Landmark Of Richton Park Rehab & Nsg Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Richton Park, Illinois.
- Location
- 22660 South Cicero Avenue, Richton Park, Illinois 60471
- CMS Provider Number
- 145424
- Inspections on file
- 41
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Landmark Of Richton Park Rehab & Nsg Ctr during CMS and state inspections, most recent first.
Surveyors found that the facility’s always-available substitution menu consisted mainly of sandwich-type items (hamburgers, hot dogs, deli sandwiches, PB&J) without vegetables or balanced sides, resulting in substitutes that were not nutritionally comparable to the planned meals. A cognitively intact resident with diabetes, cardiac disease, and amputation reported only being offered sandwiches and hot dogs and being unable to obtain salads, while another cognitively intact resident with CHF, ESRD on dialysis, diabetes, and obesity showed photos of meals lacking protein and described frequently not receiving adequate protein or comparable alternatives when declining beef or pork. The Regional Dietary Director claimed the always-available items were nutritionally equivalent to entrées, but the RD acknowledged that vegetables were missing and that some items, such as hot dogs, might not provide appropriate protein, demonstrating that the facility failed to provide nutritionally equivalent substitutes in practice despite written policies requiring nutritionally comparable alternates across food groups.
A resident with multiple chronic conditions and a documented indwelling/suprapubic catheter was observed with an uncovered urinary drainage bag hanging from a wheelchair, with urine clearly visible. The cognitively intact resident voiced dissatisfaction with care, including the lack of a privacy cover for the catheter bag. An RN acknowledged the missing privacy cover, and the DON stated that all catheter bags are expected to have privacy covers due to dignity concerns. Facility policy on resident rights requires that residents be treated with dignity and respect, yet the uncovered catheter bag demonstrated a failure to uphold this standard.
A resident with schizophrenia and other comorbidities, who was cognitively intact and reported signing their own consents, had two PRN haloperidol orders (IM and oral) written with indefinite end dates and left in place for an extended period, contrary to federal requirements and facility policy that PRN psychotropic and antipsychotic medications be limited to 14 days with documented rationale and duration for any extension. The resident reported that staff were giving medications at incorrect times, sometimes late or not at all, and that staff did not listen to concerns about medication dosing. The ADON, DON, and NP acknowledged that PRN psychotropics should be time-limited and reassessed, and facility policies specified 14‑day limits, required physician evaluation and documentation for extensions, and required informed consent and clear indication for use, but these requirements were not implemented for this resident’s PRN haloperidol orders.
Surveyors found that the facility failed to ensure accurate and timely medication administration for two residents, resulting in repeated late or undocumented doses of antihypertensive medications for a dialysis patient and incorrect once-daily dosing of Eliquis for another patient with Afib and chronic heart failure. One resident, cognitively intact and dependent on dialysis, repeatedly received nifedipine ER and metoprolol outside the facility’s 1‑hour window, with multiple late or missing administrations and no consistent documentation or provider notification, despite facility policies requiring timely dosing, documentation, and clarification of scheduling conflicts. Another cognitively intact resident was admitted on Eliquis 5 mg BID per hospital discharge instructions but was ordered and given Eliquis 5 mg only once daily for several days due to an admission order entry error, even after pharmacy questioned the order, contrary to policies requiring accurate transcription, double‑check of admission orders, and adherence to standard dosing practices.
A resident with multiple chronic conditions and a diabetic diet order reported that facility meals were unappetizing and often lacked protein, providing photos of prior trays with plain rice and vegetables, plain oatmeal, and a burnt, unidentifiable meat item. During an observed lunch, instead of the posted menu, the resident received a small bowl of greasy chicken-and-corn soup, a very small piece of cornbread, dry iceberg lettuce with minimal dressing, and mostly melted strawberry ice cream. A CNA and an RN both confirmed the food looked unappetizing, the salad dry, and the ice cream melted, and noted frequent resident complaints that the food tastes bad and is insufficient. The interim dietary manager and consultant RD acknowledged that the observed tray did not look appetizing and that food should be attractive and served at appropriate temperatures, which conflicted with the facility’s own food presentation policy.
A resident with multiple comorbidities, including HF, CKD stage 3, Afib, T2DM, morbid obesity, PVD, anemia, and a history of falls, had physician orders for Midodrine, nutritional supplements, VS three times daily, blood sugar checks three times daily, and STAT labs (CBC and CMP). An RN reported calling in the STAT labs and obtaining a confirmation number, then endorsing the pending labs to the next shift, but there was no evidence the labs were ever drawn and no documentation of follow-up or VS on the following day. The DON stated that nurses are expected to carry out and follow up on all provider orders, including STAT labs, consistent with facility policy requiring all physician orders to be implemented and followed throughout the resident’s stay.
A resident with multiple complex diagnoses, including quadriplegia and severe protein calorie malnutrition, reported chewing only on one side due to painful teeth with holes on the opposite side, yet had not been seen by dental services at any time during her stay. The DON stated that residents are supposed to receive dental screenings on admission, quarterly, and as needed, but this process was not carried out for this resident. This was inconsistent with the facility’s dental services policy, which requires licensed nurses to perform comprehensive oral assessments, inquire about chewing difficulties and pain, inspect the oral cavity, and promptly address any negative findings through physician and dental provider notification.
A resident was sent out for an appointment without the required transfer documentation, including a face sheet, physician orders, and MAR, contrary to facility policy. The DON stated that staff are informed of appointments in advance and are expected to prepare and send this paperwork with the transporter. The resident’s night nurse reported she was unaware of the appointment and, although she had printed the necessary documents, did not send them because she could not access the computer room to retrieve them.
A resident who required assistance with ADLs was sent to an outside medical appointment in an unclean and unkempt condition, despite facility policy requiring routine hygiene care. The DON reported learning from the resident’s family that the resident had been sent out dirty, and acknowledged that staff are informed of appointments in advance and are expected to have residents ready. The night RN stated she was unaware of the appointment initially, then instructed a CNA to clean the resident while she prepared required paperwork, but could not confirm that the cleaning was completed. The resident, who had a stage 3 pressure ulcer on the heel under wound care, nonetheless arrived at the appointment without having been properly cleaned, contrary to the facility’s ADL guidelines.
Two residents experienced repeated colostomy leaks when staff did not consistently provide effective colostomy care in accordance with facility policy. One cognitively intact resident returned from the hospital and was twice observed with a leaking colostomy bag, while CNAs acknowledged they had not checked him promptly and that nurses were responsible for colostomy care. Another resident with severe cognitive impairment was observed with a leaking colostomy and stool on his abdomen after a recent colostomy change, and an LPN stated the appliance should not leak and did not know who had changed it. A nurse consultant confirmed that nurses are responsible for colostomy changes and that colostomies should not leak because this can cause skin irritation and infection.
Two residents experienced leaking colostomies and improper catheter management when staff failed to follow facility policies. One cognitively intact male with a colostomy and suprapubic catheter was observed with a leaking colostomy appliance taped at the insertion site, a dirty, soaked, loose dressing at the catheter site beneath the colostomy, and a urinary catheter bag placed in the bed instead of below bladder level; he reported recent hospitalizations for infection and was receiving IV antibiotics for UTI. Another male with severe cognitive impairment was found with a colostomy leaking a moderate amount of stool onto his abdomen after a recent appliance change. Staff interviews confirmed that nurses are responsible for colostomy care, that colostomies should not leak, and that catheter drainage bags should be kept below bladder level, consistent with the facility’s written policies.
A post‑surgical resident with bilateral hip ORIF and high ADL needs did not receive coordinated follow‑up, therapy, or basic care as ordered. A clearly documented orthopedic follow‑up appointment was not scheduled, and two later appointments arranged by the facility were also missed due to transportation issues, without documentation or physician notification. Despite orders for PT/OT/ST, therapy was discontinued after a short period because of a non‑weight‑bearing order, and the resident remained out of therapy while staff waited for updated weight‑bearing instructions that never came. The resident, who required substantial/maximal assistance and was dependent for toileting and transfers, reported not receiving showers or bed baths, sitting in urine and feces for hours, and attempting transfers alone when call lights were unanswered. Surveyors observed full urinals left on the bedside table and bed rail, and there was no documented nursing assessment of the surgical site, which later became swollen and painful with imaging showing likely DVT. The resident expressed feeling hopeless and uncared for regarding his pain and healing.
A resident with a history of spinal and pelvic fractures and a recent hip surgical site experienced uncontrolled post‑op pain rated 10/10 because ordered PRN oxycodone and acetaminophen were not consistently administered, monitored, or documented. Staff at various times told the resident there was no oxycodone order or that the medication was not available in the narcotic box, while pharmacy manifests showed multiple deliveries of oxycodone. MAR review revealed that oxycodone and Tylenol were largely not signed out as given over two months, and Tylenol was never documented as offered or refused, despite a care plan requiring administration of analgesics as ordered, offering PRN medication before ADLs and wound care, and monitoring effectiveness. The DON later stated that nurses were not signing the MAR even though the resident was receiving oxycodone, and facility policies required complete MAR and PRN documentation and emphasized effective pain management based on the resident’s reported pain, yet the resident reported ongoing severe pain and psychological distress.
A resident admitted post-ORIF with a history of fractures, anemia, anxiety, and substance abuse did not have PRN oxycodone or acetaminophen consistently documented on the MAR, despite active orders and pharmacy records showing multiple deliveries of oxycodone. Narcotic receipt and disposition records were missing for one month, and there was no documentation of medication refusals, PRN indications, or effectiveness of pain medications. Nursing staff also failed to document shift assessments of the surgical site, and an RN reported not assessing the site or being aware of staples and swelling, contrary to facility policies and RN/LPN role expectations for charting, drug administration, and narcotic accountability.
A resident with a tracheostomy, hemiplegia, and no speech did not have access to a working call light system, as the device was out of reach and nonfunctional for at least a week. Staff discovered the call light system was disabled due to the bathroom switch being in the middle position, contrary to facility policy requiring accessible and operational call lights for all residents.
A nurse engaged in loud, verbally abusive behavior toward a resident, including yelling and belittling language. Two residents with tracheostomies did not receive needed suctioning, resulting in one experiencing difficulty breathing and another with low oxygen saturation. Additionally, a resident with diabetes did not receive her prescribed nightly insulin after the nurse failed to check her blood glucose or administer the medication. These actions violated the facility's abuse prevention policy and resulted in neglect of care.
A resident with multiple pressure ulcers and complex medical needs did not receive wound care in accordance with physician orders and facility policy. There were repeated failures to document wound treatments, update treatment orders after wound specialist visits, and perform required weekly wound assessments and measurements. Staff interviews confirmed missing documentation and discrepancies between physician recommendations and recorded care.
