Nexus At Columbia
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Illinois.
- Location
- 253 Bradington Drive, Columbia, Illinois 62236
- CMS Provider Number
- 145717
- Inspections on file
- 42
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Nexus At Columbia during CMS and state inspections, most recent first.
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.
The facility failed to report an allegation of abuse after a resident with a history of cerebral infarction, moderate cognitive impairment, and wheelchair use told an LPN that another resident hit him and showed a bruise on his arm. The resident later described being punched by another resident in the hallway, stating that a CNA and another staff member witnessed the incident. The Administrator and DON focused on investigating the bruise as resulting from the resident bumping into a door frame or another resident’s wheelchair and, based on that conclusion, did not report the allegation to authorities, despite the facility’s abuse policy requiring immediate protection of residents and prompt investigation of all possible abuse reports.
A resident with cognitive impairment and a history of cerebral infarction, identified as at risk for abuse, reported to an LPN that another resident punched them in the arm and showed a bruise, while other staff and the other resident described only a collision with a wheelchair and denied any hitting. The Administrator was unaware that an abuse allegation had been made, and the DON’s investigation focused on the bruise without obtaining statements from the reporting resident or the LPN, and without completing initial or final reports or determining the cause of the bruise or whether abuse occurred, in contrast to the facility’s abuse policy requiring prompt and thorough investigation of all abuse reports.
Two cognitively intact residents with histories of behavioral issues engaged in a physical altercation after one repeatedly demanded money and became verbally abusive. During a group activity, one resident pushed and pulled the other's chair, leading to the other swatting and making contact with her breast, after which both exchanged physical blows. Staff were unable to intervene in time, and the incident left one resident feeling unsafe.
Two residents experienced undignified treatment when CNAs failed to provide timely toileting assistance and made dismissive or harsh remarks, including in public areas. One resident, dependent on a mechanical lift, was made to wait for bathroom help and spoken to in a demeaning manner, leading to emotional distress and incontinence. Another resident felt depressed after being told her personal belongings took up too much space. These actions did not align with facility policy on resident dignity and a home-like environment.
The facility failed to provide scheduled showers for four residents, as documented in records and confirmed through interviews. A resident reported issues with the shower room lacking heat and hot water, while others missed scheduled showers due to documentation inconsistencies and lack of oversight. Staff interviews revealed discrepancies in documentation practices, and the facility's policy requires showers to be provided as per schedule or request, with completed or refused showers documented in the medical record.
The facility failed to serve food at a palatable temperature, as observed during a survey. Cognitively intact residents reported receiving consistently cold meals, an issue highlighted in a resident council meeting. Observations showed that trays were prepared with lids but no bases, and food was placed on wire carts, leading to temperatures below the required 135 degrees Fahrenheit. The Dietary Regional Manager acknowledged the problem, noting that the lack of coverage on wire carts caused the temperature drop.
A facility failed to notify a resident's POA of new psychotropic medication orders, including Buspirone and Seroquel, for a resident with Huntington's Disease. The POA was not informed of the risks and benefits, nor was consent obtained as required by the facility's policy. The Director of Nursing expected nurses to notify the POA, but this did not occur, leading to a deficiency in communication and consent procedures.
A resident received multiple psychotropic medications without the facility obtaining informed consent from the Power of Attorney (POA). The POA was not informed of the risks and benefits of the medications until after administration, and was unaware of some medications being given. The facility's guidelines require informed consent before administering new psychotropic medications, but this was not followed, leading to the deficiency.
A resident with severe cognitive impairment was verbally and physically abused by her brother, despite a care plan restricting his visits. The facility failed to enforce these restrictions, allowing unsupervised access that led to multiple abuse incidents. Staff reported the brother's behavior, but the facility did not take adequate action to protect the resident.
The facility failed to alternate physician and NP visits every 60 days for four residents, as required by policy. Residents with various medical conditions were predominantly seen by NPs, with minimal physician visits documented. Interviews revealed a lack of clarity regarding visit frequency, and the facility lacked documentation for required physician visits.
The facility failed to report and investigate suspected abuse and injuries of unknown origin for two residents. One resident, with severe cognitive impairments, was found with a bruise of unknown origin, and verbal abuse by a family member was witnessed but not reported. Another resident accused an LPN of inappropriate conduct, but the allegation was not immediately reported or investigated. These incidents highlight deficiencies in the facility's handling of suspected abuse and injuries.
A facility failed to investigate allegations of verbal abuse and injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a bruise, but the DON did not conduct a thorough investigation. Multiple reports of verbal abuse by a family member were not reported to the state by the Administrator. The facility's abuse policy was not followed, resulting in a deficiency in addressing the resident's safety.
The facility failed to provide the required protein portions to residents, as observed when turkey servings were not weighed accurately, resulting in insufficient portions. Residents complained about food portions and running out of food. The Dietary Manager was unsure of the cause, while the Consulting Dietician noted insufficient food ordering. Facility policy requires 6 ounces of protein daily per resident.
A Dietary Aide in an LTC facility failed to maintain hygienic practices while handling food, including rubbing her nose and brow without washing her hands, despite being instructed to do so. This occurred while she was preparing and distributing food to residents, contrary to the facility's policy requiring adherence to FDA food code standards.
