Pearl Of Joliet, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 306 North Larkin Avenue, Joliet, Illinois 60435
- CMS Provider Number
- 145372
- Inspections on file
- 43
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Pearl Of Joliet, The during CMS and state inspections, most recent first.
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 receiving tube feeding was observed lying flat in bed while the feeding was infusing, contrary to physician orders and facility policy requiring the head of bed to be elevated 30-45 degrees. CNAs indicated they believed elevation was only necessary when turning the resident, while the DON confirmed elevation is required during tube feeding to prevent complications.
A resident being treated for a UTI did not receive the ordered initial dose of Levofloxacin IV or a scheduled dose of Meropenem due to medication unavailability and lack of documentation. Nursing notes indicated the antibiotic was not available and would be delivered later, but there was no record of administration, and the DON confirmed the absence of documentation or pharmacy authorization requests as required by facility policy.
The facility did not maintain hot food temperatures during meal service, as observed through interviews and direct temperature checks. Multiple alert and oriented residents reported receiving lukewarm or cold meals, and food items were found to be served well below the required holding temperature. Staff delivered meals using non-insulated carts and without plate warmers, contrary to facility policy requiring food to be served at safe and appetizing temperatures.
Staff did not consistently wear gowns during high-contact care activities for residents on Enhanced Barrier Precautions (EBP), including those with a history of Candida Auris, end stage renal failure with IV access, and multidrug-resistant organisms. Despite posted EBP signage and facility policy requiring gown and glove use for such care, CNAs and a nurse were observed providing hygiene, incontinence care, and vital sign checks without proper protective equipment.
A resident with complex medical needs developed extensive skin rashes and redness in the groin, perineal area, buttocks, and under the breasts, which were not properly assessed, monitored, or treated by staff. Orders from a wound care NP for barrier and antifungal creams were not consistently implemented, and required documentation and physician notification were not completed. The resident experienced prolonged pain and discomfort due to these failures.
The facility failed to conduct thorough abuse investigations, affecting all residents. In one case, a CNA reported an LPN being verbally discourteous to a resident, but the investigation lacked interviews and documentation. Another case involved an alert resident, but there was no documentation of interviews. A third investigation also lacked evidence and documentation, despite the facility's policy requiring comprehensive investigations.
The facility failed to maintain proper kitchen sanitation and food storage, affecting 133 residents. Observations revealed dusty vents, improper sanitizing solution levels, and a dishwasher not reaching the required temperature. Unlabeled and spoiled food items were found in the walk-in cooler, and resident refrigerators lacked thermometers and temperature logs. Dented cans were improperly stored, posing a risk of foodborne illness.
The facility failed to provide necessary care for residents with decreased ROM, as evidenced by the lack of application of prescribed splints and supportive devices. Residents with conditions such as hemiplegia and contractures were observed without their required devices, despite having physician orders. The restorative staff were often reassigned, leading to a lack of consistent care and potential worsening of residents' conditions.
The facility failed to maintain a safe environment by not securely storing oxygen cylinders and cleaning supplies, and by not keeping residents' beds at a safe height. Several residents, including those at risk for falls, had their beds and overbed tables left in high positions. Unrestrained oxygen tanks were found in residents' rooms and the medication room, and cleaning chemicals were accessible in unlocked closets, contrary to facility policies.
A resident with severe cognitive impairment was found with hemorrhoidal cream at her bedside, which she used for lubrication rather than its prescribed purpose. The facility failed to assess her ability to self-administer medication, as required by policy. Staff confirmed the resident did not have orders to self-administer or store medications at her bedside.
The facility failed to ensure call lights were within reach for three residents, including one with hemiplegia and another with a self-care deficit. Despite care plans and facility policy requiring accessible call lights, they were placed out of reach, forcing residents to scream for help.
The facility failed to protect residents from verbal and mental abuse, involving an LPN who allegedly yelled at a resident with cognitive impairment and hearing loss, criticized another resident's toileting habits, and belittled a third resident over outside medication. The facility's investigation was incomplete, and the LPN's behavior did not meet facility standards.
