Neighbors Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Byron, Illinois.
- Location
- 811 West 2nd, Byron, Illinois 61010
- CMS Provider Number
- 145440
- Inspections on file
- 29
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Neighbors Health Center during CMS and state inspections, most recent first.
A resident who engaged in self-harm was sent to a hospital behavioral unit, and on the same day the facility issued an involuntary discharge notice stating the resident’s needs and welfare could not be met and that safety was endangered. The hospital psychiatric NP later documented that the resident was A&O x4, denied SI/HI, expressed remorse, was on low suicide precautions, and only required routine psychiatric follow-up and medication monitoring, and reported that the facility declined to readmit the resident despite her being cleared for discharge. The Administrator and a general NP expressed concerns about supervision and lack of onsite psychiatry, but the facility did not perform or document any clinical or psychosocial assessment of the resident between transfer and the proposed return, nor did it document specific needs that could not be met, contrary to its own involuntary discharge policy.
Multiple residents on one hall experienced prolonged cold room temperatures below the stated comfort range, with blankets placed over windows and AC units to block drafts and residents sleeping under several blankets or in coats and hoodies. Cognitively intact residents reported that it had been cold for weeks to months, described feeling sad, angry, disappointed, and depressed, and some refused showers or washed quickly because their rooms were too cold. Staff, including CNAs and an LPN, confirmed that the hall was "freezing" for an extended period, that residents complained continuously, and that they responded mainly by providing extra blankets and notifying maintenance. A representative payee monitor and the ombudsman observed or were aware of ongoing heating complaints, including residents in bed with multiple blankets and coats, and noted that heating concerns raised in resident council were not reflected in the minutes. The maintenance director and administrator reported boiler blockages and flow issues, acknowledged that a boiler remained down, and documented room temperatures in the mid-60s, which did not meet the expected comfortable temperature range.
Staff were observed distributing ice water to several residents using unsanitary practices, including placing a wet scoop on the water cart and holding cups above an open cooler, contrary to facility policy and increasing the risk of cross contamination.
A resident with severe cognitive impairment and a stage 4 pressure ulcer experienced a significant change in condition, including unusual inactivity and possible blood in urine. CNAs reported these changes to an LPN, who checked vital signs but did not perform or document a full assessment or notify the nurse practitioner as required by facility policy. The lack of timely assessment, documentation, and communication resulted in delayed care until the resident was sent to the hospital.
Multiple residents were subjected to physical abuse by other residents, resulting in serious injuries including a head laceration, subdural hematoma, and a spinal fracture. Staff and medical documentation confirmed that altercations occurred in common areas and resident rooms, with staff sometimes unable to intervene in time to prevent harm. The facility's abuse prevention policy was not effectively implemented, leading to residents being harmed by peers.
Mechanical lift equipment was not kept in safe working order, as multiple CNAs reported frequent battery failures and malfunctioning emergency release mechanisms during resident transfers. In several cases, a resident was left suspended in the air when the lift lost power, and staff had to manually lower the individual due to nonfunctional emergency releases. Staff and residents described ongoing problems with unreliable batteries and broken lift components, while maintenance and safety checks were not consistently performed.
During a shift change, an LPN, another LPN, and the Dietary Manager engaged in a loud argument at the nurses' station, using profane and insulting language about the facility's menu planning. A resident was present and witnessed the altercation, which violated the facility's policy on resident dignity and privacy.
Two residents were involved in a physical altercation, resulting in one being knocked down and kicked, with subsequent bruising documented. Despite the incident and later disclosure of physical contact, the facility did not report the abuse allegation to the state agency or police until months later, only after receiving an anonymous hotline call. The facility's policy requiring immediate reporting of abuse was not followed.
A resident sustained a head injury when their wheelchair flipped backwards during transport by non-clinical staff. The incident was not reported to clinical staff, and upon return, the acting DON/ADON assessed the resident but failed to document the assessment, perform or document neuro checks, or notify the physician. The RN assigned to the resident did not complete or document neuro checks, and the event was not recorded in the medical record, contrary to facility policy.
