Momence Meadows Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Momence, Illinois.
- Location
- 500 South Walnut, Momence, Illinois 60954
- CMS Provider Number
- 145713
- Inspections on file
- 39
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Momence Meadows Nursing & Rehab during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including severe back pain, reported that PRN pain medications were often late and that nurses gave conflicting information about how frequently the medications could be administered, despite existing physician orders. Surveyors observed that several residents with diabetes and other serious comorbidities had EMAR profiles highlighted in red during a scheduled medication pass, indicating that ordered blood glucose checks and sliding‑scale insulin due before meals had not been given within the required one‑hour window. An agency RN and an LPN confirmed that red highlighting meant medications were past due, while an RN stated that medications were sometimes given but not signed out and that it was not possible to administer and document all medications on time. The interim DON verified the EMAR color‑coding system and the facility policy requiring medications to be administered within sixty minutes of the scheduled time and before‑/after‑meal orders to be given precisely as ordered.
The facility failed to ensure timely response to resident call lights, resulting in prolonged waits for assistance reported by three alert and oriented residents with complex medical conditions, including functional quadriplegia, COPD, CHF, cerebral palsy, paraplegia, morbid obesity, and multiple psychiatric diagnoses. Residents stated that call light responses often took from about thirty minutes to over an hour, especially when the assigned CNA was on break or busy. Surveyors observed multiple instances where call lights alarmed for extended periods while nurses sat at the nurses’ station and other staff, including activity aides, housekeeping, and CNAs, walked past without responding, with one call light remaining unanswered for approximately 35 minutes until a CNA picking up dietary trays turned it off. Staff interviews and the written call light policy confirmed that all staff are responsible for answering call lights promptly.
A resident with multiple complex conditions, including neuroleptic Parkinson’s, selective mutism, and major depressive disorder, had a documented legal guardian and substitute decision maker, but the facility failed to recognize and communicate with this representative. The guardian’s status was noted in a general note on the face sheet and in hospital discharge instructions, yet staff relied only on the EMR contact list, which did not list the guardian, and did not review other EMR sections. The guardian reported making multiple unsuccessful attempts over several months to reach the care team for updates on the resident’s condition, finally receiving a return call only after repeated efforts, resulting in the resident’s representative not being able to exercise the resident’s rights.
Two residents with significant physical disabilities and incontinence needs did not receive required ADL assistance, including hygiene, toileting, transfers, and positioning. One resident, dependent on staff for maximal assistance with toileting, showers, dressing, and personal hygiene, was observed with greasy hair and soiled clothing and reported going to bed without an adult brief, lying all night on wet sheets, struggling to change briefs alone, receiving only one shower since admission, being told to bathe independently, and being required to self-propel long distances in a wheelchair despite fatigue. Another resident, dependent for toileting, transfers, showers, and dressing, reported long waits for brief changes while a CNA was on break, not being gotten up as scheduled because staff said they were short staffed, and remaining uncomfortable and slumped to one side in a wheelchair without staff repositioning, while being pushed by another resident as staff walked by. Both residents’ care plans called for staff assistance with incontinence care, scheduled toileting, and ADLs, and facility leadership stated residents should be assisted regardless of dependence level, which did not match the observed and reported care.
A resident with multiple chronic conditions who required maximal assistance with ADLs received incontinence care from two CNAs who did not follow the facility’s hand hygiene policy. One CNA applied gloves without performing hand hygiene before starting care, and both CNAs failed to perform hand hygiene after removing gloves at the end of care, despite the facility policy and the Interim DON’s expectation that staff clean their hands before and after direct resident contact and after glove removal.
Two residents with moderate cognitive impairment and multiple medical conditions were not adequately protected from sexual abuse when one resident, known to be violent, was found in another resident's room with the sleeping resident's shirt lifted and breast exposed, and a CNA observed the first resident's hand on the other's chest area before intervening and reporting the incident.
A resident with a history of suspected abuse, care planned to be kept in a safe environment, sustained a head injury and facial laceration requiring sutures after being struck in the head with a cane by another resident. Staff documentation noted bleeding below the resident’s right eye and subsequent hospital evaluation confirmed the need for sutures. The facility’s incident report described inappropriate physical contact between the two residents, and the Administrator reported that one resident hit the other with his cane. The resident who struck the other had a care plan addressing inappropriate sexual behavior but lacked assessment or planning for potential physical aggression, despite the facility’s abuse prevention policy prohibiting physical abuse such as hitting.
A resident who was fully dependent on gastrostomy tube (G-tube) feedings for nutrition experienced significant weight loss and severe protein-calorie malnutrition after staff failed to consistently provide ordered enteral feedings on time. The resident appeared cachectic and repeatedly communicated hunger, while several CNAs reported that he often was not fed, especially during night and early-morning hours. Although the MAR showed most feedings as signed off, an audit revealed numerous late entries, feedings documented hours after scheduled times, some signed days later, and some apparently pre-dated. The PCP and RD both stated there was no medical reason for the weight loss other than inadequate feedings, and that the ordered Jevity regimen should have prevented weight loss if administered as ordered.
The facility failed to maintain adequate licensed nurse staffing, resulting in delayed or missed medications and inconsistent gastrostomy tube feedings for multiple residents. An LPN reported being the only nurse on one side of the building with numerous overdue medications on the eMAR, while an RN on an extended shift did not begin morning med pass until late morning, causing scheduled antihypertensives to be given hours late. A resident fully dependent on G‑tube feeding experienced significant weight loss, and the physician stated there was no medical cause other than not being fed. Facility records confirmed repeated shifts with fewer nurses than the staffing plan required, and several alert residents and CNAs reported nights with no nurse on the floor, residents not receiving pain or sleep medications, and residents begging or threatening to call 911 for their medications, while leadership acknowledged awareness of shifts staffed with only one nurse.