The facility failed to uphold residents' rights to privacy and dignity, as multiple residents reported CNAs frequently using cell phones during care, leading to ignored requests and compromised privacy. The DON acknowledged the issue, particularly with agency CNAs, and stated efforts to address it.
The facility failed to provide personal hygiene care to two residents who were dependent on staff for ADLs. One resident was found with a dirty mouth, dry skin, messy hair, and untrimmed nails, while another had similar hygiene issues. Both residents had diagnoses requiring assistance with personal care, as documented in their MDS and care plans. The DON confirmed that staff are responsible for providing morning care to these residents.
A medication error occurred when a resident in hospice care was mistakenly given another resident's medications due to an incorrect room assignment in the electronic health care record. The error involved a narcotic, Methadone, among other medications. The mistake was discovered when the second resident requested his medications. The resident who received the wrong medications was monitored and experienced no adverse effects.
A resident with a history of aggressive behavior assaulted another resident, causing physical harm and distress. Despite previous incidents, the facility failed to implement effective interventions to prevent further occurrences, resulting in a significant deficiency.
The facility failed to maintain a clean environment, as observed in the 300/400 hall shower room, which had a persistent foul odor and dirty clothing on the floor. Residents reported having to clean the shower room themselves before use, and the Housekeeping Manager admitted that cleaning protocols were not consistently followed.
The facility failed to cohort COVID-19 positive residents and ensure consistent PPE use among staff, affecting all 112 residents. An occupational therapist and other staff members did not adhere to full PPE protocols, and a COVID-19 positive resident was housed with a negative resident due to room shortages.
The facility failed to notify family representatives of two residents about positive COVID-19 test results and the presence of COVID-19 in the building. One resident, moderately cognitively impaired, was not documented as having their responsible party informed of their positive status. Another resident, severely cognitively impaired, was not documented as having their POA informed about exposure to a COVID-positive resident or the outbreak. This was contrary to the facility's policy requiring notification of changes in condition.
The facility failed to administer medications timely to four residents, with observations showing delays in the scheduled 8:00 AM medication pass. Residents reported receiving medications late, sometimes as late as noon, due to the division of nursing assignments and workload. The Director of Nursing confirmed the expectation for timely administration but denied concerns, despite the facility's policy emphasizing proper timing.
The facility failed to maintain, clean, and return resident clothes in a timely manner, leading to missing, stained, or incorrect clothing for six residents. Despite multiple complaints and grievance forms, the issues persisted, causing significant distress and inconvenience for the residents.
The Facility failed to provide appetizing and warm food for seven residents, with multiple reports of cold meals in both the dining room and on hall trays. Observations confirmed unattended food carts and inadequate food temperatures, contrary to the Facility's policy.
The facility failed to have an RN on duty for 8 hours daily, as required. Time cards showed that an RN did not stay until 8:00 AM on certain Sundays, resulting in non-compliance with the 8-hour RN coverage requirement. The Administrator confirmed the staffing schedule, and the facility's policy states that staffing is based on IDPH requirements. The facility has a census of 107 residents.
A facility failed to identify and assess an AV shunt for a severely cognitively impaired resident, leading to a lapse in required daily checks and precautions. The oversight was only discovered after the resident was sent to the hospital for evaluation due to arm pain.
The facility failed to protect residents from abuse, including physical and verbal abuse by a family member and staff, and physical assault by another resident. Despite clear evidence and witness statements, the facility did not substantiate the abuse.
The facility failed to report multiple allegations of abuse involving a resident, who was observed being verbally and physically abused by a male individual. Despite staff and EMS personnel witnessing the abuse and reporting it to the administration, the facility did not take appropriate action to address and report these incidents as required by their abuse policy.
The Facility failed to investigate allegations of abuse involving a resident by a male individual. Multiple staff members and EMS personnel reported witnessing the individual verbally and physically abusing the resident. Despite these reports, the Facility only provided one investigation report dated several months prior, indicating a lack of thorough investigation into the ongoing abuse allegations.
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 Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident when the resident reported being hit by another resident and presented with a bruise. The resident, who had a history of cerebral infarction, was moderately cognitively impaired per the MDS and used a wheelchair, and was care planned as being at risk for abuse and neglect. The resident told an LPN that someone had hit him and showed a bruise on his left arm; the LPN notified the Administrator. The resident later stated he had been going down the hall, asked another resident to move, and that the other resident punched him in the arm, allegedly witnessed by a CNA and another staff member. The Administrator stated she was not aware of the abuse allegation and that they investigated the bruise as having resulted from the resident bumping into a door frame, and therefore it was not reported. The DON stated she conducted interviews regarding the bruise and concluded it was caused by the resident running into another resident’s wheelchair, and also did not report the allegation, despite the facility’s abuse policy requiring immediate protection of residents and prompt investigation of all reports and allegations of abuse. The deficiency centers on the facility’s failure to treat the resident’s statement that another resident hit him as a reportable allegation of abuse and to report it to the proper authorities, instead focusing only on determining an alternative cause for the bruise. This inaction occurred despite the resident’s documented risk for abuse and the facility’s written abuse policy that requires immediate protection and aggressive investigation of all possible abuse reports.