A resident with a history of acute respiratory failure, pneumonia, and high elopement risk was left unsupervised during a smoking break when the assigned staff member remained inside due to cold weather. The resident used a crate to climb onto a gazebo and jumped a six-foot fence, leaving the facility without authorization. The care plan lacked interventions for elopement risk, and staff only learned of the incident from another resident. The resident spent several days outside in cold weather before returning, unkempt and dirty. Facility policy requiring direct supervision during smoking breaks was not followed, and the family was not promptly notified.
A resident with quadriplegia and multiple comorbidities was unable to use a motorized wheelchair for an extended period due to a dead battery. Despite the care plan requiring timely repair and staff awareness of the issue, the necessary follow-up to obtain a replacement battery was not completed, resulting in the resident's loss of independent mobility.
Two residents with diabetes experienced prolonged periods of critically high blood glucose due to staff failing to follow care plans, obtain appropriate physician orders, administer insulin as ordered, and notify the physician as required by facility policy. Documentation was incomplete or missing, and critical values were not addressed in a timely manner.
The facility did not follow its policy to notify physicians and responsible parties about critical blood glucose levels for two residents with diabetes. Despite multiple instances of critically high blood glucose readings, there was no documentation of required notifications or new orders in the medical record, and family members were not informed as outlined in the care plans and facility guidelines.
The facility failed to conduct timely assessments and documentation of skin impairments for residents at high risk for pressure ulcers. Multiple residents were not properly monitored or treated for existing and new skin conditions, and the facility did not adhere to the manufacturer's recommendations for low air loss mattresses. The wound care coordinator was unaware of several conditions, and there was no comprehensive care plan developed upon admission to address skin impairments. The facility's policy on wound assessment and treatment was not followed, leading to inadequate prevention and management of wounds.
The facility failed to provide adequate nail and foot care to residents dependent on staff for ADLs. Observations showed several residents with long, dirty fingernails and toenails, despite policies requiring CNAs to provide nail care and report the need for podiatrist referrals. This neglect occurred despite the residents' significant medical conditions and need for total assistance with personal hygiene.
A facility failed to ensure proper infection control practices for residents on Enhanced Barrier Precautions (EBP). Instances included a CNA improperly handling soiled linens, a CNA and family member providing care without required PPE, and a Wound Care Coordinator performing wound care without proper PPE. An LPN administered medication without full EBP, and a resident's room lacked an isolation bin setup. The facility's policy requires gloves and gowns during high-contact care to prevent MDRO spread.
A facility failed to uphold a resident's right to dignity by allowing them to wear a sweater with large food stains. The resident, who was alert but confused and dependent on ADLs, was observed in this condition. A CNA mentioned the sweater was clean but stained, and the Social Service Director acknowledged the need for residents to wear clean clothing, as per facility policy.
A resident's call light was found on the floor behind the bed, making it inaccessible, despite the facility's policy requiring call lights to be within reach. The resident, who requires partial assistance due to multiple medical conditions, was unable to locate the call light. Staff confirmed the call light should be accessible, but it was not placed correctly.
The facility failed to submit PASRR Level II screenings for two residents who required psychological services. The Social Services Director was unaware of the residents' needs, leading to the oversight. The Administrator acknowledged the responsibility of the social services department in submitting these screenings, as mandated by the facility's policy.
The facility failed to follow physician orders and care plans for two residents, leading to deficiencies in safety protocols. One resident was found with three side rails up instead of the prescribed two, while another high-risk resident was transferred without the required mechanical lift and two-person assistance. These actions were contrary to the facility's policies designed to ensure resident safety and independence.
A facility failed to ensure proper verification of a gastrostomy tube's placement before administering medication to a resident. An LPN was observed administering medication without checking for gastric residual, a necessary procedure confirmed by the DON. The resident had a diagnosis of gastrostomy status and dysphagia, with a care plan requiring gastric residual checks. The facility lacked a specific policy on feeding tube placement.
The facility failed to maintain temperature logs for resident personal refrigerators, affecting two residents. Observations showed undated food items and inappropriate temperature monitoring logs. Staff interviews revealed a lack of consistent monitoring and knowledge of acceptable temperature ranges. The facility's policy on monitoring food from outside sources was not followed, and no specific policy for personal refrigerators was provided.
The facility did not comply with its policy to post daily staffing information, as required by CMS. During a survey, the staffing posting was not observed, and both the scheduler and the DON confirmed it should have been displayed. This failure potentially affects 69 residents, as the policy requires posting the shift schedule, nursing staff numbers, and hours worked by licensed staff.
A resident was found tied to a wheelchair in a hallway without proper clothing, and pictures were taken, violating their dignity and privacy. Staff members were aware of the situation, and a CNA and scheduler overheard discussions about the incident. The facility's abuse prevention policy prohibits such actions, and the incident was recognized as a HIPAA violation.
A CNA violated facility policy by taking unauthorized photos of a resident restrained in a wheelchair, which was demeaning and humiliating. Despite reporting the restraint to the DON, the CNA was told to leave if unwilling to monitor the resident. The CNA documented the situation with photos, violating the facility's abuse prevention policy. The resident, with multiple diagnoses, was later transferred to a hospital. Staff were aware but failed to report the incident immediately.
A resident with multiple diagnoses, including dementia and schizoaffective disorder, was improperly restrained in a wheelchair using a gait belt and bed sheet, inhibiting his freedom of movement and causing agitation. Despite the facility's policy against restraints, staff failed to assess the need for restraints or develop a care plan, leading to the resident's distress.
A resident with multiple diagnoses was reportedly restrained improperly, and a CNA assigned to monitor the resident took unauthorized pictures and discussed the resident's condition over the phone, violating HIPAA. Despite being informed, the DON and other staff did not follow the facility's abuse prevention policy, allowing the CNA to continue caring for the resident, which compromised the resident's safety.
Two residents engaged in a physical altercation during a supervised smoke break when one, experiencing hallucinations and delusions, struck the other with a cane. Despite staff presence, the situation escalated, highlighting inadequate supervision and de-escalation strategies for residents with known behavioral issues.
A facility failed to execute a STAT order for a chest x-ray within the expected 4-hour timeframe for a resident with new chest bruising. Despite the nurse practitioner's order for urgent labs and x-rays, the diagnostic company delayed, and the resident's condition worsened, necessitating hospital transport. Staff interviews revealed communication lapses and procedural gaps, as the facility's policy did not address STAT orders, and the diagnostic contract was not provided.
The facility failed to discard 15 prepared cold cut sandwiches by their use-by date, as observed during an inspection. Both the Dietary Aide and the Food Service Director confirmed that the sandwiches should have been discarded on the indicated date, in accordance with the facility's policy on Food Safety and Sanitation.
The facility failed to maintain the dignity of a resident by not following their policy regarding the use of dignity bags for urinary drainage bags. The resident was observed with an uncovered drainage bag, which was confirmed by both the DON and an LPN as a violation of the facility's policy.
The facility failed to ensure a clean environment for a resident who was observed with dirty bed sheets, pillows, and equipment. Despite the housekeeping aide's claim of cleaning the room, stains from enteral feeding spillage remained. The infection preventionist acknowledged the issue, and the facility's cleaning policy was not followed.
The facility failed to update the abuse assessment and formulate a care plan after a resident experienced verbal abuse from a CNA. Despite the facility's policy requiring such updates, the necessary assessments and care plans were not completed until after the surveyor's inquiry.
The facility failed to perform a pacemaker check as ordered and did not obtain a copy of the hospice plan of care for two residents. One resident's pacemaker checks were not documented since June 2020, despite orders for checks every three months. Another resident's hospice plan of care was not obtained as required by the facility's agreement with the hospice company.
The facility failed to prevent the worsening of a moisture-associated skin disorder (MASD) in a high-risk resident. Despite the wound care physician's recommendations for specific treatments and interventions, including the use of a low air loss (LAL) mattress, the facility did not implement these measures. The resident's condition worsened significantly, and the facility's policy on the prevention and treatment of pressure ulcers was not adhered to.
The facility failed to follow up on pharmacy recommendations for two residents, resulting in deficiencies. One resident had multiple medications prescribed without appropriate indications, and another had a recommendation for gradual dose reduction of a psychotropic medication that was not addressed. The facility did not adhere to its policy on medication regimen review.
A resident's nebulizer mask was found dirty and uncovered, placed next to various opened and used items on the bedside table. The facility's staff acknowledged that the mask should be cleaned and stored properly after each use, and that barrier ointments and creams should be kept in the treatment cart, not at the bedside.
The facility failed to protect a resident from verbal and physical abuse by another resident. Despite the aggressor's known history of delusional and aggressive behavior, the victim was not moved to a new room until the next morning, and the aggressor was only given medication and monitored. The facility did not follow its abuse prevention policy, leading to a deficiency in ensuring resident safety.
The facility failed to provide proper catheter care for a resident with a suprapubic catheter, resulting in brownish sediments in the catheter tubing and improper handling of the catheter site. The resident had a history of UTIs and required close monitoring, which was not adequately performed.
The facility failed to transmit assessments within 14 days of completion for three residents. The MDS/Care Plan Coordinator and MDS Consultant confirmed the delays, with assessments being submitted more than 14 days after completion.