Multiple residents did not receive significant medications as ordered or within required time frames, including repeated late, missed, and incorrectly transcribed doses. A resident with severe chronic conditions reported frequently receiving muscle relaxants and neuropathic pain medications hours late, while the eMAR showed numerous overdue medications for residents on the hall. Several residents with diabetes received short-acting and long-acting insulin doses far outside scheduled times, with evening doses often given the following morning and pre-meal doses clustered late in the morning or afternoon. A resident with serious psychiatric diagnoses had clozapine, lithium, and benztropine routinely administered several hours after scheduled times. Another resident with brain cancer and epilepsy experienced highly irregular administration of twice-daily anticonvulsants, including overnight delays, clustered doses, and at least one missed evening dose. A resident with functional quadriplegia and recent pneumonia had a hospital order for levofloxacin 750 mg once daily for five days incorrectly transcribed and administered as intermittent twice-daily doses on two separate days, with doses given only hours apart. These practices met the facility’s own definition of medication administration errors related to timing and missed doses.
The facility failed to immediately report multiple abuse allegations to the state agency as required by its abuse policy. An alert and oriented resident reported that another resident threatened her with a knife, and staff later found weapons and other dangerous items belonging to that resident, but the Administrator did not report the allegation. Another alert and oriented resident alleged that staff ripped his shirt and placed a knee on his neck during a verbal altercation; although this was reported internally, the external report was delayed by several days and omitted the ripped-shirt allegation. In a separate event, a resident reported that while choking, one CNA assisted her but another CNA stated he would have let her choke, and this allegation, though reported to the Administrator, was not reported to the state agency.
The facility failed to promptly investigate and report multiple abuse allegations and to protect residents during the investigation period. An alert and oriented resident alleged that staff ripped his shirt and placed a knee on his neck during an altercation, which was reported by a CNA to the Administrator and DON, but the Administrator delayed the investigation and late-reported the incident to the state without all details. Another alert and oriented resident reported that another resident held a knife to her neck and threatened her; CNAs confirmed hearing the threat and later found a knife, taser, pocketknife, hammer, drill, and lighters belonging to that resident, yet the Administrator did not investigate or report the abuse allegation. The same resident also reported that a CNA stated he would have let her choke after another CNA assisted her while choking, and although this was reported to the Administrator, no investigation or state report was initiated, contrary to the facility’s abuse policy.
Two alert and oriented residents were involved in an incident where one resident reportedly held a knife to another resident’s neck and threatened her, after which staff discovered multiple potentially dangerous items, including knives, a taser, a drill, a hammer, lighters, scissors, and razor blades, in resident rooms and later stored in the med room and Administrator’s office. CNAs reported hearing the threats and finding these items, and the resident who made the threats admitted keeping a hammer, drill, and pocketknife for protection. The Administrator confirmed the items belonged to this resident and acknowledged they made the environment unsafe. Record review showed this resident had a care plan for maladaptive behaviors that may detrimentally affect others, but no care plan focus on aggressive behaviors or possession of weapon-like objects, while another resident had intact cognition and a care plan addressing mood and psychosocial well-being. The facility’s policy required that the environment and furnishings be safe, clean, and comfortable.
A resident dependent on staff for ADL and incontinence care, with a history of chronic ulcers and a stage 3 sacral pressure ulcer, was found with soiled bedding and a strong urine odor after waiting extended periods for assistance. Staff interviews and observations confirmed that incontinence care was not provided as required by the care plan and facility policy, resulting in inadequate hygiene and increased risk of skin complications.
Two residents with cognitive impairments and histories of behavioral issues were involved in separate incidents of inappropriate physical and sexual contact with other residents. In both cases, staff did not witness the incidents, and the affected residents either reported the abuse or were found with minor injuries. The facility's policy required identification and monitoring of residents at risk for abuse, but repeated incidents occurred involving residents with known behavioral risks.
A resident with a history of cognitive impairment and bipolar disorder was physically abused by a CNA who slapped the resident's hand during an altercation involving the CNA's personal laptop. The incident, witnessed by other staff, led to the resident's increased agitation and emotional distress. The facility's investigation confirmed the abuse, resulting in the CNA's termination.
A resident with severe cognitive impairments and vision loss was not protected from sexual abuse by another resident with dementia and a history of boundary issues. A cook witnessed the inappropriate touching in a hallway, but the facility's investigation did not substantiate the abuse allegation despite the resident's known vulnerabilities.
The facility failed to maintain its kitchen to prevent foodborne illness, affecting 74 residents. Observations revealed expired food items, improperly stored and open food packages, dented cans in use, and a sour odor from the milk cooler. The walk-in cooler contained improperly wrapped and expired food items, and an oscillating fan was covered with dust and grease. Additionally, there was no log for documenting sanitizer concentration, violating facility policies.
The facility failed to provide written discharge notices and notify the ombudsman for four residents transferred to the hospital. The DON admitted to not notifying the ombudsman and relying on phone notifications for residents and their representatives. Residents were transferred due to various medical conditions, including aggressive behavior, suicidal ideations, and altered mental status, without receiving the required written notices.
The facility failed to provide written notification of the bed hold policy to residents and their families or POAs during hospital discharges. This deficiency affected four residents who were transferred to the hospital for various medical reasons, including aggressive behavior, respiratory issues, and suicidal ideations. The facility's administrator acknowledged that the bed hold policy should be provided during each hospital discharge, but this was not done.
The facility failed to obtain physician orders and conduct self-administration assessments for three residents who had medications at their bedside. One resident's nasal spray was found on her roommate's dresser without proper orders or assessments, and another resident had pills on his bedside table without documentation. The facility's policy requires assessments and orders for self-administration, which were not completed.
A resident with a PICC line had a gauze dressing that was not changed by staff, leading to a deficiency in infection control. The resident reported changing the dressing herself after 4 to 5 days, and the dressing was found to be soiled and exposing the insertion site. The facility's policy required more frequent changes, but there was no documentation of dressing changes in the resident's medical record.
The facility failed to refund resident funds after discharge, affecting three residents. The Business Office Manager acknowledged the oversight and stated that he would contact the new facilities of two residents to transfer the funds, while he would continue to try to locate the third resident or send the funds to social security if unsuccessful. The Corporate BOM confirmed that the facility has a policy requiring resident funds to be returned within 30 days of discharge.
The facility failed to follow the menu plan and provide residents with alternatives for refused food items. Menus were often not posted, and the food served did not match the planned menu. Residents reported dissatisfaction due to menu changes and unmet dietary needs. The dietary manager acknowledged issues with food orders, and the administrator confirmed that the facility should not run out of food.
