Palm Garden Of Mattoon
Inspection history, citations, penalties and survey trends for this long-term care facility in Mattoon, Illinois.
- Location
- 1000 Palm, Mattoon, Illinois 61938
- CMS Provider Number
- 145584
- Inspections on file
- 54
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Palm Garden Of Mattoon during CMS and state inspections, most recent first.
The facility failed to protect a resident from verbal abuse by another cognitively intact resident with a history of verbal aggression and mental health diagnoses. The aggressive resident, who uses an electric wheelchair and is care planned for verbally aggressive behavior and use of racial slurs, confronted another wheelchair-bound resident in the smoking area, misinterpreted the resident’s laughter, and responded by yelling profanities and racial slurs, including comments about the resident’s Black spouse and biracial children, while pointing a finger in the resident’s face and bumping his wheelchair. Multiple residents corroborated that this resident frequently yells racial slurs in hallways, claims to be a Nazi, makes Nazi salutes, and attempts to intimidate others, and the Administrator confirmed a known history of such verbally aggressive, racist behavior toward residents and staff.
A resident with dementia, severe cognitive impairment, documented wandering, and high elopement risk eloped unsupervised after staff failed to consistently perform care‑planned 15‑minute visual checks and did not ensure that exit door alarms were audible and effective. In the weeks before the incident, records showed repeated exit‑seeking, attempts to push on exit doors, and aggressive behaviors requiring frequent redirection. On the day of the event, CNAs were in a resident room with the door closed and an LPN was in the dining room, leaving the hall unsupervised; staff near the front door and on the unit reported hearing no alarms. Maintenance later confirmed that exit doors produced only local beeping and that the front door’s louder alarm was delayed long enough for a resident to pass through unnoticed. The resident was found off‑site by a community member with abrasions and a knee contusion after an unwitnessed fall.
The facility failed to initiate and develop complete elopement care plans, including focus areas, goals, and interventions, for three residents who had been assessed as high risk for elopement. One resident had severe cognitive impairment with multiple psychiatric and neurologic diagnoses, while two others were cognitively intact but identified as high elopement risks on formal evaluations. An LPN reported she began reviewing high-risk charts mid-month and had not yet reviewed all relevant residents, and she only added elopement care plans for these residents later in the month. The Administrator stated that all residents at any elopement risk level should have had care plans initiated and reviewed by the interdisciplinary team earlier, consistent with facility policy requiring assessment-based identification of risks, targeted interventions, and documented implementation and monitoring.
A resident with CHF, bilateral AKA, neuromuscular bladder dysfunction, anxiety, depression, and a buttocks pressure ulcer, who was dependent on staff for toileting and hygiene, reported that two night-shift agency CNAs became upset during incontinence care, called him derogatory names, pinned his arms, and caused fingernail-type skin tears while he was soiled with diarrhea, then struck his hand so that his drink flew across the room. A CNA on the next shift found the resident crying uncontrollably, observed fresh crescent-shaped skin tears consistent with fingernail injuries, and noted feces on the bedding, pillow, and floor, as well as a pop bottle across the room with dried, sticky liquid on the floor. An RN skin assessment documented a skin tear and adjacent crescent-shaped break in the skin with dried blood, consistent with a fingernail injury, and one involved CNA admitted to holding the resident’s wrists down and leaving him soiled until the next shift, while the DON confirmed staff should not restrain or antagonize residents and that this resident was not known to make false allegations.
A resident with multiple comorbidities, moderate cognitive impairment, and total dependence for ADLs was identified as at risk for pressure ulcers but did not receive timely pressure-relieving interventions or thorough skin assessments. New open areas with necrotic tissue and drainage were documented on the right heel, and the left heel was noted as red without full assessment. Heel protectors were not obtained on admission, and the resident’s heels reportedly rested directly on the bed most of the day. A wound care referral and heel guard order were not documented until later, and no complete wound assessment was recorded upon the resident’s readmission from the hospital. When a wound physician evaluated the resident, the right heel ulcer was classified as Stage IV and larger than previously documented, indicating worsening of the pressure injury.
Two residents experienced falls and injuries due to the facility’s failure to implement and follow fall-prevention interventions and to maintain safe equipment. One high fall-risk resident with multiple comorbidities, dizziness on standing, and on anticoagulant therapy had repeated falls, including unwitnessed and witnessed events in common and dining areas, after attempting to stand or move between chairs without adequate supervision or access to a wheelchair as care-planned, and without a bedside table to keep personal items within reach. Another resident with mobility impairments and a right AKA fell when a prescribed bed side rail detached from the bed frame as it was used for support; the maintenance director and DON confirmed the rail had not been properly secured and that only maintenance staff were supposed to install bedrails.
The facility failed to maintain sufficient licensed nurse and CNA staffing to meet residents’ needs, as evidenced by schedules and staff interviews showing that one LPN and one CNA were responsible for the front half of the building on a night shift and that only one LPN was on duty in the entire building for several hours on a subsequent day shift. An LPN reported being the only nurse on the front halls at night with limited CNA and unit aide support, and described periods when only one CNA was available for extensive morning care while the LPN was completing an early medication pass. The DON confirmed ongoing staffing shortages and that one LPN was alone in the building for several hours, during which a resident in another hall had a seizure and fell, and staff reported that care and safety were compromised and tasks had to be rushed when staffing was inadequate.
The facility did not employ a full-time Certified Dietary Manager (CDM) to oversee food and nutrition services for all residents. Instead, a Certified Food Protection Manager (CFPM) directed dietary staff, educated kitchen staff, and assisted with meal preparation and service, despite stating she was not a CDM and was not enrolled in a CDM program. During part of the survey period, there was no CDM employed or onsite, and a regional RN confirmed that the facility lacked a CDM while the CFPM functioned as the acting dietary manager.
A dietary aide prepared ready-to-eat frozen pancakes for a breakfast meal without following required hygiene and protective measures. The aide handled the pancakes with bare hands, did not wash hands immediately before food preparation, wore an oversized winter coat whose sleeves contacted the food, and used a hair net that did not fully cover her hair. The facility’s Certified Food Protection Manager and written policy require glove use for ready-to-eat foods, proper hair restraints, and handwashing prior to food preparation, but these standards were not followed while preparing food for all residents.
The facility failed to maintain a clean, homelike environment and safe furnishings for several residents. Walls in multiple rooms were dented and scratched, closet doors were missing, and nails were protruding from a wall behind a dresser. One resident expressed a desire for her damaged wall to be repaired so her room would look neat and well cared for. Another resident’s mattress was worn, with a large wet area, and a CNA reported the resident had to lie on a wet bed nightly, with urine seeping through the degraded mattress surface and saturating clothing. Staff reported that a prior written maintenance request system had been discontinued, leaving only undocumented verbal reports to the Administrator, and a housekeeper stated that the chemical spray used to clean mattresses degraded their surfaces, allowing urine to soak into them.
The facility failed to prevent misappropriation of smoking materials when a cognitively intact resident with a documented history of taking others’ property repeatedly obtained cigarettes and vape cartridges belonging to another cognitively intact resident. Smoking materials were stored at the nurses’ station and placed on the counter without resident names at smoking times, and access to the storage cabinet was possible when an agency nurse left the doorway to the nurses’ station unlocked, allowing the resident to climb over the counter and reach the cabinet. The affected resident reported multiple missing vape cartridges that were later found in the other resident’s possession, sometimes after delays, including one instance where he was observed using her vape and sharing it with other residents, constituting misappropriation under the facility’s abuse policy.
The facility failed to report multiple allegations of misappropriation of resident property to the state surveying agency as required by its abuse policy. A resident with a documented history of behavioral problems related to misappropriation admitted to taking cigarettes and vape cartridges that belonged to others, while two residents reported their smoking materials repeatedly went missing and were later found in this resident's possession. Several staff, including CNAs and a psychiatric rehabilitation services assistant, stated they had direct knowledge of these incidents over several months and had reported them to the Administrator, who, based on guidance from regional corporate staff, did not treat the incidents as theft or report them unless the items were fully consumed. Only one incident was ultimately reported to the state agency, despite multiple separate allegations.
A cognitively intact paraplegic resident with multiple chronic conditions was issued an emergency involuntary discharge, and the facility independently selected an accepting out-of-state facility without allowing the resident to participate in choosing the destination. The resident, who wished to return to a different state where he had previously lived, reported that he was not asked about his preferences or offered options consistent with his wishes. The Administrator, SSD, and Director of Admissions acknowledged that referrals were sent and an accepting facility was secured before informing the resident, and that the resident was not permitted to suggest facilities, despite policy and resident-rights materials stating that residents have the right to participate in their own care planning.
A cognitively intact resident with multiple comorbidities and limited physical mobility was care planned for a Restorative Nursing Active ROM Program, including bilateral lower-extremity ROM exercises twice daily, along with supportive care and gentle ROM as tolerated. The resident reported wanting assistance with ROM and strengthening exercises and stated staff did not ask him to participate in any restorative ROM program. Review of restorative documentation over several months showed numerous gaps with no evidence that exercises were attempted or completed and multiple entries listing the resident as unavailable, despite the DON confirming the resident was consistently in the room and available, that the program could be done in bed, and that it should be offered multiple times per day. The DON also stated that the restorative aide did not really perform his job and that more than one restorative aide was needed for the facility’s census.
The facility failed to protect a resident’s BiPAP mask from potential cross-contamination and did not obtain complete BiPAP orders for two residents. One resident with multiple respiratory and cardiac conditions had a BiPAP mask observed resting directly on a bedside table without any protective covering, even though the resident required staff assistance to apply and remove the mask and the facility practice was to store such masks in plastic bags. Additionally, two residents with chronic respiratory and cardiac diagnoses had BiPAP orders that lacked required inspiratory and expiratory pressure settings, despite facility policy directing staff to ensure physician orders include specific CPAP, IPAP, and EPAP settings.
A resident with multiple mobility and coordination impairments, including COPD, a fractured tibia, gait abnormalities, muscle wasting, and a right AKA, had a physician order and signed consent only for a left half side rail to assist with bed mobility. Facility policy required proper installation and informed consent for bed rail use. The resident was later found on the floor after the left rail detached from the bed frame when used for support. Observation showed both left and right half rails on the bed, with the right rail loose and unstable. The Maintenance Director reported that nursing staff often remove or replace rails and do not secure them correctly, and confirmed there was no order or consent for the right rail, while the DON confirmed only maintenance staff were authorized to install or remove bed rails.
A resident with an indwelling urinary catheter was observed seated in a wheelchair with an uncovered urinary collection bag placed on the armrest, leaving approximately 100 cc of urine clearly visible to anyone passing by. The resident reported feeling that her dignity was largely lost in the nursing home, citing both exposure during catheter and perineal care and family members reacting negatively to seeing the urine bag. The DON later confirmed in an activity area that the bag remained uncovered in the presence of other residents and acknowledged it should have been covered, despite the facility’s policy requiring staff to help residents keep catheter bags concealed to maintain dignity.
