Morgan Park Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 10935 South Halsted Street, Chicago, Illinois 60628
- CMS Provider Number
- 145764
- Inspections on file
- 68
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Morgan Park Healthcare during CMS and state inspections, most recent first.
Multiple residents did not receive their scheduled 9:00 a.m. medications within the required one-hour window, and an IV medication bag was left hanging at a bedside without any label indicating when it was hung or who administered it. Around midday, several cognitively intact or moderately impaired residents reported they had not yet received their morning medications, which included opioids, antipsychotics, anticonvulsants, antihypertensives, anticoagulants, and bowel regimen drugs. An LPN was observed at the medication cart with the EMAR showing red flags for overdue 9:00 a.m. medications but stated the medications were not late and just not signed out. Another resident reported feeling sluggish and still being in bed because morning medications had not been given, while an empty 50 mL IV bag was observed at the bedside with no date, time, or nurse initials. The LPN later acknowledged that the IV bag should have been labeled and that medications should be signed out in the MAR, and the DON confirmed that 9:00 a.m. medications must be given between 8:00 a.m. and 10:00 a.m. and that IV bags must be labeled per facility policy.
A resident with multiple comorbidities, severe cognitive impairment, and a known high fall risk fell from bed, sustained a head laceration, and was sent to the hospital, returning with staples. Staff reported the resident was a total assist, confused, did not use the call light, and had new fall interventions implemented such as a low bed, floor mat, and a helmet for seizures. However, the comprehensive care plan remained focused on general fall risk and call light use, with its last revision months earlier, and was not updated to include the new post-fall interventions, contrary to facility policy requiring timely care plan revision after significant changes in condition.
The facility failed to adequately monitor and supervise residents with known substance use disorders and to prevent accidents such as falls. Multiple cognitively intact residents and staff reported that illicit drugs, including heroin and crack cocaine, were brought into the building and sold by residents, with small baggies of white powder repeatedly found in rooms and on bedside tables. Several residents with histories of opioid and other substance abuse were found unresponsive in their rooms, some requiring Narcan and hospitalization, and one resident was found cold and rigid in the morning after an apparent overdose, with other residents stating that staff had not performed rounds. Care plans and substance abuse assessments lacked specific monitoring interventions, incidents were sometimes not documented, and drug screening was not consistently performed when contraband was discovered. Separately, a resident sustained a left femur fracture after a fall inside the facility, and another resident’s fall care plan was not updated and assessments were not followed after a fall, demonstrating broader failures in supervision and accident prevention.
Two cognitively intact residents reported ongoing verbal abuse and bullying by a neighboring resident with a documented history of verbal aggression and manipulative behavior, including sexually explicit name-calling, derogatory comments that they "stink," and intimidation over use of a shared bathroom, leading them to use a bedside commode in their room instead. Another resident described the alleged aggressor as disrespectful, prone to picking on others, and believing they "run" the floor, and reported hearing about conflicts over the shared bathroom. Despite prior progress notes and a care plan describing the aggressor’s verbal altercations and threatening behavior, staff interviewed denied awareness of any bullying or abuse, and no concerns about the shared restroom had been brought forward, indicating the facility did not follow its abuse prevention policy to protect residents from verbal and psychological abuse.
Staff failed to follow the facility’s cell phone policy by using personal phones in resident care areas and ignoring the nurses’ station phone. A central supply manager was observed talking on a personal cell phone at the nurses’ station while the unit phone rang, and a restorative CNA was simultaneously texting on a personal phone and not responding to the ringing phone, despite stating that everyone is responsible for answering it. On another unit, a CNA assigned to monitor the hallway for resident safety was observed scrolling on a personal phone instead, and acknowledged this was against expectations and could interfere with resident monitoring. The employee handbook prohibits personal cell phone use while on duty except in designated break areas, and the DON confirmed that CNAs and nurses are not allowed to use cell phones on the units due to distraction, potential HIPAA issues, and interference with proper resident care.
A resident’s right to retain and use personal property was not honored when the resident’s television was broken in the facility and not properly assessed or addressed by staff. A CNA reported that the family had purchased both the original and replacement TVs and had heard that a nurse broke the first TV by hitting it with a bathroom door. An LPN acknowledged the TV fell during a mechanical lift transfer but did not inspect it afterward and later heard she was being blamed for the damage. The Administrator, contacted by the family about the broken TV, assumed the TV had simply stopped working and did not verify its condition in the room, while the Maintenance Director confirmed the TV had been broken in the facility and that the family supplied the replacement, which he installed.
A resident with confusion, gait/balance problems, incontinence, and a history of falls had an existing fall care plan with multiple interventions such as low bed, floor mat, frequent checks, and environmental safety measures. After the resident experienced another fall, the Restorative Nurse, who is responsible for entering fall-prevention interventions, acknowledged that the care plan was not updated with new or revised interventions, despite her understanding that interventions should change after each fall. Review of the care plan confirmed that no new fall-prevention measures were added following the subsequent fall, contrary to facility policy requiring review and updating of the care plan after a significant change in condition.
Two residents did not receive proper indwelling catheter care, leading to infection control concerns and a catheter-related hospitalization. One resident with urinary retention and obstructive uropathy was observed in bed with a half-full catheter drainage bag placed directly on the floor, despite staff, including an LPN and the DON, acknowledging that catheter bags must be hung off the floor on the bed frame below the kidneys to prevent contamination and backflow. Another resident with a Foley catheter and neurogenic bladder, care planned for infection risk, was found lethargic and hypoxic and was sent to the hospital, where the Foley was reported as non-draining for an unknown period, the urine was dark brown and turbid with large leukocyte esterase and many bacteria, and the resident was diagnosed with AMS, sepsis, hypotension, and UTI; the Foley was found clogged and was replaced to restore drainage.
Surveyors identified environmental hazards and inadequate cleaning practices, including a broken picture frame with exposed glass shards on an upper-floor hallway and a shower room toilet area with apparent feces on the wall and urine-like debris on the toilet and floor. Staff, including a housekeeper and a CNA, acknowledged that the broken frame posed a danger and could be used as a weapon, and housekeeping staff confirmed that the bathroom should have been cleaned more frequently. Facility policies required that all areas be kept clean, safe, and properly disinfected, but these conditions were not met.
Surveyors identified multiple failures in food sanitation and temperature control during a meal service. A dietary aide and a cook prepared meal trays with uncovered beards despite facility policy requiring beard guards. The aide licked his ungloved hand and then handled menu tickets and prepared about 20 trays before sanitizing and donning gloves, and later adjusted his face mask with gloved hands and continued tray preparation without changing gloves or sanitizing. When a meal cart was checked, hot ham on a tray was found well below required hot-holding temperatures. The cook stated he had taken food temperatures but had not documented them, leaving no required temperature log, despite policies mandating temperature checks and recording for hot and cold foods.
Surveyors found that the dietary department failed to maintain clean and sanitary conditions in the kitchen and food storage areas, with dirty floors, trash, and debris throughout and glue traps for pests under storage racks. The Dietary Manager and a dietary aide both confirmed that dietary staff are responsible for cleaning and verified the presence of dirt, trash, and pests, including roaches on a counter. These conditions conflicted with facility policies and job descriptions that require the Food Service Supervisor and dietary aides to keep food service areas clean, orderly, and compliant with infection control and food sanitation standards for all residents.
The facility failed to properly manage its dumpster area, where surveyors twice observed foul odors, two dumpsters with all lids open, and scattered trash on the ground. A maintenance staff member stated that dumpster lids should be closed and that housekeeping was responsible for the area, and acknowledged that open lids and trash could allow pests into the building. The housekeeping supervisor confirmed the area should be cleaned more than daily and that leaving trash and lids open can attract animals and rodents. These conditions occurred despite a written waste management policy requiring trash bags to be placed inside the dumpsters, lids kept closed, and the dumpster area kept clean by maintenance and housekeeping staff, with the potential to affect all 213 residents.
Surveyors identified widespread environmental deficiencies, including missing baseboards and floor panels, broken tiles, holes in walls, stained and unsecured ceiling tiles, and dirty, poorly maintained shower rooms with brown splatter, debris, standing water, and missing drywall. Staff interviews confirmed that maintenance is responsible for repairs and floor techs for cleaning common areas, and leadership acknowledged that walls with holes and stained ceiling tiles do not provide a homelike environment. Review of the work order binder showed these issues were not documented, despite facility policies and job descriptions requiring that all areas be kept clean, safe, and in good repair.
The facility failed to maintain effective pest control for roaches and mice, as multiple residents reported seeing roaches in hallways, rooms, dining areas, and shower rooms, and mice in rooms, hallways, and a nourishment room. Staff, including CNAs and housekeeping, acknowledged frequent roach sightings and incidents involving dead or trapped mice that residents sometimes had to dispose of themselves. Surveyors observed rodent droppings under a nourishment room sink, dead roaches near a bedside, and live roaches in a shower room, as well as dumpsters with open lids and trash scattered around them. These conditions conflicted with facility policies requiring closed, clean dumpsters and a pest control program conducted regularly and as needed, while the administrator reported limited awareness of mouse issues and confirmed pest control visits only twice monthly.
Surveyors found that multiple residents were living in rooms with trash on the floors, dirty bathroom surfaces, and inadequate window coverings, as well as broken or missing furniture such as damaged drawers and a hanging call light box. Several rooms had baseboards pulled away from walls, large holes or missing drywall, and unsecured wall cut-outs exposing plumbing, while a shared room lacked a toilet lid. One resident reported seeing a mouse enter through an open wall hole and stated that only hot water worked at the sink and sprayed everywhere despite having reported it weeks earlier. Shower rooms were observed with dirty floors, brown splatter on walls, standing water with debris in a tub, and missing drywall, even though staff acknowledged their responsibility for cleaning and maintenance and facility policies required a safe, clean, and homelike environment.
The facility failed to protect residents from physical abuse and to ensure complete documentation and reporting of resident-to-resident incidents. A resident with significant psychiatric diagnoses and moderate cognitive impairment was involved in multiple aggressive episodes toward other residents, including hitting a wheelchair-dependent resident and throwing a pitcher of ice water into another resident’s face after being refused money or items. One cognitively intact resident reported being struck from behind and having belongings knocked from a bedside table, but this event was not documented in the medical record. Another resident with chronic respiratory and cardiac conditions and hemiplegia clearly reported having ice water thrown in his face, which was reflected in progress notes. Despite staff being told of these events, the administrator and DON later stated they were unaware of the incidents until reviewing documentation days later, indicating failures in timely internal reporting and adherence to the facility’s abuse policy.
The facility failed to timely investigate and report two resident-to-resident physical abuse allegations to the state agency. One resident reported that a roommate entered the room, knocked belongings to the floor, grabbed the resident from behind, and struck the resident’s jaw, but this was not documented as a physical assault in the EHR. Another resident reported that a peer entered the room, demanded money, then cursed and threw a water pitcher into the resident’s face, which was documented in a progress note. An RN and an LPN each stated they reported these incidents to the administrator/abuse coordinator, while the administrator stated they were not informed and only later saw documentation of one incident and did not report it because it was "too late," and also denied being told about the alleged hitting. This occurred despite existing abuse education, resident rights, and abuse prevention policies requiring immediate reporting of alleged abuse.