The facility failed to provide alternate food to meet residents' needs, affecting three residents who reported not receiving requested or necessary food items. The Dietary Manager and Facility Administrator provided conflicting information on the policy for ordering meal substitutes, contributing to the deficiency.
Failure to Administer and Document Medications Within Required Time Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered within acceptable time parameters and in accordance with physician orders and facility policy. One resident with multiple chronic conditions, including spinal stenosis, CHF, type II diabetes, atrial fibrillation, morbid obesity, functional quadriplegia, chronic low back pain, and depression, reported that pain medications often arrived late. This resident stated that when requesting ordered PRN acetaminophen and oxycodone for back pain, nursing staff gave inconsistent explanations, including that pain medications could only be given every eight hours or that the resident had to wait twenty‑four hours, despite orders allowing more frequent administration. The resident reported that their significant back pain was not taken seriously. Surveyors also observed systemic issues with timely administration and documentation of scheduled medications, particularly insulin and blood glucose checks. Three residents with extensive diagnoses including hemiplegia/hemiparesis, type II diabetes, cardiovascular disease, and other chronic conditions had EMAR profiles highlighted in red during the 1100 medication pass, indicating that ordered blood glucose checks and sliding‑scale insulin doses due before meals at 0600/0700, 1100, and 1600 had not been administered within the one‑hour before/after window. An agency RN confirmed that red highlighting meant medications were past due and not given. On another day, an RN and an LPN were observed passing medications while multiple resident profiles were highlighted in red; the RN first stated that medications had been given but not signed out, then acknowledged that it was not possible to administer and sign out medications within the allotted time due to workload. The interim DON confirmed the EMAR color‑coding system and the facility policy requiring medications to be administered within sixty minutes of the scheduled time, with before‑ and after‑meal orders to be given precisely as ordered, and that a red profile meant medications were not administered within the required time frame.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect by responding promptly to call lights, as required by facility policy. Three alert and oriented residents reported that staff were often slow to respond, with delays ranging from about thirty minutes to over an hour, particularly when the assigned CNA was on break or busy. One resident with multiple conditions including spinal stenosis, CHF, type II diabetes, cardiomyopathy, morbid obesity, functional quadriplegia, and depression stated that staff were often slow to respond to call lights and sometimes did not come at all. Another resident with cerebral palsy, paraplegia, epilepsy, morbid obesity, type II diabetes, schizoaffective disorder, schizophrenia, and other psychiatric diagnoses reported that call light responses could take from thirty minutes to over an hour, and that if the assigned CNA was on break, they had to wait for that CNA to return instead of another staff member responding. A third resident, who is bedbound with COPD, lymphedema, venous thrombosis, hypothyroidism, hypertension, and morbid obesity, stated that call light response was a major concern and that if the assigned CNA was busy, they might wait a little over an hour. Surveyor observations corroborated these reports: on one occasion, a call light alarmed while a nurse sat at the nurses’ station and activity staff and another nurse walked past before a CNA answered it approximately 8 minutes later. On another date, two call lights alarmed while two staff members sat at the desk, and one was not answered for about 17 minutes. In a separate incident, a call light alarmed while several nurses were at the nurses’ station for an in‑service with the interim DON; the light continued to alarm for approximately 35 minutes, during which housekeeping and CNAs passed by and nurses remained at the station, until a CNA picking up dietary trays finally turned it off. Multiple staff, including an activity aide, CNA, LPN, RN, and the interim DON, stated that all staff are responsible for answering call lights promptly, and the facility’s call light policy requires that call lights be answered promptly by any staff who see them activated.
Failure to Honor Resident’s Chosen Legal Representative and Maintain Communication
Penalty
Summary
The facility failed to honor a resident’s chosen representative by not recognizing and communicating with the resident’s legal guardian and substitute decision maker. The resident was readmitted with multiple diagnoses, including neuroleptic Parkinson’s, selective mutism, major depressive disorder, need for assistance with personal care, weakness, muscle wasting, tremors, catatonic disorders, and anxiety. The resident’s face sheet contained a general note indicating that a family member (V16) was the resident’s power of attorney, and hospital discharge instructions identified this same individual as the resident’s legal guardian and substitute decision maker. Despite this documentation, the facility did not consistently acknowledge or act upon V16’s role as the resident’s representative. For several months, V16 attempted to contact the facility’s care team to discuss the resident’s condition, calling multiple times in January, February, and March, but did not receive a response until early April. V16 reported relying on the care team for information because they did not live close to the facility and the resident was mute and unable to self-advocate. Facility staff, including Social Services (V6) and the Interim DON (V2), stated they had not entered the general note listing V16 as POA and had not reviewed that section of the electronic medical record (EMR). V2 acknowledged that they only checked the contact list, which did not list V16, and therefore had not contacted V16 in the absence of a change in condition. This failure to review all available EMR sections and to respond to repeated contact attempts resulted in the facility not ensuring the resident’s representative could exercise the resident’s rights.