A facility failed to report an allegation of verbal abuse involving a resident to the Illinois Department of Public Health. A CNA reported that a nurse was verbally discourteous to a resident, including shouting and telling the resident to 'shut up.' Despite the facility's policy requiring immediate reporting, the administrator confirmed that neither the initial nor final reports were sent to IDPH.
A resident with multiple medical conditions was found wearing both an incontinence brief and pad, without being on a toileting program. The facility's staff confirmed this practice, which contradicts the facility's policy and could lead to skin breakdown. The resident's care plan did not include a scheduled toileting program, despite the facility's policy to maintain personal hygiene for dependent residents.
A resident with a midline IV catheter experienced inadequate care, as the dressing was saturated with blood and lacked documentation of changes. The facility's policy requires dressing changes every 48 hours if gauze is present, but this was not followed. The DON confirmed no documentation of dressing changes, and the resident's POS showed no orders for catheter care, leading to a deficiency in maintaining the catheter.
The facility failed to document the pharmacy's monthly Medication Regimen Reviews (MRR) recommendations and physician responses for two residents. The ADON admitted to missing recommendations and a lack of a proper tracking system, while the DON emphasized the need for escalation if no response is received. The facility's policy requires timely communication and documentation, which was not followed.
A resident with multiple health conditions was found storing opened bottles of Miracle Whip and horseradish sauce on her windowsill, despite needing refrigeration. The facility had removed personal refrigerators, leaving the resident without proper storage options. The administrator acknowledged the issue, noting that the facility's policy requires regular inspections and proper food storage.
A CNA failed to wear a gown when entering the room of a resident on contact precautions for MRSA, despite facility policy and signage indicating the need for full PPE. The resident had multiple diagnoses, including MRSA, requiring strict adherence to infection control protocols. The CNA realized the mistake after entering, and the DON confirmed the necessity of wearing both a gown and gloves in such situations.
The facility failed to use an antibiotic use protocol tool for two residents on antibiotics, as confirmed by the IP and DON. One resident was on Ciprofloxacin for a UTI, and another on Meropenem for a positive sputum culture, without the McGeer's tool being completed. This tool is essential for ensuring appropriate antibiotic use, as per the facility's policy.
A resident's bed was found with side rails extending five inches on both sides, creating a potential entrapment hazard. An LPN confirmed the risk of the resident becoming stuck between the rails due to the space between the bed rail and mattress. The DON acknowledged the need for regular inspections to prevent such safety risks.
A resident at high risk for skin breakdown developed a Stage 3 pressure ulcer due to the facility's failure to conduct effective skin assessments and address skin issues. Despite orders for regular skin checks, staff did not notice or report the resident's skin condition, resulting in untreated open and bloody skin areas.
A resident's family requested information to install a camera in the resident's room during a care conference, but the facility failed to provide the necessary information or follow up on the request. The resident, who required assistance with daily activities, was moderately impaired. Despite the facility's policy allowing cameras, the request was not addressed within the expected timeframe, resulting in a violation of the resident's rights.
A resident with anxiety disorder did not receive scheduled doses of Buspirone, Clonazepam, and Hydroxyzine over several days due to a failure in the medication reordering process. Despite the resident's reports and staff awareness, the medications were not reordered in time, leading to increased stress for the resident.
A resident with a history of pressure injuries developed new stage 2 and stage 3 pressure injuries on the right hip, which were not promptly reported or treated by the facility staff. The CNA initially failed to report the wounds, and the LPN was unaware until later notified. The facility's protocols for immediate reporting and treatment of skin alterations were not followed, resulting in a deficiency.
A resident with fragile skin and a history of skin tears did not receive proper assessment and treatment orders for her wounds. The Wound Care Nurse was unaware of the resident's active wounds, and the facility failed to document or obtain treatment orders in the EMR. The Hospice RN changed dressings without access to the EMR, and the Director of Nursing expected staff to report skin issues, but the EMR lacked active wound care orders, leading to a deficiency.
The facility failed to maintain a clean and homelike environment for residents, as observed during an inspection. The bedroom floors were found to be dirty, with accumulated dirt, dust, and debris, including plastic pieces from PPE packaging. Residents and a family member expressed dissatisfaction with the cleanliness, and a housekeeper acknowledged that some rooms had not been swept for days, despite daily cleaning expectations. Resident Council Meetings had previously documented concerns about the need for cleaning.