A resident in a fully occupied four-bed room was observed without a ceiling-suspended privacy curtain around the bed after the curtain and track had fallen months earlier and were never replaced. The resident reported having no privacy and being unable to change clothes at the bedside. The Administrator stated that all residents should have privacy and window curtains for privacy and a homelike environment, while the Housekeeping Supervisor reported that housekeeping is responsible for replacing privacy curtains. Facility policies and job descriptions assign responsibility for maintaining a safe, comfortable, and homelike environment, including ensuring privacy curtains are present and in good condition.
Two residents reported that staff used paper towels instead of appropriate towels or wipes for peri care, causing them distress and anger. CNAs acknowledged using paper towels and even torn shirts, blankets, and sheets to clean residents when linens were unavailable. An LPN confirmed that staff should not use paper towels and should use proper towels or wipes. This practice conflicted with residents’ rights materials stating that individuals must be treated with dignity and respect and cared for in a manner that promotes quality of life.
The facility failed to follow its policies for community survival skill assessments, physician orders, and care plan interventions for residents leaving on community passes. Several residents were allowed to leave on independent passes without proper assessment or authorization, and responsible parties or families were not notified when residents left against medical advice or did not return. These failures affected residents with histories of substance abuse, psychiatric diagnoses, and prior incidents of not returning from passes.
A resident left the facility on a community pass and did not return, but the facility failed to notify the family or provide timely cooperation with law enforcement. Despite documentation showing family involvement in care, only the physician was notified, and there was no evidence of notification to the State Ombudsman. Required documentation and communication per facility policy were not completed.
A resident with multiple psychiatric and medical diagnoses, but intact cognition, left the facility on an independent pass and did not return. The facility failed to respond to law enforcement requests for information and did not notify the resident's involved family members, resulting in an inability to report the resident's whereabouts or status.
Surveyors found that staff did not ensure call lights were within reach for several residents, leaving some unable to call for assistance and unaware of their call light's location. In one case, a resident was not provided with a properly sized wheelchair despite repeated requests, resulting in discomfort and risk of skin breakdown. Staff and care plans indicated that call lights should be accessible and wheelchairs properly fitted, but these requirements were not met.
A resident with a gastrostomy and severe cognitive impairment did not receive tube feeding as ordered when staff failed to turn the feeding pump back on after care. The pump was found off and the resident was not receiving the prescribed continuous feeding, contrary to the physician's order and care plan.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to safeguarding residents from harm.
A resident with chronic kidney disease alleged inappropriate behavior by another resident with schizoaffective disorder and mild cognitive impairment. Although immediate protective actions were taken and authorities were notified, the facility failed to report the abuse allegation to the state health department within the required timeframe, resulting in a deficiency.
A facility failed to investigate an incident involving a verbal and physical altercation between a resident and the Maintenance Director to rule out abuse. The administrator did not interview the resident or consider the possibility of abuse, relying only on staff accounts and not following facility policy requiring investigation of all such incidents.
Two residents with significant respiratory and cardiac conditions were found to be receiving supplemental oxygen without active physician orders. Both the LPN and DON confirmed the absence of required orders, despite facility policy mandating physician authorization for oxygen therapy. The facility's oxygen report included these residents, but their medical records did not reflect any current orders for oxygen.
Multiple areas within the facility, including resident rooms and common spaces, were found with chipped paint, exposed drywall, missing outlet covers, clogged sinks, broken plaster, peeling paint, brown stains, loose and stained ceiling tiles, missing wall tiles, and missing hand railings. Staff and residents reported that much of the damage was caused by beds and wheelchairs, and maintenance staff indicated that repairs had been neglected and were difficult to keep up with. Facility policies requiring regular environmental audits and hazard identification were not effectively followed, resulting in ongoing environmental hazards and a lack of homelike conditions.
Two residents engaged in a physical altercation resulting in scratches and a bruise after staff failed to intervene in time, despite being present on the unit. Staff responded only after hearing yelling, and both residents were found with injuries. The facility's abuse policy, which requires immediate intervention to prevent abuse, was not followed.
A resident with Alzheimer's and a left below-the-knee amputation was injured during a transfer when a CNA attempted to move them without a Hoyer lift or additional staff, contrary to the care plan. The facility had insufficient mechanical lifts, contributing to the unsafe transfer and resulting in a leg fracture requiring surgery.
A resident with Alzheimer's and a left leg amputation fell during a transfer due to inadequate staffing and lack of equipment. The incident was inaccurately documented, with discrepancies in the date and staff involved. The facility's administration could not clarify these inconsistencies, impacting the credibility of the records.
The facility failed to provide adequate linen and towels for 205 residents, impacting daily care activities. Staff reported frequent shortages, leading to delays in resident care and discomfort. CNAs used makeshift solutions like cutting sheets for towels, and some purchased supplies themselves. Residents expressed frustration over waiting for care due to the lack of supplies.
The facility failed to administer medications as ordered, maintain secure medication storage, and provide adequate nursing coverage, leading to residents not receiving timely care. A nurse's absence resulted in delayed medication administration, and a lack of linen hindered incontinence care. Additionally, a medication cart was left unlocked, compromising resident safety and privacy.
The facility failed to protect residents from abuse, with multiple incidents of physical altercations and alleged abuse occurring. Residents with cognitive impairments and behavioral issues were involved in altercations, and a CNA was accused of abusing a resident during toileting. The facility's abuse prevention policy was not effectively implemented, leading to deficiencies in resident safety.
A resident with a history of falls and cognitive impairment sustained a leg fracture due to inadequate supervision and care plan management. The LPN discovered the injury after noticing the resident's pain, but the care plan lacked updated fall interventions. Additionally, a CNA was distracted by a personal device while responsible for monitoring residents, violating facility policy and compromising safety.
The facility failed to thoroughly investigate abuse allegations involving three residents. In one case, key witnesses were not interviewed following a physical altercation between two residents. In another incident, a resident reported being abused by a CNA during toileting, but the facility did not obtain witness statements. The resident involved has a complex medical history and requires substantial assistance.
A facility failed to maintain a clean environment for three residents, as brown stains were found on their shared bathroom wall. A resident reported the issue, suspecting the stains to be feces, but the housekeeping staff was unaware of the problem. The Director of Nursing and Housekeeping Director acknowledged the responsibility to maintain cleanliness, highlighting a lapse in communication and action.
A resident with significant mobility impairments and a BIMS score of 15 experienced a delay in receiving incontinent care due to an uncharged mechanical lift. The resident remained soiled for over an hour, despite informing staff of the need for assistance. The facility's policies emphasize timely care to prevent skin breakdown and maintain dignity, which was not met in this case.
A resident with a history of aggression assaulted another resident, despite the facility's knowledge of their behavior and the need for 1:1 supervision. The incident occurred without the required supervision, leading to a physical altercation in the dining room.
The facility failed to provide adequate catheter care for three residents, resulting in health issues such as UTIs and purple urine bag syndrome. Residents with indwelling catheters lacked proper documentation and monitoring, leading to adverse outcomes. The facility did not follow its catheter care policy, contributing to these deficiencies.
The facility failed to ensure accurate fall risk assessments for two residents. One resident with hemiplegia fell while being assisted, and their post-fall assessment did not reflect their balance and coordination issues. Another resident with paraplegia was inaccurately assessed as ambulatory and continent, despite using a wheelchair and having a catheter. The DON acknowledged these inaccuracies during the survey.
The facility failed to maintain the community shower room on the third floor North-Wing, affecting 53 residents. Observations included a leaking sink, soiled towels, missing ceiling tiles, and a broken soap dispenser. The housekeeper acknowledged these as maintenance issues, but the Maintenance Director was unaware of them. The facility's Preventative Maintenance Program policy was not effectively implemented.
A resident with a surgical wound did not receive proper wound care as ordered, resulting in unclean dressings and increased infection risk. The wound care nurse and coordinator had not performed the necessary care, despite records indicating otherwise. Additionally, a housekeeper improperly handled waste by dragging an unsecured garbage bag, risking cross-contamination. These actions reflect a failure in the facility's infection prevention and control program.
A facility failed to provide adequate linen and towels for 197 residents, leading to unmade beds and improvised solutions by staff. CNAs and nurses reported shortages, with some purchasing towels themselves. The laundry department struggled with limited supplies, and the Housekeeping Director cited a restricted budget. Residents expressed dissatisfaction, noting delays in their routines due to the lack of towels. The Administrator and DON were aware, but the issue persisted, impacting residents' rights to a safe and homelike environment.
The facility failed to secure Soiled Utility rooms containing sharps and infectious waste, posing a safety hazard to residents. Surveyors found doors open or unlocked, with access to biohazard bags, full sharps containers, and cleaning chemicals. Staff acknowledged the rooms should be locked, and the facility's policies on safety and sharps disposal were not followed.
The facility failed to maintain a clean and sanitary kitchen environment, affecting all 196 residents. Observations showed dirty fans and air conditioners, stagnant water attracting insects, and expired testing strips for the three-compartment sink. The Food Service Director and Maintenance Director had conflicting views on cleaning responsibilities, and the facility lacked a policy for kitchen cleaning.
The facility failed to provide functional hot water for four residents, with reports of cold or lukewarm water persisting for about two weeks. The Maintenance Director acknowledged the issue, citing the need for a second water heater. Additionally, a resident was exposed to sharp metal edges from an uncovered air conditioner unit, posing a safety risk. The facility's policies on maintenance and safety were not effectively implemented, leading to these deficiencies.
The facility failed to maintain an effective pest control program, resulting in unsanitary conditions in the kitchen and pest sightings in resident rooms. Observations revealed dirt and food wrappers under kitchen equipment, stagnant water with insects, and a cockroach near food preparation areas. Two residents reported seeing roaches in their rooms, and a pest was observed by an LPN. The pest control company visits twice a month, but documentation lacked specifics, and no traps were found. The facility's pest control policy was not effectively implemented.
The facility failed to refer six residents with serious mental disorders for PASRR Level II assessments, as required. The Social Service Director was unaware of the need for referrals upon new diagnoses, leading to missing documentation for several residents. The facility's policy requires compliance with PASRR standards, but lapses in the process were acknowledged by both the Social Service Director and the administrator.
