spoilage. The facility's policy on the storage of refrigerated and frozen foods requires monitoring of food temperatures and the functioning of refrigeration/freezer units.
Infection Control Deficiencies in PPE Use and Signage
Penalty
Summary
The facility failed to ensure proper disposal of personal protective equipment (PPE) by staff handling soiled linens, as observed in the case of a laundry aide who reused a blue plastic gown throughout an entire shift. The aide, who had been working at the facility for six years, was not informed of the requirement to wear a new gown each time they sorted dirty linens. This practice was contrary to the facility's infection control guidelines, which mandate the use of new gowns and gloves after handling soiled items to prevent the spread of infectious microorganisms. Additionally, the facility did not appropriately post precautionary signage for a resident on enhanced barrier precautions. An isolation bin was observed outside the resident's room without the necessary precaution sign on the door. The resident had a gastrostomy tube and an indwelling catheter, which required enhanced barrier precautions as per the facility's policy. Staff acknowledged that the sign should have been posted to inform caregivers of the necessary precautions when providing care to the resident. The facility's infection control policies and guidelines emphasize the importance of handling soiled linens with protective apparel and posting precaution signs for residents requiring enhanced barrier precautions. However, these protocols were not followed, as evidenced by the reuse of PPE by the laundry aide and the absence of a precaution sign for the resident with medical devices. These oversights have the potential to affect all residents by increasing the risk of spreading infectious microorganisms.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that medication was not left inside the room of a resident whose ability to self-administer medications had not been assessed. This deficiency was observed when a small plastic bag containing a tube of medication was found on a resident's bedside table. The medication was intended for topical application to the resident's right thigh and perineal area for a skin condition. However, there was no self-administration care plan or assessment in place for the resident, and no physician's order had been written to allow the resident to self-administer the medication. The resident involved had a severely impaired mental status, as indicated by a Brief Interview for Mental Status (BIMS) score of 03. The Director of Nursing confirmed that the resident did not have a self-administration assessment or care plan, and highlighted the risk posed by leaving medication at the bedside, as other residents could potentially access and ingest it. The facility's policy requires an interdisciplinary team to assess a resident's ability to self-administer medication and obtain a physician's order, neither of which had been completed for this resident.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as observed during a survey. In one instance, holes and cracks were found on the walls inside the room shared by two residents. A registered nurse acknowledged that the damage might have been caused by staff pushing the bed against the wall. A maintenance assistant confirmed the presence of holes, cracks, and chipped paint on the walls and window, admitting that these conditions did not contribute to a homelike environment. Both residents involved were documented as having cognitive intactness, with one diagnosed with cerebral palsy and spinal stenosis, and the other with a wedge compression fracture and gastrointestinal hemorrhage. Additional observations included peeling faux wood covering on the footboard of a resident's bed and a hole in the wall beneath a window in another room. The maintenance director noted that the bed was very old and that the hole in the wall was due to beds being pushed against it. The director also acknowledged that these conditions did not represent a homelike environment for the residents. The facility's resident rights documentation emphasized the right to a dignified existence and a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Improper Low Air Loss Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that low air loss mattresses were set to the appropriate settings for four residents, which is crucial for pressure ulcer prevention. Observations revealed that the mattresses for these residents were set at higher weight settings than the residents' actual weights. For instance, one resident's mattress was set at 240 lbs, while their actual weight was 168.4 lbs. Another resident's mattress was set at 250 lbs, despite their weight being 123.8 lbs. These discrepancies were confirmed by the facility's staff, including the Director of Nursing and the Wound Care Coordinator. The report highlights that the incorrect settings on the low air loss mattresses could interfere with circulation and pressure relief, potentially leading to skin breakdown. The facility's guidelines and the mattress system's intended use emphasize the importance of setting the mattress according to the resident's weight to prevent pressure ulcers. However, the facility did not adhere to these guidelines, as evidenced by the incorrect settings observed during the survey. The residents involved had various medical conditions that increased their risk for pressure ulcers, such as impaired mobility, diabetes, and incontinence. The care plans for these residents included interventions like pressure-reducing mattresses, yet the improper settings on the mattresses compromised these interventions. The facility's failure to ensure the correct settings on the low air loss mattresses represents a significant oversight in pressure ulcer prevention and care.