The facility failed to accurately complete MDS assessments for three residents by incorrectly coding insulin use in Section N despite no corresponding physician orders. For each of these residents, the MDS documented that insulin was received, while the December physician order sheets contained no insulin orders. A regional clinical nurse later confirmed that these MDS assessments were coded incorrectly, as the residents did not in fact receive insulin.
Surveyors found that the facility failed to ensure accurate and timely PASRR Level 2 screenings and renewals for three residents with serious mental illness and intellectual disabilities. One resident’s PASRR omitted documented diagnoses of schizophrenia with hallucinations and bipolar disorder, incorrectly stating there was no SMI and resulting in no recommendation for specialized mental health services. Two other residents, each with multiple psychiatric diagnoses including schizophrenia, psychotic disorder, major depressive disorder, bipolar disorder, and PTSD, had PASRR Level 2 determinations that were approved only for short-term stays, but the required redeterminations were not completed before the prior approvals expired, as later confirmed by facility nursing leadership.
A resident with multiple serious behavioral health diagnoses, including BPD, bipolar disorder, MDD, PTSD, and substance abuse, had a care plan goal to return to the community with interventions such as evaluating appropriate living arrangements, arranging community support resources, and providing written instructions. The resident resided on a locked behavioral health unit and expressed concern that staff wanted to remove him, seeking clarification from the Administrator. The DON acknowledged plans to discharge the resident to another facility, and the Social Services Director stated that the current facility could not provide the group services needed to support the resident’s community re-integration goal and that another facility could provide those services, demonstrating a failure to provide the necessary behavioral health services to meet the resident’s identified goal.
The facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD) for its locked mental illness behavioral unit, despite state requirements for this role and for provision of community reintegration groups. A resident with multiple serious mental health diagnoses, who was generally independent in ADLs and had a documented goal to return to the community, reported concerns about being forced to leave. The DON, Administrator, and a PRSC all confirmed there was no current PRSD, the position had been vacant for months, and community reintegration groups were not being provided. The Administrator stated an LPN had unsuccessfully attempted to fill the role and that the PRSC was qualified but not selected, and staff indicated that needed reintegration services would instead be provided at another facility.
Surveyors found that meals were not consistently palatable, adequately portioned, or served at appetizing temperatures. Observations showed chili being scraped from the bottom of the pan, appearing very thick with no visible liquid, and meal trays sitting on a cart for a period before being passed to residents. A resident council president and other residents reported that meals were cold, tasted bad, arrived late, and were served in small or inconsistent portions, with one resident leaving a full tray untouched and relying on outside food. The food service manager later acknowledged resident complaints and confirmed that staff had run out of appropriate bowls and chili for residents needing pureed textures.
Two residents with cognitive impairment and behavioral issues experienced significant injuries due to the facility's failure to implement and document appropriate fall prevention and behavioral interventions. One resident suffered a coccyx fracture after an unwitnessed fall without evidence of required safety checks or reminder signs, while another resident with a history of putting fingers in his mouth sustained a traumatic fingertip amputation during a fall, with no care plan interventions addressing this behavior. Staff relied only on verbal reminders, and investigative documentation was incomplete.
A resident who began using a wheeled walker after a fall and was independently transferring and ambulating did not have their care plan updated to reflect these changes. Staff confirmed the care plan inaccurately documented the resident's transfer status and assistive device use, despite the resident's current needs and therapy interventions.
Two residents with respiratory conditions did not receive oxygen therapy in accordance with physician orders, including missing orders for oxygen administration, incorrect flow rates, and failure to change humidifier bottles and tubing as scheduled. Observations included dry or nearly empty humidifier bottles and undated equipment, with staff confirming that required procedures were not followed.
Nursing staff, including agency nurses, documented that oxygen therapy equipment for two residents was changed according to physician orders, but observations revealed the equipment had not been changed as recorded. The DON confirmed the documentation was inaccurate, and facility policy requires complete and accurate recording of all treatments.
Staff failed to maintain resident dignity during incontinence care by not providing privacy and during mealtime by not offering individualized assistance, particularly for residents with severe cognitive and physical impairments. One resident was exposed during care without the privacy curtain drawn, and several residents requiring feeding assistance were left unattended or assisted in a rushed, impersonal manner due to staffing shortages.
A dependent resident with severe cognitive impairment and multiple health conditions did not receive timely or complete incontinence care. CNAs failed to maintain a clean field, did not cleanse the front perineal area, and left a saturated incontinence brief on the resident's personal pillow. Staff interviews confirmed that facility policy for perineal cleansing was not followed.
A resident with multiple psychiatric and medical diagnoses had changes made to psychotropic medication and lab orders without the required notification to the court-appointed guardian. Despite the guardian's legal authority and prior communication of her role, facility staff did not document or provide timely notification of these changes, as confirmed by staff interviews and record review.
A resident with multiple psychiatric and medical diagnoses was not administered her prescribed Ativan for anxiety on ten occasions due to delays in obtaining a renewal prescription and lack of timely physician notification, despite facility policy requiring prompt action when medications are unavailable.
Surveyors found that four community shower rooms were not maintained in a clean, safe, or homelike condition, with issues such as thick dust on vents, missing floor tiles, exposed heating components, non-functioning ventilation, and black mold. Two residents reported ongoing problems with cleanliness, mold, flooding, and poor air quality, while staff and maintenance confirmed persistent plumbing and ventilation failures.
A resident with a history of mental health and cardiac conditions was repeatedly subjected to verbal abuse, threats, and attempted physical aggression by another cognitively intact resident. The incidents, witnessed by staff and another resident, caused significant emotional distress and fear, yet the victim's care plan lacked interventions for abuse risk, and staff failed to document or report the altercations as required by facility policy.
A resident with a history of anxiety and heart failure was repeatedly subjected to verbal and mental abuse by another cognitively intact resident, including threats and profanities, over the course of a day. Staff were aware of the ongoing abuse but did not intervene or provide increased supervision, leaving the affected resident feeling scared and altering her routine to avoid further abuse. Facility policy requiring separation of residents during abuse investigations was not followed.
Multiple incidents of verbal and mental abuse between residents were not promptly reported to the Abuse Coordinator as required by facility policy. In each case, staff either failed to recognize the need to report or did not notify appropriate supervisory personnel, resulting in delayed investigation of the allegations.
The facility did not maintain sufficient CNA staffing on multiple days, falling short of its own assessment of required staff. As a result, several cognitively intact residents experienced prolonged waits for assistance with transfers, toileting, and other care needs, with some waiting up to an hour for their call lights to be answered. Staff confirmed the ongoing staffing shortages and the impact on timely resident care.
A medication administration pass resulted in a 10.7% error rate when an LPN failed to follow medication orders for a resident, including administering Gabapentin and TUMS together against label instructions, giving an incomplete dose of Levetiracetam, and omitting a prescribed Calcium + D3 tablet due to unavailability.
A resident experienced decreased urination and abdominal distention over several days, which staff observed but did not promptly report to a provider, resulting in hospitalization for urinary retention, UTI, and acute kidney injury. Additionally, a CNA failed to perform hand hygiene after providing toileting care to another resident. These actions were not in accordance with facility policies for change notification and infection control.
The facility did not provide enough CNAs during night shifts to meet the care needs of all residents, with staffing records and staff interviews confirming that only one CNA was sometimes available for entire units, including those with residents requiring high levels of assistance and behavioral management. Staff reported that missed shifts by agency CNAs were not always covered, leading to delays in incontinence care and challenges in supervising residents with behavioral issues.
The facility did not have a full-time DON for several months and failed to provide RN coverage for at least 8 consecutive hours per day, as required. Staffing records and staff interviews confirmed that only LPNs and agency nurses were available for many shifts, with the sole full-time RN working nights. This deficiency affected all residents, many of whom required complex care and behavioral health support.
A resident with moderate cognitive impairment who required substantial staff assistance for transfers experienced a staff-assisted fall during a transfer from bed to wheelchair. Facility staff did not document key details of the incident, including staff involved and use of a gait belt, and failed to conduct a thorough fall investigation or update the care plan as required by policy.
A resident with a urinary catheter was prescribed antibiotics for a UTI without documented clinical symptoms or urine culture results to support the diagnosis. Antibiotics were started before obtaining appropriate laboratory confirmation, and a repeat urine culture was not performed as recommended, leading to treatment that did not follow established infection control protocols.
A resident's advance directive was not accessible during a choking emergency, leading to a delay in CPR initiation. The resident's code status was not documented in the medical records, causing staff to hesitate before starting resuscitation. The resident, who was severely cognitively impaired, had no respirations and a low pulse when CPR was eventually started.
The facility failed to ensure all nursing personnel were CPR certified, potentially affecting all 86 residents. Despite a policy requiring certification within 90 days of hire, a Registered Nurse admitted they were still working on a plan for certification. A Regional Clinical Nurse could not provide CPR cards for all staff, indicating non-compliance.
The facility failed to supervise a resident with hot food, resulting in burns, and did not remove a tripping hazard, leading to a fall and hospitalization for another resident. Additionally, a resident experienced siderail entrapment due to improper use of bed rails. These incidents highlight lapses in supervision and safety measures.
The facility failed to employ a full-time DON, affecting 83 residents. The facility's assessment required a full-time RN as DON, but during a survey, no DON was onsite. The Administrator confirmed the absence of a DON for months and is seeking to fill the position.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruises, but the facility failed to report these injuries of unknown origin to the State Agency as required by their policy. Despite staff efforts to determine the cause, no direct cause was identified, and the facility's Administrator did not comply with reporting requirements.
A facility failed to conduct a Level II PASARR for a resident who was initially screened as not having a serious mental illness but later diagnosed with a Psychotic Disorder with Hallucinations. The resident's Level I PASARR did not indicate a history of severe mental illness, but a new diagnosis was added to their record. The Admissions and Marketing Coordinator confirmed the absence of a Level II PASARR and stated that arrangements were being made to complete one. The facility administrator acknowledged the lack of a specific policy for PASARR screening.
A facility failed to obtain a Level II PASARR for a resident with serious mental illness, including diagnoses of Schizophrenia and major depression. The resident's Level I PASARR indicated a need for further evaluation, which was not completed. The Admissions and Marketing Coordinator acknowledged the oversight, and the facility administrator confirmed the lack of a specific PASARR policy.
A facility failed to prevent cross contamination during wound care and did not document or monitor pressure ulcers for a resident with multiple medical conditions. The resident's open wounds contacted a contaminated wheelchair cushion, and the LPN did not cleanse the wounds before applying dressings. The facility's policies for wound care and documentation were not followed.