Staff transferred multiple residents using a mechanical lift with a non-functioning emergency release and unreliable batteries. In one case, a CNA had to manually lower a resident when the lift failed, and the broken equipment was not removed from use. Staff continued to use the malfunctioning lift for other residents, and transfers were performed without proper assessment or care plan updates for residents with cognitive and physical impairments.
The facility did not maintain accurate and up-to-date medical records for three residents following significant incidents, including a transport van fall, an elopement, and a mechanical lift malfunction. In each case, staff were aware of the events but failed to document them in the residents' records as required by facility policy.
The facility failed to accurately monitor and record the weights of several residents, resulting in significant discrepancies without reweighs or physician notifications. Despite the facility's policy requiring investigation of significant weight changes, this was not followed, leading to a deficiency in maintaining residents' nutritional status.
The facility failed to securely store medications when the ADON found the nurse's keys under a binder on the medication cart. The DON confirmed that keys should always be with the nurse to ensure medication security, as per the facility's policy revised in August 2023.
A facility failed to follow proper infection control practices during incontinence care and linen handling. A CNA transported soiled linens without bagging them, contrary to policy, and another CNA did not change gloves between dirty and clean tasks while caring for a resident with multiple health issues. The DON confirmed the importance of these practices to prevent cross-contamination.
Two residents in an LTC facility did not receive adequate ADL assistance, leading to deficiencies in personal hygiene and incontinence care. One resident, with Alzheimer's and other conditions, did not receive oral care or shaving assistance as required. Another resident, with severe malnutrition and dementia, did not receive proper incontinence care from a new CNA. The DON confirmed that these care practices are standard and all aides are trained accordingly.
A resident with a catheter was observed with the urinary drainage bag improperly placed on his thighs, contrary to the care plan and facility policy requiring it to be below bladder level to prevent backflow and UTIs. The DON confirmed the importance of proper bag positioning, especially since the resident had recently been treated for a UTI.
Failure to Assess and Document Needs Before Involuntary Discharge After Psychiatric Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for return from an acute care psychiatric hospitalization and to document specific needs that could not be met upon the resident’s proposed return, prior to issuing an involuntary discharge. The resident had been found in her room cutting her arm with cuticle scissors and was sent to the hospital. On the same day as the transfer, the Administrator completed an Involuntary Discharge (IVD) form and had it delivered to the emergency room, citing that the resident’s self-harm indicated she would require additional support services the facility could not provide. The Administrator stated that the facility did not have onsite behavioral health services and only had a psychiatric NP visit every two weeks, and that they believed they lacked the resources to keep the resident safe. Following the resident’s transfer, the hospital’s psychiatric NP evaluated the resident and documented that the resident was alert and oriented, denied suicidal or homicidal ideation, expressed regret for the self-harm incident, and requested to return to the nursing home where she felt safe. The hospital NP reported that the resident’s anxiety medication was adjusted but remained essentially the same as before, that the resident was on low suicide precautions, and that 15-minute checks were a standard hospital protocol not required at the nursing home. The hospital NP stated that the only ongoing psychiatric need was follow-up for medication monitoring and management, and that the resident no longer met criteria for inpatient admission and was cleared for discharge back to the facility. The hospital NP also stated that the facility did not have the resident evaluated by a medical professional prior to providing the involuntary discharge and that the facility immediately decided not to take the resident back. The Administrator reported that when the hospital first called to discharge the resident back, she referenced hospital documentation indicating 1:1 supervision, moderate suicide risk, and new medications needing monitoring, and used this as a basis to refuse readmission. The Administrator also stated that a general NP agreed it was not safe for the resident to return, although that NP later clarified she did not recommend the IVD and that the facility makes discharge decisions. The facility’s contracted psychiatric NP indicated she had not evaluated the resident or spoken with hospital staff and therefore could not comment on the resident’s safety to return. Review of the resident’s EMR showed no assessments documented between the date of transfer and the later survey date, and no notes regarding the proposed return or specific needs that could not be met by the facility. The facility’s own Involuntary Discharge Policy requires a thorough clinical and psychosocial assessment, documentation of current status and needs, behaviors prompting discharge, interventions tried, and evidence that the facility cannot meet the resident’s needs, but such assessment and documentation were not present in the resident’s record. The IVD notice given to the resident stated that the transfer or discharge was due to the resident’s welfare and needs not being able to be met in the facility, as documented by the physician, and that the safety of individuals in the facility was endangered. The notice listed the hospital as the relocation site and indicated that the transfer/discharge date was the same day as the emergency transfer. The hospital psychiatric NP reported that many facilities typically come to the hospital and assess residents once stabilized to determine if they can meet their needs, but that this facility did not do so for this resident. Overall, the record review and interviews showed that the facility did not perform or document a clinical assessment of the resident’s condition and needs at the time of the proposed return from the hospital, nor did it document specific unmet needs in the EMR, despite issuing an involuntary discharge and asserting that the resident’s needs and safety could not be managed at the facility.