Failure to Thoroughly Investigate Resident’s Abuse Allegation and Unexplained Bruise
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse related to a resident with a history of cerebral infarction who was moderately cognitively impaired and used a wheelchair. The resident’s care plan identified them as being at risk for abuse and neglect. The resident reported to an LPN that another resident had punched them in the arm while they were going down the hall, and showed the LPN a light purple circular bruise on the back of the left arm, approximately two inches in diameter. The LPN notified the Administrator of the resident’s report. Other staff and the alleged perpetrator resident provided written and verbal statements describing an interaction in which the resident in question ran into the other resident’s wheelchair, and they denied seeing or performing any hitting. Despite the allegation of being hit and the presence of a bruise, the facility’s investigation did not include a statement from the resident who alleged the abuse or from the LPN who initially received the report. The Administrator stated she was not aware that the resident had made an abuse allegation and believed they were only investigating a bruise. The DON stated that she conducted interviews regarding the bruise but did not obtain a statement from the resident and acknowledged she probably should have. The investigation file lacked initial or final reports, did not determine the cause of the bruise, and did not reach a conclusion about whether the alleged abuse occurred, contrary to the facility’s abuse policy that requires immediate protection of residents and prompt, aggressive investigation of all reports and allegations of abuse.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two cognitively intact residents with documented histories of behavioral issues, including verbal aggression and inappropriate interactions with peers and staff. One resident, who had diagnoses including metabolic encephalopathy and generalized anxiety disorder, was noted to have escalating behaviors such as demanding money, verbal abuse, and combative actions toward both staff and other residents. The other resident, with major depressive disorder and bipolar disorder, also had a history of verbal aggression and was identified as being at risk for abuse and neglect. On the day of the incident, the first resident was observed asking for money from peers and staff, becoming verbally abusive when refused. During a music activity in the dining room, the second resident confronted the first resident about their behavior. Video footage and multiple staff interviews confirmed that the second resident aggressively pushed and pulled the first resident's chair, after which the first resident swatted at the second resident, making contact with her breast. The second resident then retaliated by hitting and kicking the first resident. Staff present at the time reported difficulty in de-escalating the situation, and one aide had to leave the room to seek additional help, during which time the altercation occurred. The facility's investigation confirmed that an altercation took place, with both residents engaging in physical contact. The incident resulted in the second resident feeling unsafe in the facility. The facility's abuse prevention policy prohibits physical abuse, including hitting and controlling behavior, but the measures in place were insufficient to prevent this resident-to-resident altercation.
Failure to Provide Dignified Care and Respect Resident Rights
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner by not providing timely toileting assistance and by not respecting residents' rights to a home-like environment. One resident, who was morbidly obese, had reduced mobility, and was dependent on staff for toileting hygiene, was repeatedly made to wait for bathroom assistance. Certified Nursing Assistants (CNAs) assigned to her hall, particularly one CNA, were reported to have spoken harshly to her, told her to wait until after meal service or until the next shift, and made dismissive comments about her age and emotional responses. Multiple staff and the resident's sister confirmed that the resident was left waiting, sometimes resulting in incontinence, and that the CNA in question was resistant to using the mechanical lift required for the resident's safe transfer. The resident expressed feeling mistreated and was moved to another hall as a result of these interactions. Another resident, diagnosed with depression and anxiety and cognitively intact, reported feeling nervous and a little depressed due to a CNA's comments about her personal belongings taking up too much space in her room. The resident was reluctant to discuss the issue but indicated that the CNA's tone and remarks negatively affected her emotional well-being. Staff interviews corroborated that the CNA had a pattern of speaking harshly to residents and that such interactions occurred in public areas, further impacting residents' dignity. The facility's own policy emphasizes the importance of accommodating resident needs and preferences to maintain dignity and a home-like environment, including the right to retain personal possessions and receive timely assistance. However, observations, interviews, and record reviews demonstrated that these standards were not upheld for at least two residents, resulting in emotional distress and a lack of respect for their rights.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents, as documented in the facility's records and confirmed through interviews. The residents, identified as R1, R11, R12, and R15, did not receive showers according to their scheduled days, with multiple instances marked as 'not applicable' in the shower documentation. R1, who is cognitively intact, reported that the shower room on the 500 hall lacked heat and hot water, and due to his size, he could not use the equipment in the 400 hall. R11, who is moderately cognitively impaired, and R12, who requires partial/moderate assistance, also missed several scheduled showers. R15, who requires similar assistance, refused a shower on one occasion but also missed several scheduled showers. Interviews with staff revealed inconsistencies in documentation practices, with some CNAs stating they document completed showers in the computer, while others use a shower sheet due to lack of charting ability. The Regional Nurse confirmed that the bath and skin report sheet is a QA tool and not mandatory. The facility's policy requires showers to be provided as per schedule or request, and staff are expected to document completed or refused showers in the medical record. However, the facility failed to provide January's shower documentation, and the Director of Nursing was unaware of the broken shower room on the 500 hall, indicating a lack of communication and oversight in ensuring residents' hygiene needs were met.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature for four residents, as observed during a survey. The residents, who are cognitively intact, reported that their meals were consistently cold upon delivery. The issue was highlighted in a resident council meeting, where it was noted that the wire racks used for room trays did not keep the food warm, resulting in cold meals. During an observation, it was found that trays were prepared with lids but no bases, and the food was placed directly on wire carts. The temperature of the food was measured, with the pasta and ground beef mix at 126 degrees Fahrenheit and the green beans at 120 degrees Fahrenheit, both below the required hot holding temperature of 135 degrees Fahrenheit. The Dietary Regional Manager acknowledged the problem, stating that while food is held at the correct temperature on the steam table, the lack of coverage on the wire carts leads to a drop in temperature by the time the food is served. The facility's policy requires hot foods to be held at temperatures greater than 135 degrees Fahrenheit, but this was not adhered to, resulting in the deficiency. The residents expressed dissatisfaction with the cold food, and the issue was noted as ongoing, with no resolution at the time of the survey.