Inadequate Nutritional Equivalence of Menu Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that menu substitutes offered to residents who declined the planned meal were of similar nutritive value to the original menu. The facility census documented 101 occupied residents, with 3 residents listed as NPO, meaning that 98 residents consumed food from the facility’s kitchen and were affected by the substitution practices. The facility’s “Always Available” substitution menu, presented to surveyors, listed only sandwich-type items—cheeseburger or hamburger, hot dog, deli meat sandwich, and peanut butter and jelly sandwich—with no vegetables or other balanced side dishes included. This substitution menu did not provide nutritionally comparable alternatives across food groups, despite facility policy stating that nutritionally comparable alternates for protein, grains, fruits, and vegetables would be planned during menu planning. A cognitively intact resident with multiple diagnoses including type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and a left below-knee amputation reported that there were no meaningful substitutes beyond sandwiches and hot dogs and specifically noted being unable to obtain a salad. This resident stated that all the substitutes were sandwiches and hot dogs and expressed dissatisfaction with the food, describing it as cold and limited in variety. Another cognitively intact resident with diagnoses including heart failure, hypertensive heart disease, type 2 diabetes mellitus, end-stage renal disease with dependence on dialysis, and obesity reported that the food was “terrible” and provided photographs of meals received. These photos showed meals such as a plate with half plain white rice and half mixed vegetables with no protein, and a roll with a small bowl of plain oatmeal without protein, as well as a serving of brown meat that appeared burnt over more than half of the portion and was not clearly identifiable by staff. This second resident stated that they frequently did not receive protein with meals and that, although substitutes were offered, they were not comparable to what was being served. The resident gave examples such as being offered a peanut butter and jelly sandwich instead of a pork chop, and receiving a peanut butter and jelly sandwich at breakfast instead of sausage, while noting that poultry-based alternatives like chicken or turkey sausage were not provided despite the resident not eating beef or pork. The Regional Director of Operations for Dietary stated that residents could choose items from the always-available menu and asserted that these were nutritionally equivalent to entrée portions, but also acknowledged that vegetables were not posted in advance and might not be automatically replaced unless requested. The Registered Dietician, when asked if the always-available menu met the same nutrient requirements as the planned menu, responded “yes and no,” and specifically identified that while a hamburger could provide protein, a hot dog was questionable and that vegetables were missing from the alternatives, suggesting that even a glass of tomato juice would be needed to meet equivalent nutritional value. These observations, interviews, and record reviews demonstrate that the facility did not consistently provide nutritionally comparable substitutes that met residents’ nutritional needs and preferences as required by its own policies and regulatory standards. Additionally, documentation showed that the facility had policies titled “Menu Alternates (per your request menu)” and “Dietary Preferences, Nutritional Requirements, and Portion Management,” which committed to providing nourishing, palatable, well-balanced meals that meet assessed nutritional needs and to making nutritionally comparable alternates available for resident preferences. The policies also required that resident preferences, substitutions, and special portion exceptions be documented in the resident’s record. While one resident’s concern referral form documented that the resident liked salads and vegetables and that the meal ticket was updated to reflect salads and double vegetables for lunch and dinner, the overall substitution system in place at the time of survey remained limited to primarily bread-based sandwich items without consistent inclusion of vegetables or balanced sides. The Registered Dietician’s acknowledgment that the existing always-available menu was missing vegetables further confirmed that the substitutes being offered were not nutritionally equivalent to the planned meals, resulting in the cited deficiency. The Administrator reported that a new always-available substitution menu existed but that the food items for it had not yet arrived, indicating that, at the time of the survey, residents were still being served from the older substitution menu consisting mainly of sandwiches and hot dogs. Record review of the new menu showed an expanded list including chef salad with meat, egg salad with crackers, and pasta meat salad with dressing, which would add more variety and food groups; however, these options were not yet in use during the survey period. Consequently, the deficiency centers on the facility’s actual practice during the survey timeframe, in which residents who declined the planned meal were offered substitutes that did not consistently provide similar nutritive value or balanced food groups, despite the facility’s written policies and staff statements about accommodating preferences and nutritional needs.
Failure to Maintain Dignity by Leaving Urinary Catheter Bag Uncovered
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and privacy when a resident’s urinary catheter drainage bag was observed hanging uncovered from the resident’s wheelchair with approximately 225 mL of clear yellow urine visible. The resident, who had diagnoses including type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and a left below-knee amputation, was documented as cognitively intact with a BIMS score of 13. The resident’s care plan noted the presence of an indwelling/suprapubic catheter/urostomy. During the observation, the resident stated that staff were not concerned about their privacy bag and expressed dissatisfaction with the facility, including concerns about not receiving medications on time, limited food options, and the lack of a privacy cover for the urinary drainage bag, which the resident stated they would like to have. In an interview, an RN acknowledged the absence of a urinary privacy cover and indicated they would go put one on. The DON stated that the facility’s expectation is that all residents with urinary catheter bags should have a privacy cover because it is a dignity issue. Review of the facility’s policy on resident rights documented that each resident has the right to be treated with dignity and respect and that staff must treat each resident with dignity in all situations. Despite this policy and the facility’s stated expectations, the resident’s urinary catheter drainage bag was left uncovered, resulting in a failure to honor the resident’s right to dignity and privacy.
Failure to Limit and Justify PRN Antipsychotic Orders per Policy and Regulation
Penalty
Summary
The deficiency involves the facility’s failure to follow federal regulations and its own policies regarding PRN psychotropic medications for one cognitively intact resident. The resident had multiple diagnoses, including schizophrenia, type 2 diabetes, hypertension, atrial fibrillation, chronic right heart failure, and a left below-knee amputation. The resident’s BIMS score was 13, indicating intact cognition, and the resident reported signing their own consents and managing their own bills. The resident stated that since admission they had repeatedly told nursing staff that their medication doses and administration times were wrong, that medications were passed late or sometimes not given at all, and that staff would not listen to their concerns. Record review showed that the resident had two PRN haloperidol orders, one for intramuscular haloperidol lactate 5 mg/mL at 0.4 mL IM every 6 hours PRN, and one for oral haloperidol 2 mg every 6 hours PRN. Both orders were written with an “indefinite” end date and remained active for 41 days before being discontinued. These PRN antipsychotic orders did not include a 14‑day limit or documented rationale and duration for extending beyond 14 days, as required by federal regulation and by the facility’s own policies on psychotropic medications and unnecessary drugs/chemical restraints. Interviews with the ADON and DON confirmed that facility policy requires PRN psychotropic medications, including antipsychotics, to be limited to 14 days, with reassessment and documented rationale if continued beyond that period. The Family Nurse Practitioner stated that when she first saw the resident, the resident had PRN haloperidol ordered but was having no behaviors and that there had been no behaviors since admission. She indicated that haloperidol should be ordered for 14 days to monitor for adverse side effects and to ensure the dose is working properly. Facility policies titled “Guidelines for Psychotropic Medication” and “Guidelines for Use of Unnecessary Drugs to Include Chemical Restraints” specify that PRN psychotropic and antipsychotic drugs are limited to 14 days, require physician evaluation and documented rationale for any extension, and require that PRN psychotropics only be used to treat a diagnosed specific condition documented in the clinical record. The policies also state that residents have the right to be fully informed and to participate in or refuse treatment, including psychotropic medications, and that proof of informed consent must be documented in the medical record. Despite these requirements, the resident’s PRN haloperidol orders were written as indefinite and remained in place beyond 14 days without the required time limitation or documented justification, constituting the cited deficiency.
Failure to Ensure Accurate and Timely Medication Administration for Antihypertensives and Anticoagulant
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow its own medication administration policies, particularly regarding timeliness, accuracy of orders, and documentation. One resident (R3), who has diagnoses including heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease with dependence on dialysis, and obesity, and who is cognitively intact with a BIMS score of 14, reported frequently receiving medications late and stated that on the day of observation the resident had not received any medications despite returning from dialysis at 10:30 AM. At 12:17 PM, an RN (V18) assessed R3’s blood pressure at 147/89 with a heart rate of 100 and acknowledged to the resident that the blood pressure was high because medications were being given late, specifically referencing the resident’s beta blocker and hypertension medications. At approximately 12:24 PM, V18 prepared R3’s morning medications, including nifedipine ER 60 mg, metoprolol tartrate 12.5 mg, gabapentin 100 mg, sevelamer 800 mg, and calcitriol 0.5 mcg, and stated these medications should have been given around 9:00 AM but were late. At 12:30 PM, V18 administered the medications to R3 and told the resident that medications were not supposed to be given outside the one-hour before/after window, describing this as a legal requirement, but proceeded with administration due to the elevated blood pressure. V18 further explained that the facility’s procedure is to check vital signs and then administer medications, and admitted that R3’s medications should have been given as soon as possible after returning from dialysis at 10:30 AM. V18 stated that the medications were not given timely because the nurse was responsible for 27–30 residents and acknowledged having given R3’s medications late on prior occasions, describing it as difficult to complete medication passes on time. The consultant pharmacist (V16) confirmed that nifedipine and metoprolol were being used to treat blood pressure and stated that if these medications are not received, blood pressure is expected to increase, emphasizing that nifedipine ER should be given at the same time every day. Upon reviewing R3’s record, V16 found no documentation of when the previous evening’s metoprolol dose was given and could not determine whether it had been administered, noting that nurses should document all administrations or refusals. The DON (V2) confirmed that facility policy allows a one-hour before and after window for medication administration and that medications for residents on dialysis should be scheduled so they can be administered at the same time every day, with nurses expected to notify the provider if scheduled times conflict with dialysis. V2 verified that R3’s nifedipine and metoprolol were scheduled for 9:00 AM, during dialysis chair time, and that R3 had not been consistently receiving these medications at the ordered times. V2 stated that V18 could have administered the medications closer to the scheduled time and confirmed there was no documentation that the 6:00 PM metoprolol dose was given on 4/12/2026. Review of R3’s Medication Administration Audit Report showed multiple late administrations of metoprolol and nifedipine on various dates, as well as missing documentation for certain metoprolol doses. R3’s progress notes contained only one entry indicating the resident requested morning medications after dialysis, with no further documentation explaining late administrations or provider notification about late or missed doses. These practices conflicted with facility policies requiring medications to be administered within 60 minutes of the scheduled time, accurate documentation of administration or refusal, and explanatory notes when doses are withheld, refused, or given at times other than scheduled. A second resident (R2), admitted with diagnoses including type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and a left below-knee amputation, and cognitively intact with a BIMS score of 13, reported that nurses had R2’s medication doses and times wrong and that medications were often passed late or not given at all. Hospital discharge documentation for R2 listed Eliquis 5 mg to be taken orally twice daily, but R2’s March MAR showed an order for Eliquis 5 mg once daily starting shortly after admission, and R2 received the medication only once daily for eight days. The MAR later reflected a corrected order for Eliquis 5 mg twice daily. A progress note documented that pharmacy contacted the facility on 3/10/26 stating Eliquis is always given twice daily and that the MD needed to correct the order; the nurse noted reaching out to the provider but receiving no response at that time. The consultant pharmacist confirmed that Eliquis is never given once daily, that manufacturer recommendations are for twice-daily dosing, and that once-daily dosing for atrial fibrillation management could lead to irregular heart rate or increased risk for clots. The DON stated that the admitting nurse entered the Eliquis order incorrectly, that Eliquis is supposed to be given BID, and that R2 received the wrong Eliquis dose for a few days. Facility policies titled “Guidelines For Physician Orders (Following Physician Orders)” and “Section 5.0 Medication Administration” require that physician orders be accurately implemented and followed, that two nurses review admission and readmission orders as a double check, and that medications be administered as prescribed and within 60 minutes of the scheduled time. These policies also require that unusual doses or orders that appear inconsistent with a resident’s diagnosis be clarified with the physician prior to administration, that the MAR be initialed for each dose given, and that any withheld, refused, or off-schedule doses be circled and explained in the record, with physician notification if two consecutive doses are withheld or refused. The observed late, inconsistent, and undocumented administration of antihypertensive medications for R3, the lack of timely rescheduling or provider notification related to dialysis conflicts, and the incorrect once-daily Eliquis order and administration for R2, despite pharmacy input and existing policies, collectively demonstrate the facility’s failure to ensure residents were free from significant medication errors and to adhere to its own medication administration procedures.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food in a palatable, attractive manner and at an appetizing temperature for a cognitively intact resident. The resident had multiple diagnoses including heart failure, hypertensive heart disease, type 2 diabetes mellitus, end-stage renal disease with dialysis dependence, and obesity, and physician orders for a regular texture, thin consistency, diabetic diet with no pork or tomato products. The resident reported that the food was “terrible” and provided photographs of prior meals showing an unappetizing plate consisting of half plain white rice and half mixed vegetables with no protein, a roll of bread and a small bowl of plain oatmeal with no protein, and an unidentifiable brown meat item that appeared burnt over more than half of its surface. The resident stated that the facility frequently did not provide protein, that they did not eat beef or pork, and that the facility should be able to accommodate those preferences. On the observed lunch service, the posted menu called for beef stew, cornbread, a side salad with dressing of choice, an ice cream novelty, and coffee or hot tea. Instead, the resident was served a small bowl of what appeared to be chicken and corn soup with a thick layer of orange grease covering about half of the broth, a small piece of cornbread approximately 3 by 2 inches with no other food on the plate, a bowl of dry iceberg lettuce, a condiment cup with only about one-fifth filled with white dressing, and a bowl of strawberry ice cream that was mostly melted, with about three-quarters in liquid form. A CNA confirmed that the tray did not look good, described the salad as very dry, the ice cream as “pretty much all melted,” and the cornbread as only a bite or two at most, and stated that residents complain a lot that the food tastes bad or is not enough and that “these people is hungry in here.” The resident added that they did not like iceberg lettuce but felt they had to eat it and later described the soup as bland, “chicken and water,” without any flavor. A RN who observed the tray confirmed that the lettuce appeared dry, the ice cream was melted, and the soup did not appear appetizing and could not clearly identify what the soup was. The RN stated that residents often complain about the food and that it was not something they would want to eat or feed to their family, and that residents end up ordering out a lot because they do not like the food. The interim dietary manager, who also served as the regional director of operations for dietary, acknowledged being familiar with the resident’s dietary requests and stated that the resident voiced many concerns about the food and had many items listed as not wanted on the dietary ticket. When shown pictures of the lunch tray, the dietary manager stated that it did not look appetizing, acknowledged the ice cream should not be melted, and identified the entrée as a chicken stew made specifically for the resident. The consultant RD stated that appearance is a matter of opinion but acknowledged that “you eat with your eyes” and that food should be served at appropriate temperatures and generally appear attractive so people will want to eat it. These observations and statements were inconsistent with the facility’s written policy on food presentation, which requires meals to be prepared and served in an attractive manner that enhances palatability.