Late Medication Administration and Unlabeled IV Bag for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer scheduled 9:00 a.m. medications within the required one-hour window and to properly label an IV medication bag. At approximately 12:00 p.m., an LPN was observed at the medication cart reviewing the EMAR, where the 9:00 a.m. medications for four residents were flagged in red, indicating they were an hour or more late. The LPN stated that the medications were not late and that they just had not been signed out yet, despite the EMAR indication. The facility’s DON later confirmed that medications scheduled for 9:00 a.m. should be administered between 8:00 a.m. and 10:00 a.m., and that if a medication is not signed out on the MAR, it is considered not given. Around midday, three cognitively intact or moderately impaired residents reported not having received their morning medications. One resident with a BIMS score of 15 stated at 12:15 p.m. that she had not received her 9:00 a.m. medications, which included acidophilus/pectin, docusate sodium, methadone, and quetiapine, and had diagnoses including essential hypertension, bipolar disorder, opioid abuse, and neuralgia/neuritis. Another resident with a BIMS score of 15 stated at 12:23 p.m. that he had not received his morning medications, which included gabapentin, polyethylene glycol, and sennosides-docusate, and had diagnoses including schizophrenia, amputations, gangrene, and joint pain. A third resident with a BIMS score of 10 stated at 12:30 p.m. that he was still waiting on his morning medications, which included enoxaparin, Flomax, Keppra, nifedipine ER, Suboxone, and bowel regimen medications, and had diagnoses including COPD, epilepsy, toxic encephalopathy, and neuralgia/neuritis. In addition, an unlabeled, empty 50 mL IV bag was observed hanging at the bedside of another cognitively intact resident shortly before 1:00 p.m. This resident reported not having received any medications yet that day and stated that morning medications were supposed to be given early but were always late, and that she remained in bed feeling sluggish because she had not received them. The LPN then entered to administer this resident’s scheduled 9:00 a.m. medications, which included multiple oral medications and an IV penicillin G sodium dose. The LPN stated that the overnight nurse might have given the IV medication early and acknowledged that the IV bag should have been labeled with the date, time, and nurse’s initials, and that medications should be signed out in the MAR to prevent duplicate dosing. The DON confirmed that IV solution bags should be labeled with contents, date and time hung, and expiration period, and that medications must be documented immediately after administration, consistent with facility policies on medication administration and IV therapy.
Failure to Update Care Plan After Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan after a significant change in condition related to a fall with head injury. The resident had multiple serious diagnoses, including hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, COPD, major depressive disorder, anxiety disorder, end stage renal disease with dependence on dialysis, dementia, epilepsy, seizures, Alzheimer’s disease, and diabetic retinopathy with macular edema. The resident’s BIMS score was 7, indicating severe cognitive impairment. The resident experienced a fall from bed, was found on the floor next to the bed with an open area to the back of the head, and was transported to the hospital, returning with staples/sutures to the back of the head. Following the fall and hospital transfer, staff implemented new fall-related interventions upon the resident’s return, including use of a low bed and floor mats, and staff reported that the resident also used a helmet for seizures. Interviews with staff indicated that the resident was considered a high fall risk, was a total assist, confused, and did not use the call light despite it being within reach. One CNA reported checking on the resident every 5–10 minutes and noted that at the time of the fall the resident was in a low bed without a floor mat. Another nurse stated the resident was monitored in the dining room, had the bed in the lowest position, and wore non-skid socks. Despite the implementation of new interventions after the fall, the resident’s care plan was not updated to reflect these changes. The existing care plan focus documented the resident as at risk for falls related to cardiorespiratory conditions and comorbidities, with interventions such as ensuring the call light was within reach, encouraging its use, and anticipating and meeting needs, with the last revision dated several months prior to the fall. The DON acknowledged that new interventions of a floor mat and low bed were implemented after the fall but was unsure why the care plan was not updated. The restorative nurse, who was responsible for entering fall interventions within 24 hours, stated that if the interventions were not entered in the care plan, it meant the care plan had not been properly updated, which is inconsistent with the facility’s written policy requiring care plans to be reviewed and updated when a significant change occurs.
Failure to Control Illicit Drug Use and Provide Adequate Supervision Leading to Overdoses and Falls
Penalty
Summary
The deficiency involves the facility’s failure to monitor, supervise, and intervene for multiple residents with known substance use disorders, and to provide adequate supervision to prevent accidents such as falls. Several residents with documented histories of opioid and other substance abuse were able to obtain and use illicit drugs within the facility, resulting in episodes of unresponsiveness and suspected overdoses. One resident with diagnoses including opioid dependence, anxiety disorder, obstructive sleep apnea, and major depressive disorder was found unresponsive during morning rounds with no respirations or pulse, and resuscitation efforts were unsuccessful. Another cognitively intact resident reported that this resident had overdosed, was found on the floor with liquid coming from his nose, and that staff did not check purses or conduct searches, making it easy to bring drugs into the building. Multiple residents and staff reported that this was not the first overdose death in the facility and that drugs such as heroin and crack cocaine were being sold by residents on specific units. Additional residents with substance use histories experienced overdoses or suspected overdoses while in the facility. One resident with a history of opioid abuse and withdrawal admitted to buying cocaine inside the facility and reported being given Narcan after overdosing. Another resident with diagnoses including abuse of psychoactive and non-psychoactive substances, and opioid abuse in remission, admitted to substance use and possession of contraband on more than one occasion, with contraband baggies found in the room and Narcan reportedly administered after an overdose requiring hospitalization. A resident with opioid abuse reported that illegal drugs, including crack cocaine and heroin, were sold by other residents, and that staff were supposed to check bags but did not. Staff interviews confirmed finding small clear baggies with white powdery substances in residents’ rooms and on bedside tables, sometimes inside narcotic boxes, and that some residents had tested positive for cocaine. One LPN acknowledged not documenting an incident where a resident dropped a baggie of suspected cocaine, despite recognizing the importance of maintaining a history of such events. The facility also failed to ensure adequate supervision and monitoring for residents at risk for accidents unrelated to substance use. One resident fell inside the facility and sustained a left femur fracture, and another resident’s fall care plan was not updated and assessments were not followed after a fall, despite being identified as at risk. For residents with substance use disorders, care plans and assessments were incomplete or lacked specific monitoring interventions. For example, one resident’s care plan documented substance use and a positive opioid test with relapse but contained no interventions regarding monitoring. The facility’s own substance abuse protocol, as described by the substance abuse counselor, called for drug screening when substance use was suspected, room searches, incident reporting, care plan updates, and substance abuse assessments, but in at least one case the counselor acknowledged that a required substance abuse assessment was not completed after contraband was found. Staff also reported that residents were supposed to be monitored every 30 minutes, yet a resident with a known substance use history was found cold, rigid, and unresponsive in the morning, with other residents stating that staff did not perform rounds or announce themselves that shift. Further, the report describes an incident where a newly admitted resident with a history of overdose and polysubstance abuse was found unresponsive shortly after a visitor left the room, with an unknown white powdered substance on the chest and additional baggies discovered under the sheets. The LPN on duty administered multiple doses of Narcan and called 911, and hospital records later confirmed polysubstance abuse with positive screens for fentanyl, heroin, and benzodiazepines. Another resident with severe cognitive impairment was found unresponsive with nasal flaring and no response to verbal or painful stimuli; Narcan was administered and the resident was transferred to the hospital, where records documented an opiate overdose despite a negative urine drug screen, with the physician noting that the naloxone response and history of opioid misuse suggested recent opioid exposure. The nurse practitioner stated that Narcan had been given to residents on multiple occasions due to the large population with illicit drug use history and that Narcan was used when nurses suspected opioid or illicit drug use. Staff across disciplines, including nursing, housekeeping, and social services, acknowledged that there were “a lot of overdoses,” that residents were “doing drugs,” and that some residents relapsed in the building, underscoring the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for residents at risk of overdose and falls.
Failure to Protect Residents From Ongoing Verbal Abuse and Bullying by a Peer
Penalty
Summary
The facility failed to protect two cognitively intact residents from verbal abuse and bullying by another resident and did not follow its abuse prevention policy. One resident and their mother, who share a room and bathroom with a neighboring resident, reported that the neighboring resident had repeatedly used foul and sexually explicit language toward one of them, including calling them a “b**l sucker” and “d**k sucker,” and made derogatory comments that they “stink.” The two residents stated that this behavior had been occurring for about two months, often when no staff were present, and that the neighboring resident did not want them to use the shared restroom. As a result, they chose to use a bedside commode in their room to avoid ridicule; surveyors observed a bedside commode with urine in it in their room. The two residents reported feeling unsafe, frustrated, angry, stressed, and anxious due to the ongoing bullying and verbal abuse, and one resident expressed fear that reporting the situation might make it worse. Another resident on the unit, who had been in the facility for nearly two years, described the alleged aggressor as someone who becomes “ignorant and disrespectful” when angry, “picks at people,” and “thinks they run this floor,” and reported having heard about conflicts involving the shared bathroom, including accusations that the two residents left the bathroom dirty. This resident also stated that the alleged aggressor knows about other residents’ diagnoses and suggested that this information may have come from staff. Despite these reports and the facility’s own documentation that the alleged aggressor had a history of verbal altercations, verbal aggression toward peers and staff, and manipulative, threatening, and disrespectful behavior, staff interviewed denied awareness of any bullying or abuse between the involved residents and reported no prior incidents or concerns regarding their shared restroom. Progress notes for the alleged aggressor from multiple prior dates documented episodes of verbal aggression and derogatory name-calling, and the resident was care planned for manipulative and aggressive behavior. The facility’s Abuse Prevention Program policy states that residents have the right to be free from abuse, defined as intimidation or punishment resulting in mental anguish, yet the ongoing verbal aggression and intimidation toward the two residents were not identified or addressed by staff prior to the surveyor’s involvement.
Staff Cell Phone Use in Resident Care Areas and Failure to Answer Nurses' Station Phone
Penalty
Summary
The facility failed to follow its employee handbook policy prohibiting personal cell phone use while on duty, resulting in staff using personal phones in resident care areas and ignoring the nurses' station phone. On the second-floor north nurses' station, a surveyor observed a central supply manager/transportation staff member talking on her personal cell phone while the nurses' station phone rang audibly nearby, and she did not initially answer it. At the same time, a restorative CNA was seated at the nurses' station, looking down and texting on his personal cell phone, also ignoring the ringing nurses' station phone and not looking up from his device. When they noticed the surveyor, both staff members stopped using their phones, and the central supply manager then answered the nurses' station phone. The central supply manager stated she did not hear the nurses' station phone because she was on her personal call, and the restorative CNA stated he did not hear the phone because he was texting and that, although everyone is responsible for answering the nurses' station phone, he typically does not answer it because calls are usually for the nurses. The census documented 57 residents residing on the second-floor north unit. On another unit (3N), a CNA was observed sitting in the hallway with her personal cell phone in her hands, scrolling on the phone while she was supposed to be monitoring the hallway for resident safety. This CNA stated she is not supposed to be on her personal phone when monitoring the hallway, acknowledging that if she is on the phone, she might not properly monitor residents, which can lead to residents not receiving needed care, sustaining injuries, or getting into confrontations. She reported she is assigned 20 residents and that 3N houses 58 residents in total, and that staff using personal phones while in the units is not part of her job description. The facility’s employee handbook states that cell phone usage while on duty is prohibited, that personal devices may only be used in designated areas while on break, and that employees who use personal devices while on duty may be subject to disciplinary action. The DON confirmed that CNAs and nurses are not supposed to use their cell phones on the units, that phones are only allowed in the break room when staff are on break, and that cell phone use in the units is distracting, can cause HIPAA violations, is unprofessional, and prevents CNAs and nurses from providing proper care to residents, which can lead to accidents and injuries.