The facility failed to provide timely incontinence care and assistance with ADLs for three residents. Two residents were found with saturated briefs, with the last change occurring several hours prior. Another resident was left in bed for an extended period without being offered assistance to get up, despite expressing a desire to do so. The DON confirmed that staff are required to check and change residents every two hours and assist them in getting up unless medically contraindicated.
A facility failed to monitor and check glucose blood sugar levels for a resident with a history of Diabetic Ketoacidosis, resulting in hospitalization for DKA. The resident's blood glucose levels were consistently elevated despite insulin doses, and there was no documentation of rechecking sugar levels or notifying the physician.
A resident scheduled for eye surgery was fed toast and cereal despite having an NPO order, leading to the rescheduling of the surgery. Interviews confirmed the staff's failure to follow the physician's order.
The facility failed to maintain a resident's bed equipment, specifically the bed control cord, which had approximately two inches of exposed wires. The resident involved is a [AGE] year old female with osteoarthritis, type 2 diabetes, and bilateral cataracts. The issue was observed on two separate occasions, and the Director of Maintenance was notified on the same day as the second observation.
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 Elevate Head of Bed During Tube Feeding
Penalty
Summary
Facility staff failed to maintain the head of bed at the required 30-45 degree elevation while a resident's tube feeding was infusing. During an observation, the resident was found in a flat position in bed with tube feeding of Nepro 1.8 Cal infusing at 40 mL per hour via feeding pump. Certified Nursing Assistants (CNAs) present during care stated that they believed it was acceptable for the resident to remain flat during tube feeding unless the resident was being turned side to side. The Director of Nursing (DON) later clarified that the head of bed should be elevated during tube feeding to prevent vomiting or aspiration. Review of the resident's physician orders and facility policy confirmed that the head of bed should be elevated to 30-45 degrees during tube feeding unless otherwise ordered.
Missed Antibiotic Doses Due to Medication Unavailability and Documentation Lapses
Penalty
Summary
The facility failed to administer the ordered initial dose of an antibiotic to a resident being treated for a urinary tract infection (UTI). The nurse practitioner's progress note documented a plan to treat the resident with Levofloxacin IV, starting with a 750 mg dose, followed by a 500 mg dose every 48 hours, and Meropenem 500 mg IV daily. The Medication Administration Record (MAR) showed a missed dose of Meropenem on 9/14/25 and no documentation of the administration of the initial Levofloxacin 750 mg dose on 9/13/25 or 9/14/25. Nursing notes indicated that Levofloxacin was not available and would be delivered later, but there was no documentation that the dose was ever administered. The Director of Nursing confirmed there was no documentation of the administration of either the Meropenem dose or the initial Levofloxacin dose, and no authorization requests were received from the pharmacy for the one-time Levofloxacin dose. Facility policy requires prompt reporting of medication discrepancies and omissions, but this was not documented in this case.
Failure to Serve Meals at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to maintain palatable and appetizing food temperatures when serving meals to residents. Observations and interviews with several alert and oriented residents revealed consistent complaints that food was being served lukewarm or cold. A family member also reported that a former resident frequently complained about cold food. During meal service observations, food carts were delivered to the dining room and resident rooms using non-insulated carts covered with plastic zippered covers. Staff were seen setting up trays and serving food without the use of plate warmers or metal heating plates, which are important for maintaining food temperature. Temperature checks of food trays revealed that hot foods, such as turkey with gravy and cornbread dressing, were served at temperatures significantly below the required holding temperature of 135°F, with some items measured as low as 50.1°F. The Dietary Manager confirmed that food temperatures are checked in the kitchen before delivery, but acknowledged that the lack of metal heating plates and insulated carts contributed to the inability to maintain appropriate temperatures during transport and service. Facility policy requires that food be served at safe and appetizing temperatures, but this standard was not met during the survey period.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to adhere to standard infection control practices regarding the use of gowns during care for residents on Enhanced Barrier Precautions (EBP). Observations revealed that staff did not wear gowns while providing high-contact care to three residents who were on EBP due to conditions such as a history of Candida Auris, end stage renal failure with IV access, and a history of multidrug-resistant organisms. Specifically, two CNAs provided hygiene care to a resident with a history of Candida Auris without donning gowns, despite EBP signage being present. Another CNA provided incontinence care to a resident with an AV fistula and IV midline catheter, who was also receiving IV antibiotics, without wearing a gown. Additionally, a nurse checked vital signs at the bedside of a resident with a wound, indwelling urinary catheter, and history of KPC, again without wearing a gown, even though EBP signage was posted. Interviews and record reviews confirmed that these residents were on the facility's EBP list and that staff were expected to wear gowns and gloves during high-contact care activities, as outlined in the facility's EBP policy and posted signage. The policy specifically required gown and glove use for activities such as dressing, bathing, hygiene, incontinence care, and device care for residents on EBP. Despite these clear expectations and procedures, staff failed to consistently implement the required infection control measures during the observed care activities.