Failure to Notify POA of Medication Changes
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of medication changes for a resident diagnosed with Huntington's Disease, anxiety, and metabolic encephalopathy. The resident's care plan indicated the use of psychotropic medications, including Risperidone, Clonazepam, Ativan, Fluoxetine, and Mirtazapine, to manage mood, behavior, anxiety, and depression. However, the POA was not informed of the addition of Buspirone and Seroquel to the resident's medication regimen until after the medications had been administered. The facility's policy requires that the resident or their representative be informed of the risks and benefits of new psychotropic medications and that informed consent be obtained. Interviews revealed that the POA was not aware of the resident's new medication orders until a week after they were implemented, and the psychiatric nurse confirmed that the family had not given consent for the psychotropic medications. The Director of Nursing stated that while the Nurse Practitioner enters orders into the system, it is expected that nurses notify the POA of new orders. The facility's psychotropic program guidelines emphasize the necessity of obtaining informed consent, either verbally or in writing, for new psychotropic medications, which was not adhered to in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication for one resident, identified as R5, who was part of a sample of 15 residents reviewed for unnecessary medication. R5's care plan indicated the use of multiple psychotropic medications, including Risperidone, Clonazepam, Ativan, Fluoxetine, and Mirtazapine, to manage mood, anxiety, and depression related to Huntington's Disease and other diagnoses. Despite the administration of these medications, the facility did not obtain informed consent from R5's Power of Attorney (POA) until after the medications had been administered. The POA was not informed of the risks and benefits of the medications until a later date, and was unaware of certain medications, such as Buspirone, being administered. Interviews with the POA and facility staff, including the Director of Nursing (DON) and a psychiatric nurse, revealed that the facility had issues with obtaining and documenting consents for psychotropic medications. The DON acknowledged the problem and stated that the facility was working on addressing it. The facility's psychotropic program guidelines require that informed consent be obtained and documented before administering new psychotropic medications, but this protocol was not followed in R5's case, leading to the deficiency.
Failure to Prevent Resident Abuse by Family Member
Penalty
Summary
The facility failed to prevent verbal and physical abuse of a resident by her brother, who had a known history of abusive behavior towards her. Despite previous incidents and a care plan that restricted the brother's visits to supervised window and phone interactions, he was allowed unsupervised access to the resident. This led to multiple instances of verbal and physical abuse, including an incident where he threatened to break her neck and physically shoved her head. The resident, who is severely cognitively impaired and dependent on staff for all activities of daily living, was left vulnerable due to the facility's failure to enforce the care plan and monitor the brother's interactions. Staff members, including CNAs and LPNs, reported hearing the brother's abusive language and witnessing his aggressive behavior, yet these reports were not adequately addressed by the facility's administration. The facility's inaction and lack of proper documentation and communication among staff and management contributed to the continuation of the abuse. Despite being aware of the brother's behavior, the facility did not implement effective interventions to protect the resident, resulting in a situation of Immediate Jeopardy.
Removal Plan
- The administrator initiated the abuse investigation.
- To ensure the safety and well-being of R2, the DON completed an assessment. The result of the assessment was documented in the resident's EHR, and the attending physician will be notified.
- The following actions were taken to prevent alleged aggressor from perpetrating additional abusive behaviors: Visitor was banned from visitation pending investigation, Police were notified of incident, Interdisciplinary team (IDT) will review and revise R2's care plan and implement interventions to ensure R2's safety, The care plan review and revision were completed by the DON/MDS Nurse.
- All residents have the potential to be affected by the alleged deficiency.
- Administrator and DON education. RNC/designee will provide training to administrator and DON. The training will include abuse prevention, allegation of abuse checklist, reporting abuse within required timeframe, completing investigation per policy and protocols, reporting and investigation injuries of unknown origin, immediate action to ensure all potential abuse allegations are identified, reported, and investigated as abuse to safeguard the residents' safety, protection of residents from further abuse from alleged perpetrators.
- Staff Education - the administrator will provide training to all staff. The training will include abuse prevention including identification of the Abuse Coordinator, reporting abuse allegations to the administrator, abuse investigation procedures and documentation process, reporting and investigation of injuries of unknown origin, immediate action to ensure all potential abuse allegations are identified, reported to the administrator to safeguard the residents' safety, protection of residents from further abuse from alleged perpetrator.
- The training will be started.
- All staff who are not available and/or currently on vacation will also receive the same education upon their return to work. The administrator will provide the same training.