The facility failed to prevent cross-contamination during incontinence care for a resident with severe cognitive impairment and a recent UTI recovery. CNAs did not perform hand hygiene or change gloves during care. Additionally, a resident's catheter bag was found on the floor without a dignity cover, contrary to facility policy.
Failure to Protect Resident From Ongoing Verbal and Racially Abusive Behavior by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident verbal abuse, as required by its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program Policy, which states that each resident has the right to be free from abuse, including verbal abuse. One resident (R2), who has diagnoses of Major Depressive Disorder and Generalized Anxiety and is care planned for potential verbal aggression and inappropriate social behaviors such as racial slurs and offensive gestures, was documented in nurses’ notes as verbally attacking staff and residents, using racial slurs, and ramming his electric wheelchair into another resident’s (R1’s) chair. R2 later admitted to surveyors that he “got into it” with R1, became upset when he believed R1 was laughing at him, and used the N-word toward R1. R1, who is cognitively intact with paraplegia, chronic pain, a history of traumatic brain injury, and uses a manual wheelchair, reported that R2 came to the smoking area while upset with staff, misinterpreted R1’s laughter at a phone video, and then began verbally attacking him with profane language and racial slurs, including calling him a “N***** lover” because R1’s wife is Black and his children are biracial. R1 stated that R2 got in his face, pointed a finger, and bumped him with his electric wheelchair, and that R2 frequently yells racial slurs in the hallways, makes Nazi salutes, and says “[NAME] Hitler,” making R1 feel uncomfortable where he lives. Two other residents (R4 and R5) corroborated that they witnessed R2 verbally abusing R1 with racial slurs, cursing, pointing a finger in R1’s face, and ramming his wheelchair into R1’s wheelchair, and they described R2’s ongoing racist, intimidating behavior toward residents and staff. The Administrator confirmed that R2 has a history of verbal aggression toward other residents, including the use of racial slurs, and that R2 and R1 were involved in a verbal altercation on the specified date.
Failure to Supervise Exit-Seeking Resident and Maintain Audible Door Alarms Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and ensure that a door alarm was audible to staff, which allowed a cognitively impaired, exit‑seeking resident to elope from the building. The resident had diagnoses of dementia with behavioral disturbance, Alzheimer’s disease, anxiety, major depressive disorder, and a need for assistance with personal care. The resident was documented as severely cognitively impaired on the MDS, required supervision for bed mobility, transfers, and ambulation, and had been assessed as high risk for elopement. Social service and other assessments documented wandering behavior, inability to safely navigate community streets, lack of awareness of dangerous situations, and a need for 24‑hour supervision and monitoring. The care plan identified risk for wandering and/or elopement, impaired safety awareness, and included interventions such as monitoring the resident’s location, providing diversions, and performing visual checks every 15 minutes. In the weeks prior to the elopement, multiple records documented the resident’s escalating behaviors and repeated exit‑seeking. Behavior tracking showed exit‑seeking and elopement attempts on several dates, and nursing notes described the resident wandering into other residents’ rooms, being agitated with redirection, yelling at staff and a roommate, following staff, and physically punching staff. Staff documented that the resident repeatedly attempted to exit the facility, pushed on exit doors, and demanded that staff open the doors, requiring frequent redirection away from exits. A community survival skills screen documented that the resident was not capable of unsupervised outside privileges. Despite these documented risks and the care‑planned 15‑minute visual checks, staff interviews revealed that the visual checks were not consistently completed as ordered. On the day of the elopement, staff last observed the resident around lunchtime when the resident was redirected from another resident’s room back to the nurse’s station area, at a time when no staff were present on the hall because CNAs were in a resident room with the door closed and the LPN was in the dining room with other residents. During this period, the resident exited the facility without staff awareness. Multiple staff members who were present near the front door or on the resident’s hall reported that they did not hear any door alarms sound at the time of the elopement. Subsequent testing of the exit doors by maintenance showed that pushing on the alarm bar produced only intermittent and then continuous beeping at the door itself, with no audible alarm at the nurse’s station, and that opening the exit doors did not trigger any additional audible alarm. The front door was configured so that a louder alarm would not sound unless the door remained open beyond a set delay, allowing a resident to pass through without staff being alerted. The resident was later found by a community member eight blocks away, having sustained abrasions to the right palm and a contusion to the right knee from an unwitnessed fall, and was noted to be alert and oriented only to self, consistent with baseline cognitive impairment. Additional documentation after the elopement continued to show the resident’s ongoing exit‑seeking and aggressive behaviors, including making fists, asking to leave, demanding that CNAs open the door, and requiring multiple redirection attempts. Staff interviews confirmed that some nurses were unaware of existing elopement binders listing high‑risk residents, and that prior to the incident, residents at high risk for elopement did not all have specific elopement care plans distinct from wandering care plans. The surveyors determined that these failures in supervision, failure to implement care‑planned 15‑minute visual checks, and failure to maintain an audible and effective door alarm system resulted in the resident’s unsupervised elopement, fall, and injuries, and exposed the resident to significant danger including road hazards, uneven terrain, and railroad tracks.
Failure to Initiate and Develop Elopement Care Plans for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to initiate and develop elopement care plans for three residents who had been assessed as high risk for elopement. One resident had multiple diagnoses including dementia, disorganized schizophrenia, anxiety, major depressive disorder, psychotic disorder with delusions, mild intellectual disabilities, and unsteady gait, and was documented on the MDS as severely cognitively impaired. This resident’s elopement risk assessment identified a high risk for elopement, yet the elopement care plan was not initiated until 3/30/26 and did not contain a focus area, goal, or interventions prior to that date. Two other residents were documented on their MDS assessments as cognitively intact but were also identified as high risk for elopement on their respective elopement risk evaluations. Despite these high-risk assessments, their elopement care plans were likewise not initiated until 3/30/26 and similarly lacked a focus area, goal, or interventions before that date. Interview with the MDS/care plan LPN revealed that she began reviewing charts for residents at high risk for elopement on 3/13/26 and was still in the process of the initial review as of 4/1/26, stating she had not yet reviewed care plans for residents at low or moderate elopement risk. She confirmed that she added elopement care plans for the three high-risk residents on 3/30/26. The Administrator stated that all residents at any level of elopement risk should have had their care plans initiated, reviewed, and/or updated by 3/16/26, and that elopement care plans should have been initiated when each resident was first assessed as being at risk. The facility’s policy on safety and supervision of residents requires the interdisciplinary care team to analyze assessment information to identify accident hazards or risks, target and implement interventions, communicate and assign responsibility for those interventions, and document and monitor their effectiveness, which was not done for these three high-risk residents prior to 3/30/26.
Failure to Protect Resident From Staff Physical and Emotional Abuse During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from staff-to-resident physical and emotional abuse, contrary to its Abuse Prevention Program, which affirms residents’ rights to be free from abuse, mistreatment, and willful infliction of injury or mental anguish. The resident had significant medical conditions, including congestive heart failure, bilateral above-the-knee amputations, neuromuscular bladder dysfunction, generalized anxiety, depression, and a buttocks pressure ulcer, and was dependent on staff for toileting and hygiene. During an early morning episode of incontinence with a large amount of diarrhea, two night-shift agency CNAs entered the resident’s room to provide care. The resident reported that the CNAs became upset about the extent of cleanup required, called him derogatory names, and one CNA with very long fingernails pinned him down by holding his arms, causing skin tears. The resident stated that when he attempted to drink his pop, the same CNA struck his hand so hard that the drink flew out of his hand. A CNA who arrived on the next shift reported hearing the resident yelling, finding him crying uncontrollably and extremely distraught, and observing two fresh skin tears on his left arm shaped in a manner consistent with fingernail injuries. She also observed that the resident’s bedding and pillow were covered in feces, feces were on the floor, and the pop bottle was across the room with dried, sticky pop on the floor, consistent with the resident’s account that the CNAs left him soiled and had struck the bottle from his hand. An RN who completed a skin assessment after the allegation documented dried blood on the resident’s left arm, a skin tear on the left forearm, and an adjacent crescent-shaped indentation that broke the skin and appeared consistent with a fingernail injury. One of the involved agency CNAs admitted that when the resident became upset and combative, she held his wrists down on the bed and that they left him soiled until the next shift. The DON confirmed that staff should never antagonize or restrain a resident by holding their arms, that this resident was typically cooperative when treated respectfully, and that the resident was not known to make false allegations, corroborating that the resident alleged both emotional and physical abuse by staff.
Failure to Timely Assess and Protect Heels Resulting in Worsening Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough pressure ulcer care and prevention for a resident at risk for skin breakdown, resulting in a right heel pressure ulcer that progressed to Stage IV. The resident was admitted with multiple medical diagnoses, was moderately cognitively impaired, and was dependent on staff for all ADLs including bed mobility and transfers. A pressure risk assessment identified the resident as at risk for developing pressure ulcers. On 2/4/25, nursing documentation identified new open areas on the right heel with black tissue, bloody drainage, red wound edges, and edema. A skin-only evaluation the same day documented two open areas on the right heel with necrotic tissue and bloody drainage, and noted redness on the left heel without measurements or further assessment. Despite these findings and the resident’s immobility and preference to lie on her back with heels resting directly on the bed, heel protectors were not obtained upon admission. The record further shows that a wound care referral was not documented until 2/13/25, when a wound physician was notified and orders were obtained for a heel guard and wound supplements for a right heel Stage III pressure ulcer. There is no documentation of a full wound assessment of the right heel upon the resident’s return from the hospital on 2/13/25, despite facility policy requiring a complete description of pressure ulcers and examination of the skin of newly admitted residents. When the wound physician evaluated the resident on 2/20/25, the right heel ulcer was documented as a Stage IV pressure ulcer measuring 4.0 cm by 3.0 cm by 0.2 cm. Staff interviews confirmed that the wound appeared worse on 2/20/25 than when the resident returned from the hospital, that the wound had been identified as facility-acquired, that the resident’s heels had been resting directly on the bed most of the day, and that the facility could not provide documentation of a right heel wound assessment upon readmission.