Failure to Safeguard and Respect Resident’s Personal Television
Penalty
Summary
The facility failed to respect and safeguard a resident's personal belongings, specifically the resident's television (TV), and did not ensure the resident had appropriate access to this personal possession. A surveyor observed a functioning 32-inch black TV on a portable stand in the resident's room, which staff reported had been recently purchased by the resident's family because the previous TV had been broken in the facility. A CNA stated that the family had also purchased the prior TV and reported hearing that a nurse had broken it by bumping it with the resident's bathroom door. The LPN involved reported that, during a transfer using a mechanical lift with three CNAs present, the resident's TV fell from the bedside table onto a bag of dirty clothes and was then placed back on the table by a CNA; she stated she did not inspect the TV afterward and was unaware it was broken. She later heard that she was being blamed for breaking the TV but did not address these reports. The Administrator stated that the family had contacted her months earlier about the broken TV and that she believed the TV had simply stopped working after five years of use; she did not go to the room to verify the condition of the TV. The Maintenance Director confirmed that the resident's TV had been broken in the facility several months earlier, did not know how it broke, and stated that the family purchased the replacement TV, which he installed on the TV stand. The Ombudsman Residents' Rights document cited in the report affirms that residents may keep and use their own property.
Failure to Revise Fall Care Plan After Recurrent Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s fall care plan after a subsequent fall, as required by facility policy and care planning standards. Interview with the Restorative Nurse established that she is responsible for entering fall-prevention interventions into residents’ care plans and that care plans should be updated to reflect each fall, with different interventions added when a resident experiences multiple falls. She stated that if a resident continues to fall, maintaining the same interventions indicates they are not effective and that not changing them puts residents at greater risk of falling. The Restorative Nurse acknowledged that she did not update the fall interventions in the resident’s care plan after the resident experienced another fall. Record review showed that the resident’s care plan, dated 10/15/2025, identified the resident as being at risk for falls related to confusion, gait/balance problems, incontinence, and a history of falls. The care plan listed multiple fall-prevention interventions, including anticipating and meeting needs, proper positioning in bed, ensuring the call light is within reach, use of bed bolsters, safety education, appropriate footwear, following the facility fall protocol, frequent monitoring, keeping items within reach, maintaining a clutter-free environment, keeping the bed in a low position, monitoring medication side effects, use of dycem in the wheelchair, provision of a floor mat, and use of hip protectors. Additional interventions for history of falls included a floor mat on the side of the bed, frequent checks, and a low bed. However, review of the care plan dated 11/09/2025 showed no updates or new interventions added after the resident’s fall on the specified date, despite the facility’s policy stating that when a significant change occurs in a resident’s condition, the MDS coordinator or designee is notified and the care plan is reviewed and updated.
Failure to Provide Proper Indwelling Catheter Care and Infection Control
Penalty
Summary
The deficiency involves failure to provide proper indwelling urinary catheter care for two residents, resulting in infection control concerns and a catheter-related hospitalization. One cognitively intact resident with multiple medical diagnoses, including urinary retention and obstructive/reflux uropathy, was observed in bed with an indwelling catheter whose drainage bag was approximately half full and placed directly on the floor. The resident stated he could not see what was on the floor and did not know the bag was there. An LPN confirmed during observation that catheter bags are not supposed to be on the floor, but should be hooked to the bed frame below the bladder to prevent germs from the dirty floor from entering the catheter and causing UTIs. The DON and another LPN separately stated that catheter bags should be hung on the side of the bed, away from the floor and below the kidneys, and that the catheter area is cleaned daily with normal saline and bags are positioned to allow downward urine flow and prevent backflow. The second resident had an indwelling Foley catheter and was care planned for risk of infection or complications related to catheter use due to neurogenic bladder. A nursing progress note documented that the resident was found lethargic, slow to respond, warm to touch, with abnormal vital signs including low oxygen saturation on room air and elevated temperature, and was sent to the hospital. Hospital records documented that the Foley catheter was reported as non-draining for an unknown period of time with a change in urine color to dark brown. On arrival to the ER, the resident had turbid urine, large leukocyte esterase, many bacteria, and was diagnosed with AMS, hypoxia on BiPAP, sepsis, hypotension, and UTI. The Foley catheter was found to be clogged and was changed, after which it drained freely, with urine described as dark brown. The resident’s catheter care order included changing the Foley catheter as needed for blockage, leaking, or malfunctioning.
Failure to Maintain Safe and Clean Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, functional, clean, and comfortable environment for residents, staff, and the public. On the third floor at the end of the North Hall, a surveyor observed a picture frame with its glass broken out at the top and middle, leaving glass shards at the bottom of the frame, partially covered by a bath blanket. A housekeeper confirmed that the picture frame was broken with glass shards and stated that if someone bumped into it, it could be dangerous. A CNA also described the frame as having glass shards protruding from the bottom and identified it as a hazard to residents that could be used as a weapon. On the second floor, in a shower room, the surveyor observed a wall behind a toilet with a brown substance splattered on it and yellowish gray and black debris on the bottom of the toilet and floor. A housekeeper stated that the brown substance looked like feces and the yellowish gray substance looked like urine, and acknowledged that the bathroom should be cleaned twice a day and that this mess should have been cleaned up. The Housekeeping Director later stated that the entire toilet and the wall behind it should be cleaned daily and as needed to disinfect the bathroom and allow it to appear homelike. Facility documents, including the Preventative Maintenance Program and a housekeeping performance evaluation, require that all facility areas be kept clean and in safe condition and that dirt and contaminants be removed from surfaces using proper cleaning and disinfecting solutions.
Food Sanitation, Hand Hygiene, and Temperature Control Failures During Meal Service
Penalty
Summary
The deficiency involves failures in food sanitation and handling practices during meal preparation and service. During a noon meal service, a dietary aide and a cook were observed preparing resident meal trays while both had full facial beards without beard coverings, contrary to facility policy requiring hair restraints and beard guards during food preparation. The dietary manager confirmed that both staff members should have been wearing beard coverings to prevent hair from falling into residents' food and described the lack of beard coverings as unsanitary. The cook stated he did not know beard hair nets were available and acknowledged he should have been using one. Additional unsanitary hand hygiene practices were observed on the tray line. The dietary aide was seen licking his hand and then using that same ungloved hand to pick up a menu ticket and place it on a resident’s meal tray, and he continued preparing multiple trays—counted by the dietary manager as 20 trays—before sanitizing his hands and donning gloves. The aide later stated he should not have licked his fingers and continued tray preparation, acknowledging that this was unsanitary. Later, while wearing gloves, the same aide adjusted his face mask at the ears and nose and then resumed preparing meal trays without removing his gloves and sanitizing his hands, which the dietary manager stated should have occurred before continuing the tray line. Temperature control and documentation deficiencies were also identified. When meal carts were delivered to a dining room, the dietary manager checked a random tray and found the ham at 87.8°F, below the facility’s stated expectations for hot food temperatures and below the policy requirement that hot food prepped for serving maintain a minimum of 135°F, or at least 120–135°F at time of service for palatability. The dietary manager stated the ham should have been at least 110°F and that serving food at the right temperature makes it safe and palatable. When the surveyor requested the temperature log for the lunch meal, the cook reported that he had checked food temperatures before serving but had not documented them and was unable to provide a temperature log. The dietary manager stated that food temperatures should be taken before serving and recorded on a log, consistent with facility policies requiring temperatures to be taken and documented prior to service and during meal service, and maintained on file for one year.
Unsanitary Kitchen and Food Storage Conditions in Dietary Department
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the kitchen and food storage areas, where floors and walls were not maintained in a clean state. Observations revealed dirty floors with trash and debris throughout the kitchen and along the walls, as well as mice and insect glue traps placed under storage racks in the food storage room. These conditions were determined to compromise safe and sanitary dietary conditions for the 213 residents residing in the facility. During interviews, the Dietary Manager stated that dietary aides and cooks are responsible for cleaning the floors in their assigned stations and acknowledged that the kitchen contained dirty floors with trash and debris. The Dietary Manager also confirmed the presence of mice and insect glue traps in the storage room. A Dietary Aide reported that all dietary staff are responsible for keeping the kitchen clean and sanitary, stated that she had mopped after breakfast, and acknowledged seeing roaches on the kitchen counter by the sink. She verified that the kitchen floor still contained dirt, trash, and debris. Facility policies and job descriptions for the Food Service Supervisor and Dietary Aides require maintaining the kitchen and storage rooms in a clean, safe, and sanitary manner and adhering to infection control and food sanitation practices, which were not followed as evidenced by the observed conditions.
Improper Dumpster Management and Open Lids with Scattered Trash
Penalty
Summary
The facility failed to properly manage its dumpster area, resulting in open dumpster lids and scattered trash in violation of its waste management policy. On 2/13/2026 at 10:01 a.m., the surveyor and a Maintenance Assistant observed the dumpster area with a foul odor, two dumpsters with all four lids open, and debris and trash scattered on the ground around the perimeter. The Maintenance Assistant stated that he believed the dumpster lids should be closed and identified housekeeping as responsible for the dumpster area, and further explained that leaving lids open and trash around the area could allow pests such as roaches and mice to enter the facility. At 10:07 a.m. the same day, the surveyor and the Housekeeping Supervisor again observed the dumpster area in the same condition, with foul odor, open lids, and scattered trash. The Housekeeping Supervisor stated that the dumpster area should be cleaned more than daily and acknowledged that leaving trash and lids open is not good and can attract cats, varmints, and rodents. The facility’s waste management policy dated 5/14 requires that plastic liners be tied and placed in outside dumpsters with lids kept closed, and that Maintenance and Housekeeping personnel ensure the dumpster area is kept clean, all trash bags are inside the dumpster, and dumpster lids are closed. This deficiency had the potential to affect all 213 residents residing at the facility, as the improper disposal and management of garbage and refuse occurred in a shared environmental area intended to prevent the spread of infection.