- The facility will provide similar training to the agency staff.
- Residents were interviewed to identify if they felt safe and/or if they have experienced verbal or physical abuse while living in this facility. No concerns were identified.
- Care plan meetings. The IDT will review care plans at least quarterly and as needed.
- As part of monitoring, the Administrator will monitor through facility audit tools five staff members daily for one week and then weekly to ensure any allegations of abuse are reported to the abuse coordinator and investigated and reported to organizations.
Failure to Alternate Physician and NP Visits Every 60 Days
Penalty
Summary
The facility failed to ensure that physician visits were alternated with Nurse Practitioner (NP) visits every 60 days after the first 90 days of admission for four residents. The facility's policy requires that each resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter, with the option to alternate visits with an NP. However, the records for residents R1, R2, R6, and R7 showed that they were predominantly seen by NPs, with minimal physician visits documented. Resident R1, who has multiple diagnoses including hemiplegia and congestive heart failure, was seen by an NP 26 times in the past year but only once by a physician. Similarly, resident R2, with severe cognitive impairment and multiple health issues, was seen by an NP 32 times and by a physician only once. Resident R6, also severely cognitively impaired, was seen by an NP 25 times and by a physician twice. Resident R7, who is cognitively intact but has several health conditions, was seen by an NP 16 times and by a physician only once since admission. Interviews with staff revealed a lack of clarity regarding the frequency of physician visits, with the Assistant Administrator acknowledging the absence of documentation for the required physician visits. The Regional Director of Operations expected the policy to be followed, indicating a discrepancy between policy and practice. The facility's failure to adhere to its policy on physician visits resulted in a deficiency in ensuring adequate medical oversight for the residents.
Failure to Report and Investigate Suspected Abuse and Injuries
Penalty
Summary
The facility failed to report and investigate incidents of suspected abuse and injuries of unknown origin for two residents, R2 and R8. R2, who has severe cognitive impairments and multiple medical conditions, was found with a bruise of unknown origin on her left upper arm. Despite the facility's care plan indicating R2's risk for abuse and neglect, the Director of Nursing did not report the bruise to the Illinois Department of Public Health (IDPH) or conduct an investigation. Additionally, staff members witnessed R2's brother, V6, verbally abusing R2, but these incidents were not reported or investigated by the facility's administration. For R8, who is moderately cognitively impaired, an allegation of inappropriate conduct was made against an LPN, V25. R8 accused V25 of inappropriate behavior, but V25 did not immediately report the allegation to management, as required by the facility's abuse policy. Instead, V25 reported the incident the following morning, after his shift had ended. The Director of Nursing was informed of the allegation but did not take immediate action to investigate or report the incident to the appropriate authorities. The facility's failure to adhere to its abuse policy and report these incidents to the IDPH highlights a significant deficiency in handling suspected abuse and injuries of unknown origin. The lack of timely reporting and investigation of these incidents demonstrates a failure to protect residents from potential harm and ensure their safety within the facility.
Failure to Investigate Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate allegations of verbal abuse and injury of unknown origin for a resident with severe cognitive impairment and multiple diagnoses, including dementia and intellectual disabilities. The resident was found with a bruise of unknown origin on her left upper arm, which was reported by a CNA to an LPN. The LPN evaluated the bruise, notified the family and the facility's Nurse Practitioner, and an interdisciplinary team meeting was held. However, the Director of Nursing did not conduct a thorough investigation, assuming the bruise was from a transfer without interviewing staff or documenting the investigation in the resident's electronic medical record. Additionally, there were multiple reports of verbal abuse by the resident's family member, V6, who was witnessed by maintenance staff and CNAs yelling and using vulgar language towards the resident. Despite these reports, the facility's Administrator did not report the incidents to the state or take appropriate action. The maintenance staff expressed concerns about the lack of proper steps being taken and the discomfort caused by V6's behavior towards both the resident and staff. The facility's abuse policy requires immediate reporting and investigation of any allegations or suspicions of abuse, but this was not followed. The policy also mandates that suspicious bruises be reported and documented, which was not done in this case. The Regional Director of Operations acknowledged the expectation for the Administrator to report abuse but was unsure if the allegations were ever investigated. The facility's failure to adhere to its abuse prevention program and reporting procedures resulted in a deficiency in addressing the resident's safety and well-being.
Failure to Provide Adequate Protein Portions
Penalty
Summary
The facility failed to provide the required amount of protein to its residents, as observed during a survey. The facility's recipe for Oven Herb Roasted Turkey Breast specified that each portion should weigh 2.5 ounces to provide a 2-ounce protein serving. However, the facility was initially not using a scale to weigh the turkey portions, and the District Manager, V21, indicated that they were serving about one slice per person. Upon weighing, the turkey portions were found to be only 2 ounces, and the kitchen ran out of turkey, necessitating a substitute. Residents expressed dissatisfaction with the food portions and the facility running out of food during a Resident Council Meeting. The Dietary Manager, V12, was unsure why they ran out of turkey, suggesting it might have been due to double portions or requests for more. The Consulting Dietician, V22, stated that if the facility ran out of food, it was because they did not order enough. The facility's policy on meal planning requires that each resident be served food to meet their needs and physician's orders, including a total of 6 ounces of good quality protein daily. The facility has 102 residents, as documented in the CMS 671 form.