Prolonged Inadequate Room Temperatures and Resident Discomfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within a comfortable range, resulting in prolonged cold conditions on the 100 hall for most residents reviewed. Multiple resident rooms had blankets placed on windowsills and over air conditioning units to block drafts. Residents consistently reported that their rooms had been cold for weeks to months, particularly during the winter, and that the problem persisted whenever the outside temperature was low. Facility temperature logs for the 100 hall documented room temperatures ranging from approximately 62.6 to 68.1 degrees Fahrenheit on specific dates, with a baseboard temperature as low as 54.6 degrees Fahrenheit, which is below the stated comfortable range of 71 to 81 degrees Fahrenheit. Cognitively intact residents described needing multiple blankets to stay warm, with some sleeping under three to five blankets or wearing coats and hoodies in bed. Several residents stated that it had been cold “all winter” or for “months,” and some reported specific low temperatures such as 61 degrees. Residents reported feeling sad, angry, disappointed, depressed, and as though they were not being heard because of the ongoing lack of heat. Some residents refused showers or had to wash quickly due to the cold in their rooms, and at least one resident’s shower refusal was documented on a shower sheet. Residents also reported that while they were offered the option to move to other, warmer units, they declined because they did not want to move their belongings or change rooms. Staff interviews corroborated the residents’ reports, with CNAs and nursing staff describing the 100 hall as “freezing” and cold for about a month to several months, noting that residents complained all day about being cold and often stayed in bed. Staff reported that they responded by providing extra blankets, wearing hoodies themselves while working, and notifying maintenance, but they were not informed why the hall remained so cold. A representative payee monitor and the ombudsman both observed or were aware of ongoing heating issues, with the monitor noting a clear temperature difference between administrative and resident areas and seeing residents in bed with multiple blankets and wearing coats. The ombudsman stated that residents had been complaining about no heat for most of the winter and that these concerns were raised in a resident council meeting, although the meeting minutes did not reflect the heating complaints. The maintenance director acknowledged receiving complaints about cold temperatures on specific dates and identified problems with the facility’s boiler system, including a blockage in the fourth boiler and flow issues throughout the building, with the 100 wing being the most concerning. He stated that the fourth boiler remained down and that room temperatures were being kept at 68–69 degrees, which is below the 71–81 degree comfort range cited in the deficiency. Blankets were intentionally placed on windowsills and air conditioners to reduce drafts. The administrator reported that there were blockages in the boiler system and that a new heating and cooling system had been ordered but not yet installed. The facility’s own severe cold weather procedures required assuring that heating systems were working correctly in residents’ rooms, and the Illinois Department on Aging residents’ rights booklet stated that the facility must be safe, clean, comfortable, and homelike, underscoring that the prolonged cold conditions and substandard room temperatures constituted a failure to provide a comfortable environment.
Unsanitary Water Distribution Practices Identified
Penalty
Summary
Facility staff failed to provide water to residents in a sanitary manner, as observed during the distribution of ice water to five residents. An activity aide used a scoop to fill residents' cups from a cooler containing water and ice, placing the wet scoop back onto the water cart after each use, rather than storing it in a sanitary location. Additionally, the aide held residents' water cups, which had been removed from their rooms, directly above the open cooler while filling them. The food service director confirmed that these practices were not in accordance with facility policy, which prohibits placing the scoop on the cart and holding cups above the cooler due to the risk of cross contamination. These actions were observed during the survey and were inconsistent with the facility's policy on ice dispensing, which requires food and beverages to be stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness.
Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of a stage 4 sacral pressure ulcer was properly assessed and monitored following a change in condition. Staff observed that the resident, who was typically confused but active and frequently attempted to get up unassisted, was unusually inactive, did not use her call light, and did not attempt to get out of bed. Certified Nursing Assistants (CNAs) reported these changes to the nurse on duty, who responded only by checking vital signs multiple times throughout the shift but did not perform or document a comprehensive assessment or follow-up. Additionally, possible blood in the resident's urine was reported during the morning shift, but there was no documented assessment or notification to the nurse practitioner until the resident was sent to the hospital later that night. The facility's policy required prompt assessment, documentation, and notification of changes in a resident's condition, but these steps were not followed. The nurse on duty did not recall being informed of the possible blood in urine and did not document any assessment or communication regarding the resident's change in status. The Director of Nursing and Nurse Practitioner both confirmed that, according to facility policy and standard practice, a full assessment and notification should have occurred, and all actions should have been documented in the resident's medical record. The lack of timely assessment, documentation, and communication led to a delay in appropriate care for the resident.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in significant injuries. In one incident, a resident in the memory care dining room sustained a posterior head laceration and an acute subdural hematoma after an altercation with another resident. Staff accounts indicate that two residents were struggling over a chair, leading to both falling, with one resident landing on top of the other and causing a head injury that required hospital treatment. Witnesses described one resident shoving a chair into another, causing a fall and head trauma, with visible damage to the wall and significant bleeding. Documentation from the hospital confirmed the head injury and subdural hematoma, and staff noted that the aggressor had previously shown aggression toward staff but not other residents. Another incident involved two roommates who had a history of disagreements. During an altercation, one resident fell from his wheelchair and was then kicked multiple times by his roommate. Staff intervened to separate them, and subsequent medical assessment revealed bruising consistent with defensive injuries and a fracture in the lower spine. The resident reported being kicked while on the floor, and staff and nurse practitioner documentation supported the account of physical abuse. The aggressor admitted to kicking the other resident after a verbal threat, and the victim was later discharged from the facility. The facility's records and staff interviews indicate that these incidents were not isolated and involved failures to prevent resident-on-resident abuse. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the documented events show that residents were subjected to physical harm by other residents, with staff sometimes unable to intervene in time to prevent injury. The incidents were reported to the state agency and local authorities, but the documentation reveals gaps in preventing and documenting abuse between residents.
Mechanical Lift Equipment Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that mechanical lift equipment was maintained in safe and operable condition for five residents who required mechanical lifts for transfers. Multiple CNAs reported that batteries for the mechanical lifts frequently failed to hold a charge, resulting in situations where residents were left suspended in the air or unable to be safely lowered during transfers. In one instance, a CNA described attempting to lower a resident onto the toilet when the lift battery died, and after trying several replacement batteries that also failed, the emergency release mechanism did not function. The CNA ultimately had to manually lower the resident using a gait belt and her own knees for support. The same lift was later observed to have a broken emergency release ring that was not attached to the shaft, rendering it ineffective. Other staff members confirmed ongoing issues with lift batteries, malfunctioning emergency releases, and damaged wheels on some lifts. Residents who regularly used the sit-to-stand machines also reported repeated incidents where lifts lost power while they were suspended. The facility's maintenance policy assigns responsibility for equipment upkeep to the maintenance department, but interviews revealed uncertainty about whether safety checks had been performed and that staff continued to use lifts with known safety issues.
