Loft Rehab & Nursing Of Normal
Inspection history, citations, penalties and survey trends for this long-term care facility in Normal, Illinois.
- Location
- 510 Broadway, Normal, Illinois 61761
- CMS Provider Number
- 145031
- Inspections on file
- 45
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Loft Rehab & Nursing Of Normal during CMS and state inspections, most recent first.
The facility failed to ensure dignified and respectful communication when the former Administrator repeatedly used loud profanity and derogatory language toward staff in hallways and near the nurse’s station, in violation of the facility’s conduct policy. A resident with severe cognitive impairment was frequently positioned near the nurse’s station and Administrator’s office where loud cursing and yelling occurred, while a cognitively intact resident with a history of abuse reported that the Administrator’s yelling during an emergency increased the resident’s anxiety and that the Administrator had cursed at staff on other occasions. Another resident with moderate cognitive impairment reported feeling disrespected when the Administrator became angry and walked out of the office without addressing a concern about a wheelchair part, leading the resident to feel looked down upon.
Two residents experienced significant changes in condition that were not adequately assessed or communicated, and one resident’s continuous oxygen order was not followed. A resident with severe cardiopulmonary disease and an order for continuous O2 at 2 L via nasal cannula had repeated episodes of SOB, tachypnea, and abnormal vitals; staff administered nebulizer treatments but did not notify a provider, and the resident was later sent to a clinic without O2 despite the continuous order, arriving there in acute respiratory distress and ultimately being hospitalized with acute respiratory failure and CHF exacerbation. Another resident admitted for rehab after a femur fracture developed hypotension, pallor, lethargy, weakness, nausea, and poor intake; CNAs and an NP reported these changes to an LPN, but the LPN did not perform a timely hands-on assessment, did not notify a provider of the low BP or held medications, and documentation of medication administration and skilled assessments was lacking before the resident was later found unresponsive. These events occurred despite facility policies requiring prompt physician notification and documentation for significant changes in condition and oxygen therapy.
The facility did not employ a full-time Certified Dietary Manager (CDM) to oversee food and nutrition services, instead relying on a part-time CDM who worked only a few days per week and was often unavailable. Staff interviews, including with dietary personnel and the corporate dietary manager, confirmed the absence of a full-time CDM, and the employee roster listed the CDM as part time. A resident serving as Resident Council President, who is cognitively intact and has multiple complex diagnoses including COPD, CKD, HTN, PTSD, GERD with esophagitis, coronary artery disease with angina, prior MI, blood and immune disorders, and generalized epilepsy, reported that only a part-time CDM was in place and usually unavailable, while 83 residents were documented in the facility census.
Surveyors found that the facility did not follow its posted menus and frequently ran out of planned food items. During an observed lunch, some residents received mixed vegetables instead of the posted cauliflower because the kitchen ran out, and the listed dessert was not served. Staff acknowledged that the kitchen often runs out of food and cannot follow the menu, and one staff member reported a breakfast where all residents received only a donut and fruit. Multiple residents reported that the food served often does not match the menu and that the kitchen frequently runs out of items. Grievance logs and resident council minutes documented ongoing concerns about missing food and insufficient supplies, affecting a census of 83 residents, including individuals with complex conditions such as CHF, DM with CKD, chronic ulcers, lymphedema, and metabolic encephalopathy.
Surveyors found that hot foods were not maintained at or above 135°F during a lunch meal service, with ravioli, hamburger patties, and vegetables on multiple trays measuring well below required temperatures. A CNA confirmed the low temperatures as trays were served. The dishwasher and corporate dietary manager reported that the steam table had broken and that staff left hot cart doors open while removing trays, allowing food to cool. Facility policy required hot foods to be held at 135°F or higher, and prior grievances and resident council minutes documented repeated complaints of cold, undercooked, and unappetizing food affecting multiple residents.
The facility failed to provide dinner within the posted meal time, with at least one cognitively intact resident reporting that dinner was not served until 8:30 p.m. on one occasion. The resident, who had multiple chronic conditions including CHF, DM, CKD, and PVD, informed a family member of the late meal, and this concern was documented in the grievance log. Multiple RNs, the DON, and the corporate dietary manager confirmed that on a date in February the evening meal was served very late, after 8:00 p.m., due to kitchen staff calling in and resulting staff shortages, and resident council minutes also reflected concerns about meals being served late, potentially affecting all residents.
Staff were directed to retroactively complete missing ADL documentation for multiple residents over an extended period, contrary to facility policy requiring accurate, timely, and shift-based charting. Several CNAs reported receiving multi-page lists of residents and tasks to backfill, being threatened with removal from the schedule, termination, or potential license repercussions if they did not comply. Some CNAs stated they could not remember the care provided and either made up information or documented entries as N/A to avoid falsifying records, while a nursing supervisor and a regional nurse consultant acknowledged running missing documentation reports and instructing staff to complete the gaps so there were no holes in the records.
During an RSV outbreak, the facility failed to ensure timely and proper respiratory testing for two residents with respiratory symptoms. The IP and clinical leadership reported delays related to agency staff using incorrect collection materials and difficulty obtaining appropriate swabs, while policy required COVID-19 testing first for residents with respiratory illness. One resident with ongoing congestion and low oxygen saturation had an RSV specimen rejected due to improper collection before later testing positive, and another resident with fever and wheezing underwent multiple COVID-19 tests before being swabbed for RSV, with RSV positivity confirmed after a delay. The facility’s infection control policy assigned the IP responsibility for surveillance and monitoring of infectious disease exposures.
A resident with known swallowing difficulties and ongoing speech therapy, who safely tolerated only one pill at a time with applesauce, reported that an RN administered multiple medications at once and left the room while the resident was still swallowing. The resident’s preference and need for single-pill administration had been documented, and she attempted to signal the RN but was not heeded. A CNA then entered to provide incontinence care and lowered the head of the bed from elevated to flat while the resident was still trying to swallow, after which the resident began coughing, drooling, gasping, and choking. The RN returned to find the resident cyanotic with low O2 saturation, performed the Heimlich maneuver, and the resident expelled applesauce and undigested food, consistent with an esophageal obstruction that occurred during medication administration, contrary to facility policy requiring proper positioning and observation during medication administration.
A resident who was cognitively intact, used a mechanical lift, and had a pressure-relieving mattress activated the call light to request help retrieving food from the floor, but the call light reportedly remained unanswered for about 40 minutes. The resident then attempted to reach the item independently, rolled from a regular-height bed, and was found face down between the bed and the wall, complaining of pain. The resident was sent to the ED and diagnosed with multiple nondisplaced rib fractures. Staff, including CNAs, an LPN, rehab staff, and the DON, reported that call lights sometimes go unanswered for 20–40 minutes due to having only two CNAs on certain shifts, especially around dinner and bedtime, despite facility policies requiring call lights to be within reach and response times to be a priority.
A resident reported a missing cell phone and, after searching their room and common areas, staff notified the resident’s POA and management. Law enforcement was contacted, and location data suggested the phone had been taken off-site, but it was not recovered. The administrator told the POA the facility had no responsibility for the missing phone, did not report the incident to the state agency, and did not replace the phone. The POA ultimately purchased a replacement phone using the resident’s own funds, despite facility policy stating residents have the right to be free from misappropriation of property and to be informed of investigation conclusions.