Failure to Implement Fall Interventions and Maintain Safe Equipment Leading to Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement fall prevention interventions and maintain a safe environment for two residents, resulting in multiple falls and injuries. One resident had multiple medical diagnoses including chronic respiratory failure with hypoxia, systolic heart failure, schizophrenia, cognitive communication deficit, morbid obesity, pulmonary embolism, and hepatic encephalopathy, and was assessed as moderately cognitively impaired and dependent on staff for most activities of daily living. A fall risk evaluation identified this resident as high risk for falls, and the fall care plan identified dizziness upon standing as the root cause of falls. The care plan included interventions such as use of a wheelchair, staff assistance to the dining room and to a chair, and keeping a bedside table within reach for personal items. The resident also had a physician order for Rivaroxaban, an anticoagulant, for pulmonary embolism. On one occasion, the resident experienced an unwitnessed fall in a common area after attempting to stand, feeling dizzy, and falling backward, striking her head and sustaining a large purple bruise on the coccyx/sacral area. She was sent to the hospital and diagnosed with a closed head injury, cervical strain, and multiple contusions. A nurse later documented that the resident stayed in her room, expressed fear of coming out due to fear of falling, and refused to get out of bed unless in a wheelchair, sometimes choosing to soil herself rather than ambulate. Another fall occurred in the dining room when the resident, who had been walked there with staff assistance, walked independently to move to another chair, missed the chair, and fell, striking her head. This fall was witnessed by a CNA who reported seeing the resident’s head bounce off the floor, and hospital records documented a scalp hematoma. Staff interviews indicated that the resident had been complaining of dizziness when standing for several days, that staff knew she was dizzy every time she stood, and that there was no documentation showing fall interventions were in place at the time of the falls. Staff also stated that a wheelchair, which was an intervention in the care plan, had not been left with the resident in the dining room. A further unwitnessed fall occurred when the same resident slid out of bed while reaching for candy because she did not have a bedside table. The fall investigation and nursing documentation identified the root cause as the resident reaching for personal items at bedside without a bedside table, and the intervention added afterward was to keep a bedside table at the bedside. A nurse and a regional RN stated that all residents should have a bedside table, that it is a standard piece of equipment, and that there was no reason this resident did not have one. The regional RN also stated that staff should have supervised the resident when they knew she was complaining of dizziness upon standing and that staff should follow interventions put in place to reduce falls. The facility’s falls policy stated that after a first fall, staff and the physician, if possible, should observe the individual rising from a chair, walking, and returning to sitting, and that additional evaluation should occur if there is difficulty or unsteadiness. The second resident involved had medical diagnoses including COPD, a fractured left tibia, muscle disorder, lack of coordination, gait abnormalities, muscle wasting, phantom limb syndrome, and a right above-the-knee amputation. A physician order specified a left half side rail in the up position while in bed to enhance bed mobility, with staff to check positioning and functioning of the device. An incident note documented that staff heard the resident yelling and found her on the floor by the bed, with the left side rail on the floor beside her. The resident reported that she attempted to sit on the side of the bed using the side rail, which then fell off the bed frame, causing her to fall to the ground. The maintenance director later stated that nursing staff often remove or replace side rails and do not secure them properly, and he believed this occurred in this case, confirming the bed rail was not properly secured. The DON confirmed that only maintenance staff are to remove and install bedrails, that they must be installed correctly to be safe, and that when this resident fell, the bed rail came off the bed, indicating it had not been secured and posed a hazard that resulted in the fall.
Insufficient Licensed Nurse and CNA Staffing Across Multiple Shifts
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nurses and CNAs on multiple shifts to meet residents’ needs for safety and quality of care. The facility assessment documented an average daily census of 80–85 residents and a goal to maintain adequate qualified staff to meet each resident’s needs. However, the daily nursing schedules showed that on the night shift of 1/24/26 there was only one nurse and one CNA assigned to the front half of the building, and on the day shift of 1/25/26 there was only one nurse in the entire building until 11:00 AM. An LPN assigned to the front hall on the night shift of 1/24/26 reported being alone in the front of the building for approximately one and a half hours, from 10:00 PM to 11:30 PM, before any other staff arrived, and confirmed she did not feel this staffing level was safe or in the best interest of residents. The same LPN stated she is always the only nurse assigned to the front halls at night, typically with one CNA and one unit aide, and that from 4:00 AM to 6:00 AM the front halls require two CNAs for toileting and morning care while she is occupied with the early morning medication pass and unable to consistently assist the sole CNA. The DON confirmed that staffing levels on 1/24/26–1/25/26 were very low, that the DON did not arrive until close to 11:00 AM, and that one LPN was the only nurse in the building from 8:00 AM until nearly 11:00 AM. That LPN reported being assigned to the back halls while a resident in the front hall experienced a seizure and fell to the floor during this period, and stated that the facility is often short-staffed, especially on weekends, causing resident care to suffer and resident safety to be compromised, with nurses having to rush through their duties when staffing is inadequate.
Lack of Certified Dietary Manager Oversight for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager (CDM) to oversee the food and nutrition services for the 94 residents documented on the daily midnight roster dated 1/20/26. From 1/21/26 through 1/23/26, a Certified Food Protection Manager (CFPM) was observed educating kitchen staff, providing direction to dietary staff, and assisting with meal preparation and service to residents, despite not being a CDM. From 1/27/26 through 1/29/26, the facility did not have a CDM employed or onsite. The CFPM stated she was not a CDM, had not started any classes, and was not enrolled in a CDM program. A regional RN confirmed that the facility did not have a CDM, that the CFPM was serving as the acting dietary manager, and that she was unsure whether there was a policy requiring the facility to have a CDM, while acknowledging the facility was supposed to have one. This deficiency centers on the absence of a qualified CDM and the reliance on a CFPM without CDM credentials to perform dietary management functions for all residents during the survey period.
Failure to Maintain Sanitary Practices During Food Preparation
Penalty
Summary
Surveyors identified a deficiency in sanitary food preparation practices when a dietary aide prepared frozen pancakes for a scheduled breakfast meal without following required hygiene and protective measures. The aide was observed pulling apart frozen pancakes with bare hands, placing them on a large sheet pan without wearing gloves, and not washing her hands immediately prior to food preparation. She reported that she had only washed her hands at the beginning of her shift and had not washed them again since arriving at work. At the time of the observation, 94 residents were documented as residing in the facility, and pancakes were listed on the weekly menu for the upcoming breakfast meal. During the same observation, the dietary aide was wearing an oversized down winter coat while preparing the pancakes, and the sleeves of the coat made direct contact with multiple pancakes. The aide’s hair net did not fully cover all of her hair. When questioned, she asked whether she should be wearing gloves. The facility’s Certified Food Protection Manager later stated that staff who prepare or serve food should always wear hair nets that fully cover all hair, wear gloves when preparing or serving food, and wash their hands prior to food preparation and service. The facility’s written policy on preventing foodborne illness requires employees to wear gloves when directly touching ready-to-eat foods, prohibits bare-hand contact with such foods, and requires hair restraints when cooking, preparing, or assembling food.
Failure to Maintain Clean, Homelike Rooms and Safe Bedding
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for multiple residents and lacked any documented system for tracking maintenance requests or completed repairs. Surveyors observed that one resident’s wall next to the closet had a large area of dents and scratches measuring approximately three feet by one foot, and the closet door was missing. Another resident’s closet also lacked a door, and the wall behind that resident’s dresser had five nails protruding approximately one inch from the wall. A third resident’s wall next to the head of the bed had multiple scratches and dents covering an area approximately two feet by one foot, and this resident stated she wanted the wall repaired and liked her room to look neat and well taken care of. A fourth resident’s mattress had a large wet area in the center, and the top layer of the mattress was very worn and thin. Staff interviews confirmed there was no formal process in place for the maintenance department to know what needed repair, as prior written request slips had been discontinued and staff were instead verbally notifying the Administrator, with nothing documented. The Maintenance Assistant reported that this lack of written tracking made it difficult to keep up with repairs. A CNA stated that the resident with the wet mattress had to lie on a wet bed every night because the mattress surface was so worn that urine seeped through and saturated the mattress, causing the resident’s clothes to become wet when sitting on the bed even if the resident was dry and not incontinent at that time. A housekeeper reported that the chemical spray used to clean mattresses degraded their surface, allowing urine to remain on and soak into the mattress. A Regional RN confirmed that the previous paper system for documenting maintenance requests and repairs had been eliminated by the Administrator in favor of verbal reporting. The Illinois Long Term Care Ombudsman Resident Rights pamphlet states that residents have the right to a clean and homelike environment.
Failure to Prevent Misappropriation of Residents’ Smoking Materials
Penalty
Summary
The facility failed to protect a cognitively intact resident from misappropriation of personal property by another cognitively intact resident, specifically involving cigarettes and vape cartridges. One resident admitted to picking up cigarettes and vape cartridges that did not belong to him from the nurses’ station counter when smoking materials were placed out for use and were not labeled with resident names. His care plan documented behavioral problems related to misappropriation of others’ property, including vapes, lighters, and smoking materials. Staff interviews confirmed ongoing allegations over more than six months that this resident took other residents’ smoking materials, with staff sometimes confronting him only after he had already taken items. The administrator and human resources director acknowledged that this resident had taken vape cartridges belonging to another resident and that staff would retrieve the materials after he picked them up. The affected resident reported that at least four of her vape cartridges went missing after she turned them in to be locked up following smoking times, and that when she returned for the next smoking period, the cartridges were gone. She stated staff consistently found her missing vape cartridges in the other resident’s possession, sometimes after delays ranging from one day to a couple of days, and that on one occasion staff found him outside smoking her vape cartridge and sharing it with other residents. A CNA reported that the resident taking items had been observed waiting for agency nurses, then accessing the cabinet where smoking materials were stored, including by climbing over the nurses’ station counter when the doorway to the nurses’ station was left unlocked. The cabinet where smoking materials were kept had not historically been locked because access behind the nurses’ station was controlled by a locked doorway, but some agency nurses left that door unlocked, allowing the resident to gain access. The facility’s Abuse Prevention Policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident’s belongings or money without the resident’s consent.
Failure to Report Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report all allegations of misappropriation of residents' personal property to the state surveying agency as required by its Abuse Prevention Policy. One resident, R74, reported that his own cigarettes and vape cartridges had gone missing and also admitted to picking up smoking materials, including cigarettes and vape cartridges, that did not belong to him. His care plan, initiated on 12/16/25, documented behavioral problems related to misappropriation of others' property, including vapes, lighters, and smoking materials. Staff interviews revealed that there had been ongoing allegations for over six months that R74 was taking other residents' cigarettes and vape cartridges. Multiple staff, including CNAs and a Psychiatric Rehabilitation Services Assistant, stated they had direct knowledge of these incidents and had reported them to the Administrator. The Administrator (V1) acknowledged there had been allegations of R74 taking other residents' cigarettes and vape cartridges, including from R81, but stated she did not report these allegations to the state surveying agency based on guidance from regional corporate staff that if items were retrieved at the same time they were taken, it was not considered theft. Former and current staff reported that they were told by the Administrator that if R74 did not consume all the cigarettes or fully use the vape cartridges, it was not considered theft and did not need to be replaced or reported. Resident R81 stated that her vape cartridges had been taken by R74 on at least four occasions, that she had reported the missing items to staff, and that her vape cartridges were missing for periods ranging from one day to a couple of days before staff found them in R74's possession. Staff confirmed that vape cartridges were missing for periods ranging from eight hours to a couple of days. Despite multiple incidents and reports, only a single report to the state surveying agency dated 12/10/25 regarding R74 stealing vape cartridges was provided, demonstrating that not all allegations of misappropriation were reported as required by facility policy.