Resident Dignity Compromised by Uncovered Medical Information
Penalty
Summary
The facility failed to ensure the confidentiality and dignity of a resident by leaving personal medical information in plain view within the resident's room. Specifically, signs detailing the resident's dietary requirements and aspiration precautions were posted on a bulletin board at the head of the resident's bed. These signs were visible to other residents and visitors, compromising the resident's right to privacy and dignity. The signs included instructions for honey thick liquid and aspiration precautions, which were placed by a Speech Language Pathologist (SLP) to ensure staff compliance with the resident's care plan. Interviews with facility staff revealed that the signs had been posted for approximately three months without being covered, despite awareness that they should be concealed to protect the resident's dignity and comply with HIPAA regulations. The Director of Nursing (DON) acknowledged that the information should have been covered to prevent unauthorized viewing by individuals entering the room. The resident in question had a history of dysphagia and essential primary hypertension, requiring a mechanically altered diet, as documented in their care plan and order summary report.
Failure to Provide Communication Devices for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication devices for a resident, identified as R54, who was unable to communicate effectively due to a language barrier and medical condition. Observations revealed that R54, whose primary language is Spanish, was unable to answer questions in either English or Spanish and could only use hand gestures. Despite the care plan indicating the need for communication aids such as a communication board, none were present in R54's room. Interviews with R54's family member and the responsible LPN confirmed the lack of communication interventions, with the LPN relying on Spanish-speaking housekeeping staff for translation. R54's medical records document a diagnosis of Cerebral Infarction and Aphasia, contributing to the resident's communication challenges. The Minimum Data Set indicated limited ability to make self-understood requests. The care plan specifically outlined the need for communication devices to assist R54, yet these were not utilized, leading to increased frustration for the resident. The facility's policy on communication with non-English speaking residents was not followed, as it required input from the resident or responsible party and specific care planning for communication barriers.
Failure to Change Midline Catheter Dressing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the changing of a midline catheter dressing for a resident. A resident had a midline catheter placed on their left arm, and the dressing was applied on the same day. However, the dressing was not changed for a week, as observed by a registered nurse, who noted redness around the chlorohexidine patch under the transparent area of the dressing. The registered nurse confirmed that the dressing had not been changed since its application, and acknowledged that the redness could indicate a potential infection, which should be reported to the resident's physician. The Director of Nursing stated that midline dressings should be changed weekly and monitored every shift for signs of infection, such as redness, swelling, or warmth. The facility's policy specifies that midline catheter dressings should be changed 24 hours after insertion, every 5-7 days, or if compromised.
Infection Control Lapses in Respiratory Care Equipment
Penalty
Summary
The facility failed to ensure proper infection control practices for respiratory care equipment for two residents. For one resident, the nebulizer mask was observed sitting on a bedside table without being contained in a plastic bag when not in use, contrary to the facility's policy for infection control. The Licensed Practical Nurse confirmed that the mask should be stored in a plastic bag to prevent contamination. The resident had a history of chronic obstructive pulmonary disease, anemia, bipolar disorder, and schizoaffective disorder, with a moderately impaired cognitive status. The facility's policy required the nebulizer mask and tubing to be changed weekly, which was not adhered to in this instance. For another resident, the nasal cannula attached to an oxygen tank was not changed weekly as required by the facility's protocol. The cannula was dated two weeks prior, and the Registered Nurse acknowledged that it should have been changed weekly by the night shift nurse. This resident also had a history of chronic obstructive pulmonary disease, pneumonia, and heart failure, with a moderately impaired mental status. The facility's policy mandated that oxygen tubing be changed, cleaned, and maintained no less than weekly, which was not followed, leading to a lapse in infection control practices.
Failure to Follow Fall Assessment and Documentation Procedures
Penalty
Summary
The facility failed to follow their policy and procedure for resident assessment and documentation after a fall/incident for one resident. The resident, who had a complex medical history including hemiplegia, end-stage renal disease, and a history of falling, reported a fall to a CNA early in the morning. The CNA informed the assigned nurse, who checked on the resident but did not perform a comprehensive assessment or document the incident as required by the facility's policy. The resident's electronic health record lacked documentation of the resident's physical and mental status following the fall, and no incident report was completed by the nurse on duty during the night shift. The Director of Nursing stated that after a fall, the nurse is expected to complete an incident report, document in the resident's electronic health record, perform a comprehensive assessment, and check vital signs and range of motion. Additionally, follow-up documentation should be done every shift for 72 hours to monitor the resident for any injury post-fall. However, these procedures were not followed in this case, as evidenced by the lack of documentation and assessment in the resident's health record. The facility's accident incident reporting policy also mandates immediate assessment and documentation, which was not adhered to in this instance.
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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