A resident reported a missing cell phone to an RN, who then notified the resident’s POA and facility management. The POA later contacted local law enforcement and provided tracking information indicating the phone’s last known location off facility grounds, but the phone was not found. The Administrator told the POA the facility had no responsibility for the missing phone, did not reimburse the POA for a replacement, and acknowledged never reporting the allegation of misappropriated property to the state agency, despite a written abuse prevention policy requiring investigation and reporting of such allegations.
A resident reported a missing cell phone to a RN after unsuccessfully searching their room and a common area. The RN notified the resident’s POA and management, and the POA later involved local law enforcement, providing Life 360 data showing the phone’s last known location off-site. The police were unable to locate the phone. The Administrator told the POA the facility had no responsibility for the missing phone, did not report the incident to the state agency, did not identify who took the phone, and did not replace it, despite a written abuse prevention policy requiring investigation, state reporting, and keeping the resident informed regarding misappropriation of property.
Multiple residents experienced significant delays in call light response, with some waiting up to two hours for assistance. Grievance logs and resident council minutes documented ongoing concerns about slow staff response, and interviews confirmed that both cognitively impaired and intact residents were affected. Facility policy required call lights to be answered within 10-15 minutes, but this was not consistently achieved.
Three dependent residents did not consistently receive the required number of showers or bed baths, with some reporting long periods without bathing and issues with hot water availability. Staff confirmed that not all residents received two showers weekly and could not provide accurate documentation of bathing schedules, resulting in a deficiency related to inadequate ADL support and personal hygiene.
The facility failed to maintain complete and accurate medical records for several residents, including one who was not assessed by a nurse during a five-hour stay and others who did not receive adequate showers or bed baths. Documentation related to care was found to be inaccurate and altered, with inconsistencies in signatures and use of correction tape, in violation of facility policy.
Two residents with cognitive and behavioral issues engaged in a physical altercation in their shared room, exchanging hits and kicks after a verbal exchange. Staff intervened to separate them, but the incident demonstrated a failure to protect residents from physical abuse.
Staff and residents reported ongoing sightings of roaches in hallways and resident rooms over several months, with multiple rooms requiring pesticide treatment and restricted access. Despite a policy requiring effective pest control and prompt reporting, the facility did not adequately address the infestation, as confirmed by staff interviews, resident reports, and the need for an unscheduled pest control visit.
A resident with severe cognitive impairment and chronic eye conditions did not receive the prescribed Systane Complete Ophthalmic Solution as ordered by the physician. Instead, an LPN administered Ketotifen Fumarate eye drops, incorrectly assuming they were equivalent. The pharmacist confirmed these medications are not interchangeable, and the facility's policy requiring matching orders and prescriptions was not followed.
A resident with significant mobility impairments and a history of falls was propelled in a wheelchair by staff without foot pedals attached, leading to a fall and head injury. Staff interviews and documentation confirmed that the resident was dependent on staff for wheelchair mobility and that foot pedals were not routinely used, despite the resident's risk factors and the facility's fall prevention protocols.
After a resident with multiple health conditions tested positive for COVID-19, the facility did not initiate required contact tracing or testing for other residents and staff, despite policy and staff acknowledgment that these steps should have been taken. This lapse in infection control had the potential to impact all residents.
A resident with multiple diagnoses, including COVID-19, was not provided with complete and accurate nursing assessments or documentation of respiratory status and transfer to the hospital. Progress notes showed the resident became symptomatic and tested positive for COVID-19, but there were missing head-to-toe and respiratory assessments, and no record of physician or family notification regarding the hospital transfer, contrary to facility policy.
A facility failed to provide timely laboratory services for a resident who underwent kidney stone surgery. The discharge instructions required a 48-hour urine collection two weeks post-operatively and a urine culture one month post-hospitalization. However, the medical record lacked documentation of these tests, and no results were found. The Director of Nursing confirmed the absence of test results, violating the facility's policy on timely laboratory services.
The facility failed to update care plans for two residents following status changes. One resident required a wheelchair modification to prevent sliding during transport, which was not documented in the care plan. Another resident began dialysis, but this was not reflected in their care plan. The Social Service Director acknowledged the oversight.
A facility failed to assess and document the elopement risk for a resident with severe cognitive impairment and a history of attempting to leave the building. The resident's medical record lacked an elopement assessment and justification for an elopement management bracelet. Upon readmission from the hospital, the resident did not receive a new assessment or bracelet, as confirmed by the SSD and an LPN.
The facility failed to maintain sanitary conditions in its dietary services, affecting all 87 residents. Observations included mildew in the ice machine, a leaking sink, soiled kitchen floors, and dirty can openers. These issues persisted over several days, indicating inadequate cleaning and maintenance.
The facility failed to permanently affix a narcotic lock box in the medication room, leading to improper storage of controlled substances. An LPN confirmed that the lock box, containing Morphine Sulfate and Hydrocodone/Acetaminophen for three residents, was not affixed and was used due to insufficient space in the medication cart. This practice violated the facility's policy requiring Schedule II medications to be stored in a permanently affixed compartment.
The facility did not ensure arbitration agreements allowed for a mutually convenient venue selection, affecting three residents. The agreements specified arbitration would occur in the facility's county unless mutually agreed otherwise.
A resident's room was found to have large areas of peeling and torn wallpaper, creating an unhomelike environment. The resident reported the disrepair had been present since their admission, and a CNA noted the damage was caused by the bed hitting the wall.
A facility failed to develop a comprehensive care plan for a hearing-impaired resident. The resident's hearing aid broke shortly after admission, and staff used a whiteboard for communication. However, the care plan did not document the hearing impairment or the communication method. The Care Plan Coordinator and DON confirmed the omission, despite policy requirements for care plan revisions.
The facility failed to provide proper pressure ulcer care and prevention for two residents. Both residents had orders for specific wound care treatments and pressure-relieving boots while in bed, but observations showed non-compliance. The treatments were not administered correctly, with medical honey not applied properly, and the residents were often without the required boots. The facility's policy on pressure injury prevention was not adhered to.
A resident with multiple medical conditions, including malnutrition and dysphagia, did not have their Gastrostomy tube placement verified before medication and feeding administration. On two occasions, a nurse and an LPN failed to check the tube placement as required by facility policy, despite clear orders to do so. This oversight occurred during the administration of water flushes, Jevity 1.5 feeding, and medications.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer. The resident had a pressure ulcer with serosanguineous drainage, but no EBP sign was posted on the door. Staff entered the room to change the dressing without donning gowns. The infection preventionist confirmed the need for EBP but did not implement it, as the ulcer was not deemed chronic.
A resident's financial affairs were mishandled when a facility withdrew funds from the resident's bank account without permission after discharge. The resident, who was cognitively intact, had authorized monthly withdrawals for billing, but the facility continued to charge for days beyond the discharge date. The error was due to a lack of communication and awareness of the discharge, causing stress for the resident's family. The facility eventually refunded the overcharged amount.
The facility failed to maintain a clean and homelike environment, affecting 36 residents. Observations revealed dirt and debris on floors, worn and slippery vinyl flooring, damaged walls, and rusted fixtures. Residents expressed concerns about these conditions, and previous complaints about cleanliness were documented. The facility administrator acknowledged the need for improvement.