Failure to Involve Resident in Choice of Destination During Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to allow a cognitively intact resident to participate in choosing the destination facility during an involuntary discharge. The resident, who had paraplegia and multiple other medical conditions including moderate protein-calorie malnutrition, thoracic spinal cord injury, opioid dependence, neuromuscular bladder dysfunction, chronic pain, traumatic brain injury, neurogenic bowel, and a history of UTI, was issued an involuntary/emergency discharge with a receiving facility in another state already identified by the facility. The resident reported that he had lived in Kentucky before residing in Illinois, wanted to return to Kentucky, and was not asked where he wanted to go or offered any options in Kentucky. The resident stated he occasionally yelled at staff because they did not do what they were supposed to do and that he had spoken with the Ombudsman and the DON about his concerns. The Administrator stated that referrals were sent to multiple facilities and that one facility accepted the resident, after which the resident became upset about not being able to choose his destination or return to Kentucky. The Ombudsman reported that the resident had clearly expressed a desire to return to Kentucky and that this was communicated to the Administrator, who responded dismissively, and that the facility did not send referrals to facilities in Kentucky or allow the resident to participate in his own discharge. The Director of Admissions confirmed that he took over the discharge because the Administrator and Social Service Director no longer wanted to deal with the resident, that the resident was not permitted to suggest facilities, and that the involuntary discharge was issued with an accepting facility already identified by the facility. Facility policy required orientation and preparation of residents for facility-initiated discharges, and the Ombudsman pamphlet documented residents’ rights to participate in their own care planning, but the resident was not involved in selecting the discharge destination.
Failure to Provide Ordered Restorative ROM Services
Penalty
Summary
Failure to provide appropriate restorative nursing services to maintain or improve range of motion (ROM) occurred when a resident on an active ROM program did not consistently receive ordered exercises. The resident, who was cognitively intact and diagnosed with adult failure to thrive, lack of coordination, reduced mobility, heart failure, COPD, and morbid obesity, reported preferring to remain in bed but wanting staff assistance with ROM and strengthening exercises to maintain existing strength. The resident stated staff did not ask him to participate in any restorative ROM programs. The resident’s care plan documented limited physical mobility, a need for staff assistance with bed mobility, transfers, hygiene, and dressing, and directed staff to provide supportive care and gentle ROM as tolerated. The care plan also specified a Restorative Nursing Active ROM Program with bilateral lower-extremity ROM exercises for 10 repetitions, twice daily. Restorative program documentation for three consecutive months showed multiple gaps, with over 20 missing entries where there was no indication that restorative exercises were attempted or completed, and multiple entries listing the resident as unavailable. The DON confirmed the resident was always in his room and consistently available for the restorative program, stated the program could be done in bed and should be offered multiple times per day, and acknowledged that the restorative aide “doesn’t really do his job” and that the current census required more than one restorative aide to provide effective services.
Failure to Protect BiPAP Equipment and Obtain Complete BiPAP Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not protecting one resident’s BiPAP mask from potential cross-contamination and by not obtaining complete physician orders for BiPAP settings for two other residents. One resident with acute and chronic respiratory failure with hypercapnia, chronic CHF, morbid obesity with alveolar hypoventilation, insomnia, and obstructive sleep apnea had a physician order to use a BiPAP ventilator while sleeping with specified inspiratory and expiratory pressures. During observation, this resident’s BiPAP mouth mask was found sitting in direct contact with a small table surface at the foot of the bed without any protective covering, despite the resident stating she required staff assistance to place and remove the mask. The DON confirmed the mask was not in a protective covering and acknowledged the facility practice was to place BiPAP masks in a plastic bag. The facility also failed to obtain complete physician orders for BiPAP pressure settings for two additional residents with significant respiratory and cardiac diagnoses. One resident with chronic bronchitis, asthma, morbid obesity, obstructive sleep apnea, and chronic CHF had a physician order to wear a BiPAP while sleeping, but the order did not include inspiratory or expiratory pressure settings. Another resident with COPD, acute respiratory failure with hypoxia, acute and chronic CHF, morbid obesity, obstructive sleep apnea, pulmonary hypertension, tachypnea, and insomnia had a physician order to wear BiPAP as tolerated and to maintain IPAP, but no specific pressure setting was listed. These omissions occurred despite the facility’s CPAP/BiPAP Support policy requiring nursing staff to review physician orders for prescribed oxygen concentration, flow, and pressure settings, including CPAP, IPAP, and EPAP.
Failure to Obtain Consent and Safely Install Bed Rails
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent for bilateral bed rails, and to ensure bed rails were safely and securely installed and maintained. Facility policy dated August 2022 required that bed rails be properly installed and that informed consent be obtained prior to use. The resident involved had multiple medical diagnoses, including COPD, a fractured left tibia, muscle disorders, lack of coordination, gait abnormalities, muscle wasting, phantom limb syndrome, and a right above-the-knee amputation. The physician order sheet documented an order only for a left half side rail in the up position while in bed to enhance bed mobility, with staff directed to check the positioning and functioning of the device. A consent form dated 2/7/25 documented the resident’s consent for use of a left half side rail only. A health status note documented that staff heard the resident yelling and found her on the floor next to her bed, with the left side rail on the floor beside her. The resident reported she had attempted to sit up on the side of the bed using the side rail when it fell off the bed frame, causing her to fall with it. During observation, the resident’s bed was found to have both right and left half side rails, and the right rail was loose and moved significantly from side to side. The Maintenance Director stated that nursing staff often remove or replace side rails and do not secure them properly, and he believed this occurred when the resident’s bed rail came off and caused her fall. He confirmed the bed rail had not been properly secured and that the bed currently had two rails, with the right rail not properly secured and posing a hazard, and that there was no physician order or consent for a right-side rail. The DON confirmed that only maintenance staff were permitted to remove and install bed rails, that bed rails must be installed correctly to ensure safety, and that the rail came off the frame when the resident attempted to use it.
Uncovered Urinary Collection Bag Compromises Resident Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity when a resident with an indwelling urinary catheter was observed with an uncovered urinary collection bag in public view. On 1/22/26 at 12:49 PM, the resident was seated in a wheelchair in her room with the door open, and the urinary collection bag, containing approximately 100 cc of yellow urine, was placed on the right armrest of the wheelchair. The bag and its contents were clearly visible to anyone walking in the hallway. The facility’s dignity policy dated February 2021 states that residents are to be treated with dignity at all times, that demeaning practices and standards of care that compromise dignity are prohibited, and that staff are expected to promote dignity by helping residents keep urinary catheter bags covered. During interview at the same time, the resident reported that her dignity was "all but lost" in the nursing home, referencing catheter and perineal care that required her to lie on the bed with her legs wide open. She stated that when she went out of the facility, she would place her urinary collection bag in her purse to keep it from public view, and that her grandchildren had reacted negatively to seeing the bag, calling it gross. Later that afternoon, the DON and a regional nurse observed the resident in the activity room with four other residents, again with the urinary collection bag uncovered. The DON confirmed the bag should not have been uncovered and noted the facility typically used specialized bags with built-in flaps to conceal urine, while the regional nurse indicated the bag in use likely came from a recent hospital stay documented as occurring from 1/12/26 to 1/13/26.
Inaccurate MDS Coding of Insulin Use for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents when insulin use was incorrectly documented. For one resident, an MDS dated 12/15/25 indicated in Section N that the resident received insulin, while the Physician Order Sheet (POS) for December 2025 contained no insulin orders. A second resident’s MDS dated 11/13/25 also documented insulin administration in Section N, but the December 2025 POS did not include any insulin orders. Similarly, a third resident’s MDS dated 10/2/25 recorded insulin use in Section N, yet the December 2025 POS showed no insulin orders for that resident. On 1/28/2026 at 11:28 AM, the Regional Clinical Nurse (V27) confirmed that these three MDS assessments were coded incorrectly, with insulin documented for each resident despite the fact that none of them actually received insulin according to their physician orders.
Failure to Complete Accurate and Timely PASRR Level 2 Screenings and Renewals
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate and timely PASRR Level 2 screenings and renewals for residents with serious mental illness (SMI) and intellectual disabilities. One resident was admitted with documented diagnoses including schizophrenia with auditory and visual hallucinations, intellectual disabilities, suicidal ideations, bipolar disorder, depression, anxiety, and adjustment disorder. However, this resident’s PASRR Level 2, completed prior to admission, recorded only intellectual disabilities, anxiety, and adjustment disorder, and explicitly stated the resident did not have an SMI. As a result, the PASRR did not include the resident’s schizophrenia and bipolar disorder diagnoses and did not recommend specialized mental health services. A facility LPN later acknowledged that the PASRR was incorrect because the resident had several SMIs and intellectual disability and stated she would normally be the person to call for a repeat PASRR when such errors occur. The facility also failed to ensure timely PASRR renewals for two other residents approved only for short-term stays. One resident with paranoid schizophrenia, cannabis abuse with psychotic disorder with hallucinations, major recurrent depressive disorder, and anxiety had an initial PASRR Level 2 authorizing a short-term stay until a specified expiration date, but the subsequent PASRR Level 2 was not completed until after that expiration. Another resident with mood disorder, bipolar disorder, depression, and post-traumatic stress disorder had a PASRR Level 2 that authorized a short-term stay ending on a specific date, and the regional nurse confirmed the facility missed completing the PASRR Level 2 redetermination by that expiration date and only requested a reassessment after the lapse was identified. These findings show that three residents out of nine reviewed for pre-admission screening did not have accurate or timely PASRR determinations in place as required.
Failure to Provide Behavioral Health Services for Community Re-Integration
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services to support a resident’s goal of community re-integration. The resident was admitted with multiple serious behavioral health diagnoses, including Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression, Post-Traumatic Stress Disorder, Cocaine Abuse, and Nicotine Dependence. The care plan documented that the resident was independent in meeting emotional, intellectual, physical, and social needs and usually able to perform ADLs independently or with supervision. The care plan also identified a goal for the resident to return home or to the community, with interventions that included evaluating whether independent or assisted living would be most appropriate, making arrangements with community support resources, and providing written instructions to the resident. Surveyors observed the resident on a locked unit designated for individuals with serious mental illness and behavioral health needs. During an interview, the resident expressed a belief that staff wanted to remove him from the facility and requested to speak with the Administrator for clarification. The DON indicated there were plans to discharge the resident to another facility and referred questions to the Social Services Director. The Social Services Director later stated that the resident was not being forced out but that the facility was not able to provide the types of group services needed to support the resident’s community re-integration goal. The Social Services Director explained that these needed services could be provided at another nursing facility and that referrals had been sent, with a discharge scheduled, demonstrating that the facility did not provide the behavioral health services necessary to meet the resident’s identified goal for community re-integration.