Failure to Maintain Hygienic Food Handling Practices
Penalty
Summary
The facility failed to maintain hygienic practices in food handling, which has the potential to affect all residents. On 10/22/24, a Dietary Aide was observed placing diet cards and lids on residents' trays while repeatedly rubbing her nose and wiping sweat from her brow. Despite being asked by direct care staff and an Area Manager to wash her hands, the Dietary Aide appeared confused and did not comply. After washing her hands, she immediately rubbed her nose again and continued to scoop ice cream from a large bucket into bowls, which were then distributed to residents. The facility's policy, dated 2/2023, requires all food to be prepared in accordance with the FDA food code, including proper handwashing and glove use.
Violation of Resident Privacy and Dignity Due to CNA Cell Phone Use
Penalty
Summary
The facility failed to respect residents' rights to privacy and dignity during care, as evidenced by multiple reports from residents during a council meeting. Four residents reported that Certified Nursing Assistants (CNAs) were frequently on their cell phones while providing care, which compromised their privacy and dignity. One resident specifically mentioned a CNA using speaker mode on her phone while assisting him in the bathroom, leading to a lack of privacy. Other residents expressed that their requests for care were ignored because CNAs were preoccupied with their phones. The Director of Nurses (DON) acknowledged the issue, particularly with agency CNAs, and stated efforts were being made to address it. The facility's Resident Rights policy emphasizes creating a home-like environment that respects residents' dignity and preferences, which was not upheld in these instances. The DON mentioned that disciplinary actions are taken against CNAs who continue to use their phones during work, and agency CNAs may be placed on a do-not-return list if the behavior persists.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care to two residents who were dependent on staff assistance for activities of daily living (ADLs). On October 22, 2024, one resident was observed in bed with a dirty mouth, dry and flaky facial skin, messy hair, and dirty, untrimmed nails. This resident had diagnoses of hemiplegia, weakness, need for assistance with personal care, and dementia, and was documented as dependent on hygiene in their Minimum Data Set (MDS) and care plan. Similarly, another resident was observed with a dirty mouth, messy hair, a dirty gown, and dirty, untrimmed nails. This resident had diagnoses of hemiplegia, hemiparesis following cerebral infarction, and encephalopathy, and was also documented as dependent on hygiene in their MDS and care plan. The Director of Nursing acknowledged that staff are responsible for providing morning care to these residents, who require assistance with their daily care needs.
Medication Error Due to Incorrect Room Assignment
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, resulting in a medication error involving two residents. One resident, who was admitted to the facility in hospice care, was mistakenly given the medications intended for another resident. This error occurred because the electronic health care record did not reflect a room change, leading to both residents being listed for the same bed. The error was discovered when the second resident asked for his medications, prompting the realization of the mistake. The medications given in error included a narcotic, Methadone, among others. The Licensed Practical Nurse involved in the incident was an agency nurse who administered the wrong medications. The Director of Nursing was notified immediately, and the resident who received the incorrect medications was monitored for any adverse effects. The pharmacist and nurse practitioner confirmed that the ingestion of Methadone did not pose increased clinical significance due to the resident's current medication regimen, and no negative side effects were observed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a significant deficiency. Two residents, both with severe cognitive impairments, were involved in multiple altercations. One resident, with a history of aggressive behavior, physically assaulted another resident, causing physical harm and psychosocial distress. The incidents were documented in facility reports and nursing notes, highlighting a pattern of resident-to-resident altercations that were not adequately addressed by the facility. The resident identified as R5, who has a diagnosis of dementia and severe cognitive impairment, was involved in several altercations with other residents. Despite previous incidents of aggression, the facility did not implement effective interventions to prevent further occurrences. On multiple occasions, R5 physically assaulted other residents, including an incident where R5 slapped another resident in the dining room and another where R5 kicked and pushed a resident in a wheelchair. These incidents were documented, but the facility's response was insufficient, as no new interventions were added to R5's care plan after some of these altercations. The most severe incident occurred when R5 assaulted R2, another resident with severe cognitive impairment, in their shared room. R5 was observed on video repeatedly hitting R2 and attempting to choke her with a blanket. This incident resulted in physical injuries to R2, including facial bruising, and caused significant distress. Despite the severity of the incident, the facility's previous interventions had not effectively prevented such occurrences, indicating a failure to protect residents from abuse and neglect.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for three of the six residents reviewed. Observations on two consecutive days revealed that the 300/400 hall shower room had a persistent foul odor of feces, dirty clothing, and a bag of dirty linen on the floor. The toilet in the shower room contained toilet paper, although no feces were noted. Residents reported having to clean the shower room themselves before use due to its unclean state, with one resident mentioning that the room always had dirty clothes and towels on the floor, some with feces. Another resident reported a pile of feces on the floor next to the toilet that remained for almost a full day before being cleaned. Interviews with residents indicated that housekeeping did not regularly clean the shower rooms, and residents had to request cleaning services. The Housekeeping Manager acknowledged that while they aim to clean resident rooms and shower rooms daily, they sometimes get sidetracked, resulting in incomplete cleaning. The housekeeping protocols outlined a morning and PM walk-through to address trash, restock supplies, sweep/mop, and manage odors, but these were not consistently followed, leading to the unsanitary conditions observed.