Resident Exposed to Undignified Staff Altercation at Nurses' Station
Penalty
Summary
Staff members, including two LPNs and the Dietary Manager, engaged in a loud verbal altercation at the nurses' station during shift change. The argument involved the use of profane and insulting language, with one LPN calling the dietitian derogatory names and using explicit language. The altercation was witnessed by other staff, including a CNA who attempted to intervene and de-escalate the situation. During this incident, at least one resident was present and seated by the nurses' station, within earshot of the argument. The facility's policy on resident privacy and dignity specifically instructs staff to avoid discussing private or personal issues in public and to refrain from using patronizing or insulting language. Despite this, the staff's conduct during the altercation failed to uphold these standards, resulting in a situation where a resident was exposed to undignified and inappropriate staff behavior.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving two residents was reported to the state surveying agency in a timely manner. In December 2023, two residents were involved in a physical altercation in their shared room, which resulted in one resident being knocked down and kicked by the other. Progress notes indicated that one resident initially denied physical contact but later reported being kicked while on the floor, with visible bruising to his right upper arm, elbow, and head. Despite these allegations and physical findings, the incident was not reported to the state agency or local police at the time it occurred. The facility's administrator stated that the incident was not reported initially because it was determined that no contact had occurred. However, months later, after receiving an anonymous compliance hotline call, the administrator reported the incident to the state agency and local police, eight months after the original event. The facility's own abuse prevention policy requires immediate reporting of abuse allegations, but this protocol was not followed in this case. Documentation shows that the facility only submitted a report after the anonymous call, and no further information was provided to the state agency beyond the original late report.
Failure to Assess, Document, and Notify After Resident Head Injury During Transport
Penalty
Summary
A resident was transported to an orthopedic appointment by the facility's former Maintenance Director, who was not clinical staff. During transport, the resident's wheelchair flipped backwards, causing the resident to hit his head and sustain a scrape. The Maintenance Director did not notify the facility of the incident, relying on the resident's statement that he was fine and the fact that he was at a doctor's office. The resident's daughter discovered the injury at the appointment and contacted the facility, expressing concern about not being informed of the incident. Upon return to the facility, the acting DON/ADON, who had a background in neurology trauma, assessed the resident and determined he was fine but did not document the assessment, perform or document neuro checks, or notify the physician as required by facility policy. The RN assigned to the resident was instructed to perform hourly neuro checks but did not complete or document them, citing being busy with nursing students. The resident's electronic medical record contained no documentation of the incident, neuro checks, or physician notification, despite facility policies requiring such actions following a fall or head injury.
Failure to Ensure Safe Resident Transfers Due to Faulty Equipment
Penalty
Summary
The facility failed to ensure that residents were transferred safely using properly functioning equipment, as evidenced by multiple incidents involving three residents. Staff used a sit-to-stand machine and a mechanical lift with a non-functioning emergency release and unreliable batteries. In one instance, a CNA attempted to lower a resident onto the toilet using the sit-to-stand machine, but the battery died and the emergency release did not work. The CNA had to manually lower the resident to a wheelchair, and the broken equipment was not removed from use or labeled as defective. Staff reported that management had been informed about the unreliable equipment, but no immediate action was taken to prevent further use. Additionally, staff continued to use the same malfunctioning mechanical lift to transfer other residents, despite being aware that the emergency release was not operational. The care plan for one resident specified the use of a mechanical lift due to cognitive impairment and physical limitations, but staff attempted a sit-to-stand transfer without a proper assessment or care plan update. Maintenance staff later confirmed the emergency release was not attached as required, and the facility's maintenance policy indicated responsibility for keeping equipment safe and operable at all times.
Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to ensure that resident records were up to date and accurate for three residents. In the first instance, a resident was involved in an incident where he flipped backwards in his wheelchair while being transported in a van and hit his head. This event was confirmed by the resident, his daughter, and the former Maintenance Director, but there was no documentation of the incident in the resident's electronic medical record. The facility's fall prevention and management policy requires documentation of such events, including outcomes, observations, and notifications. In the second case, a resident exited the building through a dining room door and was found outside on the sidewalk. Staff responded to the alarm and brought the resident back inside without injury. The LPN involved stated she was told by the Administrator to hold off on charting, and no documentation of the event was found in the resident's record. The facility's policy requires reporting and documentation of missing residents. In the third case, a resident experienced a malfunction with a sit-to-stand machine during toileting, requiring manual assistance to be safely lowered. The CNA, LPN, and Social Service Director were aware of the incident, but no documentation was made in the resident's record, contrary to the facility's charting and documentation policy.