Failure to Employ Required Psychiatric Rehabilitation Services Director
Penalty
Summary
The facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD) as required for its locked mental illness behavioral unit, resulting in insufficient staffing with appropriate competencies to meet residents' behavioral health needs. A resident on the locked unit, diagnosed with Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression, Post-Traumatic Stress Disorder, Cocaine Abuse, and Nicotine Dependence, reported that staff wanted to "kick him out" and expressed a desire to speak with the Administrator for clarification. The resident’s care plans documented that he was generally independent in emotional, intellectual, physical, and social needs, usually able to perform ADLs independently or with supervision, and had a goal to return home or to the community, with interventions including evaluation for appropriate living environment, coordination with community support resources, and provision of written instructions. During the survey, the DON, a Psychiatric Rehabilitation Services Counselor (PRSC), and the Administrator each confirmed that the facility did not currently employ a PRSD and had not done so since November 2025. The Administrator stated that an LPN had attempted to fill the PRSD position but it was not a good fit, and that although the PRSC was qualified, the Administrator believed her personality was too timid for the role. The Administrator acknowledged that having a PRSD and providing community reintegration groups are state requirements for a mental illness behavioral unit. A staff member reported that the resident was not being discharged involuntarily but that the facility was not providing community reintegration groups and that these services could be provided at another nursing facility, which she believed would be more beneficial for the resident. The staff roster did not list a PRSD, and throughout the survey the mental illness unit Director’s office remained closed and unoccupied, further evidencing the absence of a functioning PRSD.
Inadequate Meal Portions and Poor Food Palatability
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of palatable, adequately portioned meals at safe and appetizing temperatures for three cognitively intact residents. Observation on 1/20/26 showed the cook using a premeasured scoop to serve chili while scraping the bottom of the pan, with the chili appearing very thick and without visible liquid. The cook reported there were no residents who did not eat solid foods. That same day, a cart of prepared meal trays was moved from the kitchen to the main dining room at 10:58 a.m., left there until 11:10 a.m., then moved to a resident hall, where staff began passing trays at 11:12 a.m. and completed distribution by 11:20 a.m. Residents reported receiving very small portions of chili that appeared to come from the bottom of the pan and lacking soup or liquid. Interviews with three residents documented consistent complaints about meal quality, temperature, and portion sizes. One resident, who identified as the Resident Council President, stated that meals are served cold, portions are small, and the food tastes like garbage, and reported receiving a very small portion of chili consisting only of meat and beans with no soup. Another resident with a full, untouched meal tray in his room stated the meals are awful dog food that he would not feed his dog, reported ordering outside food due to the nastiness of facility meals, and described meals as always cold with inconsistent portion sizes. A third resident stated meals are terrible, always late, never hot, and served in small portions. The Certified Food Protection Manager later acknowledged awareness of complaints about small portions and cold food and reported that staff confirmed the facility ran out of bowls and chili for residents requiring pureed textures on the day in question.
Failure to Implement and Document Fall Prevention and Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement appropriate interventions to address resident behaviors and prevent recurring injuries following falls. In one case, a resident with moderate cognitive impairment, impaired mobility, and a history of impulsive behaviors experienced an unwitnessed fall that resulted in a coccyx fracture. The care plan for this resident included 15-minute safety checks and reminder signs to call for assistance before getting up, but there was no documentation that these interventions were in place or followed at the time of the fall. Staff were unable to confirm when the resident was last checked or who last observed her prior to the incident, and there was no evidence that the required reminder signs were posted in her room or bathroom. The facility's investigation did not include critical information such as the timing of the last staff check or the resident's activity prior to the fall. In another case, a resident with severe cognitive impairment, schizophrenia, and a history of putting his fingers in his mouth suffered a traumatic partial amputation of his fingertip after a witnessed fall. The injury occurred when the resident had his finger in his mouth during the fall, resulting in a severe bite injury that required surgical amputation. Despite a known history of this behavior, the resident's care plan did not include specific interventions to address or prevent the behavior of putting fingers in his mouth or nose. Staff interviews confirmed that the only action taken was to verbally remind the resident to stop, and no formal interventions or care plan updates were implemented prior to the injury. The facility's investigative files for both incidents lacked comprehensive documentation of circumstances surrounding the falls, including corrective actions and follow-up information. The absence of documented interventions and failure to implement or monitor existing safety measures contributed to the residents experiencing significant injuries. The facility did not ensure that accident hazards were minimized or that adequate supervision and interventions were provided to prevent accidents and injuries for residents at risk.
Failure to Update Care Plan for Resident's Transfer Status and Assistive Device Use
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect the resident's current transfer and ambulation status, as well as the use of assistive devices. The resident, who is cognitively intact, reported falling in the bathroom a few weeks prior, resulting in a broken tailbone. Following the fall, the resident began using a wheeled walker and received therapy. Despite this change, the care plan continued to state that the resident did not use any assistive devices for walking and required setup assistance for transfers, which was inconsistent with the resident's current independent status and use of a walker. Observations and interviews confirmed that the resident was independently transferring and ambulating with a wheeled walker, and staff acknowledged that the care plan had not been updated to reflect these changes. The MDS documented the resident as needing staff supervision or touch assistance, but both nursing and therapy staff confirmed the resident's independence and use of a walker, which began on 7/31/25. The care plan had not been revised to accurately document the resident's current needs and assistive device usage.
Failure to Obtain Orders and Administer Oxygen Therapy per Physician Instructions
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy for one resident and did not administer oxygen according to physician orders for another. One resident with multiple respiratory and cardiac diagnoses was observed receiving oxygen therapy via nasal cannula at a rate of two and one half liters per minute, but there was no physician order specifying the oxygen therapy, rate, or delivery method. The same resident's oxygen humidifier bottle was found to be completely dry on two separate occasions, and both the humidifier bottle and nasal cannula tubing had not been changed as scheduled per the physician order sheet. The resident reported that the humidifier bottle was frequently dry and that no one had replaced it as required. Another resident with emphysema, sleep apnea, and a pulmonary nodule was observed receiving oxygen at five liters per minute, despite a physician order specifying two liters per minute at night, during naps, and as needed during the day. The humidifier bottle for this resident contained only a minimal amount of water, insufficient for proper humidification, and neither the bottle nor the tubing was dated to indicate when they were last changed. The DON confirmed that the humidifier bottle should have been changed the previous night according to orders, and the facility's policy requires verification of physician orders, proper equipment setup, and regular checks of water levels in humidifier bottles.
Inaccurate Documentation of Oxygen Therapy Treatments
Penalty
Summary
Nursing staff failed to accurately document the provision of oxygen therapy treatments for two residents. In one case, a resident was observed receiving oxygen therapy with a humidifier bottle and nasal cannula tubing that were both dated to indicate they had last been changed several weeks prior, despite physician orders requiring weekly changes. The Treatment Administration Record showed staff initials and checkmarks indicating the treatments had been completed on the scheduled dates, but physical evidence contradicted this documentation, as the humidifier bottle was completely dry and had not been changed as recorded. In another instance, a second resident was also observed receiving oxygen therapy with equipment that was not dated to indicate when it had last been changed, despite orders for weekly changes. The Treatment Administration Record again showed staff initials and checkmarks for completed treatments, but the condition of the equipment suggested otherwise. The DON confirmed that the documentation was inaccurate and that the initials were from agency nurses. Facility policies require that all treatments and services provided to residents be completely and accurately documented in the medical record, including the date, time, and name of the nurse performing the procedure.
Failure to Maintain Resident Dignity During Care and Mealtime
Penalty
Summary
The facility failed to provide dignity during incontinence care and mealtime for five residents, all of whom had significant cognitive or physical impairments. During incontinence care for one resident who was fully dependent and severely cognitively impaired, two CNAs exposed the resident's perineal area by pulling up her sweatshirt and pulling down her pants without ensuring privacy, as the privacy curtain was pushed back to the wall. This care was provided in the presence of the resident's roommate, who was also in the room at the time. One CNA acknowledged that the privacy curtain should have been pulled and that the resident was unable to provide privacy for herself. During a mealtime observation, four residents who were totally dependent on staff for eating and one resident who required supervision were seated together at a dining table with their food uncovered. No staff were present in the dining room while the residents were eating. When a CNA did assist, she did so by walking back and forth between residents, offering each a bite from a standing position rather than sitting with them individually. The CNA explained that staffing shortages due to call-ins left only two CNAs available for the front two halls, and the DON confirmed that ancillary staff are expected to help during such shortages. Facility policy requires that residents be treated with dignity and respect at all times.
Failure to Provide Timely and Complete Incontinence Care
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical diagnoses, including dementia, psychotic disturbance, and dysphagia, did not receive timely and complete incontinence care. Observation revealed that two CNAs failed to maintain a clean field for cleansing supplies, placed an open incontinence brief directly on the resident's personal pillow, and did not cleanse the resident's front perineal area. The resident's incontinence brief was found fully saturated with urine and feces, and dried feces were present on the resident's buttock. One CNA admitted to not washing the front perineal area during care, and there was a significant gap in care provision since the CNA's arrival earlier that day. Interviews with staff confirmed that complete incontinence care, as outlined in the facility's policy, was not provided. The Director of Nursing acknowledged that the resident is vulnerable to skin breakdown due to low cognition and emphasized the importance of following the care plan, which includes thorough cleansing of the perineal and perianal areas. The facility's policy specifies the correct procedure for perineal cleansing, which was not followed during the observed care.
Failure to Notify Guardian of Medication and Lab Order Changes
Penalty
Summary
The facility failed to notify a resident's court-appointed guardian of significant changes in the resident's medication regimen and laboratory orders. The resident, diagnosed with Paranoid Schizophrenia, Thyrotoxicosis, and other psychiatric and medical conditions, had a guardian legally authorized to make decisions regarding psychological, psychiatric, and medical care. Despite this, the facility did not document any notification to the guardian regarding changes in the resident's psychotropic medication (Ativan) from as-needed to scheduled dosing, nor changes in the frequency of thyroid-related laboratory tests. The guardian reported not being informed of these changes, despite having previously notified the facility of her status and the need for communication about all changes. Interviews with facility staff confirmed that there was no documentation of the guardian being notified about the medication or laboratory order changes. The Psychiatric Rehabilitation Services Director acknowledged a lack of answers for the guardian's concerns and confirmed missed doses of medication. The Director of Nursing also confirmed that the facility should have notified the guardian and that no documentation of such notification existed. Facility policy requires notification of the resident representative or next of kin within 24 hours of significant changes, but this was not followed in this case.