A resident with a history of self-harm and suicide attempts was able to access self-harm items, leading to another attempt. Despite a care plan to remove corded accessories and replace the call light with a bell, the resident's room still contained hazardous items. Staff interviews revealed a lack of awareness and communication regarding the resident's precautions, and facility policies on behavioral health services and suicide prevention were not effectively implemented.
A resident with severe cognitive impairment and a history of exit-seeking behaviors eloped from a facility during a fire drill, remaining missing for 17 hours. The resident's care plan did not address his high risk of elopement, and staff failed to provide adequate supervision or ensure exit doors were properly alarmed. The resident was found in a potentially dangerous area after crossing a busy street.
Failure to Ensure Dignified, Respectful Communication by Administrator in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to promote resident dignity and uphold residents’ rights to a dignified existence, self-determination, and respectful communication. The former Administrator (V53) was repeatedly reported by staff as using loud profanity and derogatory language toward staff in hallways and near the nurse’s station, where residents were present. The facility’s own Conduct and Behavior Policy, revised 2/11/2025, prohibits using profanity, abusive language, or other unprofessional behavior and specifies that conflicts between employees should not be discussed in front of residents or visitors. One resident (R6), with severe cognitive impairment per the MDS and care planned as being at potential risk for abuse related to dementia, was repeatedly observed independently propelling in a wheelchair to and remaining near the nurse’s station by the front door, close to the Administrator’s office and reception area. Multiple observations over several days documented R6 sitting or moving in this area. Staff, including the Business Office Manager (V41) and Receptionist (V56), reported hearing the former Administrator loudly cussing and yelling in or near this area, and V41 stated that R6 usually sat by the nurse’s station and would think R6 heard the Administrator’s loud profanity, even though R6 had impaired cognition. V41 acknowledged not reporting these incidents beyond discussion in a morning meeting where the Administrator was present. Another resident (R15), cognitively intact per the MDS and care planned as being at risk for altered well-being and/or psychological distress due to a history of abuse, reported hearing the former Administrator loudly yell at staff about hallway equipment placement during an emergency situation involving a crash cart. R15 stated already feeling anxious due to the emergency and that the Administrator’s yelling increased this anxiety; R15 also reported hearing the Administrator curse at staff on previous occasions in the hallway and expressed dislike of this behavior. A third resident (R20), with moderate cognitive impairment, reported going to the Administrator’s office to report a missing wheelchair part and stated that the Administrator became angry, walked out without looking at the wheelchair, and made the resident feel disrespected and looked down upon. These resident and staff accounts collectively describe unprofessional, profane, and disrespectful conduct by the Administrator in resident areas, contrary to the facility’s policy and residents’ rights to dignity.
Failure to Respond to Changes in Condition and Follow Continuous Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond to significant changes in condition and to follow physician orders for continuous oxygen therapy. One resident with severe cognitive impairment and multiple cardiopulmonary diagnoses, including COPD, chronic respiratory failure with hypoxia, and CHF, had an active order and care plan for continuous oxygen at 2 L via nasal cannula and monitoring for signs of respiratory distress with provider notification as needed. On one night, an LPN documented that the resident was drowsy, complained of shortness of breath, and had a respiratory rate of 44 breaths per minute; a nebulizer treatment was given and the respiratory rate decreased only to 36, but there was no documentation of provider notification. On another shift, an agency LPN found the same resident struggling to breathe, with wheezing, tachycardia, tachypnea, and oxygen saturation of 93% on 5 L of oxygen; a nebulizer treatment was administered and vital signs were reassessed, but again there was no provider notification documented. The agency LPN reported being unfamiliar with facility protocol for shortness of breath and stated that an RN advised giving a breathing treatment and passing the information to the next shift. An RN also reported observing fast, shallow respirations and a respiratory rate of 31 but was not concerned and did not notify a provider. The same resident, who had recently been hospitalized and intubated for acute respiratory failure with hypoxia and CHF exacerbation, was sent out of the facility to a nephrology appointment without oxygen, despite an active order for continuous oxygen at 2 L via nasal cannula. The transport driver reported that the resident was breathing fast and worsened during transport and was unsure if oxygen was in use. At the nephrology office, the resident was noted to be only arousable to verbal stimuli, slumped in a wheelchair, with fast, shallow respirations and not wearing oxygen. The nephrologist’s office called 911, and the resident was sent to the emergency department, where documentation showed hypoxia with an oxygen saturation of 86%, a diagnosis of acute respiratory failure and CHF exacerbation, and initiation of BiPAP. A second resident, admitted for rehabilitation after a femur fracture and documented as cognitively intact and requiring partial to moderate assistance with transfers, experienced multiple indicators of a change in condition that were not adequately assessed or communicated. On the morning of the resident’s death, vital signs showed hypotension with a blood pressure of 98/45 and pulse of 61, leading an LPN to hold Metoprolol per parameters and also to hold another medication without parameters, with no documentation of physician notification. There was no skilled nursing assessment or progress note documented for that day or the previous day, and CNA documentation of meal intake was missing for both days. A CNA reported that the resident was pale, lethargic, weak, refused breakfast, and complained of not feeling well, and stated these findings were reported to the LPN, but the CNA did not observe further follow-up. Later that morning, a nurse practitioner assessed the resident and documented that the resident appeared ill, pale, drowsy but arousable, with a dry mouth, nausea, fatigue, and a low blood pressure of 98/45. The NP reported these concerns to the LPN, advised administration of Compazine, and contacted another NP, recommending laboratory testing and/or further evaluation. The LPN acknowledged awareness of the low blood pressure and that the resident was ill, but stated that she did not physically assess the resident before going to lunch, only visually observing the resident sleeping from outside the room, did not notify a provider of the condition, and could not document the time of anti-nausea medication administration, which was not found in the record. A late entry note by the LPN later described the resident as sleeping with even, unlabored respirations. When the consulting NP arrived later that day, family friends expressed concern, and the NP found the resident unresponsive, pulseless, cold, and CPR was initiated. The DON and regional nurse consultant both confirmed that the nurse should have documented the change in condition and promptly notified the physician, and the facility’s Notification of Changes and Oxygen Administration policies require prompt provider notification for significant changes in condition and changes related to oxygen therapy. The facility’s own policies on Notification of Changes and Oxygen Administration state that physicians must be consulted when there is a significant change in condition, including life-threatening conditions or clinical complications, and that staff must document assessments and notify the physician of changes in vital signs and oxygen-related issues. In both residents’ cases, documented abnormal vital signs, respiratory distress, and clear changes from baseline were not followed by timely provider notification, comprehensive assessment, or adherence to ordered continuous oxygen therapy. These omissions and failures to follow policy and physician orders form the basis of the cited deficiency.
Lack of Full-Time Certified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager (CDM) to carry out the functions of the food and nutrition service, as required, potentially affecting all 83 residents. During an observation and interview on 03/23/26, a dietary staff member stated there was no CDM, while later that day the Corporate Dietary Manager reported that the facility employed a CDM who worked part time. On 03/24/26, the Corporate Dietary Manager confirmed that the facility did not have a full-time CDM and that the part-time CDM worked only on Tuesdays, Thursdays, and Fridays. The Resident Council President reported that the facility had only a part-time CDM and that this individual was usually unavailable. Review of the employee roster documented the CDM as a part-time employee, and the CDM was unavailable for interview because they were not in the facility and did not answer the telephone. The midnight census documented 83 residents in the facility. One resident, the Resident Council President, had a care plan noting multiple diagnoses including COPD, chronic kidney disease, hypertension, PTSD, GERD with esophagitis, atherosclerotic heart disease with angina, myocardial infarction, blood and immune disorders, and generalized epilepsy, and was documented as cognitively intact on the Minimum Data Set. The deficiency centers on the facility’s lack of a full-time CDM despite the census and the complexity of at least one resident’s medical conditions, as evidenced by staff and resident interviews and review of the employee roster and clinical records.