Failure to Maintain Safe, Clean, and Well-Maintained Physical Environment
Penalty
Summary
The facility failed to maintain a safe, functional, clean, and comfortable environment for all 213 residents, staff, and the public, as evidenced by multiple unrepaired structural issues and unclean areas throughout the building. On the first floor, surveyors observed missing baseboards by a resident room and along the hallway between two rooms, as well as missing floor panels in the center of the hallway. Additional observations included a missing baseboard and a hole in the wall by the medical equipment room, stained and unsecured ceiling panels in the first-floor dining room due to warped holding rails, and missing parts of floor squares in an elevator. On the third floor, tile was observed to be broken in front of an elevator. These issues were not documented in the facility’s work order binder when reviewed by the surveyor. On the second floor, surveyors observed environmental cleanliness and maintenance problems in the shower rooms, including a wall behind a toilet with brown substance splattered on it, a toilet and floor with grayish-black debris, a tub filled with water and debris, and missing drywall along the base of the floor behind the toilet. A CNA verified these observations and stated that maintenance is responsible for repairs, while a housekeeper stated that floor techs are responsible for cleaning shower rooms, bathrooms, hallways, dining rooms, elevators, and for taking out garbage, and that cleaning and sanitizing are for the health of residents. The Maintenance Director and Administrator both acknowledged via email that baseboards should not be peeling or pulled from walls, walls should not have holes, and residents should not have stained ceiling tiles, noting that such conditions do not provide a homelike environment. Facility policies and job descriptions in effect at the time required that all facility areas be kept clean and in safe condition, ceiling tiles be free from watermarks or spots, wall coverings be intact and free of tears or loose seams, and that maintenance ensure proper functioning and repairs in resident rooms and other areas not under housekeeping’s purview.
Failure to Maintain Effective Pest Control for Roaches and Mice
Penalty
Summary
The facility failed to maintain an effective pest control program to eliminate roaches and mice, affecting all 213 residents. Multiple residents reported seeing roaches in hallways, their rooms, the dining room on leftover food trays, and the shower room. Several residents also reported seeing mice in their rooms, in hallways, and in the nourishment room under the sink. One resident stated they had seen mice in their room since admission eight months prior, and another reported seeing mice coming through the baseboards every night despite foam being sprayed around the baseboards. Residents described instances where they personally disposed of dead mice or transported trapped mice to the nurses' station because staff did not respond to their reports. Staff interviews and direct observations further demonstrated ongoing pest issues and noncompliance with facility policies. CNAs reported seeing roaches throughout a third-floor unit, including resident rooms, and one CNA reported a resident killing a mouse and bringing it to the nursing station. Another CNA stated she sees roaches every day in all residents' rooms and that her response is simply to step on and kill them. A resident and the surveyor observed rodent droppings under the sink in the third-floor nourishment room, and the surveyor observed dead roaches next to a resident's nightstand and live roaches in the third-floor shower room behind a linen cart. Two residents reported a dead mouse in their room, with one placing it in a plastic bag and giving it to housekeeping, who then discarded it and stated they did not have glue traps. Environmental conditions around the dumpster area and administrative responses contributed to the deficiency. The surveyor and maintenance assistant observed two dumpsters with open lids and trash scattered around the area; the maintenance assistant acknowledged the lids should be closed and that such conditions can allow roaches and mice to enter the facility. The housekeeping supervisor also observed the same conditions and stated the dumpster area should be cleaned more than daily and that open lids and scattered trash can attract cats, varmints, and rodents. Despite facility policies requiring that outside dumpster lids be kept closed, the dumpster area kept clean, and a pest control program conducted on a regular and as-needed basis, the administrator stated she was unaware of mice in the facility, acknowledged only resident concerns about roaches, and confirmed that pest control services were limited to twice a month without additional treatment requests. These actions and inactions conflicted with the written pest control and waste management policies that assign responsibility to environmental services, maintenance, and housekeeping to prevent pest harborage and maintain closed, clean dumpsters.
Failure to Maintain Clean, Homelike Environment and Functional Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents by not providing adequate housekeeping and maintenance services. In one resident’s room, surveyors observed dried food, paper wrappings, disposable cups, and a dry black substance across multiple areas of the floor, along with window curtains that were too short to cover about one-third of the window. Staff, including an RN, the Maintenance Director, and the Administrator, acknowledged that the floor contained garbage that should have been picked up, that the resident’s bookshelf was broken and needed replacement, and that curtains should fully cover windows for privacy and comfort. Additional observations included trash along the walls in another resident’s bedroom and dirty bathroom floors in a different resident’s room. The facility also failed to maintain functional furniture and intact walls and fixtures in several resident rooms. One resident’s closet drawer front was detached and lying on the floor with bare screws or nails protruding, and the baseboard was pulled away from the wall with holes, held in place with masking tape. A rectangular cut-out in the wall providing access to sink pipes was not secured, and the resident reported seeing a large mouse come through the hole and stated that only the hot water worked at the sink and sprayed everywhere, which she said she had reported to staff three weeks earlier with no apparent repair documented. Another resident’s room had baseboards pulled away from the wall, disintegrating drywall, and a large hole in the wall behind the bed, with the entire call light box hanging from the wall. In a shared room, the toilet lid was missing and the baseboard was peeling away from the wall. Surveyors further observed environmental deficiencies in common-use areas. Both shower rooms on the second floor had dirty floors, brown splatter on the shower toilet wall, a tub filled with water and debris, and missing drywall along the base of the floor behind the toilet. A CNA confirmed these conditions and stated that housekeeping and floor techs are responsible for cleaning these areas, while a housekeeper stated that floor techs clean shower rooms, bathrooms, hallways, dining rooms, elevators, and remove garbage, and that cleaning and sanitizing are for residents’ health. Review of the facility’s work order binder did not show any of the identified room issues, despite the facility’s policies and job descriptions requiring a safe, clean, homelike environment, regular cleaning and maintenance, and staff responsibility to keep resident areas tidy and to detect and report hazardous conditions.
Failure to Protect Residents From Physical Abuse and Incomplete Documentation of Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident and to ensure accurate and complete documentation of such incidents. One resident with bipolar disorder, depression, delusional disorder, schizophrenia, heart failure, seizures, unspecified psychosis, and a BIMS score of 12 (moderate impairment) was identified as the aggressor in multiple resident-to-resident incidents. The facility’s abuse policy states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment, and that residents involved in possible abuse are to be immediately protected. Despite this, the resident’s care plan only addressed verbally abusive behavior and did not reflect physical aggression toward others. In one incident, a cognitively intact resident with anxiety, COPD, asthma, hypertension, substance abuse, and a left above-knee amputation reported that when she shared a room with the aggressive resident, the aggressive resident came into the room, hit her from behind in the jaw, and knocked items off her bedside table. The resident stated she was concerned due to her wheelchair dependence. A CNA heard commotion and heard the resident report to an RN that she had been hit. The RN later stated that the resident reported the aggressor had brushed past and bumped her shoulder and acknowledged that this contact was a form of abuse. However, review of the electronic health record for the resident who reported being hit showed no documentation of the incident in her progress notes, indicating a failure to document and formally recognize the reported physical abuse. In a separate incident, another resident with chronic respiratory failure, COPD, congestive heart failure, pulmonary embolism, hemiplegia, hemiparesis, and a BIMS score of 12 (moderate impairment) reported that the same aggressive resident entered his room, asked for money, and, after being refused, cursed at him and threw a water pitcher, striking him in the side of the face and covering him with water and ice. This resident reported the event to the nurse on duty and stated he was not physically hurt but was emotionally affected. Progress notes for both residents documented that the aggressive resident entered the room, begged for candy, and threw a pitcher of ice water into the resident’s face. Despite these documented and reported incidents, the administrator and DON stated they were not aware of the water-throwing incident or the reported hitting incident until much later, demonstrating a breakdown in timely reporting to facility leadership and failure to ensure residents were free from physical abuse.
Failure to Timely Investigate and Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate and report allegations of resident-to-resident physical abuse to the Illinois Department of Public Health (IDPH) within the required regulatory timeframe. One resident stated that a roommate entered the shared room, knocked belongings to the floor, swung the resident around from behind, and struck the resident on the right side of the jaw. The resident reported this incident to the nurse, and the alleged aggressor was sent to the hospital that day; however, review of the electronic health record progress notes showed no documentation that the aggressor hit the resident. Another resident reported that the same alleged aggressor entered the room, requested money, and when refused, became angry, cursed, and threw a water pitcher that struck the resident’s face, spilling water and ice. This second incident was documented in a progress note, which stated that the resident clearly verbalized that another resident threw a pitcher of ice water into the resident’s face. Nursing staff interviews revealed that one RN understood the contact as a form of abuse and stated that the incident was verbally reported to the administrator, and an LPN stated that the water-pitcher incident was reported to the administrator, who serves as the abuse coordinator. In contrast, the administrator reported not being informed of any abuse by the alleged aggressor, stating that the administrator only became aware of the water-throwing incident upon reviewing the progress note during the week of the survey and that the LPN said she did not know she was supposed to report it. The administrator also stated not being made aware of the alleged hitting incident and that the RN did not report it. This occurred despite existing facility documents, including an in-service on abuse education, a statement of resident rights requiring immediate reporting of alleged violations to the administrator and as required by state law, an abuse prevention policy, and a job description for the administrator that includes responsibility for compliance with federal, state, and local regulations.
Failure to Maintain Resident Bed Privacy Curtain in Multi-Occupancy Room
Penalty
Summary
The deficiency involves the facility’s failure to provide full visual privacy for one resident in a four-bed room by not maintaining a ceiling-suspended privacy curtain around the resident’s bed. On 08/03/25, the resident’s privacy curtain and attached track detached from the ceiling and fell while the resident was lying in bed watching television. A progress note from that date documents that the resident immediately notified staff, denied pulling on or laying against the curtain prior to the incident, and that a work order request was placed in the maintenance log. Despite this, on 02/13/26 at 12:00 p.m., surveyors observed the resident sitting in bed in a fully occupied four-person room with no privacy curtain around the bed. During an interview at the same time, the resident reported that the curtain had fallen months earlier and had never been replaced, stating that he had no privacy and could not change clothes at the bedside, and that he wanted some privacy. The Administrator stated that all residents should have privacy curtains and window curtains for privacy, comfort, and a homelike environment, and that maintenance should ensure all curtains are in place and in working order. The Housekeeping Supervisor stated that housekeeping is responsible for replacing privacy curtains and that all residents should have them for privacy. Facility policies and job descriptions reviewed by surveyors indicate that the facility is responsible for maintaining a safe, clean, comfortable, and homelike environment, including having privacy curtains that are clean and in good condition, and that the Maintenance Director is responsible for repairs and routine maintenance of the building and equipment. This failure affected one resident out of 22 residents reviewed.
Inadequate Peri-Care Supplies Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate peri-care supplies were available, resulting in staff using paper towels and torn linens instead of proper towels or wipes for residents’ personal care. On 1/29/2026 at 5:22 PM, R4 reported that staff had used paper towels to clean them, stating this made them feel bad and that staff should have towels or wipes. Later that day at 6:09 PM, R2 reported that staff used paper towels to clean them, expressing dislike and anger about this practice. At 6:27 PM, V9, a CNA, stated they had used paper towels to clean residents and had also ripped up shirts, blankets, and sheets to use for cleaning residents. At 6:38 PM, V10, another CNA, confirmed having used paper towels to clean residents when there was no linen available. On 1/30/2026 at 11:25 AM, V14, an LPN, stated that staff should not use paper towels to clean residents and should instead use towels or wipes. The Illinois Long-Term Care Ombudsman Program Residents' Rights booklet states that facilities must treat residents with dignity and respect and care for them in a manner that promotes their quality of life. These observations and interviews show that two of three residents reviewed for dignity experienced peri care with paper towels instead of appropriate supplies, and staff confirmed that lack of linens led to the use of paper towels and torn fabric items for resident cleaning, contrary to stated residents’ rights to dignity and respect.