Failure to Provide Required ADL Assistance, Hygiene, Toileting, and Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide required ADL assistance, including hygiene, toileting, positioning, and transfers, to residents who are dependent on staff. One resident with multiple diagnoses including spinal stenosis, CHF, type II diabetes, cardiomyopathy, atrial fibrillation, morbid obesity, functional quadriplegia, low back pain, edema, depression, and anxiety was care planned as cognitively intact, wheelchair-dependent, and needing maximal assistance with toileting, showers, dressing, transfers, standing, and personal hygiene, as well as incontinence care and scheduled toileting. Surveyors observed this resident with greasy hair and a soiled shirt, and the resident reported being in the same clothes worn to bed, not being assisted to dress for bed, and not receiving proper adult brief application or correct sizing, resulting in soiled clothing and linens. The resident stated that staff sometimes did not change briefs, forcing them to struggle to change themselves despite fear of falling, and that they had gone all night with wet sheets and no brief, with urinals left unemptied for long periods. The same resident reported that staff did not help push their wheelchair, requiring them to self-propel long distances to the therapy gym and to the smoking area, leaving them tired and sometimes leading to refusal of therapy or care. During one observation, the resident was visibly tired while wheeling toward the smoking area, and another resident had to ask the Activities Director to assist; the Activities Director reluctantly approached and told the resident they were encouraged to do things on their own. The resident also reported receiving only one shower since admission, being handed a bucket and towel to perform their own bed bath when assistance was requested, and being inaccurately documented as refusing showers. The resident stated they could not adequately reach certain areas due to size and back pain and sometimes attempted to transfer to bed alone because staff would not assist. A Physical Therapy Assistant later stated that the resident was supposed to wheel to the therapy gym as part of therapy but should be assisted if tired or short of breath, acknowledged not checking oxygen saturation and being unaware of the resident’s bedtime oxygen order, and confirmed that the resident should be transferred with a mechanical lift and not encouraged to transfer alone. A second resident with cerebral palsy, paraplegia, epilepsy, morbid obesity, type II diabetes, schizoaffective disorder, schizophrenia, depressive disorder, psychosis, and hypertension was cognitively intact, wheelchair-dependent, and assessed as needing touching assistance for eating, being dependent for toileting, transfers, showers, and dressing, and requiring maximal assistance for personal hygiene. The care plan called for incontinence care with cleansing and perineal care after each episode, scheduled toileting opportunities, physical assistance with toileting, and reminders every two hours. This resident reported being uncomfortable and leaning to the right in the wheelchair without staff assistance to reposition, and described waiting from 8:30 PM to 9:15 PM for a brief change because the assigned CNA was on break and they were told to wait. The resident stated they were on a list for overnight CNAs to get them up and ready for the day, but staff often said they were short staffed and did not get them up, leaving the resident to attempt tasks alone or wait for the next shift. Observations showed this resident repeatedly being pushed in the wheelchair by another resident while slumped over to the right side as several staff walked by without intervening. This resident also reported witnessing staff treat their former roommate poorly, including falls from bed and staff telling the roommate they did not need a mechanical lift and should get into the wheelchair independently. The Interim DON stated that showers are to be given twice weekly and as needed, garbage and soiled items are to be removed promptly, urinals are not to be left at bedside for hours, and staff are to assist residents regardless of dependence level and check and change residents promptly, which contrasted with the observed and reported care.
Failure to Perform Required Hand Hygiene During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinence care. One resident, R5, had multiple diagnoses including cerebral infarction, metabolic encephalopathy, cognitive social or emotional deficit, epilepsy, chronic kidney disease, bipolar disease, hypertension, and bradycardia, and required maximal assistance with all ADLs, including toileting, per the MDS. On the observed date and time, R5 was seated in a wheelchair near the nurses’ station when a CNA (V26) wheeled the resident into the bedroom to provide incontinence care. V26 applied gloves without performing hand hygiene. A second CNA (V25) entered the room already wearing gloves to assist with the care. R5 was transferred to the bed, clothing was removed, and the resident was found to be wearing an adult brief with a moderate amount of soft feces. V26 cleansed the perineal area and removed the soiled brief, then removed the soiled gloves and used hand sanitizer before donning new gloves. V25 assisted V26 with applying a clean brief, pulling up the resident’s trousers, and returning R5 to the wheelchair. V25 then removed and emptied the trash, while V26 removed gloves and escorted R5 back to the nurses’ station. Neither V25 nor V26 performed hand hygiene after removing gloves and completing the incontinence care. The Interim DON (V2) stated that staff should always perform hand hygiene before care, between patients, and after care, including during dining services, and that staff should wash hands prior to starting care and before leaving residents’ rooms. The facility’s Handwashing/Hand Hygiene Policy specified that alcohol-based hand rub or soap and water must be used before and after direct resident contact, before donning sterile gloves, and after removing gloves, and that glove use does not replace hand hygiene.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse when one cognitively impaired resident was found in another cognitively impaired resident's room with physical contact to the breast area. A laundry aide observed the first resident, who was known to be violent, sitting in the second resident's room next to the bed while the second resident was sleeping and reported this to a CNA. When the CNA entered the room, the first resident was standing up from his wheelchair next to the bed, had lifted the second resident's shirt, and had a hand on the second resident's chest area with the breast exposed. The CNA then removed the first resident from the room and reported the incident to the nurse and the administrator. Both residents involved had multiple medical diagnoses and moderate cognitive impairment per their MDS assessments. The first resident had hepatic encephalopathy, COPD, epilepsy, major depressive disorder, lack of coordination, and cirrhosis of the liver. The second resident had hyperlipidemia, diabetes, major depressive disorder, schizoaffective disorder, a brain neoplasm, and panic disorder. The facility's investigative documentation included a written statement from the CNA describing the incident in which the first resident was found standing over the second resident's bed with arms extended and hands on the chest area, and the second resident's breast exposed, before the CNA intervened.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Head Injury
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another in the head with a cane, causing a head injury and laceration that required sutures. On 12/26/25, staff progress notes documented that the injured resident was observed bleeding from below the right eye and that another resident had hit him. A subsequent hospital report confirmed a head injury and a laceration requiring three sutures, and later observation on 12/31/25 showed a bruise to the upper right cheek below the eye and three sutures on the right eyelid. The facility’s incident report to the state agency described that the two residents engaged in inappropriate physical contact, and the Administrator stated it had been reported that one resident hit the other in the head with his cane. The injured resident had a care plan dated 12/24/25 noting a history of suspected abuse with an intervention to assure he was in a safe environment, while the other resident’s care plan, focused on inappropriate sexual behavior, did not include an assessment for potential physical abuse against others, despite the facility’s Abuse Prevention Program policy prohibiting and seeking to prevent resident abuse and neglect, including physical abuse such as hitting.