Failure to Follow Posted Menus and Repeated Food Shortages
Penalty
Summary
The deficiency involves the facility’s failure to follow posted and printed menus and to consistently provide the planned food items to residents. On a specified lunch date, the posted menu listed ravioli bake, cauliflower, a bread stick, an apple orchard bar, and a beverage. During observation of that meal service, some residents received mixed vegetables instead of the listed cauliflower because the kitchen ran out of cauliflower, and no dessert was served at the time of tray distribution. The cook reported that the planned dessert item (apple orchard bar) was not available and that ice cream was intended instead, but this was not reflected on the posted menu. A dishwasher stated that the kitchen ran out of cauliflower because there was only one bag available and that the kitchen frequently runs out of food and is unable to follow the menu. The corporate dietary manager confirmed that cauliflower was substituted after running out of supply and that the apple orchard bar was not prepared or served. Multiple residents and records corroborated that menu items and served food often do not match. Randomly interviewed residents stated they would have preferred the cauliflower over the mixed vegetables and reported that the kitchen frequently runs out of various foods, with one resident stating that most of the time the kitchen sends different food than what is on the menu and another stating that the menu and served food often do not match. The grievance log and resident council minutes documented repeated concerns over several months about the kitchen running out of food and missing food items. One staff member reported that on one breakfast occasion in February, all residents received only a donut and fruit, though the reason was unknown. Two residents referenced in the report had multiple chronic conditions, including anemia, CHF, morbid obesity, type 2 DM with CKD, peripheral vascular disease, chronic ulcers, lymphedema, and metabolic encephalopathy, and were documented as cognitively intact or mildly cognitively impaired, respectively. The facility census showed 83 residents who could potentially be affected by these failures to follow the menu as printed and posted.
Failure to Maintain Safe Hot Food Holding Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to hold and serve hot foods at or above 135°F as required by the facility’s food temperature policy. During a lunch service, three random trays being plated at the serving window were observed with ravioli bake measuring 108°F. In the main dining room at the same meal, one tray with baked ravioli measured 95.3°F, another tray with two hamburger patties on buns had hamburger meat at 79.5°F, and a third tray had cauliflower at 86°F. A CNA present in the dining room confirmed the temperatures of the food trays as they were being taken while the trays were being served to residents. Further interviews and record review showed that the dishwasher reported the food was not usually cold but stated that on that day the steam table had broken down just before serving. The corporate dietary manager later confirmed the steam table was broken and also observed that staff would open the doors of the hot cart, remove a tray, and leave the doors open, allowing food to cool. The facility’s written policy dated 11/10/21 requires hot food to be cooked to a minimum safe temperature and held at no lower than 135°F, with hot food holding temperatures taken and recorded for food on the steam table. Review of the grievance log and resident council minutes documented prior complaints that meat needed to be cooked more precisely, meals were unappetizing, potatoes were cold and undercooked, and food was coming out cold to rooms and the dining room, including reports that meat was overcooked and food was cold. The facility census showed 83 residents resided in the facility at the time of the survey.
Late Dinner Service Due to Kitchen Staff Shortages
Penalty
Summary
The facility failed to serve the dinner meal during the posted time of 5:30 p.m. to 6:30 p.m., resulting in at least one resident receiving dinner significantly later than scheduled. One cognitively intact resident, admitted with multiple diagnoses including anemia, essential hypertension, chronic diastolic congestive heart failure, morbid obesity, type 2 diabetes with chronic kidney disease, and peripheral vascular disease, reported that on an unspecified date in February the dinner meal did not arrive until 8:30 p.m. The resident’s family member confirmed that the resident had reported not being served dinner until 8:30 p.m. in late February. Review of the grievance log documented that on 02/25/26 the dinner meal was served late. Multiple staff interviews corroborated that on a date in late February the evening meal was served very late due to kitchen staff calling in and resulting staff shortages. Two RNs stated that the dinner meal was served very late, after 8:00 p.m., because kitchen staff had called off. The DON confirmed that on an unknown date in February the dinner meal was served very late for the same reason and that CNAs went into the kitchen to help prepare the meal. The corporate dietary manager confirmed that on 02/25/26 the evening meal was served late due to kitchen staff shortage. Resident council minutes from early January also documented that meals were served late, and the facility census showed 83 residents resided in the facility at the time, indicating the potential for all residents to be affected by late meal service.
Failure to Ensure Accurate and Timely ADL Documentation and Professional Conduct
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff maintained professional standards of conduct and accurate, truthful, and timely documentation in the medical record, specifically related to ADL bathing documentation for four residents. A Point of Care (POC) Audit Report printed on 3/27/2026 showed missing ADL bathing documentation for these residents over a period from early January through late March 2026. The facility’s own documentation policy required that each resident’s medical record contain an accurate representation of the resident’s actual experiences, with documentation completed at the time of service or no later than the end of the shift, and in chronological order. Multiple CNAs reported receiving multi-page lists of residents and tasks for which documentation was missing, covering weeks to months in the past, and being instructed to complete this documentation retroactively. One CNA stated they were told their job and schedule were at risk if they did not complete the backdated charting and admitted to making up information because they could not remember what had occurred. Another CNA reported being told that failure to complete the missing charting could result in removal from the schedule, termination, and possible revocation of their CNA license, and that these directives came from corporate. A CNA supervisor confirmed receiving a list from a regional nurse consultant and being instructed to have staff complete the missing documentation, with the expectation that staff assigned on those days must go back and fill in the records so there were no “holes” in the report. One CNA, unable to recall the care provided, documented “N/A” on most entries to avoid lying, despite being asked to document care such as showers, meals, and other tasks from prior shifts.
Delayed and Improper RSV Testing During Respiratory Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to perform timely and appropriate testing for respiratory infections during a known RSV outbreak, affecting two residents reviewed for infection control. The Assistant DON/Infection Preventionist reported that the facility had an RSV outbreak involving eleven residents and acknowledged delays in testing some residents due to agency staff using incorrect materials, which was discovered after the Infection Preventionist returned from a weekend absence. The ongoing infection control log documented the first confirmed RSV case on 2/20/26. The President of Clinical Services stated that facility policy and Department of Public Health guidance required testing for COVID-19 first when a resident presented with respiratory illness, even during the RSV outbreak, and further stated that delays in RSV testing were also related to difficulties obtaining appropriate swabs. For one resident (R3), records showed an initial negative RSV test on 2/24/26, followed by continued congestion documented on 2/27/26. On 3/2/26, R3’s oxygen saturation was 89%, oxygen was initiated, and the physician was notified after no response over the weekend. A laboratory report dated 3/2/26 indicated that the RSV specimen collected for R3 was unacceptable because it was not a nasopharyngeal swab in the required red cap viral transport medium, necessitating recollection. R3’s subsequent test on 3/3/26 was positive for RSV. For another resident (R19), progress notes documented a fever of 102.1 and a negative COVID-19 test on 2/27/26, followed by wheezing and a chest x-ray order on 3/1/26, with repeat COVID-19 testing again negative. R19 was then swabbed for RSV, COVID-19, and influenza, with specimens collected on 3/2/26 and RSV positivity reported on 3/3/26. The facility’s Infection Prevention and Control Program policy stated that the Infection Preventionist is responsible for oversight of the program, including monitoring exposures and conducting surveillance and epidemiological investigations of infectious diseases.