Failure to Assess, Treat, and Monitor Resident Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who developed significant skin abnormalities, including a rash and redness in multiple areas. Despite the presence of a care plan and specific orders from a wound care nurse practitioner to keep the skin clean and dry, apply barrier and antifungal creams, and monitor the affected areas, staff did not consistently implement these interventions. Documentation shows that the resident's skin issues, including redness and rash in the groin, perineal area, buttocks, and under the breasts, were present for several months without adequate assessment, monitoring, or treatment. Staff did not complete required wound or skin event documentation in risk management, nor did they notify the physician or wound care nurse of changes or worsening conditions. Direct observations revealed that the resident, who was dependent on staff for all activities of daily living and had multiple complex medical diagnoses, was left in a soiled incontinence brief for over four hours. The resident's skin was found to be bright red, with extensive rash and evidence of pain during care. Staff failed to apply barrier cream as ordered, citing lack of access to supplies, and did not follow through with timely application of zinc oxide ointment. The wound care nurse practitioner's recommendations for antifungal and barrier cream application, as well as regular reassessment, were not documented as being followed, and there was no evidence of ongoing measurement or evaluation of the skin condition. The facility's own policies required head-to-toe skin assessments by licensed nurses upon admission, weekly skin checks, daily CNA observations, and prompt documentation and follow-up of any abnormalities. However, there was no documentation of physician notification, wound or skin event completion, or follow-up assessments for the resident's ongoing and worsening skin issues. The lack of adherence to care plans, provider orders, and facility policies resulted in the resident experiencing prolonged pain and discomfort due to untreated and unmonitored skin conditions.
Inadequate Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough abuse investigations, which has the potential to affect all residents. In one instance, a CNA reported hearing an LPN verbally discourteous to a resident, R81, who is legally deaf and moderately cognitively impaired. The facility's investigation was incomplete, as there was no evidence of an interview with R81 or a written statement from the LPN involved. The investigation included statements from other staff, but these were related to a separate Human Resources incident. Additionally, resident interviews conducted were undated, lacked specific questions about the incident, and did not include staff names. In another case, the facility's investigation into an abuse allegation involving R29 was insufficient. The final report indicated that R29 was alert and oriented, yet there was no documentation of an interview with R29 or any other residents. The administrator claimed to have spoken with R29, but this was not documented. The investigation relied on random patient and staff interviews, which did not yield any complaints, but lacked thorough documentation and evidence. A third investigation concerning R252 was similarly inadequate. The facility provided initial and final reports but no other investigatory evidence. The administrator stated that there were no staff interviews and that resident interviews were verbal and undocumented. The final report mentioned staff interviews and random resident inquiries about safety, but these were not substantiated with documentation. The facility's abuse policy requires comprehensive investigations, including interviews with all relevant parties and documentation, which were not adhered to in these cases.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 133 residents receiving dietary services. During an inspection, it was observed that the vents over the stove were dusty, and the sanitizing solutions in the red buckets and the three-compartment sink were not within the manufacturer's recommended range of 200-400 ppm. The dishwasher failed to reach the required sanitizing temperature of 180 degrees Fahrenheit, with the highest recorded temperature being 99 degrees Fahrenheit. The Dietary Manager and Morning Cook confirmed these discrepancies, noting that the automated sanitizer dispenser was not functioning properly, and the dishes could not be verified as sanitized. In the walk-in cooler, several food items were found unlabeled or improperly dated, including cheese, pickles, sandwiches, and various meats. Some items, such as tomatoes and green peppers, were visibly spoiled. The facility's policy requires that leftovers and open foods be clearly labeled with a discard date, but this was not adhered to. Additionally, staff personal food was stored in the kitchen refrigerator without proper labeling, contrary to the facility's policy. The resident refrigerators on the first and second floors lacked thermometers, and temperature logs were not maintained. The first-floor refrigerator contained expired chocolate milk and unlabeled take-out containers, while the second-floor refrigerator also had unlabeled containers and felt warm. The Maintenance Director confirmed the absence of thermometers and blank temperature logs. Furthermore, the dry storage area contained dented cans that were not marked, posing a risk of botulism if used. The facility's policy requires dented cans to be stored separately or returned to the vendor, which was not followed.