Inadequate Cohorting and PPE Use for COVID-19
Penalty
Summary
The facility failed to properly cohort residents with COVID-19 and adhere to infection control protocols, potentially affecting all 112 residents. On July 16, 2024, it was observed that an occupational therapist was in a room with two COVID-19 positive residents, wearing only an N95 mask without additional PPE, under the mistaken belief that the residents were no longer in isolation. Despite contact/droplet precaution signage, there was inconsistency in PPE usage among staff, with some unaware of the requirement to wear full PPE, including face shields. A housekeeper was unaware of the need for face shields, and a computer technician was not informed about the COVID-19 status of residents, leading to non-compliance with mask-wearing protocols. Additionally, the facility's failure to cohort residents appropriately was highlighted when a COVID-19 positive resident was housed with a negative resident due to a lack of available rooms. The facility's policy required full PPE for staff and cohorting of residents with the same respiratory pathogen, but these measures were not fully implemented. The administrator acknowledged the lack of available rooms and the decision to house residents together despite the risk, citing centralized admitting processes and room availability issues.
Failure to Notify Family Representatives of COVID-19 Cases
Penalty
Summary
The facility failed to notify the family representatives or Power of Attorney (POA) of two residents, R3 and R4, about positive COVID-19 test results and the presence of COVID-19 in the building. R3, who is moderately cognitively impaired, was placed under strict contact/droplet isolation due to COVID-19. However, the facility did not document notifying R3's responsible party about the positive COVID-19 status on the date of the test. Although R3's daughter stated she was informed of the positive test result, she was not notified when the facility first identified COVID-19 in the building. R4, who is severely cognitively impaired, tested negative for COVID-19 but was in proximity to a COVID-positive resident, R3. The facility's records did not document any notification to R4's POA about the exposure to a COVID-positive resident or the outbreak in the facility. The facility's policy requires notifying the resident, their physician, and responsible party of any change in condition, which was not adhered to in these cases.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications timely to four residents, as observed and documented in the report. Resident 1, who has multiple diagnoses including hypertension and diabetes, was observed receiving her 8:00 AM medications at 9:20 AM. This delay in medication administration was not in accordance with the prescribed schedule documented in her Medication Administration Record (MAR). Resident 2, who is cognitively intact and has a history of reporting late medication administration, stated that he often receives his 8:00 AM medications as late as noon. On the day of observation, his medications were administered at 9:45 AM. The resident had previously reported these delays to the facility's Administrator and Director of Nursing, but no explanation was provided to him. The delay was attributed to the nursing staff's workload and the division of hallways, which resulted in the 400 hall being attended to last. Residents 3 and 4 also experienced delays in receiving their 8:00 AM medications, with administration occurring at 9:25 AM and 9:38 AM, respectively. The nursing staff cited various reasons for these delays, including the time it takes to complete the medication pass and interruptions during the process. The Director of Nursing confirmed the expectation that medications should be administered within one hour before or after the scheduled time, yet denied any concerns regarding late administration. The facility's Medication Administration Policy emphasizes the importance of timely medication administration, but the observed practices did not align with this policy.
Laundry Management Deficiency
Penalty
Summary
The facility failed to ensure that resident clothes were being maintained, cleaned, and returned in a timely manner for six out of thirteen residents reviewed for laundry. Residents reported that their clothes were often missing, returned with bleach stains, or replaced with someone else's clothes. Specific instances included residents finding their clothes with white spots, missing clothes for months, and being forced to wear clothes that did not belong to them. One resident even noted that their clothes were labeled, yet still went missing, and another resident mentioned that their clothes were not labeled correctly, leading to further confusion and distress. The issue was brought up multiple times during resident council meetings and through grievance forms, but the problems persisted. The facility's administrator acknowledged the complaints and mentioned that activities staff were helping to ensure residents received their clothes. However, the residents continued to experience issues with their laundry, indicating that the measures taken were insufficient. The facility outsourced its laundry services, and the EVS Area Manager for Laundry stated that they were aware of the complaints and were in the process of addressing them, but the problems had not been fully resolved. The facility's policies on resident rights and personal clothing emphasize the importance of maintaining a homelike environment and ensuring the dignity and well-being of residents. Despite these policies, the facility failed to uphold these standards, leading to significant distress and inconvenience for the residents. The ongoing issues with laundry management highlight a critical deficiency in the facility's ability to provide a safe, clean, and comfortable environment for its residents.
Failure to Provide Palatable and Warm Food
Penalty
Summary
The Facility failed to provide food that is appetizing and at palatable temperatures for seven residents. Multiple residents reported that the food served in the dining room and on hall trays was often cold. Specific instances included a resident stating that breakfast was cold and staff were unwilling to warm it, another resident mentioning that food is never hot whether eaten in the dining room or in their room, and another resident noting that food takes a long time to be served, resulting in it being cold. Additionally, the Ombudsman confirmed that residents had been complaining about cold food in both March and May Resident Council Meetings, with no resolutions being implemented by the Facility. On the day of observation, a cart with hall trays was left unattended beside the nurse's station, and a family member had to take a tray to a resident's room to ensure the food was warm. Test tray temperatures were taken, revealing that the fried egg and waffle were cool to the touch, measuring 84°F, and the oatmeal measured 126°F. The Facility's policy states that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, as evidenced by the observations and resident interviews.