Failure to Complete STAT Lab Orders and Required Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s STAT (immediate) laboratory orders and associated monitoring orders for one resident. A registered nurse (V13) reported that she received STAT lab orders for the resident, called the lab, and obtained a confirmation number, then endorsed the pending lab work to the oncoming shift. However, there was no evidence that the STAT labs ordered on 12/31/25, specifically a complete blood count and comprehensive metabolic panel, were ever drawn. Additionally, there was no documentation on 1/1/26 of any follow-up related to the STAT labs or of any vital signs being obtained for the resident, despite existing physician orders for vital signs three times daily and blood sugar monitoring three times daily. The Director of Nursing (V1) stated that her expectation is that nurses carry out all physician or nurse practitioner orders and follow up on STAT labs by calling them in, obtaining a confirmation number, and, if endorsed to the next shift, ensuring the next nurse checks the lab’s estimated time of arrival or notifies the provider if the lab cannot be drawn. The facility’s policy on following physician orders, revised 6/18/23, states that all physician orders received for a resident will be implemented and followed throughout the resident’s stay. The affected resident is an older adult with multiple significant diagnoses, including myopathy, spinal stenosis, hypertensive heart disease, heart failure, chronic kidney disease stage 3, unspecified atrial fibrillation, type 2 diabetes, morbid obesity, peripheral vascular disease, anemia, and a history of falls, and had admission orders including Midodrine, Ensure supplement, vital signs three times daily, blood sugar monitoring three times daily, and the STAT labs that were not completed.
Failure to Provide Routine Dental Services and Oral Assessment
Penalty
Summary
The facility failed to provide routine dental services as required, affecting one resident who reported ongoing dental pain and functional impairment. During an interview, the resident stated she could only chew on the left side of her mouth because the upper and lower teeth on the right side had holes and became painful when food became stuck. Observation, interview, and record review confirmed that this resident had not received dental services during her stay, despite her reported symptoms. The DON stated that residents are to be screened upon admission, quarterly, and as needed for dental concerns, but acknowledged that this resident had not been seen by dental services at any time during her residency. The resident, who is diagnosed in part with quadriplegia, unspecified severe protein calorie malnutrition, neuromuscular dysfunction of the bladder, asthma, myasis, myopathy, and essential hypertension, was therefore not assessed and referred for dental care in accordance with the facility’s own dental services policy. That policy requires licensed nurses to conduct comprehensive oral assessments, including asking about chewing difficulties and pain, physically inspecting the oral cavity, and immediately addressing negative findings by notifying the physician and dental provider, which did not occur for this resident.
Failure to Send Required Transfer Documentation With Resident to Appointment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to follow its own discharge/transfer guidelines when sending a resident out for an appointment. On 2/10/26, the resident was transported to an appointment without a face sheet, physician order sheet, or medication administration record, as reported by the receiving RN. The facility’s written policy, “Guidelines for discharge and transfer,” requires that for transfers to a higher level of care or hospital, staff complete the EHR discharge/transfer form and send the face sheet, advance directives, MAR/TAR, and other pertinent information. The DON stated that staff are aware of residents’ appointments the day prior and are expected to have the required paperwork ready and provided to the transporter at pickup. However, the resident’s night nurse reported she was not aware the resident had an appointment and therefore did not send the required documents. She further stated she had printed the face sheet and physician order sheet but did not send them because she could not access the computer room to retrieve them. As a result, the resident arrived at the appointment location without the documentation required by facility policy.
Failure to Provide Adequate ADL Hygiene Before Medical Appointment
Penalty
Summary
The facility failed to follow its guideline policy for activities of daily living (ADLs) for one resident who required assistance with hygiene and routine care. On 2/10/26, the resident was sent out for a medical appointment and arrived unclean, unkempt, and unchanged for some time, as reported by the receiving RN. The Director of Nursing later stated she was informed by the resident’s family that the resident had been sent to the appointment in this unclean condition and acknowledged that staff are made aware of appointments the day prior and are expected to have residents ready on the day of the appointment. The Director of Nursing also noted that the resident had a stage three pressure ulcer on the right heel under treatment by a wound physician. The night RN assigned to the resident reported she was not aware of the appointment, stated she instructed a CNA to clean the resident while she prepared the paperwork, and was unsure whether the resident was actually cleaned before transport. This sequence of events occurred despite a facility policy stating that residents are to receive routine daily care by CNAs or RNs to promote hygiene and comfort throughout the day, evening, and night as care planned or as needed, coordinated with resident and caregiver with emphasis on resident preference. The facility’s protocol also required that a face sheet and physician order sheet be provided to the transporter when a resident is picked up, and the night RN focused on preparing this paperwork while delegating hygiene care to a CNA without confirming completion. The failure to ensure that the resident was properly cleaned and groomed prior to leaving for the appointment, in accordance with the facility’s ADL policy and with prior knowledge of the scheduled appointment, led to the resident being transported and arriving at the appointment in an unclean and unkempt state.
Failure to Provide Effective Colostomy Care Resulting in Repeated Leaks
Penalty
Summary
The facility failed to follow its colostomy care policy for two residents, resulting in repeated colostomy leaks. One cognitively intact male resident with a diagnosis including colostomy and UTI was observed on two consecutive days with a leaking colostomy bag, first on his return from the hospital and again the next day with a new bag leaking through the base dressing. A CNA stated she had not had a chance to check on him after his hospital return and that nurses were responsible for colostomy care, and another CNA confirmed the colostomy should not leak. A second male resident with severe cognitive impairment was observed with a leaking colostomy and a moderate amount of stool on his abdomen, and an LPN stated the colostomy had been changed that day, did not know who changed it, and acknowledged it should not leak. The nurse consultant confirmed that nurses are supposed to change colostomies and that they should not leak because this can cause skin irritation and infection. The facility’s colostomy care policy stated that the purpose of colostomy care is to prevent infection and skin irritation. These observations, staff interviews, and the facility’s own policy demonstrate that colostomy care was not consistently provided in a manner that prevented leakage for the two residents reviewed for colostomy care.
Failure to Follow Colostomy and Catheter Care Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for colostomy care and indwelling catheter management for two residents. One cognitively intact male resident with a colostomy, suprapubic catheter, and recent UTI was observed in an isolation room with his urinary catheter bag placed in the bed rather than kept below bladder level. Shortly after his return from the hospital, his colostomy bag was observed leaking, with the insertion site resealed using additional tape, and a dirty, soaked, loose dressing was noted at the suprapubic catheter site beneath the colostomy bag. The resident reported having recently been hospitalized twice due to feeling very ill and stated that the colostomy bag was leaking onto his catheter site. A CNA reported she had not yet checked on him after his readmission, and the DON later stated that nurses are expected to check residents immediately upon readmission and ensure all tubing and drains are safely positioned. The resident’s POS showed he was receiving IV Meropenem for a UTI. A second male resident with severe cognitive impairment was observed in bed with a leaking colostomy and a moderate amount of stool on his abdomen. An LPN stated the colostomy had been changed that day but did not know who changed it and acknowledged it should not be leaking. A nurse consultant confirmed that nurses are responsible for changing colostomies and that they should not leak, as well as reiterating that urinary catheter bags should be maintained below bladder level. The facility’s colostomy care policy stated that the purpose of colostomy care is to prevent infection and skin irritation, and its catheter care guidelines specified that urinary drainage bags must always be kept below bladder level, but these practices were not followed for the two residents observed.