Failure to Provide ROM Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for residents with decreased range of motion (ROM), as evidenced by the lack of assessment, treatment, services, devices, and care planning. Five residents were identified as not receiving the necessary interventions to manage their conditions, which included hemiplegia, hemiparesis, and contractures. Despite having physician orders for splints and other supportive devices, these were not consistently applied, leading to potential worsening of their conditions. Resident R114, who was admitted with hemiplegia and hemiparesis following a stroke, had a physician order for a resting hand splint to manage contractures. However, observations over several days showed that the splint was not applied, and the resident's left hand remained closed into a fist. The Director of Rehab and Restorative Aide confirmed the necessity of the splint to prevent contractures, yet it was not utilized as ordered. Similarly, Resident R86, with a history of cerebral infarction, had orders for a resting hand splint, but it was not applied consistently. The restorative staff, who were responsible for applying the splints, were often reassigned to work as CNAs, leaving the residents without the necessary restorative care. This lack of adherence to physician orders and care plans was also evident in the cases of Residents R46, R94, and R99, who were observed without their prescribed splints or other supportive devices, indicating a systemic issue in the facility's management of residents with impaired mobility.
Unsafe Storage and Bed Positioning in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment for residents by not securely storing oxygen cylinders and cleaning supplies, and by not maintaining residents' beds at a safe height. Several residents, including those at risk for falls, were found with their beds and overbed tables in high positions, contrary to their care plans which specified that beds should be kept low to minimize fall risk. Staff members, including CNAs and LPNs, were observed leaving beds in high positions, and there was a lack of communication and understanding among staff regarding the importance of maintaining beds at a safe height for all residents, regardless of their fall risk score. Additionally, oxygen tanks were found unrestrained and unholstered in residents' rooms and the second-floor medication room, posing a potential hazard. The facility's policy requires oxygen tanks to be stored in holders to prevent mechanical shock and combustion risks. Furthermore, the housekeeping closet and soiled utility room were left unlocked, with unsecured cleaning chemicals accessible, despite the facility's policy that such areas should be locked to prevent resident access. These oversights indicate a failure to adhere to safety protocols designed to prevent accidents and ensure resident safety.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically hemorrhoidal ointment. The resident, who had severe cognitive impairment, was observed with a tube of hemorrhoidal cream on her bedside table. She reported using the cream for lubrication between her butt cheeks to help her sit, rather than for its intended use as prescribed. The resident stated she did not have hemorrhoids and was unaware of who provided her with the cream. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is safe, which was not conducted in this case. The resident's medical history included gastrointestinal hemorrhage, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, congestive heart failure, gout, and repeated falls. Despite having an order for hemorrhoid cream to be applied rectally, the resident had not received assistance with its application since the previous year. Facility staff, including an LPN and RN, confirmed that the resident did not have orders to self-administer or store medications at her bedside. The Director of Nursing stated that residents with severe cognitive impairment should not have medications at their bedside, and the cream should not be used as a barrier cream.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident R114, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was found with her call light placed on a side dresser, out of her reach. Despite her care plan indicating that the call light should be within reach due to her limited mobility and weakness, she was unable to use it and had to resort to screaming for help. The Director of Nursing confirmed that call lights should be attached to the bed linen or wrapped around the side rail to ensure accessibility. Resident R2, who is cognitively intact and at risk for falls, had her call light placed near her shoulder, making it difficult for her to reach. She expressed the need for the call light to be closer to her hand. Similarly, Resident R44, also cognitively intact with a self-care deficit and decreased mobility, had her call light wedged between the bed frame and side rail, making it inaccessible. Despite multiple observations, her call light remained out of reach, and she reported having to scream for assistance. The facility's policy requires that call lights be accessible to residents capable of using them, but this was not adhered to in these cases.