Failure to Administer Psychotropic Medication as Ordered
Penalty
Summary
A resident with a primary diagnosis of Paranoid Schizophrenia, along with other medical conditions including thyrotoxicosis, noncompliance with medication regimen, cannabis abuse with psychotic disorder with hallucinations, major depressive disorder, anxiety, and insomnia, was not administered her prescribed psychotropic medication, Ativan 0.5 mg, as ordered by her physician. The resident missed a total of ten doses over the course of June and July, as documented in the Medication Administration Record (MAR). The facility's records show that the medication was delivered by the pharmacy, but several scheduled doses were not given on both morning and evening shifts across multiple dates. The Director of Nursing (DON) acknowledged that there were issues obtaining a renewal prescription from the physician, and that the facility failed to notify the physician in a timely manner before the resident ran out of Ativan. The facility's medication administration policy requires staff to call the pharmacy and notify the physician if a medication is not available, and to report any missed doses as soon as practical. Despite these policies, the resident's medication was not administered as ordered due to delays in obtaining the necessary prescription renewal, resulting in missed doses.
Failure to Maintain Clean and Safe Community Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in four community shower rooms, as evidenced by multiple observations and staff and resident interviews. Surveyors observed significant environmental deficiencies, including thick dust on ceiling vents, missing floor tiles around toilets, exposed internal heating components, non-functioning ventilation systems, and evidence of black mold on shower room ceilings. Staff reported that the shower rooms often became messy, with overflowing toilets, garbage cans full of soiled briefs causing odors, and frequent flooding due to outdated plumbing. Maintenance staff acknowledged awareness of these issues, including missing tiles, persistent plumbing problems, and non-functional vents, but noted that repairs had not been completed due to lack of supplies or oversight. Two cognitively intact residents reported direct negative experiences with the shower rooms. One resident stated that the mold problem in the shower room persisted despite being painted over and that he used this room regularly. Another resident described the east end shower room as dirty, with pooled water up to her ankles and poor ventilation making it difficult to breathe. Staff confirmed that the ventilation systems in several shower rooms were not operational, leading them to open windows for air circulation. These conditions were present in areas actively used by residents for bathing and daily hygiene.
Failure to Protect Resident from Verbal and Mental Abuse by Another Resident
Penalty
Summary
A resident with diagnoses including Bipolar Disorder, Anxiety, and Congestive Heart Failure, who was cognitively intact, was subjected to repeated verbal and mental abuse, as well as physical threats, by another cognitively intact resident. The abusive resident yelled, screamed profanities, and called the victim derogatory names in the presence of another resident, causing the victim to cry, feel embarrassed, and become fearful for her safety. The abusive resident also made sexual comments and advances toward the third resident, further escalating the situation. Multiple staff members and residents witnessed the abusive behavior, including threats of physical harm and an attempt to physically strike the victim, though no physical contact occurred. The victim expressed ongoing fear, altered her behavior to avoid the abuser, and was visibly distressed during interviews. Staff interviews confirmed that the abusive resident's actions were loud, disruptive, and caused significant emotional distress to the victim, who required consolation from both staff and family. Despite these events, the victim's care plan did not include any focus area, goals, or interventions related to her risk of being abused. Nurse progress notes failed to document the altercations, and the psychiatric unit director was not informed that the incidents needed to be reported as abuse. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the policy was not effectively implemented in this case, as staff did not take adequate steps to protect the victim or monitor the abuser following the initial incident.
Failure to Protect Resident from Repeated Verbal and Mental Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident (R4) from repeated verbal and mental abuse by another resident (R5) over the course of an entire day, despite staff being aware of the ongoing abuse. R4, who has diagnoses including Bipolar Disorder, Anxiety, and Congestive Heart Failure, was documented as cognitively intact. R5 was also cognitively intact and required supervision for several activities of daily living. On the day in question, R5 repeatedly approached R4, yelling profanities, making threats, and at one point swinging an arm at R4, though not making physical contact. R4 reported feeling scared, changed her activity routine to avoid R5, and experienced significant emotional distress, including crying during interviews and reporting an inability to sleep due to fear of further abuse. Multiple staff members, including the Psychosocial Rehabilitation Director and Assistant, were aware of R5's behavior throughout the day. Staff witnessed R5 using threatening and abusive language towards R4 and acknowledged that R5 should have been placed on closer observation, such as one-to-one monitoring, but this was not done. R4 reported that staff did not intervene or provide protection during the incidents, and only reported the abuse to a Registered Nurse the following morning, whom she trusted to help her. Observations confirmed that there were times when both residents were in common areas without staff present, further exposing R4 to potential abuse. Interviews with staff and a Nurse Practitioner indicated that R5's behavior was out of character and may have indicated a new or acute mental health issue, but no immediate action was taken to remove R5 from contact with R4 or to provide a psychiatric evaluation. The facility's own abuse prevention policy requires that residents who allegedly abuse others be removed from contact with the victim during the investigation, but this was not followed. As a result, R4 was left unprotected and subject to repeated abuse, in violation of facility policy and resident rights.
Failure to Timely Report Resident-to-Resident Verbal and Mental Abuse
Penalty
Summary
The facility failed to timely report allegations of verbal and/or mental abuse to the Abuse Coordinator on three separate occasions involving resident-to-resident altercations. In the first incident, one cognitively intact resident verbally abused another, including yelling, screaming profanities, and attempting to strike the other resident. The staff member who witnessed the event did not report it, stating she was unaware that verbal or mental abuse required reporting. The incident was only reported after the affected resident informed a nurse the following day. In the second incident, a cognitively intact resident yelled and used derogatory language toward a severely cognitively impaired roommate over a dispute about noise. The altercation was documented in a nurse's progress note, but the agency LPN who witnessed the event did not notify supervisory staff or the Abuse Coordinator. The affected resident reported feeling hurt by the name-calling, and the incident was not reported or investigated until much later. The third incident involved two cognitively intact residents who engaged in a screaming match during a group activity, resulting in one resident being verbally abused and becoming upset to the point of crying. The staff member present did not report the incident, expressing a lack of awareness that such behavior constituted reportable abuse. In all three cases, the facility's policy requiring immediate reporting of potential abuse to supervisors and the administrator was not followed, and the incidents were not promptly investigated.
Failure to Provide Adequate CNA Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate Certified Nursing Assistant (CNA) staffing for eight out of fourteen days reviewed, as documented by daily staffing assignment sheets and confirmed by facility leadership. The facility assessment indicated a need for 16 CNAs per 24-hour period, but on multiple days, staffing fell below this requirement, with as few as 10 CNAs present on some days. This staffing shortage was acknowledged by the Regional Director of Operations and the scheduler, who noted ongoing difficulties in filling shifts and reliance on agency staff and flexible scheduling to cover gaps. Multiple residents, all documented as cognitively intact, reported significant delays in having their call lights answered, sometimes waiting up to an hour for assistance with basic needs such as transfers, toileting, and getting out of bed. One resident, who required two staff and a mechanical lift for transfers, waited over 30 minutes for help and was told to wait until the day shift arrived due to insufficient staff. Other residents described similar experiences, including long waits for assistance and unaddressed hygiene needs. Staff interviews corroborated these accounts, with an agency LPN stating that call lights were going unanswered and that she had to choose between providing resident care and completing medication passes due to the lack of available CNAs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication administration pass, resulting in a 10.7% error rate. Out of 28 medication administration opportunities observed, three errors were identified for one resident. The errors included administering Gabapentin and Calgest (TUMS) together despite a warning label instructing not to give Gabapentin with aluminum/magnesium antacids within two hours, administering only one tablet of Levetiracetam instead of the ordered three tablets, and failing to administer a prescribed Calcium 600 mg + D3 200 mg tablet because it was not available from the pharmacy. The resident involved was documented as cognitively intact and had specific physician orders for multiple medications. The LPN responsible for the medication pass admitted to not reading the Gabapentin label, being in a hurry and not administering the correct dose of Levetiracetam, and not providing the Calcium + D3 tablet due to its unavailability. Facility policy requires verification of medications with physician orders and checking medication labels at least three times for safety and accuracy, which was not followed in these instances.
Failure to Timely Report Urinary Changes and Perform Hand Hygiene
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who was always incontinent of bowel and bladder and dependent on staff for toileting. Over several days, the resident exhibited decreased urinary output and abdominal distention, which were observed and reported by CNAs to an LPN. However, the LPN did not notify a physician or APRN of these changes, instead instructing staff to continue monitoring. Documentation of the resident's urinary output and abdominal distention was incomplete, and there was a delay in transcribing and acting on an order for a urinalysis. The resident's condition worsened, resulting in hospitalization for urinary retention, UTI, and acute kidney injury, with laboratory findings confirming elevated BUN and creatinine levels. Hospital records indicated significant urinary retention, hematuria, and additional complications including stercoral proctitis and bladder wall thickening. Additionally, the facility failed to ensure proper hand hygiene practices during toileting assistance for another resident. During direct observation, a CNA was seen removing gloves after providing perineal care and changing a soiled brief but did not perform hand hygiene before leaving the room and transporting the resident to a common area. The CNA later acknowledged the omission and confirmed that hand hygiene should have been performed after providing toileting care. Facility policies required prompt notification of a physician or on-call provider for significant changes in a resident's condition, as well as documentation of such changes and adherence to hand hygiene protocols after toileting care. These policies were not followed, as evidenced by the lack of timely provider notification, incomplete documentation, and failure to perform hand hygiene, contributing to the deficiencies identified during the survey.
Insufficient CNA Staffing During Night Shifts
Penalty
Summary
The facility failed to provide a sufficient number of certified nursing assistants (CNAs) to meet the basic care needs of all residents, as required. Review of staffing records, daily assignment sheets, and timecards for multiple dates revealed that the number of CNAs scheduled and present during night shifts was consistently below the facility's own documented staffing requirements. On several occasions, only one CNA was present to care for as many as 53 residents on a locked behavioral unit, and there were instances where only one CNA was available for entire wings, despite the facility assessment indicating a high level of resident dependency for activities of daily living and behavioral health management. Interviews with staff, including CNAs, LPNs, and RNs, confirmed that the facility was often short-staffed, particularly during night shifts. Staff reported that agency CNAs did not always show up for their scheduled shifts, and replacements were not consistently found. As a result, incontinence care and other basic needs were not always provided in a timely manner, and staff had to catch up on care at the start of the next shift. Staff also expressed concerns about the ability to supervise residents with behavioral issues and those who wander, given the inadequate staffing levels. The facility's human resources director and clinical scheduler acknowledged the staffing shortages and confirmed that the facility relies on agency staff to supplement their workforce. However, there was no formal guideline or formula used for scheduling, and the scheduler was sometimes unaware when staff did not show up for their shifts. The facility's own assessment tool documented the need for more CNAs per shift than were actually present, and the staffing records reviewed for March and April confirmed the accuracy of the reported shortages.