Failure to Coordinate Post‑Op Follow‑Up, Therapy, and ADL Care for Post‑Surgical Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered post‑operative follow‑up care, therapy, and ADL assistance to a cognitively intact male resident admitted after bilateral hip ORIF. The resident had a clearly documented post‑op follow‑up appointment with orthopedics, including date, time, location, and contact information, listed both in the physician order summary and prominently on the first page of the hospital discharge summary. The admitting nurse was expected to communicate this to the scheduler per facility procedure, but the appointment on 2/3 was not scheduled, and the DON later attributed this to miscommunication. A subsequent appointment arranged by the facility was not completed because the ambulance arrived without a stretcher, and another rescheduled appointment was missed when the ambulance did not show up. These missed appointments were not documented in the medical record, and the physician was not notified. The facility also failed to ensure the resident received therapy as ordered. Physician orders dated 1/27 and 1/29 included PT evaluation and treatment three times weekly for four weeks, and PT/OT/ST evaluation and treatment for 30 days. The Therapy Director reported that therapy saw the resident for two weeks and then stopped due to a non‑weight‑bearing order from orthopedics, and that they were waiting for an updated weight‑bearing order from the follow‑up appointment that never occurred. As of mid‑February, the resident was still not in therapy, despite orders indicating that post‑operative therapy should begin upon admission. There was no indication in the record that alternative therapy interventions, such as upper body training, were consistently provided within the constraints of the non‑weight‑bearing status. The facility further failed to provide necessary ADL care and monitoring of the surgical site. The MDS documented that the resident was cognitively intact but required substantial/maximal assistance for most ADLs and was dependent for toileting and transfers, with a care plan reflecting these needs. The resident reported not receiving showers or bed baths, having to attempt transfers independently because call lights were not answered, and having episodes of incontinence where he remained in urine and feces for hours without assistance. Surveyors observed a full urinal on the bedside table with food and personal items, and later an almost full urinal on the bed rail, which staff acknowledged should have been emptied. Nursing staff did not document required shift assessments of the surgical site, and the DON was unsure when staples should be removed. On observation, the right hip surgical site was swollen and painful, and a venous doppler later showed findings likely due to DVT. The resident stated he felt hopeless and believed no one cared about his pain or healing process.
Failure to Administer and Document Ordered Post‑Operative Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate post‑operative pain management for one resident (R3) by not administering ordered pain medications, not monitoring and documenting pain relief, and not implementing care‑planned non‑pharmacological interventions. R3, who had a history including lumbosacral and pelvic fractures with routine healing, motor vehicle accident injury, anemia, and anxiety disorder, reported that his pain was not being controlled and that staff told him there was no oxycodone order despite it being listed on his discharge summary. Physician orders dated 1/27/2026 included oxycodone 10 mg by mouth every 4 hours as needed for pain and acetaminophen 325 mg, three tablets by mouth every 6 hours as needed for pain. On multiple observations, R3 rated his pain as 10/10 and stated that the facility was not getting his pain medication orders straight. During medication pass, an LPN assigned to R3 stated that his pain medication was not scheduled, did not know when he last received pain medication, and reported that there was no oxycodone in the narcotic box at that time. Later, the DON stated that R3 did have an oxycodone order and that the medication was in stock, explaining that the nurse had been unable to find it earlier. On another observation during a dressing change, swelling and tenderness were noted at R3’s right hip surgical site, and he again rated his pain as 10/10. R3 later reported that the facility had run out of pain medication again and that he had not received any pain medication for the past two days. An RN acknowledged that R3 received oxycodone every 4 hours, that the medication had to be reordered and sometimes ran out, and that R3 would not take Tylenol and only wanted oxycodone. Review of the care plan initiated 2/10/2026 documented that R3 was at increased risk for alteration in pain/discomfort, with goals and interventions including administering analgesics as ordered, offering PRN analgesics prior to ADLs/rehab/wound care, observing for effectiveness of pain relief, and notifying the physician for new pain complaints or signs/symptoms of pain. However, review of the MAR for January showed that oxycodone or Tylenol were not signed out as given from admission through the end of the month, despite pharmacy records showing delivery of oxycodone 10 mg tablets on 1/31/2026. The DON could not locate the narcotic receipt and disposition form for January. For February, oxycodone was signed as given only about five times and Tylenol was not signed out at all, even though pharmacy manifests showed additional oxycodone deliveries. The DON stated that R3 was getting oxycodone and that nurses were not signing the MAR, and acknowledged that R3 was supposed to be offered Tylenol and refusals documented. Facility policies required medications to be administered as prescribed, MARs to be signed by the person administering, and PRN medications to be fully documented, as well as guidelines emphasizing effective pain management and recognition that pain is what the resident says it is. These failures contributed to R3 suffering psychological harm and feeling hopeless because no one cared about his pain or healing, with pain rated 10/10.
Failure to Document and Manage PRN Pain and Narcotic Medications per Professional Standards
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality for a male resident admitted after an open reduction and internal fixation (ORIF) procedure, with a history including lumbosacral and pelvic fractures, motor vehicle accident, anemia, anxiety disorder, and psychoactive substance abuse. The resident reported that his pain was not being controlled and that staff told him there was no oxycodone order, despite an active physician order for oxycodone 10 mg every 4 hours PRN for pain and acetaminophen 325 mg, three tablets every 6 hours PRN for pain. Review of the Medication Administration Record (MAR) for January showed no documentation that oxycodone or acetaminophen had been administered from admission through the end of the month, even though pharmacy records showed delivery of oxycodone tablets. The narcotic receipt and disposition form for January could not be located. In February, oxycodone was documented as given only about five times, acetaminophen was not signed out at all, and additional oxycodone deliveries were documented by the pharmacy. There was no documentation in the record of medication refusals, PRN indications, or effectiveness assessments as required by the facility’s medication administration guidelines. The facility also failed to ensure appropriate assessment and documentation of the resident’s pain and surgical site. The record lacked documentation of the effectiveness of administered pain medications, any non-pharmacological pain interventions, or assessments of the resident’s surgical site each shift by floor nurses. An RN stated that the resident’s surgery was healed and that wound care was responsible for the surgical site, and she was not aware of the presence of staples or swelling at the right hip, indicating she had not assessed the site. These practices were inconsistent with the facility’s policies and the RN/LPN job descriptions, which require accurate charting, signing and dating all entries, complete MAR documentation for PRN medications (including results), and ensuring narcotic records are accurate for each shift.
Failure to Provide Accessible and Functional Call Light for Nonverbal Resident
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy, hemiplegia, and no speech had access to a functioning call light system. The resident, who uses a communication board and is alert and oriented, was observed with the call light string on the floor, out of reach, and the call light itself was not working—there was no illumination or audible sound when activated. The resident communicated via the board that the call light had not worked for a week. Upon inspection, it was found that the call light did not display any indication at the nursing station panel. Staff investigation revealed that the call light system in the resident's room would not function if the bathroom call light switch was in the middle position. Maintenance staff stated they were unaware of how the bathroom switch was moved, as the resident does not use the bathroom independently. Facility policy requires that residents have access to a functioning call light system that is easy for them to use and placed within reach, but this was not followed in this instance.
Failure to Prevent Verbal Abuse and Neglect of Resident Care
Penalty
Summary
The facility failed to protect residents from verbal abuse and neglect, as evidenced by multiple incidents involving a nurse (V18). One resident (R7), who was alert and oriented, reported being subjected to loud, verbally aggressive, and combative behavior by V18, including being called by the wrong name, yelled at in a threatening tone, and belittled. Another staff member (V4) corroborated that V18 engaged in unprovoked yelling and used abusive language toward both staff and residents. The Director of Nursing and the administrator confirmed that such behavior is considered verbally abusive and inappropriate. In addition to verbal abuse, the facility did not ensure that residents with tracheostomies received necessary care. Two residents (R2 and R12), both diagnosed with respiratory failure and requiring tracheostomy care, did not receive suctioning as needed during V18's shift. R2 reported difficulty breathing and panic due to lack of suctioning, and R12 was found with low oxygen saturation (88%), which is below the normal range and requires medical attention. Documentation and staff interviews confirmed that tracheostomy care was not provided as required, and R2's call light was not functioning when he attempted to seek help. Furthermore, another resident (R6), who was cognitively intact and diagnosed with diabetes, did not receive her prescribed nightly long-acting insulin because V18 failed to check her blood glucose or administer the medication. R6 did not refuse her medication and attempted to communicate the issue to facility staff. Nursing documentation later confirmed that R6's blood sugar was elevated and insulin was administered by another nurse. The facility's abuse prevention policy prohibits all forms of abuse and neglect, including failure to provide necessary medical care, which was not upheld in these instances.
Failure to Follow Pressure Ulcer Care Policies and Physician Orders
Penalty
Summary
The facility failed to follow its own policies and physician orders regarding pressure ulcer care for a resident with multiple wounds. The resident, who had significant comorbidities including type II diabetes, protein malnutrition, ventilator dependence, muscle wasting, and incontinence, was identified as being at high risk for skin integrity issues. Despite care plans and physician orders specifying weekly wound measurements, documentation, and specific wound treatments, there were multiple instances where these were not followed. Treatment administration records showed missing documentation for wound care on several days for multiple wounds, including the sacrum, occipital area, left posterior knee, right ischium, right posterior thigh, and left forehead. In some cases, there was no documentation of treatments being administered at all, and in others, the treatments documented did not match the physician's recommendations or orders. Interviews with facility staff, including the DON and wound nurse, revealed that they were unable to locate documentation for several wound treatments and assessments, and could not explain discrepancies between physician orders and what was recorded in the treatment administration records. The DON confirmed that if a treatment was not documented, it was considered not done. Additionally, the wound care nurse was responsible for updating treatment orders after wound specialist visits, but this was not consistently completed. There was also a lack of weekly wound assessments and measurements for some wounds, and outdated or discontinued treatment orders remained in the resident's record without being updated or removed. Facility policies required weekly wound evaluations and documentation, as well as prompt updating of treatment orders following wound specialist recommendations. The failure to document treatments, update orders, and perform required assessments resulted in the facility not providing the necessary care and services to prevent and heal pressure and non-pressure wounds for the resident, as required by professional standards and the facility's own policies.
Failure to Supervise High-Risk Resident During Smoking Break Leads to Elopement
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for elopement and moderate to high risk for wandering, was not adequately supervised during a scheduled smoking break. The resident's care plan did not include any interventions or plans addressing elopement risk, despite multiple assessments indicating elevated risk. During the smoking break, the assigned activity aide distributed cigarettes and then remained inside the building's doorway due to cold weather, rather than being present on the patio as required by facility policy. There were approximately ten to fifteen residents outside, and no staff was physically present on the patio to monitor them. The resident used a crate to climb onto a gazebo and then jumped over the facility's six-foot fence, leaving the premises without authorization. The absence of direct supervision allowed the resident to elope without immediate detection; staff only became aware of the incident after being informed by another resident. The facility's policy required residents to remain within eyesight of the smoking monitor, no more than 8-10 feet away, and for staff to be present during smoking breaks, but these protocols were not followed. No code was called when the resident left, and the family was not promptly notified. Following the elopement, the resident spent several days outside in cold, inclement weather, sleeping in an abandoned home and at a train station. Upon return, the resident was observed to be unkempt, dirty, and in the same clothes as when he left. Staff interviews confirmed that no new interventions were implemented after the incident, and the resident's family was not informed until days later. The facility's failure to provide adequate supervision and to address the resident's known elopement risk in the care plan directly led to the resident's unauthorized departure and subsequent exposure to unsafe conditions.