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse, as evidenced by incidents involving three residents. One resident, who is moderately cognitively impaired and legally deaf, was allegedly verbally abused by an LPN during a medication pass. The CNA reported overhearing the LPN yelling at the resident to 'stop that' and 'shut up.' The facility's investigation into the incident was incomplete, as there was no written statement from the LPN, and the resident was not properly interviewed due to his hearing impairment. Another resident, with intact cognition, reported being verbally criticized by the same LPN regarding his toileting habits. The resident described the interactions as hostile and found the LPN's behavior to be inappropriate and offensive. The facility's report acknowledged that the LPN's demeanor did not meet facility standards and noted similar negative interactions with other residents, but it did not specify whether the abuse allegation was substantiated. A third resident, also with intact cognition, recounted an incident where the LPN yelled at her for having outside medication in a package from her sister. The resident felt belittled and humiliated by the LPN's actions. The facility's abuse policy defines verbal and mental abuse and emphasizes a no-tolerance philosophy, yet the incidents suggest a failure to adhere to these standards, resulting in the residents' experiences of verbal and mental abuse.
Failure to Report Verbal Abuse Allegation to IDPH
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the Illinois Department of Public Health (IDPH). The incident involved a Certified Nursing Assistant (CNA) who alleged that a facility nurse was verbally discourteous to a resident, identified as R81. The CNA reported overhearing the nurse speaking disrespectfully to the resident, including shouting and telling the resident to 'shut up' loudly. Despite the facility's policy requiring immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, the initial and final incident reports were not sent to IDPH. The facility's administrator, who also serves as the Abuse Coordinator, acknowledged that neither the initial nor the final reports were sent to IDPH, despite believing they had been. The administrator confirmed that the fax verifications provided did not include the necessary details to show that the reports were actually sent. The facility's abuse policy mandates that a complete written report of the investigation's conclusion, including the steps taken in response to the allegation, be sent to the Department of Public Health within five days of the occurrence. This failure to report constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Incontinence Care and Lack of Toileting Program
Penalty
Summary
The facility failed to properly assess and implement a toileting program for a resident, identified as R32, who was incontinent of bowel and bladder. During an observation, it was noted that R32 was wearing a disposable incontinence brief with an additional disposable incontinence pad inside the brief. This practice was confirmed by R32, who stated that she wore the briefs and pads for protection and was not on a toileting program or schedule. The Certified Nursing Assistant (CNA) assisting R32 mentioned that the resident drinks a lot of coffee and water, which was used to justify the use of both the pad and the brief due to heavy urine output. The Restorative Nurse, identified as V15, acknowledged that residents should not wear both an incontinence brief and a pad inside the brief, as it could lead to skin breakdown. It was confirmed that R32 was not on a toileting program. R32's medical history includes conditions such as hemiplegia, hemiparesis, diabetes, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, major depressive disorder, and dysphagia. The facility's policy on Supporting Activities of Daily Living (ADL) emphasizes the necessity of providing services to maintain good nutrition, grooming, and personal hygiene for residents unable to perform these activities independently, yet R32's care plan lacked a scheduled toileting program.