Failure to Follow Community Pass Policies and Involve Responsible Parties
Penalty
Summary
The facility failed to follow its own policies and procedures regarding community survival skill assessments, physician orders for community passes, and involvement of responsible parties or families when residents left the facility against medical advice. Multiple residents were allowed to leave the facility on independent community passes without proper assessments or physician orders, and in some cases, despite having restrictions in place due to prior non-adherence or substance abuse. Documentation shows that at least two residents left on independent passes and did not return, while others were allowed out without the required physician authorization or in violation of care plan restrictions. One resident with a history of schizophrenia, substance abuse, and prior incidents of not returning from passes was allowed to leave on an independent pass, despite only being assessed as suitable for supervised passes. The resident did not return, and the facility did not notify the family or provide adequate cooperation with law enforcement. The care plan did not address the resident's history of not returning from passes, and there was no evidence of a current community survival skill assessment or physician order supporting independent pass privileges. Additionally, the facility failed to notify the responsible party or family, even though social service notes indicated family involvement in the resident's care. Other residents were also affected by similar failures. One resident with a restricted pass due to non-adherence was able to leave the facility, and staff could not confirm if family or police were notified. Additional residents were allowed out on independent passes without proper physician orders, and their care plans did not reflect the necessary restrictions or assessments. The facility's own policies require community survival skill assessments upon admission and quarterly, physician orders for pass privileges, and involvement of responsible parties in cases of discharge against medical advice or missing residents, but these procedures were not consistently followed.
Failure to Notify Family and Authorities During Resident Discharge
Penalty
Summary
The facility failed to follow its own policies regarding notification and documentation during the discharge process for one resident who left the facility on a community pass and did not return. The administrator confirmed that the resident had a history of not returning from passes and that, in this instance, the family members listed on the face sheet were not contacted when the resident failed to return. The administrator also stated that the resident's current location or status was unknown at the time of the interview. The Director of Nursing indicated that only the physician is notified when a resident responsible for themselves leaves against medical advice, and was unaware that the family was involved in the resident's care, despite documentation in the social service notes indicating family involvement. The family later confirmed they were not informed by the facility about the resident's departure and only learned of the situation through other means. Additionally, law enforcement reported difficulty in obtaining cooperation and communication from the facility when the resident was reported missing, with multiple attempts to contact the facility going unanswered. The facility's policies require notification of the physician and administrator in cases of discharge against medical advice, and suggest involving the responsible party, such as family, if available. However, there was no documentation that the family or the State Ombudsman were notified, and the facility was unable to provide evidence of such notifications or a physical copy of the police report. The lack of required documentation and notification to proper parties constituted a failure to meet regulatory requirements for discharge procedures.
Failure to Coordinate with Law Enforcement and Notify Family After Resident Does Not Return from Pass
Penalty
Summary
The facility failed to coordinate with law enforcement and provide necessary information regarding a resident who left on an independent community pass and did not return. Despite the resident having a history of not returning from passes and being reported missing, the facility was unresponsive to multiple attempts by law enforcement to obtain information. The administrator did not contact the resident's family members listed on the face sheet, and there was no documentation of family notification. The administrator also did not initially respond to emails or phone calls from law enforcement, and there was no physical copy of the police report maintained by the facility. The facility did not notify the state health department, as the incident was considered a discharge against medical advice rather than an elopement. The resident involved had diagnoses including schizophrenia, insomnia, auditory hallucinations, cocaine abuse, movement disorder, major depressive disorder, and suicidal ideations, but was assessed as having intact cognition. The DON stated that independent passes are based on cognitive status, not psychiatric diagnosis, and that family is only contacted if designated as POA. However, social service notes indicated that the family was involved in the resident's care. The lack of communication and coordination with both law enforcement and the resident's family contributed to the facility's inability to report the resident's whereabouts or status.
Failure to Ensure Call Light Accessibility and Proper Wheelchair Sizing
Penalty
Summary
Surveyors identified that the facility failed to follow its own policies to accommodate residents' needs by not ensuring that call lights were within reach for four residents and by not providing an appropriately sized wheelchair for another resident. Multiple observations revealed that call lights were either on the floor, at the foot of the bed, or otherwise out of reach for residents who required them to request assistance. In several cases, residents were unaware of the location of their call lights, and staff confirmed that the call lights should have been accessible but were not. Additionally, one resident's room was missing a second call light, and the call light system was observed to be malfunctioning, with the indicator light flashing but no sound being emitted. The report details that staff, including CNAs and LPNs, were either unaware of the call light's location or acknowledged that the call light was not within reach, contrary to facility policy and individual care plans. The Director of Nursing confirmed that call lights are expected to be within reach and that failure to do so could prevent residents from calling for help. Care plans for the affected residents specifically required that call lights be accessible and that residents be encouraged to use them for assistance, but these interventions were not consistently implemented. In addition to the call light deficiencies, one resident reported discomfort and skin irritation due to being provided with a wheelchair that was too small, despite repeated requests for a larger one. The resident demonstrated that the wheelchair was causing pressure on the thighs, and both the DON and a nurse confirmed that the wheelchair was not properly fitted. The resident's care plan included interventions to prevent skin breakdown, but the lack of an appropriate wheelchair was not addressed.
Failure to Resume Tube Feeding as Ordered After Care
Penalty
Summary
A resident with multiple diagnoses, including gastrostomy, dysphagia, vascular dementia, and severe cognitive impairment (BIMS score of 03), was observed in bed with a feeding pump at the bedside that was turned off. The feeding pump was connected to the resident and contained a bottle of Jevity 1.2. Upon inquiry, a registered nurse confirmed that the pump was off and stated that the tube feeding is supposed to run continuously for 24 hours, with flushes every 4 hours. The nurse indicated that the certified nurse assistant may have turned off the pump during patient care and did not notify the nurse to resume the feeding afterward. The facility's care plan required the resident to receive tube feeding as ordered, with the head of the bed elevated, and for the nurse to be responsible for turning the feeding pump on and off during care or therapy. The Director of Nursing confirmed that if the feeding pump is off when it should be infusing, the resident would not receive the scheduled feeding. The failure to ensure the feeding pump was turned back on after care resulted in the resident not receiving tube feeding in accordance with the physician's order.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for timely reporting of an allegation of resident-to-resident abuse. On 4/27/25, a resident with chronic kidney disease and no cognitive deficits alleged that another resident, who has schizoaffective disorder and mild cognitive impairment, engaged in inappropriate behavior toward him. The incident was documented in progress notes, and immediate actions were taken, including separating the residents, initiating 1:1 monitoring, conducting a body check, and notifying the medical doctor, family, and police. A petition for involuntary admission was also completed for the alleged perpetrator. Despite these actions, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required by its Abuse Prevention Program policy, which mandates immediate reporting, but not later than two hours after the allegation is made if abuse is involved. The incident, which occurred on 4/27/25, was not reported to IDPH until 7/17/25, well beyond the required timeframe. The administrator confirmed that this was a reportable incident and acknowledged the delay in reporting.
Failure to Investigate Resident-Staff Altercation for Possible Abuse
Penalty
Summary
The facility failed to investigate an incident involving a verbal argument and physical altercation between a resident and the Maintenance Director to rule out abuse. The incident began when the resident and the Maintenance Director had a confrontation in the elevator, which escalated to physical contact, with both parties reportedly swinging at each other and the Maintenance Director sustaining a contusion and muscle injury. The resident reported feeling harassed and being called derogatory names, while the Maintenance Director described attempts to deescalate the situation and reported the injury to human resources and the administrator. Despite the altercation and the resident's allegations, the administrator did not conduct an investigation into the incident, did not interview the resident, and did not consider the possibility of abuse, relying solely on staff accounts that the resident was the aggressor. The facility's policy requires that all incidents, whether or not abuse is alleged or suspected, be reviewed, investigated, and documented. However, the administrator, who also serves as the abuse coordinator, stated that incidents involving residents being aggressive toward staff are not reported to public health and are not investigated as abuse. The administrator did not follow the facility's investigation procedures, which include interviewing all parties involved, including the resident. As a result, the incident was not properly investigated to rule out abuse, contrary to facility policy and regulatory requirements.
Failure to Obtain Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that two residents who were receiving supplemental oxygen had active physician orders for this therapy. Both residents had significant medical histories, including chronic obstructive pulmonary disease, morbid obesity, anemia, congestive heart failure, malignant neoplasms, and muscle wasting. During the investigation, one resident was observed receiving oxygen via nasal cannula, and both residents confirmed ongoing use of supplemental oxygen. However, review of their medical records and order summaries revealed no active physician orders for oxygen for either resident. Nursing staff, including an LPN and the Director of Nursing, confirmed the absence of these orders and acknowledged that physician authorization is required for oxygen administration. The facility's own oxygen report listed both residents as receiving supplemental oxygen, yet their order summaries did not reflect any such orders. The facility's policies require that physician orders be transcribed and implemented according to professional standards and that necessary information for immediate care, including oxygen therapy, be provided at or before admission. Despite these policies, the lack of active physician orders for oxygen was not identified or addressed prior to the surveyor's investigation.
Failure to Maintain Safe and Homelike Environment Due to Environmental Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of chipped and damaged wall paint, exposed drywall, missing outlet covers, clogged sinks, broken plaster, peeling paint, brown stains from previous leaks, loose and stained ceiling tiles, missing wall tiles, and missing hand railings. These deficiencies were noted throughout resident rooms and common areas, including shower rooms and bathrooms. Staff interviews confirmed that the damage was often caused by beds and wheelchairs being pushed into walls, and that repairs had been neglected over time. The maintenance staff reported difficulty keeping up with repairs due to the extent of the damage and challenges accessing resident rooms. Residents and staff acknowledged the ongoing environmental issues, with some residents attributing the damage to routine activities such as moving wheelchairs. The facility's preventive maintenance and safety policies require regular environmental audits and prompt identification of hazards, but these were not effectively implemented, resulting in persistent environmental hazards and a lack of homelike conditions. The administrator acknowledged awareness of the environmental concerns and the need for significant improvements.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy for two residents, resulting in both sustaining scratches to their faces, necks, and arms after an altercation. Staff did not intervene in time to prevent the incident, despite being present on the unit. According to staff interviews, the altercation occurred when one resident entered another's room, and yelling was heard before staff responded. Upon entering the room, staff found both residents with visible injuries. Both residents were assessed, and their injuries were documented as scratches and a bruise, with one resident unable to verbalize what had happened due to poor cognition. The facility's abuse policy prohibits all forms of abuse, including physical and mental abuse, and requires immediate intervention to protect residents. Staff members on duty at the time reported hearing commotion and responding after the incident had already occurred. This was the first known altercation between the two residents, who were previously considered friends. The failure to intervene promptly allowed the situation to escalate, resulting in physical harm to both residents.