Failure to Provide Ordered G-Tube Feedings Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident receiving all nutrition via gastrostomy tube was provided adequate and timely tube feedings to maintain his weight. The resident, an adult male with brain damage from a lightning strike, functional quadriplegia, dysphagia, cognitive communication deficit, and gastrostomy status, was entirely dependent on enteral nutrition and took no food orally per physician orders. During observation, he appeared very thin and frail, and communicated via a communication board that he frequently did not receive his feedings or medications, and that when he did, they were often late. Multiple CNAs reported that the resident had told them he was hungry, that he had lost a lot of weight, and that they rarely or never saw him receive his scheduled early-morning or night-time feedings. The resident’s weight records showed a decline from 114.2 pounds to 98.8 pounds over 38 days, a 13.49% weight loss. A recent hospital discharge summary documented severe protein-calorie malnutrition, a 30% weight loss in less than one year, severe muscle mass loss in specific muscle areas, and described his appearance as cachectic. The December medication administration record (MAR) showed an order for Jevity 1.2, 300 ml every 6 hours via gastrostomy tube at four scheduled times daily. The MAR boxes were largely checked as if feedings were given, with only a few blanks, and the DON stated that if there is nothing documented in the EMAR, the medications or feedings were not given. However, the MAR audit report revealed that many feedings were documented as administered significantly later than scheduled, sometimes hours late, and in some cases signed off days later or even pre-dated as if given before the actual date. Numerous entries showed feedings signed more than three or four hours after the scheduled times, and some early-morning and night-time feedings were not observed by staff on those shifts. The resident’s primary care physician stated he had not been informed of the weight loss or missed feedings and that there was no medical reason for the weight loss other than not being fed. The registered dietician stated that if the resident had received the ordered feedings, he would not have lost weight because the prescribed regimen exceeded his nutritional needs, and concluded that the only reason for the weight loss was that he was not getting enough feedings. The administrator acknowledged awareness that the resident was not being fed as ordered and that he was malnourished.
Insufficient Licensed Nurse Staffing Leading to Delayed Medications and Tube Feedings
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to administer medications and gastrostomy tube feedings as ordered. On one survey day late in the morning, a cognitively intact resident remained in bed, restless, reporting that he had not received his morning medications and that on many nights his 9:00 PM medications were not given until around midnight, with morning medications often delayed until late morning. At the same time, an LPN passing medications showed an eMAR screen with 14 residents on the hall having overdue medications, confirming that the pink color indicated overdue doses. This LPN stated there was only one nurse on that side of the building when there were supposed to be two, and that he had worked the overnight 12‑hour shift as well. Another RN reported she did not begin passing morning medications until around late morning because she had been working on the other side of the building with another new nurse, and she had been on duty since the previous night. Medication administration records showed that a resident’s 9:00 AM antihypertensive medications with blood pressure parameters were actually administered around midday. A resident dependent on gastrostomy tube feeding, with diagnoses including functional quadriplegia, dysphagia, and gastrostomy status, experienced significant weight loss from 114.2 pounds in November to 98.8 pounds in late December. The resident’s physician stated there was no medical reason for the weight loss and that if the resident was losing weight, it would only be from not being fed. The ADON confirmed that the facility’s staffing plan required a minimum of three nurses on day shift and two on night shift, yet review of daily assignment sheets, staffing sheets, and time sheets showed multiple dates in November and December when only one nurse, or fewer than the planned minimum, were on duty for substantial portions of shifts. The ADON stated that not meeting minimum staffing affects care such as timely medication passes and tube feedings. Multiple alert and oriented residents reported that there were not enough nurses, that some nights there was no nurse on duty, and that they did not receive medications, including pain and sleep medications, sometimes having to yell or threaten to call 911. CNAs also reported there were not enough nurses, that some residents did not receive medications or G‑tube feedings and had to wait, and that they had notified leadership when only one nurse was on the floor and residents were waiting for medications and exhibiting behaviors, without receiving a response. The Administrator and DON acknowledged that the minimum number of nurses was not always met and that having only one nurse for the whole facility was unsafe, and that they were aware of at least one night when only one nurse was working.
Failure to Administer Significant Medications as Ordered and Within Required Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to ensure that significant medications were administered as ordered, including repeated late, missed, and incorrectly transcribed doses for multiple residents. One cognitively intact resident with malignant lung neoplasm, bilateral above-knee amputations, and chronic painful skin disease reported frequently not receiving his 9:00 PM medications until around midnight and his morning medications until around 11:00 AM or 12:00 PM, stating that he needed them and that not getting them on time was making him sicker. On one observed day, his baclofen and gabapentin, ordered three times daily and scheduled for 9:00 AM, 5:00 PM, and 9:00 PM, were actually administered at 11:24 AM, 4:35 PM, and 8:10 PM, respectively. At the time of observation, the eMAR system showed his medications as overdue, and the nurse confirmed that 14 residents on the hall had overdue medications. Another resident with diabetes and hyperglycemia had short-acting insulin ordered three times daily before meals and long-acting insulin once daily in the evening. On the observed day, the 7:00 AM and 11:00 AM short-acting insulin doses were both signed as administered at 11:35 AM. For the long-acting insulin scheduled at 8:00 PM, the audit report showed that several consecutive evening doses were actually given the following mornings between approximately 6:00 AM and 7:00 AM, with one dose documented as refused at 8:00 PM but administered the next morning at 6:48 AM, and another dose given about 14 hours after its scheduled time. A resident with schizoaffective disorder, bipolar type, and recurrent major depressive disorder had benztropine, clozapine, and lithium ordered at specific times (twice daily or three times daily). On one day, all three 9:00 AM doses were signed as administered at 12:58 PM, and the 1:00 PM lithium dose at 12:59 PM; on the previous day, the 9:00 AM doses were signed at 2:58 PM and the 1:00 PM lithium dose at 2:20 PM. A resident with diabetes with hyperglycemia and foot ulcer, combined heart failure, and hypertension had daily amlodipine and lisinopril ordered at 9:00 AM with parameters to hold for low systolic blood pressure, and insulin orders including long-acting insulin at bedtime and short-acting insulin before meals. On the observed day, the RN stated she began passing medications around 11:00 AM, and the resident’s blood pressure had last been taken the previous afternoon; the 9:00 AM hypertension medications were administered around noon. The prior day’s 9:00 AM hypertension medications were administered at 3:00 PM. For this resident’s insulin, an 11:00 AM short-acting insulin dose on one date was administered at 6:20 PM, and another 11:00 AM dose on a different date at 2:23 PM. The bedtime long-acting insulin scheduled for 9:00 PM was repeatedly administered the following mornings between about 6:00 AM and 7:00 AM on several consecutive days, with one dose given approximately 14 hours after its scheduled time. A resident with malignant brain neoplasm and epileptic seizures had levetiracetam and lacosamide ordered twice daily, twelve hours apart at 9:00 AM and 9:00 PM. The audit report showed a pattern of significant deviations from the ordered schedule: on multiple consecutive days, 9:00 PM doses were administered the following mornings between about 6:00 AM and 7:00 AM, 9:00 AM doses were delayed by several hours into the afternoon or evening, and on one day three doses were given within approximately 15 hours. On another day, the 9:00 PM doses were not signed off as administered at all, and the next day’s 9:00 AM doses were given about 22 hours after the prior morning dose. Another resident with functional quadriplegia, dysphagia, and a history of acute respiratory failure and pneumonia was discharged from the hospital with instructions to start levofloxacin 750 mg daily for five days. In the facility, the order was transcribed incorrectly as levofloxacin 750 mg twice a day via gastrostomy tube every five days, and the MAR showed 9:00 AM and 5:00 PM doses signed as administered on two non-consecutive days instead of once daily for five straight days. The audit report further showed that on one of those days, the 9:00 AM dose was administered at 5:19 PM and the 5:00 PM dose at 7:13 PM, less than two hours apart. The facility’s medication error policy defined medication not administered within an allowed time frame greater than one hour from its scheduled time or missed medications as administration-based errors, which were present in these cases.