Failure to Timely Repair Motorized Wheelchair for Quadriplegic Resident
Penalty
Summary
A resident with quadriplegia, diabetes, hypertension, chronic embolism, a history of traumatic brain injury, major depressive disorder, muscle wasting, and a right leg fracture was unable to use his motorized wheelchair due to a non-functioning battery. The resident, who was alert and oriented, reported that his wheelchair had been broken for an extended period, requiring aides to transport him around the facility. The resident expressed a preference for using his motorized wheelchair independently. The resident's power of attorney confirmed that the wheelchair had been inoperable for months and required repair. Facility staff interviews and record reviews revealed that the maintenance department does not service motorized wheelchairs and that responsibility for contacting the wheelchair company falls to the Rehab Therapy Director. The Rehab Therapy Director stated that the wheelchair company was contacted in September, and a technician determined a new battery was needed, pending insurance approval. However, as of the time of the survey, no follow-up had been made with another company, and the battery had not been replaced, leaving the resident without independent mobility. The resident's care plan indicated the need for a motorized wheelchair and outlined steps for repair, but these interventions were not completed in a timely manner.
Failure to Address Critical Blood Glucose Levels and Follow Diabetes Management Protocols
Penalty
Summary
The facility failed to follow its own policies and procedures regarding blood glucose monitoring and management for two residents with diabetes, resulting in critical blood glucose levels not being addressed appropriately. For one resident, who had diagnoses including morbid obesity and type II diabetes mellitus, care plan interventions required monitoring blood sugars as ordered, administering insulin per sliding scale, and reporting abnormal blood sugars to the physician. However, the physician orders did not include sliding scale insulin or parameters for physician notification, and staff failed to obtain these orders. Over the course of a month, this resident experienced multiple episodes of critically high blood glucose levels (ranging from 413 to 500) without evidence of physician notification or intervention, and documentation of these events was missing from the nurse's notes. Another resident with diabetes and hyperglycemia had physician orders for both scheduled and sliding scale insulin, but the sliding scale only covered blood glucose levels up to 399. On one occasion, this resident's blood glucose was recorded at 486 and later at 400, but insulin was not administered as ordered within the regulatory time frame, and the sliding scale was not followed for values above 399. Documentation was inconsistent, and there was no evidence that the physician was notified of the critical blood glucose levels at the required times. The facility's policy required immediate physician notification and documentation for blood glucose levels above 400, but this was not done. Interviews with staff, including the DON and Medical Director, confirmed that staff did not consistently follow physician orders, care plan interventions, or facility policy regarding blood glucose monitoring, insulin administration, and physician notification. The failures included not obtaining necessary physician orders, not administering or documenting medication within regulatory requirements, and not ensuring that critical blood glucose levels were addressed by a physician or nurse practitioner. These deficiencies resulted in prolonged periods of uncontrolled hyperglycemia for both residents.
Failure to Notify Physician and Family of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the notification of physicians and responsible parties about critical blood glucose levels for two residents with diabetes. For one resident, multiple instances of critically high blood glucose readings were recorded in the Medication Administration Record, but there was no documentation in the nurse's notes or electronic medical record that the physician or family were notified, as required by the care plan. The Director of Nursing confirmed that there was no evidence of notification for these critical values. For another resident with diabetes and hyperglycemia, critical blood glucose levels were also documented, and while insulin was administered per a nurse practitioner's order, there was no documentation that the family was notified of the change in condition. Additionally, the nurse practitioner was not notified of all critical values as required. The facility's guidelines specify that significant changes in a resident's condition, such as critical lab values, must be immediately reported to the physician and responsible party, and all notifications and new orders must be documented in the medical record. These requirements were not met for the residents reviewed.
Failure in Wound Care Management and Documentation
Penalty
Summary
The facility failed to ensure ongoing assessment and timely documentation of skin impairments for residents at high risk for pressure ulcers. Observations revealed that multiple residents were not properly monitored or treated for existing and new skin conditions. For instance, a resident with a re-opened sacral pressure ulcer was not documented or reported to the physician, and the care plan was not updated until the surveyor's intervention. Additionally, the facility did not adhere to the manufacturer's recommendations for the use of low air loss (LAL) mattresses, as multiple layers of linens were observed on the mattresses, potentially compromising their effectiveness. Another resident developed a deep tissue injury (DTI) on the right heel, along with other wounds that were not identified, documented, or treated appropriately until the surveyor's involvement. The wound care coordinator was unaware of these conditions, and there was no comprehensive care plan developed upon admission to address the resident's skin impairments and prevent further pressure ulcers. The facility's failure to implement its policy and procedures on wound prevention and management was evident in the lack of timely assessments and communication with physicians. The facility's policy on wound assessment and treatment was not followed, as evidenced by the lack of systematic, ongoing assessments and documentation of wounds. The facility also failed to implement the necessary interventions in the residents' care plans to prevent deterioration and promote healing of pressure and non-pressure wounds. The medical director acknowledged these deficiencies and emphasized the need to follow the facility's policy and procedures in the prevention, treatment, and management of wound care.
Deficiency in Nail and Foot Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail and foot care to residents who were dependent on staff for activities of daily living (ADLs). Observations revealed that several residents, including those with significant medical conditions such as encephalopathy, respiratory failure, and dementia, had long, dirty fingernails and toenails. These residents were observed in various states of dependency, requiring total assistance with personal hygiene, yet their nail care needs were neglected. During the survey, it was noted that the Certified Nursing Assistants (CNAs) were responsible for providing nail care during ADLs. However, the CNAs failed to report the need for podiatrist referrals for residents with long, thickened toenails, as required by the facility's policy. This lack of communication and follow-through resulted in residents not receiving the necessary foot care, which is crucial for their overall health and well-being. The facility's policies on ADL care and nail care emphasize the importance of maintaining personal hygiene and preventing infection. Despite these guidelines, the facility did not ensure that the CNAs adhered to the policies, leading to the observed deficiencies. The Director of Nursing and other staff members were informed of these observations, highlighting a breakdown in the implementation of care protocols.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate infection control practices for residents on Enhanced Barrier Precautions (EBP) and during Activities of Daily Living (ADL) care. This deficiency was observed in multiple instances involving residents R28, R47, R49, and R59. For instance, a CNA was observed transferring a resident and then handling soiled linens improperly by allowing them to touch her clothes and arms, which she acknowledged should have been placed in a plastic bag away from her body. In another instance, a CNA and a family member were observed providing incontinence care to a resident on EBP without wearing the required personal protective equipment (PPE), such as gowns and gloves. Additionally, a Wound Care Coordinator performed wound care on the same resident without wearing the appropriate PPE, admitting to forgetting the necessary precautions. The facility's policy mandates the use of gloves and gowns during high-contact care activities for residents on EBP to prevent the spread of multidrug-resistant organisms (MDROs). Further observations revealed that a Licensed Practical Nurse (LPN) administered medication via a feeding tube to a resident on EBP with only gloves, acknowledging the oversight. Additionally, a resident's room was found to have an EBP sign but lacked the necessary isolation bin setup, which is typically placed outside the room. The Director of Nursing confirmed that the isolation setup was missing and emphasized the expectation for staff to wear full enhanced barrier protection during direct patient care.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to protect and promote the rights of a vulnerable resident, specifically the right to be treated with dignity and respect. On March 5, 2025, a resident was observed in a recliner chair wearing a sweater with multiple large food stains. The resident was alert but confused and totally dependent on assistance for activities of daily living (ADLs). A Certified Nurse Assistant (CNA) stated that the sweater was clean but the food stains could not be removed, and that the facility was responsible for the resident's laundry. The Social Service Director acknowledged the observation and stated that residents should be treated with dignity, which includes wearing clean and neat clothing. The facility's policy on resident rights emphasizes the right to be treated with dignity and respect, which was not upheld in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs of the residents. During an observation, a resident was found in bed with the call light on the floor behind the bed, making it inaccessible. The resident expressed that he could not find the call light despite looking for it. A Certified Nurse Aide confirmed that the call light should be within reach but was unsure why it was not placed next to the resident. The Director of Nursing stated that all residents should have their call lights within reach to request assistance, and they should not be placed behind beds or on the floor. The resident involved had multiple medical conditions, including hypertension, chronic respiratory failure, and a history of amputations, requiring partial to moderate assistance from staff. The facility's policy mandates that call lights be accessible and functioning, and the resident's care plan specifically included an intervention to keep the call light within reach.
Failure to Submit PASRR Level II Screenings for Residents
Penalty
Summary
The facility failed to submit a PASRR Level II screening for two residents, R22 and R39, who were reviewed for PASRR Level II in a sample of 17. This deficiency was identified through record review and interviews. R22, who had a gradual dose reduction for Risperdal and orders for psychological services, was not submitted for a PASRR Level II screening. The Social Services Director, V6, was unaware of R22's need for psychological services or changes in medication, which contributed to the oversight. Similarly, R39 had an order for psychological services but was not submitted for the necessary PASRR Level II screening. The Administrator, V1, acknowledged that the social services department is responsible for submitting PASRR Level II screenings and indicated that the information should come from the psychotropic nurse. The facility's policy mandates that all residents seeking admission to a Medicaid-funded nursing facility must be pre-screened through the PASRR process to ensure they receive the required services for mental illness or intellectual and developmental disabilities (IDD). The failure to submit the necessary screenings for R22 and R39 indicates a lapse in the facility's adherence to this federally mandated process.