Failure to Maintain RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for 8 hours daily, as required. This deficiency was identified through the review of staff schedules and time cards for April 2024. Specifically, the time cards for an RN, identified as V13, did not document that he stayed until 8:00 AM on Sundays (4/7, 4/14, 4/21), resulting in the facility not meeting the 8-hour RN coverage requirement on those days. The Administrator confirmed that the Assistant Director of Nursing (ADON) works on the floor Monday through Friday, and another RN works from 11:00 PM to 8:00 AM on Fridays and Saturdays. The facility's policy on staffing, dated September 2023, states that staffing is based on the Illinois Department of Public Health (IDPH) requirements. The facility has a census of 107 residents.
Failure to Identify and Assess AV Shunt
Penalty
Summary
The facility failed to identify and assess an arteriovenous shunt for a resident who was severely cognitively impaired. The resident's medical records indicated the presence of an AV shunt placed in 2019 for dialysis, which required specific precautions and regular checks for bruit and thrill. However, the facility did not include these orders in the resident's care plan until after the resident was sent to the hospital for evaluation due to pain in the left arm. The hospital confirmed the presence of the AV shunt and noted it was functioning normally, but the facility had not been monitoring it as required by their own dialysis protocol. The Assistant Director of Nursing admitted that the order to check the AV shunt was forgotten, and the Administrator confirmed that the shunt was only discovered right before the resident was sent to the hospital. The facility's policy required daily checks of the dialysis site for signs of infection, bleeding, and proper function, but these checks were not performed until after the hospital visit. This oversight led to a failure in providing appropriate treatment and care according to the resident's needs and medical orders.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by multiple incidents involving four residents. One resident, who was severely cognitively impaired and required substantial assistance, was physically and verbally abused by her brother, who was also her POA. The abuse was witnessed by EMS personnel and reported to the police. Despite the brother's history of abusive behavior, the facility staff appeared to have normalized his actions, and there was no immediate intervention to protect the resident from further harm. Another incident involved a dietary staff member who verbally abused a resident. The staff member was heard cursing loudly and directed profanities at a resident who asked her to stop. The staff member was eventually escorted out of the building, but the incident caused significant distress to the resident and other witnesses. The facility's investigation concluded that the abuse was not substantiated because the employee's words were not directed specifically at the resident, despite multiple witness statements to the contrary. A third incident involved a resident who was physically assaulted by another resident in the dining room. The assaulted resident was moderately cognitively impaired and required assistance with mobility. The aggressor, who had a history of aggressive behavior, struck the resident on the head. Despite the clear evidence of physical abuse, the facility's administration did not substantiate the abuse, citing a lack of willful intent. This decision was made despite witness statements and the facility's own documentation of the incident.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving a resident, identified as R2, who was observed being verbally and physically abused by a male individual, V3. Multiple staff members and emergency medical services (EMS) personnel witnessed V3 yelling at R2, using vulgar language, and physically manipulating her head in a forceful manner. Despite these observations, the facility did not report these incidents to the appropriate authorities as required by their abuse policy and prevention program. On several occasions, EMS personnel, including V4, V5, V6, and V8, witnessed V3 verbally assaulting R2 and physically striking her forehead. V8, the EMS Chief, reported the incident to the local police department, and V3 was subsequently escorted off the premises. Staff members, including CNAs and LPNs, confirmed that V3's abusive behavior towards R2 was a common occurrence and had been reported to the facility's administration multiple times. However, the facility's administration failed to take appropriate action to address and report these allegations of abuse. The facility's abuse policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or compliance officer and documented. Despite this policy, the facility only had one documented instance of alleged verbal abuse involving R2 from May 2023. The Director of Nursing (DON) and other staff members acknowledged that no other instances of abuse had been reported, indicating a failure to adhere to the facility's abuse reporting procedures.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The Facility failed to investigate an allegation of abuse involving a resident (R2) by a male individual (V3). Multiple staff members and EMS personnel reported witnessing V3 verbally and physically abusing R2. V3 was observed yelling at R2, using vulgar language, and forcefully manipulating her head. Despite these reports, the Facility only provided one investigation report dated several months prior, indicating a lack of thorough investigation into the ongoing abuse allegations. On multiple occasions, EMS personnel and Facility staff witnessed V3's abusive behavior towards R2. EMS personnel reported hearing V3 yelling and using vulgar language towards R2, and observed him physically manipulating her head in a forceful manner. Staff members also reported that V3's abusive behavior was a common occurrence and had been reported to the administration multiple times. Despite these reports, the Facility failed to conduct a thorough investigation into the allegations. The Facility's failure to investigate the allegations of abuse is a violation of their own abuse policy, which requires immediate reporting and investigation of any incidents or allegations of abuse. The policy also mandates that the Facility take all necessary steps to protect residents from abuse, neglect, and mistreatment. The lack of a thorough investigation into the ongoing abuse allegations against V3 indicates a failure to adhere to this policy and protect the resident from harm.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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