Failure to Timely Report Multiple Abuse Allegations to State Agency
Penalty
Summary
The facility failed to timely report multiple allegations of abuse to the Illinois Department of Public Health as required by its Abuse Prevention Program policy. An alert and oriented resident (R5) reported that another resident (R1) held a knife to her neck and threatened her on 12/7/25. A CNA (V4) stated she heard R1 threatening R5 with a knife and observed R1 standing over R5, and staff found knives, a drill, a hammer, and lighters in R5's room that night. The next day, another CNA (V3) searched R1's room at the direction of the DON (V2) and found a taser and a pocketknife under R1's bed. Various potentially dangerous items, including a drill, hammer, scissors, razor blades, and lighters, were later observed in the medication room and then removed to the Administrator's office. The Administrator (V1) verified the objects belonged to R1 and acknowledged that R5's allegation of being threatened with a knife on 12/7/25 was not reported to the Illinois Department of Public Health. A second incident involved an alert and oriented resident (R9) who alleged that during a verbal altercation with staff on 12/14/25, staff ripped his shirt and had a knee on his neck. R9 reported the ripped shirt and physical aggression to a CNA (V5) and a nurse, and V5 confirmed that R9 showed her the ripped shirt and that she reported the allegation to the Administrator and DON. The facility did not submit its initial report to the Illinois Department of Public Health until nine days after the incident and the report omitted the allegation that staff ripped R9's shirt. In a third incident, R5 reported that while she was choking and a CNA assisted her, another CNA (V17) stated he would have let her choke; R5 reported this to the Administrator, who acknowledged receiving the report but did not report it to the Illinois Department of Public Health because R5 said it occurred before the Administrator started working at the facility. These actions and inactions demonstrate failures to immediately report allegations of staff-to-resident and resident-to-resident abuse as required by facility policy.
Failure to Investigate and Report Multiple Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to follow its Abuse Prevention Program policy by not promptly investigating and reporting multiple allegations of abuse and by not ensuring resident protection during the investigation period. An alert and oriented resident (R9) reported that during a verbal altercation on 12/14/25, staff ripped his shirt and placed a knee on his neck. A CNA confirmed that R9 showed her the ripped shirt that night and that she reported the incident to the Administrator and DON. The Administrator acknowledged that R9 had reported staff being physically aggressive and that the incident occurred on 12/14/25, but did not begin investigating until 12/23/25, after R9 reported the allegation to the state agency. The initial report to the Illinois Department of Public Health was made nine days after the incident and did not include the allegation that staff ripped R9’s shirt. The facility also failed to investigate and report other abuse allegations involving alert and oriented residents. One resident (R5) reported that another resident (R1) held a knife to her neck and threatened her; a CNA stated she heard R1 threatening R5 with a knife and later found a knife, drill, hammer, and lighters in the room. Another CNA reported that, the next day, she was instructed by the DON to search R1’s room and found a taser and pocketknife under the bed, and another CNA confirmed that R5 reported being threatened with a knife and being scared. The Administrator verified that the confiscated items belonged to R1 but stated she did not investigate or report R5’s abuse allegation. In a separate incident, R5 reported that a CNA told her he would have let her choke after another CNA assisted her while she was choking; the Administrator acknowledged receiving this report but did not investigate or report it, stating it occurred before her start date. These actions and inactions were inconsistent with the facility’s policy requiring immediate investigation, separation of the alleged perpetrator, assurance of resident safety, and completion of an incident report for any alleged abuse.
Failure to Prevent Resident Possession and Use of Potential Weapons
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision when a resident was able to possess and use multiple objects that could be used as weapons. One alert and oriented resident reported that another alert and oriented resident held a knife to her neck and threatened her, causing her to feel scared. A CNA stated she heard the threatening incident and observed the resident with the knife standing over the other resident. Staff reported that on the same night, a knife, drill, hammer, and lighters were found in the threatened resident’s room, and that the resident who made the threats also threatened to burn down the facility before being transferred to the hospital. The following day, a CNA, under direction from the DON, searched the threatening resident’s room and found a taser and pocketknife under the bed, and reported that a hammer and drill had also been found there the previous night. The threatening resident, who was alert and oriented, later stated she kept a hammer, drill, and pocketknife in her room for protection. Surveyors observed a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters in the medication room, and a metal folding utility-type knife in the Administrator’s desk, which the Administrator confirmed belonged to the resident who had made the threats and had been confiscated after the incident. The Administrator acknowledged that residents having such items in the facility made it unsafe. Review of the resident’s records showed a prior care plan for maladaptive behaviors that may detrimentally affect others, but there was no care plan focus on aggressive behaviors or on the resident’s possession of objects that could be used as weapons. Another resident’s records showed intact cognition and a care plan for risk of alteration in mood and psychosocial well-being with an intervention to provide a calm and positive environment. The facility’s policy on a homelike environment stated that the environment and furnishings should be safe, clean, and comfortable.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
A resident with multiple diagnoses, including an above-knee amputation, chronic ulcers, and a stage 3 sacral pressure ulcer, was dependent on staff for activities of daily living (ADL) and incontinence care. The resident's care plan required staff to check and change incontinence briefs every two hours and as needed. Observations and interviews revealed that the resident often had to wait up to 30 minutes for assistance after a bowel movement and was found in bed with soiled linens, a strong urine odor, and heavily stained bedding. Staff assigned to the resident's care stated they were occupied with other duties and had not yet attended to the resident, despite being expected to complete incontinence care within the first two hours of their shift. The facility's policies required timely and thorough incontinence care and morning rounds to ensure residents' needs were met. Documentation from the nurse practitioner indicated the resident had incontinence-associated dermatitis, attributed to prolonged moisture exposure from incontinence episodes. The failure to provide timely incontinence care and maintain cleanliness of the resident's environment was directly observed and confirmed through staff interviews, highlighting a lapse in adherence to the resident's care plan and facility policies.