Failure to Follow Side Rail and Transfer Protocols
Penalty
Summary
The facility failed to adhere to the physician's order and care plan regarding the use of side rails for a resident, identified as R37. On observation, R37 was found in bed with three side rails up, contrary to the physician's order and care plan which specified the use of bilateral 1/4 side rails for repositioning. The Assistant Director of Nursing and the Restorative Nurse both confirmed that only two side rails should be up, but there was a lack of clarity and adherence to the policy. The facility's policy on side rails emphasizes their use for enabling bed mobility and not for convenience, requiring a physician's order and regular assessments, which were not properly followed in this case. Another deficiency was observed in the transfer procedure for a resident, identified as R59, who is at high risk for falls and requires total assistance with activities of daily living. R59 was transferred by a CNA from bed to recliner chair without the use of a mechanical lift and without the assistance of a second staff member, as required by the resident's care plan and facility policy. R59's medical records and care plan indicated the need for a mechanical lift with two-person assistance due to her cognitive impairment, decreased strength, and history of falls. The facility's policy mandates the use of mechanical lifts for residents requiring two-person transfers to ensure safety, which was not adhered to in this instance. The facility's policies on side rail usage and mechanical lift transfers are designed to promote resident safety and independence. However, the failure to follow these policies and the residents' care plans resulted in deficiencies in providing a safe environment for the residents involved. The lack of adherence to established procedures and the absence of proper supervision and assistance during transfers highlight significant lapses in the facility's safety protocols.
Failure to Verify Feeding Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for checking the placement of a gastrostomy tube before administering medication to a resident. During an observation, an LPN was seen administering medication without verifying the tube's placement by checking for gastric residual, which is a standard procedure. When questioned, the LPN admitted to forgetting to perform this check. The Director of Nursing later confirmed that the correct procedure involves checking for gastric residual and listening for gastric sounds with a stethoscope. The resident involved had a diagnosis of gastrostomy status and dysphagia, and their care plan included an intervention to assess gastric residual volume according to facility policy. However, the facility was unable to provide a specific policy on feeding tube placement.
Failure to Monitor Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that resident personal refrigerators had recorded temperature logs, affecting two residents. Observations revealed that one resident's refrigerator contained undated food items, and the temperature log had not been updated since the previous month. The resident mentioned that staff usually checked the refrigerator daily, but they had not done so recently. Another resident's refrigerator was filled with various beverages, and the temperature monitoring log was not appropriate for the resident's refrigerator. The log showed that monitoring was not conducted over a weekend, and the staff responsible for monitoring was unaware of the acceptable temperature ranges. Interviews with staff, including the Housekeeping and Laundry Supervisor and the Assistant Director of Nursing, confirmed the lack of consistent monitoring and knowledge of temperature standards. The facility's policy on monitoring food brought in from outside sources was not adhered to, and the staff was unable to provide a policy specific to personal refrigerators. The facility's failure to maintain proper temperature logs and ensure staff awareness of temperature standards led to the deficiency.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to adhere to its policy on posting daily staffing information, as required by Medicare/Medicaid Services (CMS). On March 6, 2025, during a survey, the surveyor, along with the scheduler (V23), did not observe the daily staffing posting upon entering the facility. V23 acknowledged that the posting should have been displayed in a designated area by the front desk. The Director of Nursing (V2) also confirmed that the daily staffing posting should have been present. This oversight has the potential to affect the 69 residents receiving care in the facility, as the policy mandates that skilled nursing facilities (SNFs) and nursing facilities (NFs) must post the facility-specific shift schedule, the number and category of nursing staff, and the total number of hours worked by licensed nursing staff responsible for resident care at the beginning of each shift.
Resident Dignity and Privacy Violation
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident where the resident was placed in a hallway tied to a wheelchair and had pictures taken of him. The resident, who had multiple diagnoses including schizoaffective disorder and dementia, was found sitting in a wheelchair without socks or shoes, wearing a hospital gown, and covering his face with a sheet. The images taken matched the facility's hallway decor, and the resident was positioned across from the nurses' station. This incident was reported to have occurred shortly after the resident's admission to the facility, and he was later transferred to a hospital for psychiatric care. Staff members were aware of the situation, with one CNA and a scheduler overhearing discussions about taking pictures of the resident. The Director of Nursing (DON) was informed about a staff member, identified as V19, using a phone to discuss the resident's condition and taking pictures, which was recognized as a HIPAA violation. The facility's abuse prevention policy prohibits taking or using photographs of residents in a manner that demeans or humiliates them, and this incident was considered a violation of that policy. The facility's administrator acknowledged that the staff member involved should not have been allowed to continue their shift after the incident.
Unauthorized Photos of Restrained Resident
Penalty
Summary
The facility failed to adhere to its abuse prevention policy, resulting in unauthorized photos being taken of a resident, identified as R5, who was restrained in a wheelchair. This incident was considered demeaning and humiliating for the resident. The deficiency was identified during interviews and record reviews, which revealed that a Certified Nursing Assistant (CNA), V19, took pictures of R5 restrained with a gait belt and a sheet tied around him. These actions were in violation of the facility's policy prohibiting unauthorized photography of residents. The incident occurred on July 26, 2024, when V19 was assigned to monitor R5 on a one-to-one basis. Despite reporting the restraint to the Director of Nursing (DON) and other staff members, V19 was told to leave if he did not want to continue monitoring the resident. V19 left the floor but returned later to find R5 still restrained. V19 documented the situation by taking pictures, which he later provided to the Illinois Department of Public Health (IDPH). The facility's abuse prevention policy explicitly prohibits taking or using photographs of residents in a manner that could demean or humiliate them. R5, a resident with multiple diagnoses including schizoaffective disorder and dementia, was admitted to the facility on the same day of the incident and was later transferred to a hospital for psychiatric care. The facility's staff, including V18 and V24, were aware of V19's actions but failed to report them immediately. The Director of Nursing and the Administrator acknowledged that V19's actions violated the facility's policies, including HIPAA regulations, and that the situation was not handled appropriately at the time.
Resident Restrained with Gait Belt and Bed Sheet
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a gait belt and a bed sheet to restrain a resident in a wheelchair. This incident involved a resident with multiple diagnoses, including convulsions, alcohol-induced anxiety disorder, depressive episodes, schizoaffective disorder, dementia, acute cystitis, and bacterial pneumonia. The resident was admitted to the facility and shortly after, was ordered a psychiatric transfer due to his aggressive behavior. On the day of the incident, a CNA reported that the resident was being restrained with a gait belt and a bed sheet, which inhibited his freedom of movement and contributed to his agitation, aggression, and anxiety. The CNA expressed discomfort with the situation to the LPN, DON, and scheduler, but was told to leave if he did not want to monitor the resident. The CNA later documented the incident and provided this documentation to the Illinois Department of Public Health (IDPH). Interviews with various staff members, including CNAs, an RN, and the DON, revealed that the resident was considered a fall risk and was difficult to redirect. The facility's restraint policy, which was not followed in this case, states that any resident requiring a physical restraint should be assessed prior to application, and a plan of care should be developed. However, no restraint use assessment was found in the resident's chart, and the facility claimed to be a restraint-free environment.
Failure to Report and Address Suspected Abuse
Penalty
Summary
The facility failed to adhere to its policy for reporting potential abuse violations, which resulted in a deficiency. A resident, who had multiple diagnoses including convulsions, alcohol abuse, and dementia, was reportedly restrained with a gait belt and later with a sheet. A CNA, assigned to provide one-on-one monitoring for the resident, observed these restraints and reported them to the Director of Nursing (DON) and other staff members. Despite this, the CNA was told to continue monitoring the resident or leave, and the issue was not immediately escalated to the abuse coordinator or administrator as required by the facility's policy. The CNA, who was later terminated, took pictures of the resident and shared details of the resident's condition over the phone, which is a violation of HIPAA regulations. Other staff members, including another CNA and the scheduler, were aware of the situation but did not report it to the appropriate authorities, believing the initial CNA had the situation under control. The scheduler overheard the CNA discussing the resident on the phone and reported this to the DON, but the CNA continued to provide care for the resident until the end of his shift. The facility's abuse prevention program mandates immediate reporting of any suspected abuse, neglect, or exploitation to the administrator or a supervisor, who must then report to the administrator. The program also requires the separation of the alleged perpetrator from residents pending investigation. However, in this case, the CNA remained with the resident for the duration of his shift, and the incident was not reported to the administrator until after the surveyor's involvement. This failure to follow protocol resulted in the perpetrator continuing to provide care to the resident, compromising the resident's safety.
Failure to Prevent Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent an altercation between two residents during a supervised smoke break on the patio. Resident R6, who has a history of hallucinations and delusional thinking, initiated a verbal altercation with R7 by accusing him of knowing an unknown woman. When R7 denied knowing the woman, R6 became agitated and struck R7 with his cane. In response, R7 picked up a chair to defend himself, resulting in a physical altercation. Staff on duty, including a CNA, were present but unable to de-escalate the situation before it turned physical. R6 is a black male with a diagnosis of bipolar disorder and paranoid schizophrenia, and he is moderately impaired with a BIMS score of 11. He experiences hallucinations and delusions, which can lead to agitation and difficulty in redirecting his behavior. R7, a Hispanic male, is cognitively intact with a BIMS score of 14 and is generally calm. The incident occurred when R6 was hallucinating and believed R7 was involved with a woman he imagined. Despite the presence of staff, R6's delusional state led to the physical confrontation. The facility's report indicates that R6 had stopped taking his medications, which may have contributed to the increase in his delusions. The staff, including a CNA and a social worker, were aware of R6's delusional behavior and his history of hallucinations. However, the staff's inability to intervene effectively before the situation escalated to physical violence highlights a deficiency in supervision and de-escalation strategies for residents with known behavioral issues.
Failure to Timely Execute STAT X-ray Order
Penalty
Summary
The facility failed to ensure a STAT order for a chest x-ray for a resident with new chest bruising was carried out within the expected timeframe of 4 hours. The resident, who had yellowish and purplish bruising under the breast area, was assessed by a nurse practitioner who ordered STAT labs and x-rays to determine if there was any bleeding or fracture. Despite the urgency of the situation, the x-ray was not performed in a timely manner, and the resident experienced a change in condition later in the day, leading to their transport to the hospital. Interviews with facility staff revealed a lack of communication and follow-up regarding the STAT order. The Registered Nurse and LPN acknowledged the delay, and the Director of Nursing confirmed that the diagnostic company took longer than the expected 4 hours to arrive. The nurse practitioner was not informed that the x-ray had not been completed, which hindered the ability to diagnose a potential fracture. The facility's policy on physician orders did not address STAT orders, and the diagnostic contract was not presented to the surveyor, indicating a gap in the facility's procedures for handling urgent diagnostic services.