Failure to Ensure Accurate Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate weights were obtained and recorded for five residents, leading to a deficiency in monitoring their nutritional status. The report highlights significant discrepancies in daily weight recordings for these residents, with no reweighs conducted or physicians notified of the changes. For instance, one resident experienced a 21.8-pound weight loss in one day, and another had a 26.6-pound weight gain in a single day, yet there was no documentation of reweighs or physician notification. The Director of Nursing acknowledged that a weight change of five or more pounds in a day should prompt a reweigh, but this standard was not met. The facility's policy on weight management requires investigation of significant or trending weight changes, but this was not adhered to. The Assistant Director of Nursing noted that notification to a physician would depend on specific parameters, but expected reweighs for large discrepancies. Despite these expectations, the report shows a lack of action in response to significant weight changes, indicating a failure to follow the facility's policy and standard care practices.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to securely store medications, as observed during a survey. During a medication storage review, the Assistant Director of Nursing (ADON) had to locate the nurse to obtain the keys to the medication cart. Upon returning, the ADON found the narcotic count binder on the cart with the nurse's keys underneath its cover. The ADON used these keys to open the medication cart. The ADON acknowledged that the keys should be with the nurse at all times and not left on the cart. The Director of Nursing (DON) confirmed that the keys should always be with the nurse to ensure medication security and prevent residents from accessing the cart. The facility's policy, revised in August 2023, mandates that drugs and biologicals be stored safely, securely, and orderly.
Infection Control Deficiencies in Linen Handling and Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care and linen handling. A Certified Nursing Assistant (CNA) was observed transporting soiled linens without bagging them, holding them against her body, which is against the facility's policy. The CNA admitted to being aware of the correct procedure but did not follow it due to nervousness. The Director of Nursing confirmed that the facility's policy requires soiled linens to be transported in a bag or using a soiled linen cart to prevent cross-contamination. Additionally, during incontinence care for a resident with multiple health issues, including cerebral infarction and urinary tract infection, two CNAs failed to change gloves and perform hand hygiene between dirty and clean tasks. One CNA continued to wear contaminated gloves while handling clean items and performing various tasks, contrary to the facility's gloves policy. The Director of Nursing emphasized the importance of changing gloves between dirty and clean areas to prevent the transfer of germs, feces, and urine to clean areas.
Deficiencies in ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, leading to deficiencies in personal hygiene and incontinence care. One resident, diagnosed with Alzheimer's disease, major depressive disorder, dementia with psychotic disturbance, and type 2 diabetes, required maximum assistance for oral and personal hygiene. During a morning care session, a CNA provided incontinence care, dressing assistance, and hair brushing but failed to offer or provide oral care or shaving assistance, despite the resident's care plan indicating a risk for ADL decline. The resident expressed dissatisfaction with the lack of shaving assistance, indicating a preference for having facial hair removed. Another resident, with severe protein-calorie malnutrition and dementia with behaviors, was found to have moderate cognitive impairment and incontinence issues. A new CNA provided toileting assistance but failed to perform incontinence care after removing a soiled brief, instead applying a new brief without cleaning the resident. The Director of Nursing confirmed that incontinence care is standard practice for infection prevention, dignity, and cleanliness, and all aides are trained to perform these tasks. The facility's policies on ADLs and incontinence care emphasize the importance of maintaining hygiene and preventing infection.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure proper positioning of an indwelling urinary drainage bag for a resident with a catheter, leading to a potential risk of urinary tract infections (UTIs). The resident, who had diagnoses including cerebral infarction, heart disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and a UTI, was observed with the catheter bag placed on top of his thighs while lying in bed. This placement was contrary to the care plan and facility policy, which required the bag to be positioned below the bladder level to prevent backflow of urine. During an observation, the Director of Nurses (DON) and a Certified Nursing Assistant (CNA) transferred the resident using a mechanical lift, and the DON acknowledged the need to hold the bag below the bladder during the transfer. The DON later confirmed that the resident had required antibiotics for a UTI a few weeks prior and emphasized the importance of keeping the catheter bag below the bladder to prevent backflow and potential UTIs. The facility's policy also specified that the drainage bag should be attached to the bed frame below the bladder level, not touching the floor, to ensure proper urine flow and avoid backflow.
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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