Esophageal Obstruction After Multiple Pills Given at Once and Improper Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide safe medication administration consistent with physician orders, speech therapy recommendations, the resident’s expressed preferences, and facility policy, resulting in an esophageal obstruction during medication administration. The resident involved was cognitively intact, dependent for transfers, turning, and repositioning, and required setup/supervision with eating. Speech therapy documentation showed the resident had swallowing difficulties, including mild lingual weakness and coughing several minutes after oral intake, and that she could safely swallow only one pill at a time with applesauce. The resident had been receiving speech therapy for swallowing difficulties since mid-2025, and therapy notes indicated she was specifically concerned about swallowing multiple pills when agency staff were present. On the date of the incident, the resident reported in writing that an RN administered multiple medications at once, despite her preference and need to take one pill at a time with applesauce. The resident stated she attempted to signal the RN by raising her hand to indicate she needed one pill at a time, but the RN left the room while the resident was still swallowing the medications. Shortly thereafter, a CNA entered the room to provide incontinence care and began to lay the resident’s head of bed from an elevated position to flat while the resident was still trying to swallow the pills. The resident then began coughing, drooling, gasping, and showing signs of choking. Nursing documentation shows that when the RN was called back to the room, the resident’s lips were cyanotic, her oxygen saturation was 64%, and she indicated she could not breathe and was choking. The RN assessed the airway, did not see a visible obstruction, and initiated the Heimlich maneuver. The resident became unresponsive briefly, then expelled applesauce and undigested food, and later vomited a second time after being repositioned. The facility’s medication administration policy required qualified staff to position the resident appropriately for medication administration and to observe the resident consuming medications, but the resident’s account and the sequence of events indicate that multiple pills were given at once, her expressed need for one pill at a time was not followed, and she was repositioned to a flat position while still swallowing, leading to the choking episode and esophageal obstruction.
Failure to Timely Respond to Call Light Resulting in Fall With Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to respond to a resident’s call light in a timely manner, resulting in a fall with injury. A cognitively intact resident (R1), who used a mechanical lift and had a pressure-relieving mattress, activated the call light to request assistance in retrieving popcorn from the floor. R1 and a family member reported that the call light remained on for approximately 40 minutes without response. During this time, R1 attempted to reach the popcorn independently, rolled out of the regular-height bed, and was found lying face down between the bed and the wall. R1’s roommate yelled for help, and a CNA entered the room and observed R1 on the floor. Progress notes document that R1 complained of pain “all over,” 911 was called, and R1 was transported to a local emergency department. Emergency department records document nondisplaced right lateral fifth through ninth rib fractures and nondisplaced acute fractures of the anterior left sixth, seventh, eighth, and tenth ribs. R1’s care plan included interventions to keep the bedside table next to the bed within reach and to keep the call light within reach at all times. Staff interviews revealed that call lights sometimes go unanswered for 20 to 40 minutes, particularly on evening, dinner, and bedtime shifts, and that there were often only two CNAs on duty for the unit, with one CNA occasionally off the unit accompanying another resident to appointments. Nursing and rehabilitation staff acknowledged that at times they could not get to residents soon enough after call lights were activated. The facility’s call light policy required that call lights be available at each bedside and that response times be a priority, and the incident/accident policy required appropriate and immediate interventions and corrective actions to prevent recurrences.
Failure to Address Misappropriation of Resident’s Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to respond appropriately when the resident’s belongings went missing. A cognitively intact resident (R6) discovered that their cellular phone was missing and searched their room and the dining room without success. A registered nurse (V9) notified the resident’s power of attorney (POA) and facility management about the missing phone. Later that day, a police officer (V11) documented taking a theft report by phone after speaking with the resident’s POA (V10), who reported that the resident’s phone, described as having a black case, was missing. The POA provided the Life 360 location data, which showed the phone’s last known location on a nearby road at a specific time, and the officer went to that location but was unable to locate the phone. The POA stated that after being notified by the facility of the missing phone, they contacted the police department and spoke with the facility administrator (V1), who indicated the facility had no responsibility for the missing phone. The POA then purchased and brought a new phone for the resident using the resident’s own personal funds. The administrator later confirmed that the missing phone was never reported to the state agency and that the facility did not replace the resident’s cellular phone, asserting that the facility was not liable for misappropriation of goods when residents are cognitively intact. The facility’s Abuse Prevention Policy, dated 1/24, affirms residents’ rights to be free from misappropriation of property and documents that the facility would keep residents informed of the conclusions of investigations, but the report indicates the facility failed to replace the misappropriated item in a reasonable time frame and failed to report the incident to the state agency.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s property to the state agency. On 1/5/2026 at 2:40 PM, a resident (R6) informed an RN (V9) that the resident’s cellular phone could not be located after searching the resident’s room and the dining/common areas. Around 3:00 PM that same day, V9 notified the resident’s Power of Attorney (V10) and facility management that the phone was missing. Later that evening at 7:34 PM, a local police officer (V11) documented taking a theft report by phone after speaking with the resident’s Power of Attorney, who reported that the facility had called about the missing phone and provided Life 360 location data showing the phone in the roadway of a local street at approximately 2:13 PM, with no location updates for about five hours. V11 went to the indicated location but was unable to locate the phone. On 2/10/2026, the resident’s Power of Attorney stated receiving a call from the facility about the missing iPhone and reported contacting the police department and speaking with the facility Administrator (V1). According to the Power of Attorney, V1 stated the facility had no responsibility related to the missing phone. The Power of Attorney reported purchasing a replacement phone for the resident with personal funds and not being reimbursed by the facility. In an interview on 2/10/2026 at 2:15 PM, the Administrator acknowledged never reporting the missing phone to the state agency and stated the belief that the facility is not liable for misappropriation of goods when residents are cognitively intact, and that the facility did not replace the phone. The facility’s Abuse Prevention Policy dated 1/24 documents that residents have the right to be free from misappropriation of property and that the facility would investigate, report to the state agency, and keep residents informed of investigation conclusions, which was not followed in this case.