Inadequate Transfer Procedures Lead to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was transferred according to their care plan and proper procedures, resulting in a significant injury. The resident, who has Alzheimer's Disease, anxiety disorder, and a left below-the-knee amputation, was supposed to be transferred using a Hoyer lift with the assistance of two staff members. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone without the use of a Hoyer lift, as it was reportedly not working and no other staff were available to assist. This led to the resident falling and sustaining a fracture in the left leg, requiring surgery. Interviews with staff revealed that the facility had a policy against lifting residents manually and required the use of mechanical lifts for transfers. Despite this, the CNA proceeded with the transfer alone, citing the unavailability of a working Hoyer lift and the absence of additional staff. The facility's Director of Nursing and other staff members confirmed that the resident required a mechanical lift for safe transfers due to their medical condition and mobility limitations. The investigation also uncovered that the facility had an insufficient number of mechanical lifts available for the number of residents requiring them. Only one working Hoyer lift was found on the floor, which was inadequate for the needs of the residents. This lack of equipment and staffing contributed to the unsafe transfer attempt, ultimately leading to the resident's injury.
Inaccurate Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to accurately document a fall incident involving a resident, leading to inconsistencies in the resident's medical records. The resident, who has Alzheimer's disease, anxiety disorder, and a left below-the-knee amputation, reported that she fell while being transferred from a dialysis chair to her bed. The resident stated that the staff member assisting her did not use a gait belt and that it typically requires two people or a Hoyer lift to transfer her safely. However, on the day of the incident, only one staff member was available to assist her, leading to the fall. The documentation of the incident was inconsistent, with discrepancies in the date of the fall and the staff involved. The Licensed Practical Nurse (LPN) documented the incident as occurring on a different date than what was reported by the Certified Nursing Assistant (CNA) involved in the transfer. The facility's incident report and clinical notes also contained conflicting information regarding the date and staff involved. Despite inquiries, the facility's administration was unable to clarify these inconsistencies, affecting the credibility of the documentation.
Inadequate Linen and Towel Supply Affects Resident Care
Penalty
Summary
The facility failed to provide adequate supplies for activities of daily living, such as towels and linen, for all 205 residents. Observations on multiple days revealed that utility closets and rolling linen carts had very few linens and towels, with some lacking gowns, pads, or linen entirely. Staff members, including LPNs and CNAs, reported frequent shortages of linen and towels, which hindered their ability to perform necessary resident care tasks. CNAs resorted to using wet wipes or cutting sheets to make towels, and some even purchased supplies with their own money. The Director of Housekeeping confirmed the shortage and stated that orders for more supplies required approval from the owner, with a limited budget for purchasing these items. Residents expressed frustration and discomfort due to delays in receiving care, such as being cleaned or showered, because of the lack of towels and linen. Some residents reported having to wait for extended periods, even when soiled, which affected their dignity and quality of life. The facility's policies on laundry services and resident dignity were not adhered to, as there was not an adequate supply of clean linen maintained for resident care. The Assistant Director of Nursing and the Administrator acknowledged the issue but did not indicate any immediate resolution to the shortage.
Medication Management and Staffing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the residents' physician, maintain secure storage of medications, provide sufficient nursing coverage, and meet professional standards of care. On the day of the survey, a nurse did not show up for the morning shift, leading to inadequate nursing coverage. This resulted in some residents not receiving their medications on time, as observed by the surveyor. Additionally, a Licensed Practical Nurse (LPN) was found to have prepared medications for multiple residents simultaneously, which is against the facility's policy and increases the risk of medication errors. The facility also failed to provide timely incontinence care to a resident due to a lack of available linen. A Certified Nursing Assistant (CNA) reported not being able to change a resident because there was no linen available, which was corroborated by the laundry aide who stated that there was a shortage of linen in the building. This shortage was also noted in the resident council meeting minutes, where residents expressed concerns about the lack of linen and nursing staff during night shifts. Furthermore, the surveyor observed a medication cart left unlocked and unattended, with the electronic medication administration record (eMAR) visible, posing a risk to resident safety and privacy. The facility was unable to provide the surveyor with the requested HIPAA policy or medication audit report during the survey. These deficiencies highlight significant lapses in medication management, staffing, and adherence to professional standards, affecting the quality of care provided to the residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect seven residents from abuse, as evidenced by multiple incidents of physical altercations and alleged abuse. Resident 1, with a history of violent behavior and mental health disorders, was involved in a physical altercation with Resident 2, who has cerebral palsy and requires substantial assistance with activities of daily living. The altercation was witnessed by peers, and Resident 1 was noted to have made threats towards Resident 2. Additionally, Resident 3, with moderate cognitive impairment, was involved in a physical confrontation with Resident 4, who has severe cognitive impairment, during a smoking break. This incident was witnessed by an activity aide and several residents. Another incident involved Resident 5, who pushed Resident 6, a blind resident, after becoming frustrated with Resident 6's behavior. Resident 5 has a history of aggressive behavior and was noted to have lost their temper. The facility's response included separating the residents and conducting assessments, but the incident was substantiated as having occurred. Furthermore, Resident 7 alleged that a CNA, V9, physically abused them during a toileting incident, which led to a police report being filed. However, the facility's investigation did not substantiate the claim due to a lack of evidence and witness statements. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. Despite this policy, the facility failed to prevent multiple incidents of resident-to-resident altercations and an alleged staff-to-resident abuse. The report highlights deficiencies in the facility's ability to protect residents from abuse and ensure their safety, as evidenced by the repeated incidents and the lack of effective intervention to prevent such occurrences.
Inadequate Supervision and Care Plan Management
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, specifically for a resident identified as R8, who sustained a leg fracture. On the day of the incident, R8 was found by the restorative team to be in pain and unable to stand, which was unusual as R8 typically ambulated without assistive devices. Despite R8's insistence that he was fine, the LPN noticed facial grimacing and further assessed R8, leading to the discovery of a leg fracture through an x-ray. The care plan for R8 did not include updated fall interventions, such as a low bed and floor mat, which were documented elsewhere but not on the care plan itself. Additionally, the facility's supervision practices were found lacking. A CNA responsible for monitoring residents in the dining room was observed using a personal electronic device to watch social media videos, admitting that this distracted her from effectively monitoring the residents. This lack of attention could potentially lead to residents falling or injuring themselves, as the CNA acknowledged. The facility's policy prohibits cell phone usage while on duty, yet this was not adhered to, compromising resident safety. R8's medical history includes heart failure, a history of falling, dementia, and other conditions that place him at high risk for falls. Despite this, the facility did not adequately update his care plan following the incident, nor did they ensure proper supervision in common areas. The facility's policies on fall prevention and supervision were not effectively implemented, contributing to the deficiencies observed by the surveyors.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate abuse allegations involving three residents. For two residents involved in a physical altercation, the facility's investigation was incomplete as key witnesses, including a Certified Nursing Assistant (CNA) and other residents, were not interviewed. The administrator acknowledged the oversight, admitting that the investigation was not conducted thoroughly, which could lead to potential re-occurrence and inadequate care planning. In another incident, a resident reported being physically abused by a CNA during a toileting incident, which resulted in the resident being sent to the hospital and a police report being filed. The facility's investigation into this incident was also incomplete, as witness statements from the involved CNAs were not obtained. The resident involved in this incident has a complex medical history, including conditions such as chronic obstructive pulmonary disease, heart failure, and dementia, and requires substantial assistance with toileting.
Failure to Maintain Clean Environment in Resident Bathroom
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, as evidenced by the presence of brown stains on the bathroom wall shared by the residents. The issue was first brought to attention by a resident who complained about the stains, suspecting them to be feces from a previous roommate. The surveyor confirmed the presence of the stains during an inspection, and a housekeeper, upon being shown the stains, stated she was unaware of them and did not know what the substance was. The Director of Nursing acknowledged that such stains should not be present and emphasized the facility's expectation to maintain cleanliness. The Housekeeping Director confirmed that it was the responsibility of the housekeeping staff to clean and disinfect any marks on the bathroom walls. Despite a resident's report to a housekeeping staff member, the issue remained unaddressed, indicating a lapse in communication and action within the facility's housekeeping procedures.
Failure to Provide Timely Incontinent Care Due to Equipment Issues
Penalty
Summary
The facility failed to provide timely incontinent care to a resident, identified as R7, who is dependent on staff for assistance with activities of daily living due to significant mobility impairments. R7, who is cognitively intact with a BIMS score of 15, was observed by a surveyor sitting in the hallway, soiled with feces, and complaining about the delay in receiving care. The delay was attributed to the mechanical lift not being charged, which was necessary for transferring R7 to the bed for cleaning. Despite R7's complaints starting at 12:00 PM, the resident remained soiled until 1:06 PM when a CNA brought a mechanical lift from another unit to provide the necessary care. Interviews with staff revealed that the mechanical lift on the second floor was not charged, and there was only one working lift available, leading to delays in care. The LPN confirmed that R7 had informed them of the need for a change at 12:00 PM, but the issue with the lift prevented timely action. The facility's policies on activities of daily living and incontinence care emphasize the importance of timely care to prevent skin breakdown and maintain resident dignity, which was not adhered to in this instance. The Director of Nursing stated that the expectation is for residents to be changed as soon as possible when soiled, highlighting a failure in meeting this standard of care for R7.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident, R11, from abuse by another resident, R4. R11, who has a cognitive communication deficit and other health issues, reported that R4 pulled their hair and hit them with a bag of cups. This incident was witnessed by a CNA who confirmed that R4 had a history of violent behavior and had previously assaulted peers. Despite this history, R4 did not have a 1:1 aide at the time of the incident, and both residents were seated at the same table when the altercation occurred. R4, diagnosed with bipolar disorder and other conditions, has a documented history of verbal and physical aggression. The facility's records show that R4 had been physically aggressive towards peers on multiple occasions, necessitating 1:1 staff intervention. However, on the day of the incident with R11, such supervision was not in place. The facility's behavior management policy outlines preventative measures for agitated behavior, but these measures were not effectively implemented to prevent the altercation between R4 and R11.