Failure to Discard Potentially Hazardous Food by Use-By Date
Penalty
Summary
The facility failed to discard potentially hazardous food (PHF) items by the use-by date. During an observation, 15 prepared cold cut sandwiches with a use-by date of 04/24/2024 were found in the cooler on 04/30/2024. The Dietary Aide confirmed that these sandwiches should have been discarded on the indicated date. The Food Service Director also stated that prepared cold cut sandwiches should be discarded on the date indicated on the label. The facility's policy on Food Safety and Sanitation, specifically the section on Dating and Labeling, requires that PHF/TCS foods be stored, dated, and labeled in the refrigerator at 41°F for a maximum of 7 days, starting from the day the food was prepared or a commercial container was opened.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident (R90) by not following their policy regarding the use of dignity bags for urinary drainage bags. On 4/30/2024 at 11:35 AM, R90 was observed lying in bed with an indwelling catheter, and the drainage bag was half-filled with urine and not placed in a dignity bag. Both the Director of Nursing (V2) and a Licensed Practical Nurse (V6) confirmed that the drainage bag should have been in a dignity bag. R90 is a [AGE] year-old male with diagnoses including quadriplegia, tracheostomy, depression, and flaccid neuropathic bladder. The facility's policy states that urinary drainage bags should be covered unless residents are in their rooms, and even then, the bag should not be visible from the hallway if possible.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to ensure a clean environment for a resident, identified as R153, who was observed lying in bed with dirty bed sheets and pillows. The bed siderails, enteral feeding machine, IV pole, and floor were also dirty with stains from enteral feeding spillage. Despite the presence of these unsanitary conditions, the housekeeping aide responsible for cleaning the room stated that he had already cleaned it but could not remove the stains from the floor and had informed his supervisor. The infection preventionist acknowledged the issue and stated that a clean environment should be provided to the resident. R153 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, dysphagia, and gastrostomy status, with an active physician order for continuous enteral feeding. The facility's policy on general cleaning procedures for resident rooms includes cleaning and disinfecting all room furnishings and mopping the floors, which was not adhered to in this case. This deficiency affected one of the three residents reviewed for a clean environment in a sample of 20 residents.
Failure to Update Abuse Assessment and Care Plan After Incident
Penalty
Summary
The facility failed to implement its abuse prevention policy by not updating the abuse assessment and formulating a care plan after an abuse incident involving a resident. The incident occurred when a Certified Nurse Assistant (CNA) made an inappropriate comment to a resident, which was witnessed by a Licensed Practical Nurse (LPN). The CNA was immediately removed from the building and later terminated. However, the resident's abuse/trauma assessment and care plan were not updated following the incident, despite the facility's policy requiring such updates after an abuse incident. The resident, who has a diagnosis of dementia, opioid abuse, and weakness, had their most recent abuse/trauma screening done almost a year prior to the incident, and no abuse care plan was in place at the time of the incident. Interviews with facility staff revealed that the Assistant Social Service Director was unaware of the incident and that the abuse/trauma assessment and care plan were only completed after the surveyor's inquiry. The facility's policy on abuse prevention, revised in 2019, mandates that staff identify residents with increased vulnerability for abuse and formulate care plans to reduce the chances of mistreatment. Despite this policy, the necessary assessments and care plans were not updated in a timely manner following the incident, indicating a failure to adhere to the established procedures for preventing and addressing abuse.
Failure to Perform Pacemaker Check and Obtain Hospice Plan of Care
Penalty
Summary
The facility failed to perform a pacemaker check as ordered and did not obtain a copy of the hospice plan of care for two residents. For one resident with a cardiac pacemaker, the electronic health records indicated that pacemaker checks were to be conducted every three months. However, there was no documentation of any pacemaker checks since June 2020, despite the order being in place since March 2023. The Director of Nursing confirmed that the checks were not performed as required, and the facility's policy mandates trans-telephonic pacemaker monitoring and documentation of the same in the medical record or MAR. For another resident admitted to hospice care, the facility failed to obtain the hospice plan of care. The Assistant Social Service Director could not locate the hospice plan of care in the hospice binder, which should have been provided by the hospice at the time of the resident's admission. The facility's agreement with the hospice company and its policy require that the hospice plan of care be included in the resident's written plan of care and reviewed at regular intervals. The failure to obtain and include the hospice plan of care in the resident's records was confirmed during the review.
Failure to Prevent Worsening of Moisture-Associated Skin Disorder
Penalty
Summary
The facility failed to prevent the worsening of a moisture-associated skin disorder (MASD) in a resident who was at high risk for developing skin impairments. The resident, who was admitted with multiple conditions including morbid obesity, Type 2 Diabetes Mellitus, and spinal stenosis, reported that her buttocks hurt and that staff sometimes took a long time to respond to her call light for changing. The resident's care plan included the application of A&D ointment and zinc oxide-based barrier cream, as well as weekly skin checks, but these measures were not effectively preventing the worsening of her condition. The wound care physician's recommendations, including the use of a low air loss (LAL) mattress and repositioning protocols, were not followed by the facility staff, leading to the exacerbation of the resident's MASD. The wound care physician had been treating the resident for two weeks and noted that the MASD on the resident's right buttock had worsened significantly, with the affected area increasing in size and severity. Despite the physician's recommendations for specific treatments and interventions, the facility continued to apply multiple treatments to the same site and did not implement the recommended use of a LAL mattress. The wound care nurse confirmed that the resident was not provided with a LAL mattress because it was deemed only necessary for stage 3 or 4 pressure ulcers, not for MASD. The facility's policy on the prevention and treatment of pressure ulcers was not adhered to, as evidenced by the lack of ongoing assessment, monitoring, and implementation of appropriate interventions. The Director of Nursing and other staff members acknowledged that any changes or worsening of a resident's skin condition should be reported to the wound care nurse and that the wound care physician's recommendations should be carried out. However, the facility failed to ensure these protocols were followed, resulting in the deterioration of the resident's skin condition.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up with pharmacy recommendations for physician response, affecting two residents. One resident, admitted with diagnoses including major depression, anxiety disorder, and opioid dependence, had several medications prescribed without appropriate indications. A pharmacy recommendation dated 3/4/24 highlighted this issue, but no follow-up action was taken by the Director of Nursing (DON) or the physician. The resident's active physician order sheet listed multiple medications for prophylaxis without proper justification, and the facility's policy on medication regimen review was not adhered to, as the pharmacist's recommendations were not addressed in a timely manner. Another resident had a pharmacy recommendation for a gradual dose reduction of a psychotropic medication, which was also not followed up. The recommendation was made on 3/4/24, but there was no response from the physician or psych nurse practitioner. The resident's order summary report indicated an ongoing order for Quetiapine fumarate, and psychiatric progress notes from February to April 2024 did not document any attempt at dose reduction or reasons for contraindication. The facility's failure to ensure timely follow-up on pharmacy recommendations led to this deficiency.
Failure to Clean and Cover Nebulizer Mask
Penalty
Summary
The facility failed to clean and cover a nebulizer mask after each use for a resident (R16) who was observed lying in bed with oxygen via nasal cannula at 2.5LPM. The nebulizer mask was dirty and exposed, connected to the machine placed on the bedside table next to an opened container of zinc oxide cream, two opened tubes of vitamin A and D ointments, an empty pudding container, and a used spoon. The resident confirmed that the nurse provides her nebulizer treatment when she has breathing problems. The Registered Nurse (V8) acknowledged that the nebulizer mask should be cleaned and placed in a plastic bag and kept in the bedside drawer after use, and that the barrier cream and ointments should be closed and kept inside the bedside drawer after each use. The Director of Nursing (V2) and the Infection Preventionist (V3) were informed of the observations. V2 confirmed that the nebulizer mask should be cleaned and covered after each use, and the barrier ointments and cream should be kept in the treatment cart after use, not at the bedside. The resident (R16) was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Pneumonia, Pulmonary Hypertension, and Obstructive Sleep Apnea, with an active physician order for Ipratropium-albuterol solution to be inhaled every six hours as needed for shortness of breath or wheezing via nebulizer. The facility's policy on administering nebulizer therapy requires that the connecting tubing be changed weekly and cleaned and covered after each use.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from verbal and physical abuse from another resident. On 4/1/2024, a resident (R42) reported that another resident (R62) verbally abused and physically pushed her to the floor after she had an altercation with a nurse. R42 expressed fear of R62, who had a history of delusional and aggressive behavior. Despite R42's fear and the incident, R42 was not moved to a new room until the next morning, and R62 was only given medication to calm down and monitored for the rest of the shift. The Director of Nursing and the Administrator were aware of R62's aggressive tendencies but did not take immediate action to ensure R42's safety that night. The facility's records indicate that R42 is on hospice care and has a history of suspected abuse, while R62 has multiple diagnoses, including unspecified psychosis and dementia with behavioral disturbances. R62 had previous incidents of aggression towards other residents, but his care plan was not updated following the incident on 4/1/2024. The facility's policy on abuse prevention requires immediate removal of the accused resident from contact with the victim during an investigation, which was not adequately followed in this case. The facility's failure to act promptly and effectively to protect R42 from further abuse constitutes a deficiency in ensuring resident safety.
Failure to Implement Proper Catheter Care
Penalty
Summary
The facility failed to implement proper catheter care for a resident with a suprapubic catheter. On observation, the resident was found lying in bed with brownish sediments attached inside the entire catheter tubing, which was draining dark yellow-orange urine. The Registered Nurse confirmed that the catheter should be monitored every shift for sediments and changed as needed. However, the presence of sediments indicated that this protocol was not followed. Additionally, a plastic wrapper was found around the urinary tubing, which the resident could not explain, and the Wound Care Nurse suggested it might be from a food wrapper, indicating a lapse in maintaining a sterile environment around the catheter site. The resident had a history of urinary tract infections and was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and a flaccid neurogenic bladder. The care plan required monitoring the catheter and urine for signs of infection and changing the catheter bag as needed. Despite these protocols, the resident's catheter care was not adequately managed, as evidenced by the presence of sediments and improper handling of the catheter tubing. This deficiency in catheter care management was observed and confirmed through interviews with the nursing staff and a review of the resident's medical records and care plan.
Failure to Timely Transmit Resident Assessments
Penalty
Summary
The facility failed to transmit assessments within 14 days of completion for three residents. During a record review with the MDS/Care Plan Coordinator, it was found that the annual assessments for two residents and the quarterly assessment for another resident were not submitted on time. Specifically, the annual assessments for two residents were not submitted by the required dates, and the quarterly assessment for another resident was submitted 12 days late. The MDS/Care Plan Coordinator indicated that the assessments are completed by the facility but are reviewed and signed off by an MDS Consultant before submission. The MDS Consultant confirmed the delays and provided the correct submission dates, which were not met. The review of the MDS assessments and Final Validation Reports for the three residents indicated that the assessments were signed off by the person completing the care plan decisions but were submitted late. The reports showed target dates and messages indicating that the records were submitted more than 14 days after the completion dates. This failure to submit the assessments on time was confirmed through interviews with the MDS/Care Plan Coordinator and the MDS Consultant, who acknowledged the delays and provided the expected submission timelines that were not adhered to.
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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