Failure to Investigate and Address Misappropriated Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and timely address an allegation of misappropriated property for one resident. On 1/5/2026 at 2:40 PM, the resident reported to a RN that the resident’s cellular phone could not be found after searching the resident’s room and the dining room. Around 3:00 PM that same day, the RN informed the resident’s power of attorney (POA) and facility management of the missing phone. Later that evening, a local police officer documented taking a theft report by phone after speaking with the resident’s POA, who reported that the facility had called about the missing phone. The POA provided the Life 360 location data, which showed the phone in the roadway of a local street at approximately 2:13 PM, with no location updates for about five hours. The officer went to that location but was unable to locate the phone. On 2/10/2026, the resident’s POA stated that after being notified by the facility of the missing phone, the POA contacted the police department and spoke with the facility Administrator, who stated the facility had no responsibility for the missing phone. The POA reported purchasing a replacement phone with personal funds and not being reimbursed by the facility. In an interview on 2/10/2026 at 2:15 PM, the Administrator stated that the missing phone was never reported to the state agency, that the facility was not liable for misappropriation of goods when residents are cognitively intact, and that the facility did not replace the phone or identify who took it, noting it could have been taken by staff, agency staff, or visitors. The Administrator also expressed a belief that facility staff would not have taken the phone. The facility’s Abuse Prevention Policy dated 1/24 documents that residents have the right to be free from misappropriation of property and that the facility would investigate, report to the state agency, and keep the resident informed of investigation conclusions, which was not followed in this case.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as evidenced by grievance logs and resident council minutes documenting extended wait times for assistance. Grievance logs from October, November, and December 2025 recorded multiple instances where residents waited prolonged periods for help with various activities. Resident council minutes from December 2025 noted that staff needed to respond to call lights more quickly, with 13 residents present at the meeting. Interviews with residents and family members confirmed delays, including one resident who did not have a standard call light but instead used a bell that went unanswered several times. Medical records and interviews provided further details about the affected residents. One resident, admitted with multiple diagnoses including weakness, hemiparesis, cognitive decline, and multiple sclerosis, lacked an admission assessment or note from a licensed nurse during their stay. Another resident with cognitive impairment reported call light response times ranging from 30 minutes to two hours. A third resident, cognitively intact, also reported waiting up to two hours for assistance. Facility policy and statements from the corporate nurse and DON indicated that call lights should be answered within 10-15 minutes, but this standard was not met.
Failure to Provide Required Bathing Assistance and Maintain Hygiene
Penalty
Summary
The facility failed to provide adequate bathing assistance to three dependent residents who required help with activities of daily living (ADLs). One resident, admitted with acute osteomyelitis, weakness, chronic atrial fibrillation, and chronic kidney disease, reported not receiving a shower or bed bath for approximately two weeks prior to a recent bed bath, which was given with lukewarm water obtained from another area due to a lack of hot water in the resident's hall. The resident stated that the hot water issue had persisted for a couple of months and affected the entire hall. Another resident with chronic obstructive pulmonary disease, respiratory failure, and diabetes reported not consistently receiving the required two showers per week, though the showers received were warm. A third resident, admitted with a left fibula fracture and repeated falls, communicated that the lack of hot water on her hall had lasted over a month and that she was taken to another part of the facility for showers, but did not feel she received enough showers overall. Interview with the corporate nurse confirmed that not all residents were receiving the required two showers weekly and that accurate documentation of shower dates could not be provided. The facility's ADL policy requires that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including regular bathing. The failure to provide consistent bathing services and maintain proper documentation led to the deficiency identified during the survey.
Incomplete and Inaccurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents reviewed. One resident was admitted from a hospital with multiple diagnoses, including weakness, hemiparesis, cognitive decline, and multiple chronic conditions. There was no admission assessment or nursing note documenting the time of arrival or any assessment by a licensed nurse during the five hours the resident was in the facility before being transferred to another facility. Both the family member and facility staff confirmed that the resident was not assessed by a nurse during this period, and the medical record lacked any documentation of an assessment or admission note. Additionally, three other residents reported not receiving adequate showers or bed baths, with one stating they had not received a shower or bed bath for approximately two weeks. Review of the facility's shower documentation revealed inaccuracies and alterations, including the use of correction tape and inconsistent signatures compared to staff assignment sheets. The facility's own policy requires that each resident's medical record accurately reflect the care and services provided, with documentation completed at the time of service or by the end of the shift, which was not followed in these cases.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. An incident occurred between two roommates, one with diagnoses including metabolic encephalopathy, dementia with agitation, and a history of wandering, and the other with cognitive impairment and behavioral symptoms. The incident was documented in an investigation file, which noted that staff responded immediately to intervene and separate the residents after a physical altercation took place in their shared room. Staff statements indicated that the two residents exchanged words, engaged in hitting and kicking, and that yelling was heard from the room. One resident reported being hit and responding by hitting back. The care plans for both residents documented behavioral concerns, including wandering and behavioral symptoms, but the altercation still occurred, resulting in a failure to ensure the residents' right to be free from physical abuse.
Failure to Follow Pest Control Policy Resulting in Ongoing Roach Infestation
Penalty
Summary
The facility failed to follow its pest control policy for four residents, as evidenced by multiple observations and staff interviews. Housekeeping and CNA staff reported seeing roaches in hallways and resident rooms, particularly in the downtown west hallway, with sightings beginning as early as March or April. On the day of the survey, several resident rooms had been recently sprayed for pests, with doors closed and signs posted requiring ventilation. One resident attempted to enter his room but was redirected by an LPN due to recent pesticide application. Residents also reported seeing roaches in their rooms, and a resident pointed out a roach-like bug to the surveyor, which was confirmed by staff. The pest control technician was called to the facility on the day of the survey in response to a work order for bugs in resident rooms, which had been submitted earlier that morning. The facility's pest control policy requires maintaining an effective program to eradicate and contain pests, including regular treatment of the facility's exterior and prompt reporting of issues between scheduled visits. Despite this policy, staff and residents reported ongoing pest sightings over several months, indicating the facility did not effectively implement its pest control measures.
Failure to Follow Physician's Order for Eye Drop Administration
Penalty
Summary
The facility failed to follow a physician's order for the administration of eye drops for one resident with severe cognitive impairment and chronic eye conditions, including ectropion and chronic blepharitis. The resident was observed with red eyes and yellow/white matter on the lower lids, and was seen rubbing his eyes. The physician's order specified Systane Complete Ophthalmic Solution, one drop to each eye twice daily, but only Ketotifen Fumarate eye drops were available and administered. The LPN stated that Ketotifen was being used in place of Systane, believing them to be the same, although the pharmacist later clarified that these medications serve different purposes and are not interchangeable. A review of the medication cart confirmed that only Ketotifen eye drops were present for the resident, with no Systane available. The pharmacist also noted that Ketotifen was not on the resident's order profile and that any substitution would require a physician's order and pharmacy notification, which had not occurred. The facility's policy requires that physician orders and prescriptions match and that any discrepancies be resolved with a valid prescription, but this protocol was not followed in this case.
Failure to Use Wheelchair Foot Pedals Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that wheelchair foot pedals were in place prior to propelling a resident in a wheelchair, resulting in a fall and serious injury. A resident with multiple diagnoses, including hemiplegia, muscle weakness, unsteadiness, and a history of falls, was being transported by an activity aide without foot pedals attached to the wheelchair. The resident, who was dependent on staff for wheelchair mobility and did not self-propel, placed her feet on the floor while being moved and subsequently fell forward from the wheelchair, striking her head on the tile floor. This incident led to a subarachnoid hemorrhage and required an overnight hospital stay. Interviews and record reviews confirmed that staff routinely propelled the resident without foot pedals, despite the resident's care plan identifying her as at risk for falls and requiring substantial assistance for mobility. Occupational therapy staff noted that while the resident had foot pedals available, they were not often used, and the resident was known to refuse them on occasion. Multiple CNAs confirmed the absence of foot pedals prior to the fall and acknowledged the risk of falling due to their non-use. The facility's fall prevention program required individualized interventions and the use of assistive devices for residents at risk, but these measures were not implemented for this resident at the time of the incident.