Inadequate Catheter Care Leads to Health Issues
Penalty
Summary
The facility failed to provide appropriate catheter care for three residents, resulting in adverse health outcomes. Resident R2, who had a flaccid neuropathic bladder, was admitted with an indwelling catheter but lacked proper documentation and monitoring of catheter changes. The resident was transferred to the hospital with abdominal pain and diagnosed with a urinary tract infection (UTI). The facility's records did not include necessary details such as catheter size or documentation of catheter and drainage bag changes, leading to inadequate care. Resident R3, diagnosed with neuromuscular dysfunction of the bladder, also experienced insufficient catheter care. The resident's urinary catheter bag and tubing were observed to be purple and contained sediment, indicating a lack of timely changes. Despite having a care plan that required catheter and drainage bag changes as needed, there was no documentation of these changes, and the resident was unaware of when the last change occurred. Similarly, Resident R4, with a diagnosis of hydronephrosis and ureteral stricture, had a suprapubic catheter that was not properly monitored or documented. The resident's catheter bag and tubing were discolored and contained thick sediment, with no records of recent changes. The facility's catheter care policy, which mandates removal and reinsertion of catheters when urine contents are not visible, was not followed, contributing to the deficiencies observed.
Inaccurate Fall Risk Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate fall risk assessments for two residents, R2 and R3, as required by their fall prevention and management policy. R2, who had functional limitations due to hemiplegia and hemiparesis, experienced a fall while being assisted by a CNA. The post-fall risk assessment inaccurately scored R2 as a moderate risk, failing to select 'Exhibits loss of balance while standing' and 'Decrease in muscle coordination,' despite these being relevant to R2's condition. The Director of Nursing acknowledged these omissions during the surveyor's inquiry. Similarly, R3's fall risk assessment was inaccurate following a fall incident. R3, who has paraplegia and uses a wheelchair, was incorrectly assessed as having no history of falls within the last three months and was marked as ambulatory and continent, despite having an indwelling urinary catheter and neuromuscular dysfunction of the bladder. The Director of Nursing confirmed these inaccuracies when questioned by the surveyor.
Deficiencies in Shower Room Maintenance
Penalty
Summary
The facility failed to maintain the community shower room on the third floor North-Wing in good repair and a sanitary manner, potentially affecting all 53 residents on that floor. During an inspection, it was observed that the hand-washing sink was leaking and not properly affixed to the wall, two visibly soiled wet towels were on the floor of the shower stall, ceiling tiles were missing, and the soap dispenser by the sink was broken with no soap available for handwashing. These issues were confirmed by the housekeeper, who acknowledged that they were maintenance issues and stated that they would inform the maintenance team to address them. The Maintenance Director was unaware of the issues with the soap dispenser and other maintenance concerns, although he was working on resolving a hot water issue. The facility's Preventative Maintenance Program policy includes conducting regular environmental tours and safety audits to identify areas of concern, such as ensuring ceiling tiles are free from water marks or spots. However, the lack of communication between housekeeping and maintenance staff contributed to the oversight of these deficiencies in the shower room.
Inadequate Wound Care and Improper Waste Handling
Penalty
Summary
The facility failed to adhere to a doctor's wound care order for a resident, identified as R442, who was admitted with a surgical wound and hospital discharge orders for IV antibiotics for a skin and soft tissue infection. The resident's wound dressings were not changed as ordered, leading to the dressings being saturated with dark brown drainage and appearing unclean. The wound care nurse, V16, and the wound care coordinator, V17, both confirmed that they had not performed any wound care for R442, despite the treatment administration record indicating otherwise. This neglect resulted in the resident experiencing significant pain and an increased risk of infection. Additionally, the facility failed to follow proper garbage handling procedures, as observed with a housekeeper, V38, who was seen dragging an unsecured garbage bag containing soiled incontinence wear and other waste across the floor of the second-floor North unit hallway. This action was acknowledged by V38 as unsanitary and a potential cause of cross-contamination and germ spread. The Housekeeping Director, V24, confirmed that the garbage should have been carried upright and placed in a designated compartment on the housekeeping cart to prevent infection control issues. The facility's policies on wound care and housekeeping were not followed, as evidenced by the lack of completed skin assessments and wound care documentation for R442, and the improper waste handling observed. These deficiencies highlight a failure in the facility's infection prevention and control program, which could lead to further harm to residents.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to provide an adequate amount of linen and towels to meet the care needs of all 197 residents. Observations and interviews revealed that there was a consistent shortage of linens, including fitted and flat sheets, pillowcases, bath and face towels, gowns, and pads. Certified Nursing Assistants (CNAs) reported that beds were not made due to the lack of linen, and some resorted to cutting up existing linens to create makeshift towels. The linen carts and supply closets were frequently found empty or inadequately stocked, affecting the ability to provide proper care. The laundry department was observed to have insufficient supplies, with aides acknowledging the need for more linen and towels. The Housekeeping Director confirmed a limited budget of $500-$600 per month for linen purchases, which was insufficient to meet the facility's needs. Staff members, including CNAs and nurses, reported improvising with available materials and even purchasing towels with their own money to ensure residents had necessary supplies. The facility's policy on maintaining an adequate supply of clean linen was not being met, as evidenced by the lack of documentation or invoices showing consistent linen orders. Residents expressed dissatisfaction during a council meeting, stating that they often had to wait for towels to be washed before they could shower. This delay affected their daily routines, with some residents having to attend breakfast before bathing due to the lack of available towels. The Administrator and Director of Nursing were aware of the issue, but the problem persisted, impacting the residents' right to a safe, clean, and homelike environment as outlined in the facility's policies.
Failure to Secure Soiled Utility Rooms
Penalty
Summary
The facility failed to secure Soiled Utility rooms containing sharps and infectious waste materials, posing a potential safety hazard to all residents. On multiple occasions, surveyors observed doors to these rooms left open or unlocked, allowing potential resident access. The rooms contained items such as biohazard bags, full sharps containers, and cleaning chemicals, which should not be accessible to residents due to safety concerns. Staff members, including floor techs and LPNs, acknowledged that the rooms should be locked and that residents should not have access to them. The facility's policy on Supervision and Safety emphasizes making the environment as free from hazards as possible, yet the observations indicate a failure to adhere to this policy. The Director of Nursing, who had recently started, was unable to provide specific details about the contents of the Soiled Utility rooms but confirmed that residents should not have access to potentially harmful items. The facility's Sharp Object Disposal policy also outlines proper storage for filled sharps receptacles, which was not followed as evidenced by the unsecured rooms.
Deficiencies in Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen, which has the potential to affect all 196 residents, with one resident not taking food by mouth. Observations revealed that fans and portable air conditioners used in the kitchen had dirt on their grills, and stagnant water was found in a dustpan, attracting insects. The Food Service Director (V18) acknowledged the unclean state of the equipment and the presence of stagnant water, which was not supposed to be left in such a condition. Additionally, the kitchen areas, including underneath the dishwasher, three-compartment sink, and stove, were found to be dirty and littered with food wrappers. The facility also failed to ensure that testing strips for the three-compartment sink were available and not expired. The Food Service Director (V18) was unable to find any non-expired testing strips, indicating a lack of awareness that these strips have expiration dates. The Maintenance Director (V14) stated that the fans were dusty and should be cleaned by dietary and housekeeping staff, while V18 believed it was the maintenance staff's responsibility. The facility was unable to present a policy related to environmental cleaning in the kitchen, further highlighting the lack of proper procedures and oversight in maintaining a hygienic food preparation environment.
Deficiencies in Hot Water Supply and Safety Hazards
Penalty
Summary
The facility failed to provide functional and comfortable hot water for four residents, as observed and reported by the residents themselves. One resident stated that the hot water did not work during her shower, and another mentioned that the water was lukewarm despite being told it was fixed. A third resident expressed a desire to shower but was unable to due to the cold water, and a fourth confirmed that the hot water was not working in the rooms and showers. The Maintenance Director acknowledged the issue, stating that the facility was installing a second water heater due to complaints about insufficient hot water, which had been ongoing for about two weeks. Additionally, the facility failed to maintain a safe environment for one resident, who was exposed to sharp metal edges from an uncovered window air conditioner unit. The resident reported that the unit had been in this condition since shortly after moving into the room, posing a risk of injury. The Maintenance Director confirmed awareness of the issue, noting that the air conditioners were not functional and were intended to cover window holes. He admitted that the sharp edges could be hazardous, although the unit was not plugged in. The facility's preventative maintenance program policy, dated November 2023, outlines the need for regular environmental tours and safety audits to identify areas of concern, including ensuring appropriate water temperatures. Another undated policy emphasizes the importance of making the environment as hazard-free as possible, with safety risks identified through ongoing employee training. Despite these policies, the facility's failure to address the hot water and safety issues in a timely manner resulted in deficiencies affecting the residents' comfort and safety.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations of unsanitary conditions in the kitchen and pest sightings in resident rooms. On October 1, 2024, during an inspection with the Food Service Director, dirt and food wrappers were found underneath kitchen equipment, and a dustpan filled with stagnant water and insects was discovered near the walk-in freezer. The Food Service Director was unsure of the last cleaning date and acknowledged that staff should not have left the dustpan in such a condition. Additionally, a cockroach was observed moving towards the food preparation area during a tray line food preparation session, causing alarm among the dietary staff. The pest control company had visited the facility on October 1, 2024, but the documentation provided by the Maintenance Director did not specify the areas serviced. Previous pest control records indicated activity in the main kitchen area, but no traps were found during a subsequent inspection. The facility's pest control policy emphasizes the importance of maintaining cleanliness to prevent pest harborage, yet these standards were not upheld, as evidenced by the presence of pests in the kitchen and resident rooms. Two residents, both with intact cognition, reported seeing roaches in their rooms and expressed dissatisfaction with the pest presence. A Licensed Practical Nurse observed a roach in one resident's room while adjusting medical equipment. The Maintenance Director, who has been with the facility since March 2024, stated that the pest control company visits twice a month and relies on pest logs maintained by nursing staff to determine treatment areas. However, the Director does not conduct inspections for pests, leaving the responsibility to the pest control company. The facility's housekeeping guidelines require monitoring of pest control services, but these procedures were not effectively implemented, leading to the deficiencies observed.
Failure to Conduct PASRR Level II Assessments
Penalty
Summary
The facility failed to refer six residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for a Pre-Admission Screening and Resident Review (PASRR) Level II assessment. The Social Service Director, V13, was responsible for handling PASRR Level I and Level II assessments but was unaware that residents with new serious mental illness diagnoses needed to be referred for a Level II assessment. This lack of awareness led to the failure to conduct necessary screenings for residents R21, R79, R97, R120, R127, and R135. The report highlights specific cases where the PASRR process was not followed. For instance, R21 and R127, both diagnosed with serious mental disorders, had no documentation of a PASRR Level II screening. Similarly, R79 and R97 had previous Level I screenings that indicated no need for Level II, but their conditions had changed, necessitating a new assessment. R120, who transferred from another facility, lacked any PASRR documentation, and R135's PASRR records were missing, with the administrator acknowledging a lapse in the process. The facility's policy mandates compliance with federal and state PASRR requirements, including obtaining complete screening documents and reviewing them to address residents' needs. However, the report indicates that these procedures were not followed, resulting in the absence of necessary PASRR documentation for the affected residents. The Social Service Director and the facility administrator both acknowledged gaps in the PASRR process, with the administrator noting that the corporate office was responsible for providing PASRR information, which was not on file for some 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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