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents out of a sample of ten. In one incident, a resident with moderate cognitive impairment and a history of behavioral disturbances made inappropriate physical contact with another cognitively intact resident while waiting in a hallway. The incident was not witnessed by staff, and the affected resident reported that the inappropriate contact continued until staff arrived to open the door. The resident who committed the act had previous allegations of similar behavior involving other residents, some of which were witnessed by staff. In a separate incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room and attempted to take items from his table. This led to a physical altercation, during which the resident with severe dementia sustained a small scratch above her eyebrow. The altercation was witnessed by a roommate, who sought help from staff. The resident who initiated the physical contact was also severely cognitively impaired. The wandering resident had a documented history of similar incidents involving entering other residents' rooms and making physical contact. The facility's abuse prevention policy requires staff to identify residents at risk for abuse or with behaviors that may lead to conflict, and to address these risks through care planning and regular monitoring. Despite this policy, the facility did not prevent repeated incidents of resident-to-resident abuse, including both inappropriate sexual contact and physical altercations, involving residents with known behavioral risks and histories of similar incidents.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident, identified as R3, from physical abuse by a staff member, resulting in emotional distress and increased agitation for the resident. R3, who has a medical history including cerebral infarction, bipolar disorder, and moderate cognitive impairment, was involved in an incident where a Certified Nursing Assistant (CNA), V3, slapped R3's hand. This occurred when R3 attempted to grab V3's personal laptop, which should not have been present in the work environment. Witnesses, including other staff members, confirmed the physical contact initiated by V3, which led to R3 responding by hitting V3. The incident was observed by multiple staff members, including V5 and V6, who reported that V3's actions were inappropriate and contrary to the facility's policy on handling residents. R3 was known to become agitated when approached in a loud or rushed manner, and staff familiar with R3 were aware of the need for a calm approach. Despite this knowledge, V3 did not call for assistance or attempt to redirect R3 appropriately, leading to the escalation of the situation. The facility's investigation substantiated the abuse allegation against V3, who was subsequently terminated. The facility's policy on abuse prevention emphasizes the prohibition of physical abuse and the importance of a resident-sensitive environment. However, in this case, the failure to adhere to these policies resulted in a deficiency in protecting the resident from abuse, as evidenced by the physical altercation and the emotional impact on R3.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. A cook at the facility witnessed one resident, who has moderate dementia and a history of inappropriate behavior, inappropriately touching another resident who is nonverbal, blind, and has severe cognitive impairments. The incident occurred in a hallway, where the cook observed the resident patting the other resident above her right breast and then slipping his hand down her shirt to her left breast. The cook reported that the resident stopped the inappropriate behavior upon realizing her presence. The resident who was subjected to the abuse has a history of profound intellectual disabilities, vision impairment, and requires 24-hour care due to her vulnerable status. Despite the cook's eyewitness account and the resident's known vulnerabilities, the facility's investigation concluded that the allegation of abuse could not be substantiated. The facility's policy defines abuse as a willful infliction, requiring deliberate action, yet the incident was not substantiated in their final report to the Illinois Department of Public Health.
Deficiencies in Kitchen Maintenance and Food Storage
Penalty
Summary
The facility failed to maintain its kitchen in a manner that prevents foodborne illness, affecting 74 residents receiving dietary services. During an inspection, it was observed that the dry storage area contained several large bins of food items such as breadcrumbs, oatmeal, rice, flour, and thickener, all of which were past their use-by dates. Additionally, several bags of pasta were found open to air, and dented cans of various food items were in rotation for use, contrary to the facility's policy that requires dented cans to be stored separately and marked for return or disposal. The milk cooler emitted a sour/spoiled odor, indicating improper maintenance. Further inspection of the walk-in cooler revealed multiple food items, including corn, pancakes, breakfast sausage patties, cheese slices, bologna, shredded cheese, turkey meat, boiled eggs, hot dogs, and raw liquid eggs, that were either open to air, improperly wrapped, or past their use-by dates. The facility's policy mandates that all foods be wrapped in moisture-proof wrapping or placed in suitable containers to prevent contamination and that meats be stored below ready-to-eat foods. Additionally, an oscillating fan in the dish area was covered with dust and grease, and there was no separate log for documenting the sanitizer concentration for sanitizing buckets, which is required by the facility's policy.
Failure to Provide Written Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for their transfer to the hospital, as well as failing to notify the ombudsman of these transfers. This deficiency was identified in four residents who were reviewed for discharge. The Director of Nursing (DON) admitted that the facility does not notify the ombudsman about hospital transfers and does not provide written notices to residents or their representatives, relying instead on phone notifications. Resident R74 was transferred to the hospital for a CT scan and psychiatric evaluation after being found verbally aggressive and positioned on the floor. The facility notified the resident's Power of Attorney (POA) by phone but did not provide a written notice or notify the ombudsman. Similarly, Resident R7 was transferred to the hospital multiple times due to various medical conditions, including low hemoglobin and deep vein thrombosis, without receiving written discharge notices or ombudsman notification. Resident R26, who was cognitively intact, was transferred to the hospital after expressing suicidal ideations and contacting a suicide hotline. The facility did not provide a written discharge notice or notify the ombudsman. Resident R38, also cognitively intact, was transferred to the hospital due to altered mental status and other medical conditions, with no written notice or ombudsman notification provided. The facility's administrator acknowledged the lack of awareness regarding the requirement for written discharge notices and ombudsman notifications.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to residents and their families or Power of Attorney (POA) regarding the bed hold policy at the time of discharge to the hospital. This deficiency was identified for four residents who were reviewed for discharge in a sample of eighteen. The Director of Nursing (DON) acknowledged that the facility holds the bed for ten days but does not typically keep a copy of the bed hold notice. The facility was unable to show proof that the bed-hold policy was provided to the residents or their POAs. Resident R74 was transferred to the hospital for a CT scan and psychiatric evaluation following an incident of aggressive behavior. Despite the transfer, there was no documentation in the electronic medical record regarding the provision of the bed hold policy to the resident or their POA. Similarly, Resident R7, who had multiple hospital admissions due to various medical conditions, also lacked documentation of the bed hold policy being provided. The facility was unable to provide information regarding the bed hold policy given to R7 or their POA. Resident R26, who was cognitively intact and had multiple hospital admissions due to suicidal ideations, also did not have documentation of the bed hold policy being provided. Additionally, Resident R38, who had several hospital admissions due to altered mental status and other medical conditions, lacked documentation of the bed hold policy. The facility's administrator confirmed that residents and their family representatives should receive a bed hold policy each time a resident is discharged from the facility or admitted to the hospital, but this was not done for the admissions to the hospital.