Failure to Initiate Contact Tracing and Testing After COVID-19 Case
Penalty
Summary
The facility failed to follow its infection prevention, response, and reporting policy after a resident tested positive for COVID-19. The resident, who had multiple diagnoses including COVID-19, was identified as positive on 4/14/2025, with documentation showing that the Power of Attorney was notified and COVID isolation precautions were initiated. However, the Infection Preventionist (RN) stated that she was not aware that contact tracing and testing were required following the positive result and confirmed that these steps were not taken. The Director of Nursing verified that contact tracing and testing should have been initiated immediately after the positive case was identified. The facility's policy, reviewed on 10/1/2024, requires evaluation of potential exposures and either contact tracing or a broad-based testing approach for all residents and health care providers identified as close contacts or on the affected unit. Despite this, no contact tracing or testing was performed after the resident's positive COVID-19 result, and staff were noted to work throughout the facility, increasing the potential for exposure. The failure to implement these required infection control measures had the potential to affect all 108 residents in the facility.
Incomplete Documentation of Assessments and Transfer for Resident with COVID-19
Penalty
Summary
The facility failed to document complete and accurate assessments for one resident who had multiple diagnoses, including repeated falls, malignant neoplasm of the prostate, COVID-19, and chronic atrial fibrillation. After being admitted from the hospital emergency room following a fall, the resident's nursing assessments on the first two days did not indicate any respiratory symptoms and documented the resident as negative for respiratory signs. However, there were no head-to-toe or respiratory assessments documented for the following three days, despite the resident testing positive for COVID-19 and exhibiting symptoms such as chest congestion and cough. Progress notes indicated that COVID-19 isolation precautions were initiated and that the resident's power of attorney was notified. However, there was no documentation regarding subsequent assessments, the resident's transfer to the hospital, the rationale for the transfer, or whether the physician or family were informed of the transfer. The Director of Nursing acknowledged the lack of documentation and stated that it was expected for respiratory assessments and transfer documentation to be completed when a resident becomes symptomatic and is sent to the hospital. The facility's policy also requires physician notification in the event of a transfer or discharge.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who was diagnosed with a kidney stone and underwent bilateral percutaneous nephrolithotomy. The After Visit Summary (AVS) from the hospital discharge on July 25, 2024, included instructions for a 48-hour urine collection to be conducted two weeks post-operatively, and a urine culture to be collected one month post-hospitalization and then monthly for two more months. However, the resident's medical record did not document the completion of these urine tests, and no laboratory results were found in the record. On March 10, 2025, the Director of Nursing confirmed the absence of urine test results in the medical record, despite the discharge instructions. The facility's Laboratory Services and Reporting policy mandates the provision of laboratory services when ordered by a physician and emphasizes the timeliness of these services. The policy also requires that all laboratory reports be dated, contain the name and address of the testing laboratory, and be filed in the resident's clinical record. The failure to adhere to these policies resulted in a deficiency in providing timely laboratory services as ordered by the physician.
Failure to Revise Care Plans Following Status Changes
Penalty
Summary
The facility failed to revise care plans for two residents, R4 and R7, following changes in their status, as required by their policy. R4, who is cognitively intact and requires a wheelchair for mobility, experienced issues during transport due to her inability to keep her feet on the pedals of the transport wheelchair. This led to her sliding down in the wheelchair. On January 19, 2024, a Physical Therapy Assistant applied a footboard and non-slip material to R4's transport chair to prevent this issue. However, R4's care plan was not updated to document this intervention. Similarly, R7, who is also cognitively intact and requires dialysis, had a care plan that did not document the dialysis services. R7 was referred to dialysis on December 6, 2024, and began receiving dialysis three times a week starting December 25, 2024. Despite this significant change in R7's care needs, the care plan was not revised to include dialysis services. The Social Service Director/Care Plan Coordinator acknowledged that these updates should have been made but were not completed.
Failure to Assess and Document Elopement Risk for Resident
Penalty
Summary
The facility failed to properly assess and document the elopement risk for a resident, identified as R6, who was severely cognitively impaired and had a history of attempting to leave the building. Despite the facility's policy requiring a systematic approach to managing residents at risk for elopement, R6's medical record lacked an elopement assessment or documentation justifying the application of an elopement management bracelet on November 25, 2024. The Social Services Director (SSD) mistakenly believed that nursing staff were responsible for completing elopement assessments, leading to a lack of documentation and assessment for R6. Upon readmission from the hospital on January 30, 2025, R6 did not receive a new elopement assessment, nor was the elopement management bracelet reapplied, as confirmed by both the SSD and a Licensed Practical Nurse (LPN). The SSD acknowledged that R6 continued to attempt to exit the building and required an elopement management bracelet, but was unaware that the necessary assessments and interventions had not been completed following R6's readmission.
Unsanitary Conditions in Dietary Services
Penalty
Summary
The facility failed to maintain sanitary conditions in its dietary services, which could potentially affect all 87 residents. Observations revealed dark-colored mildew growth inside the dietary service ice machine, specifically on the plastic evaporator skirt. The Regional Dietary Manager indicated that the facility's maintenance department was responsible for cleaning the machine, but the issue persisted over multiple days. Additionally, the kitchen's three-basin sink had a continuously dripping sewer pipe, with discolored and opaque water collecting in a pan on the floor. The kitchen floors were sticky and soiled with food debris and other waste materials, and two can openers were found to be soiled with food debris and metal shavings. The pantry floor was also littered with various debris. These unsanitary conditions were observed over several days, indicating a lack of proper cleaning and maintenance.
Improper Storage of Narcotics in Medication Room
Penalty
Summary
The facility failed to comply with medication storage regulations by not permanently affixing a narcotic lock box in the medication room. During an inspection, it was observed that a lock box containing narcotics was placed loosely on a shelf in the medication storage room. The lock box contained medications for three residents, including Morphine Sulfate for two residents and Hydrocodone/Acetaminophen for one resident. The Licensed Practical Nurse (LPN) confirmed that the lock box was not affixed to anything and was used because there was insufficient space in the medication cart lock box. The facility's Medication Storage policy, which was reviewed and revised in December 2023, requires Schedule II controlled medications to be stored in a separately locked, permanently affixed compartment when other medications are stored in the same area. The Administrator acknowledged providing the lock box to the nurses for storing extra medications. This practice was not in alignment with the facility's policy, leading to the deficiency noted during the survey.
Arbitration Venue Selection Deficiency
Penalty
Summary
The facility failed to ensure that arbitration agreements included provisions for selecting an arbitration venue convenient to both parties. This deficiency was identified during interviews and record reviews, which revealed that three residents had signed arbitration agreements upon admission that did not contain language allowing for the selection of a mutually convenient arbitration venue. Instead, the agreements stipulated that arbitration would occur in the county where the facility is located unless both parties agreed otherwise. This oversight has the potential to affect three residents out of the five reviewed for arbitration agreements.
Failure to Maintain Homelike Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a homelike environment in a resident's room, specifically for a resident identified as R61. During an observation on October 6, 2024, it was noted that large areas of wallpaper above R61's headboard were peeling and torn, with sections dangling from the wall. A significant portion of the wallpaper, approximately four feet tall, was curling away from the wall. This condition persisted as of a follow-up observation on October 9, 2024. R61, who was present during the observations, reported that the wall had been in disrepair since their admission to the facility on March 23, 2023. A Certified Nurse Aide (V18) indicated that the damage was due to R61's bed being positioned too high and hitting the wall.