Failure to Maintain Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON) and did not provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week, as required. Review of facility records, including census data, staffing schedules, daily assignment sheets, and timecards, revealed that for multiple audited dates, there was no RN coverage for periods of 24 hours or more. The facility's own assessment documented a high level of resident care needs, including oxygen therapy, CPAP/BIPAP management, and significant assistance with activities of daily living, yet staffing levels did not meet the documented requirements. Interviews with staff confirmed that agency nurses used to supplement staffing were LPNs, not RNs, and that the only full-time RN worked night shifts, leaving day and evening shifts without required RN coverage. Further, the facility had no in-house DON for several months prior to the survey, as confirmed by both the administrator and the human resources director. The DON position was vacant until a new hire started, and during the vacancy, a regional consulting nurse was present only intermittently. Staff reported being short-staffed, with LPNs covering multiple halls and having to assist with resident care beyond their usual duties. The lack of RN coverage and absence of a full-time DON had the potential to affect all 82 residents, many of whom required complex care and behavioral health management.
Failure to Ensure Safe Transfer and Thorough Fall Investigation
Penalty
Summary
The facility failed to provide a safe transfer and adequately investigate a fall for one resident with moderate cognitive impairment who required substantial to maximal staff assistance for transfers. The resident's care plan indicated a need for moderate assistance and noted behaviors such as resistance to staff, stepping backwards, pulling away, and lowering himself to the floor. On the date of the incident, a Certified Nursing Assistant (CNA) assisted the resident in transferring from bed to wheelchair, during which the resident fell to the ground. There was no documentation in the medical record detailing how the fall occurred, which staff were involved, or whether assistive devices such as a gait belt were used, despite facility policy requiring their use for such transfers. The facility's fall prevention policy required immediate post-fall huddles and thorough documentation, but these steps were not followed. The incident audit report relied solely on nursing notes and did not identify the staff involved or the use of assistive devices. The Quality Assurance/LPN confirmed that gait belt usage should have been documented and that witness statements were missing. The fall investigation was incomplete, and the care plan was not updated with the incident or post-fall interventions, as required by facility policy.
Failure to Ensure Appropriate Antibiotic Prescribing for UTI
Penalty
Summary
The facility failed to ensure appropriate prescribing of antibiotics for one resident with a urinary catheter who was reviewed for urinary tract infections (UTIs). The resident was prescribed Bactrim DS for a UTI without documented clinical symptoms to support the diagnosis, and antibiotics were initiated before obtaining urine culture results. The infection control log indicated that criteria were not met for clinical documentation to support antibiotic use, and the urinalysis showed mixed flora, with a recommendation to repeat the specimen collection. Despite this, no repeat culture was obtained prior to the resident's hospitalization, and a sensitivity report was not completed to guide antibiotic selection. Nursing notes documented the resident was on isolation for MRSA and had a catheter-associated UTI, but there was no documentation of symptoms prompting the urinalysis or antibiotic treatment. The Quality Assurance Nurse/Infection Preventionist confirmed that the resident did not have documented symptoms of UTI prior to the antibiotics being ordered and that a repeat culture should have been performed. The Advanced Practice Registered Nurse also stated that antibiotics for UTIs should not be started until after urine culture results are received, which was not followed in this case.
Failure to Ensure Accessible Advance Directive Delays CPR
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was accessible and included in the resident's medical record during a medical emergency. This deficiency resulted in a delay in initiating cardiopulmonary resuscitation (CPR) for a resident who choked on food in the dining room. The facility's Advance Directive Policy requires that any decision regarding advanced directives be clearly indicated in the resident's chart and easily understood by all staff. However, during the incident, the resident's electronic medical record did not document the code status, nor was there a physician order indicating the code status. During the emergency, staff members attempted the Heimlich Maneuver without success and were unable to locate the resident's code status in both the electronic and hard copy medical records. This led to a delay in starting CPR, as staff were uncertain whether resuscitation was appropriate. The resident, who was severely cognitively impaired and primarily non-verbal, had no respirations and a pulse rate of 30 beats per minute when CPR was eventually initiated. The delay occurred because the staff prioritized searching for the code status over immediately starting CPR, as advised by the Nurse Practitioner when the code status is unknown.
Deficiency in CPR Certification for Nursing Personnel
Penalty
Summary
The facility failed to ensure that all nursing personnel were certified in cardiopulmonary resuscitation (CPR), which has the potential to affect all 86 residents currently residing in the facility. The facility's policy requires nursing personnel to be CPR certified within 90 days of hire. However, during an interview, a Registered Nurse acknowledged that they were still working on a plan to have all staff CPR certified. Additionally, a Regional Clinical Nurse was unable to provide CPR certification cards for all nursing personnel, indicating non-compliance with the facility's policy.
Supervision and Safety Failures in Resident Care
Penalty
Summary
The facility failed to adequately supervise a resident, identified as R31, after providing hot pureed food, resulting in the resident spilling hot liquid on their lap. This incident led to redness and blistering on R31's lower extremities, requiring ongoing treatment. R31, who is severely cognitively impaired and totally dependent on staff for eating, was left unsupervised with hot food in front of them. The facility did not initiate an incident investigation, and the administrator did not consider the injury serious enough to warrant one. The dietary manager acknowledged that the food was served at a high temperature, which contributed to the incident. The facility also failed to remove a tripping hazard and implement fall interventions for two residents, R133 and R20. R133 experienced an unwitnessed fall due to a torn fall mat, resulting in a subdural hematoma and subsequent hospitalization. Despite the fall, the facility did not conduct a thorough root cause analysis to prevent future incidents. Similarly, R20, who has a history of falls, experienced an unwitnessed fall that resulted in a fractured wrist. The facility's documentation lacked details on the resident's location or activity at the time of the fall, and no root cause analysis was conducted. Additionally, the facility failed to prevent siderail entrapment for R54, who was found with their lower extremity caught in the siderail. R54, who is severely cognitively impaired and dependent on staff for mobility, was not supposed to use two siderails, yet was found with both in the up position. The administrator was unaware of the incident, indicating a lack of communication and oversight. These deficiencies highlight significant lapses in supervision and safety measures within the facility.
Failure to Employ Full-Time Director of Nurses
Penalty
Summary
The facility failed to employ a full-time Director of Nurses (DON), which has the potential to affect all 83 residents residing in the facility. The Daily Midnight Census Report confirmed that 83 residents were present in the facility. The facility's assessment indicated that a full-time Registered Nurse (RN) would be employed as the DON. However, during the survey conducted from January 21 to January 24, 2025, there was no DON onsite during the first and second shifts. The Administrator (V1) acknowledged that the facility has been without a DON for a few months and is actively seeking to fill the position, but currently has no prospects.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident, identified as R22, to the State Agency. R22, who has multiple medical diagnoses including Cerebral Palsy, Schizoaffective Disorder, and severe cognitive impairment, was found with multiple bruises on her body, including her legs, arm, and under her eyes. These injuries were documented on a Shower/Abnormal Skin Report dated 12/19/24, but the facility did not report these injuries to the State Agency as required by their policy. The facility's records show that R22 was dependent on staff for personal care and had a care plan intervention instructing staff to follow protocols for treatment of injury. Despite this, the facility was unable to provide documentation of behavior tracking sheets or any falls for R22 during December 2024 and January 2025. Staff members, including a CNA and an LPN, noted the bruises and attempted to determine their cause, but no direct cause was identified. The facility's Administrator confirmed that the bruises were considered injuries of unknown origin but did not report them to the State Agency. The facility's policy on abuse prevention requires that all alleged violations, including injuries of unknown source, be reported immediately to the Administrator and other officials in accordance with State law. However, the Administrator did not report R22's bruising to the State Agency, which constitutes a failure to comply with the facility's policy and state regulations. This oversight highlights a deficiency in the facility's handling of potential abuse or neglect cases.
Failure to Obtain Level II PASARR for Resident with New Diagnosis
Penalty
Summary
The facility failed to obtain a Level II PASARR for a resident who was initially identified as not having a serious mental illness during the Level I PASARR screening prior to admission. The resident, identified as R31, was admitted with a Level I PASARR that did not document a history of severe mental illness. However, on 7/24/21, a diagnosis of Psychotic Disorder with Hallucinations was added to the resident's medical record. Despite this new diagnosis, the facility did not provide documentation that a Level II PASARR was conducted. During an interview, the Admissions and Marketing Coordinator confirmed the absence of a Level II PASARR for the resident and stated that arrangements were being made to complete one. The facility administrator verified that the Admissions and Marketing Coordinator is responsible for PASARR screenings and acknowledged the lack of a specific policy for PASARR screening, although the facility follows regulations.
Failure to Obtain Level II PASARR for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to obtain a Level II PASARR (Preadmission Screening and Resident Review) for a resident identified as having a serious mental illness. The resident, who was admitted on 9/12/99, has diagnoses including Schizophrenia, a history of traumatic brain injury, and major depression. The Level I PASARR completed prior to admission indicated a history of severe mental illness, necessitating a Level II PASARR, which the facility did not provide. During an interview, the Admissions and Marketing Coordinator acknowledged the absence of a Level II PASARR for the resident and mentioned plans to complete it when a screener becomes available. The facility administrator confirmed that the Admissions and Marketing Coordinator is responsible for PASARR screenings and noted that the facility lacks a specific policy for PASARR screening, instead following general regulations.
Failure to Prevent Cross Contamination and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to prevent cross contamination during wound treatment and did not adequately assess, monitor, or document treatment for pressure sores for a resident. The resident, who was admitted with multiple medical diagnoses including a right buttock pressure ulcer and a coccyx pressure ulcer, was dependent on staff for assistance with daily activities. Despite the resident's condition, the facility did not document a skin evaluation or treatment for the resident's open coccyx and left buttock wounds over a period of several days. Additionally, the resident's care plan did not include documentation of these pressure ulcers. During a wound care session, an LPN removed the resident's saturated incontinence brief, and the resident's open wounds came into contact with a contaminated wheelchair cushion. The LPN did not cleanse the wounds before applying dressings, leading to cross contamination. The LPN acknowledged the cross contamination and the potential for infection. The facility's administrator confirmed that the nursing staff should prevent cross contamination and follow facility policies for wound care and infection control. The facility's policy requires documentation and monitoring of pressure ulcers, which was not adhered to in this case.
Incontinence and Catheter Care Deficiencies
Penalty
Summary
The facility failed to prevent cross-contamination during incontinence care for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia and a recent recovery from a urinary tract infection (UTI). During an observation, two CNAs provided incontinence care to the resident without performing hand hygiene or changing gloves after removing the soiled incontinence brief and before applying a new one. Both CNAs acknowledged the oversight, and the facility's administrator confirmed that proper hand hygiene and glove changes are required to prevent cross-contamination, which could lead to another UTI. Additionally, the facility did not maintain a urinary catheter drainage bag off the floor and in a dignity bag for a resident with a suprapubic catheter and neuromuscular dysfunction of the bladder. The resident's catheter bag was observed lying on the floor without a dignity cover while the resident was seated in a recliner. A CNA confirmed that dignity bags should be used to cover drainage bags and keep them off the floor, and the facility's administrator reiterated this requirement as per the facility's policy.
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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