Failure to Obtain Physician Orders and Conduct Self-Administration Assessments
Penalty
Summary
The facility failed to obtain physician orders for residents to have medications at the bedside and did not complete self-administration of medication assessments for three residents. One resident, who was cognitively intact, had her Fluticasone Propionate nasal spray found on her roommate's dresser without a physician's order for bedside storage or a self-administration assessment. The resident confirmed she had not been taught how to use it, although she claimed to know how to administer it herself. Her roommate, who was nonverbal and had multiple diagnoses including dementia and severe mood disorders, had no orders for the nasal spray and no self-administration care plan. Another resident was found with two white pills on his bedside table without a physician's order for bedside medication storage or a self-administration assessment. This resident, who was also cognitively intact, had multiple diagnoses including cerebral infarction and cocaine abuse. The facility's policy requires an interdisciplinary team assessment for self-administration, including cognitive and physical ability evaluations, and a physician's order for bedside medication storage, none of which were documented for these residents.
Failure to Change PICC Line Dressing
Penalty
Summary
The facility failed to appropriately manage the PICC line dressing for a resident, leading to a deficiency in infection control practices. The resident, who was admitted with conditions including cellulitis, diabetes mellitus, and a cutaneous abscess, had a PICC line with a border gauze dressing that was not changed by the staff. The resident reported that the dressing had been in place for 4 to 5 days and had changed it herself, indicating a lack of staff intervention in maintaining the dressing. Upon further investigation, it was found that the dressing was soiled and rolled on the sides, exposing the PICC insertion site. The facility's Assistant Director of Nursing was unsure about the frequency of dressing changes for gauze dressings, while the Director of Nursing stated that gauze dressings should be changed daily due to an increased risk of infection. There was no documentation of the dressing changes in the resident's electronic medical record, and the facility's policy required gauze dressings to be changed every 48 hours or if compromised.
Failure to Refund Resident Funds After Discharge
Penalty
Summary
The facility failed to refund resident funds after residents were discharged from the facility. This deficiency was identified for three residents who had been discharged over three months earlier. The facility's records showed that Resident 1 had a balance of $2,097.70, Resident 2 had a balance of $120.08, and Resident 3 had a balance of $30.09 in their respective accounts. The Business Office Manager (BOM) acknowledged the oversight and stated that he would contact the new facilities of Residents 1 and 2 to transfer the funds, while he would continue to try to locate Resident 3 or send the funds to social security if unsuccessful. The Corporate BOM confirmed that the facility has a policy requiring resident funds to be returned within 30 days of discharge. The facility's policy on resident trust funds, dated February 2020, mandates that a reconciliation between the resident trust fund and the bank statement be completed monthly and that funds be refunded to the proper person upon discharge. The BOM admitted that the failure to transfer the funds was an oversight, as the residents were out of sight and out of mind after being discharged.
Failure to Follow Menu Plan and Provide Alternatives
Penalty
Summary
The facility failed to follow the menu plan and provide residents with alternatives for food items refused. On multiple occasions, the menu was not posted for residents, and the food served did not match the planned menu. For instance, on 5/15/24, the lunch menu listed Cuban style pork chop, red beans and rice, chocolate mousse, and cornbread, but residents were served banana cream pie instead of chocolate mousse, and cornbread was unavailable. Additionally, some residents did not receive red beans and rice or the correct dessert. On 5/21/24, the breakfast and lunch menus were not posted until 10:00 AM, and the menu in the kitchen did not match the one posted in the hallway. Residents reported that the menu often changes, and they cannot order substitutes in advance, leading to dissatisfaction and unmet dietary needs. The dietary manager acknowledged issues with food orders and a mix-up with the new system, while the administrator confirmed that the facility should not run out of food. Resident council minutes and grievance forms from February to May 2024 indicated ongoing issues with the kitchen running out of food items, such as hot dog and hamburger buns, and not following alternative selections. Residents also complained about smaller food portions. The facility's undated and unsigned policy and procedure for meal service stated that each resident should be served a diet appropriate for their needs, and menus should be posted and documented properly. However, these guidelines were not followed, leading to the deficiencies observed by the surveyors.
Failure to Provide Alternate Food to Meet Residents' Needs
Penalty
Summary
The facility failed to provide alternate food to meet residents' needs, affecting three residents who were reviewed for alternate food and nutritional adequacy. Resident 1, who is cognitively intact, reported not receiving a vegetable salad she requested during lunch because she had not ordered it the previous day. Additionally, she mentioned that residents do not receive a breakfast menu and are served whatever the kitchen decides. Resident 6, also cognitively intact, stated that dietary staff refused to provide a peanut butter and jelly sandwich as a substitute. Resident 15, who is cognitively intact, reported not receiving lactose-free milk because the facility could not obtain it. The Dietary Manager confirmed that meal substitutes need to be ordered the day before, while the Facility Administrator contradicted this, stating that substitutes do not need to be pre-ordered. The resident grievances and concerns document complaints about the kitchen running out of food items such as hotdog and hamburger buns and not serving alternative food items. The facility's policy on substitutions indicates that substitutions should be selected from the same food group as the item being replaced. However, this policy was not followed, leading to residents not receiving their requested or necessary food items. The inconsistency between staff members' statements and the facility's policy contributed to the deficiency in providing adequate and appropriate food alternatives to residents.
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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