Failure to Address Hearing Impairment in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a hearing-impaired resident, identified as R73. Observations and interviews revealed that R73 was sitting in his room without his hearing aids and expressed difficulty in hearing. Staff members confirmed that R73's hearing aid broke shortly after his admission, and a whiteboard was being used as an alternative communication method. However, the care plan for R73 did not address his hearing impairment or the use of the whiteboard for communication. The Care Plan Coordinator and the Director of Nursing acknowledged that the care plan lacked documentation of a hearing assessment or a plan to address the hearing deficit, despite the facility's policy requiring care plans to be reviewed and revised as necessary when a resident experiences a status change.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and implement pressure-relieving interventions for two residents, R138 and R142, who were reviewed for pressure ulcers. R138 had multiple diagnoses, including a pressure ulcer of the sacral region, with an order for treatment involving cleansing with normal saline, drying, applying medical honey, and covering with a bordered gauze dressing. Additionally, R138 was ordered to have pressure-relieving boots on while in bed. However, observations revealed that R138 was frequently without the boots, and the treatment was improperly administered as the medical honey was not applied correctly, sliding off the wound and onto healthy skin. Similarly, R142, who had a coccyx wound, was ordered to receive a similar treatment regimen and to wear pressure-relieving boots while in bed. Observations showed that R142 was also without the boots, and the treatment was not executed as ordered. The medical honey was not applied correctly, as it slid off the pressure ulcer, and the dressing was applied without the honey being on the open area of the ulcer. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of proper implementation of the care plan and interventions for these residents.
Failure to Verify Gastrostomy Tube Placement Before Administration
Penalty
Summary
The facility failed to adhere to its policies regarding the verification of Gastrostomy tube (g-tube) placement before administering medications and feedings for a resident. The resident, identified as R138, had multiple medical conditions including Unspecified Protein-Calorie Malnutrition, Dysphagia, and several malignant neoplasms. The resident's care plan included orders for nothing by mouth and specific instructions for flushing the enteral tube with water before and after medication administration and feedings. Additionally, there was an order to check the g-tube placement before administering medications and feedings every shift. On two separate occasions, staff members did not verify the g-tube placement as required. A Registered Nurse administered a water flush and a Jevity 1.5 feeding without checking the tube placement, stating that she had checked it earlier in the day. Similarly, a Licensed Practical Nurse administered medications via the g-tube without verifying its placement, acknowledging afterward that she should have done so. The facility's policies clearly state that tube placement must be verified prior to administering any fluids or medications, which was not followed in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, as observed during a survey. The resident, identified as R142, had a pressure ulcer on the coccyx with serosanguineous drainage, documented in the nurse's notes. Despite this condition, there was no EBP sign posted on or near the resident's door on multiple occasions. On one occasion, a registered nurse and a certified nursing assistant entered the resident's room to change the dressing without donning gowns, which is a necessary precaution for handling open pressure ulcers. The infection preventionist confirmed that residents with pressure ulcers should be placed in EBP but did not do so because the ulcer was not considered chronic.
Unauthorized Withdrawal from Resident's Bank Account
Penalty
Summary
The facility failed to safeguard a resident's financial affairs by withdrawing funds from the resident's personal bank account without permission. The resident, who was cognitively intact, had authorized the facility to withdraw a specific amount monthly for billing purposes. However, after the resident was discharged, the facility continued to withdraw funds for days beyond the discharge date. This unauthorized withdrawal was acknowledged by the facility's Regional Corporate Business Office Manager, who stated that the funds were removed due to a lack of awareness of the resident's discharge. The resident's Durable Power of Attorney (DPOA) confirmed that the facility overcharged the resident for days not spent at the facility, causing stress and confusion for the resident's family. Although the facility eventually refunded the overcharged amount, the incident highlighted a lack of communication and proper billing procedures. The facility's administrator admitted that there was no policy in place for such situations and acknowledged the error in billing the resident for days past the discharge date.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for its residents, affecting 36 out of 39 residents reviewed for environmental cleanliness. During an environmental tour, several deficiencies were observed, including heavy accumulations of dirt and debris on bathroom floors, worn and slippery vinyl flooring, and damaged walls and bulletin boards. Residents expressed concerns about these conditions, with one resident noting a broken wall and another mentioning the need for new walls due to noise issues. Additionally, rusted fixtures, cracked ceilings, and detached baseboards were noted in various rooms, contributing to the overall unclean and unsafe environment. Further observations included a black ring around a toilet, heavily soiled floor-to-wall junctions in multiple rooms, and a dirty entry threshold into the main dining room. The facility's Concern Log documented previous complaints from residents about sticky floors, unpleasant odors, and dirty conditions, indicating ongoing issues with cleanliness. The facility administrator acknowledged these deficiencies, agreeing that residents deserve a better environment.
Failure to Prevent Self-Harm in Resident with Known History
Penalty
Summary
The facility failed to ensure the safety and supervision of a resident with a history of self-harm and suicide attempts. This deficiency was identified when the resident, who had previously been found with a call light cord wrapped around their neck, was able to access self-harm items again, leading to another suicide attempt. The resident was found with a plastic bag over their head, resulting in emergency transport to the hospital. Despite the resident's known history of self-harm, the facility did not implement adequate interventions or update the care plan to prevent further incidents. The resident's medical records indicated a history of self-harm attempts and suicidal ideations, with documented incidents of using a call light cord and a plastic bag to attempt self-harm. The care plan had been updated to remove corded accessories and replace the call light with a bell, but these interventions were not consistently implemented. Observations during the survey revealed that the resident's room still contained corded items and plastic bags, which were accessible to the resident, indicating a lack of adherence to the care plan. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's precautions and interventions. Some staff members were not informed of the resident's history of self-harm or the necessary precautions, and there was no documentation of staff education on these matters. The facility's policies on behavioral health services and suicide prevention were not effectively implemented, as evidenced by the continued presence of self-harm hazards in the resident's environment.
Failure to Prevent Resident Elopement During Fire Drill
Penalty
Summary
The facility failed to prevent the elopement of a severely cognitively impaired resident, who exited the facility unnoticed during a fire alarm drill. The resident, who had a known history of exit-seeking behaviors and was at high risk for elopement, was not adequately supervised or reassessed for his care plan. This oversight led to the resident being missing for 17 hours, during which he was found in a potentially dangerous environment, having crossed a busy street and ended up in a grassy area next to a creek. The resident's medical history included severe cognitive impairment, dementia, and other health conditions, which increased his vulnerability. Despite previous incidents of wandering and exit-seeking behaviors documented in his progress notes, the resident's care plan did not address these risks. On the day of the incident, staff observed the resident near exit doors and attempted to redirect him, but there was a lack of consistent supervision, especially during the fire alarm when no nurses were present at the nurse's station. The facility's policies on elopement and wandering were not effectively implemented, as evidenced by the failure to ensure that exit doors were properly alarmed and monitored. The resident's personal alarm system was only functional at the front door, which did not prevent his exit through other doors. The lack of a comprehensive plan to address the resident's high risk of elopement and the absence of adequate supervision during emergency procedures contributed to the incident.
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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