Failure to Maintain Midline IV Catheter
Penalty
Summary
The facility failed to provide necessary care for a resident with a midline intravenous (IV) catheter, leading to a deficiency in maintaining the catheter. The resident, who has a diagnosis of unspecified hearing loss, was observed with a midline IV catheter in the right upper arm, where the dressing was saturated with serosanguinous blood. The dressing lacked documentation of the time, date, or staff initials indicating when it was last changed. The resident communicated that the catheter had been in place for about a month, was last used and flushed the previous month, and could not recall the last dressing change. The Director of Nursing (DON) confirmed that there was no documentation of midline catheter dressing changes in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The facility's policy requires dressing changes every 48 hours if gauze is present under the transparent dressing, but the DON was unaware of this requirement. The resident's Physician Order Sheet (POS) indicated an order for IV antibiotic infusion, but no IV medications were administered in February, and there were no orders for dressing changes or catheter care. The facility's policy outlines the need for regular dressing changes and documentation, which was not adhered to in this case.
Incomplete Documentation of Medication Regimen Reviews
Penalty
Summary
The facility failed to provide completed documentation of the pharmacy's monthly Medication Regimen Reviews (MRR) recommendations along with the physician or prescriber responses for two residents, R55 and R64, out of a sample of 30. For R55, the consultant pharmacist completed MRRs on several occasions, but the facility did not provide the referenced reports or documentation of the physician's responses. The Assistant Director of Nursing (ADON) acknowledged the need for a better tracking system and admitted that some recommendations were missing and not always scanned into the Electronic Medical Record (EMR). The Director of Nursing (DON) stated that the ADON should escalate the issue to the Medical Director if there is no response from the physicians. Similarly, for R64, the facility did not provide the referenced reports or documentation of the physician's responses to the pharmacist's recommendations. The facility's policy requires that comments and recommendations concerning medication therapy be communicated in a timely fashion, enabling a response before the next MRR. The policy also states that if the prescriber does not respond in a reasonable time, the DON or consultant pharmacist may contact the Medical Director. However, the facility failed to adhere to these guidelines, resulting in incomplete documentation of the MRR process.
Improper Storage of Resident's Personal Food Items
Penalty
Summary
The facility failed to ensure proper storage of a resident's personal food items, leading to a deficiency. A resident, identified as R45, was observed with opened bottles of Miracle Whip and horseradish sauce stored on the windowsill in her room, despite both items requiring refrigeration after opening. The resident, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease and heart failure, stated that she used to have a refrigerator in her room, but it was removed by the facility. As a result, she had no alternative storage for her personal food items. The facility's administrator confirmed that personal refrigerators were no longer available and acknowledged that the condiments should be refrigerated to prevent potential health issues. The facility's Food Storage policy mandates regular inspections and immediate disposal of improperly stored food, which was not adhered to in this instance.
Failure to Use Proper PPE in Isolation Room
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not wearing the appropriate personal protective equipment (PPE) before entering an isolation room. This deficiency was observed when a Certified Nursing Assistant (CNA), identified as V11, entered the room of a resident diagnosed with MRSA without wearing a gown, despite the presence of a sign indicating contact precautions. The resident, identified as R447, had multiple diagnoses including an infection of an amputation stump and MRSA, necessitating contact precautions as per the physician's order sheet and care plans. The CNA acknowledged the oversight, stating that they realized the mistake after entering the room to assist the resident. The Director of Nursing (DON), identified as V2, confirmed that MRSA requires contact precautions, which include wearing both a gown and gloves before entering the isolation room. The facility's policy on transmission-based precautions also mandates the use of a disposable gown upon entering and removing it before leaving the room to prevent contamination. This incident highlights a lapse in following established infection control protocols, specifically regarding the use of PPE in isolation settings.
Failure to Utilize Antibiotic Use Protocol Tool
Penalty
Summary
The facility failed to utilize an antibiotic use protocol tool for residents who were placed on antibiotics, affecting two out of five residents reviewed for antibiotic stewardship. The Infection Preventionist (IP), identified as V4, acknowledged that the McGeer's tool, which is used to screen for infections and guide antibiotic use, was not completed for these residents. Resident R27 was receiving Ciprofloxacin for a urinary tract infection, and the tool was not used to assess the necessity of the antibiotic. Similarly, Resident R120 was on Meropenem for a positive sputum culture, and again, the McGeer's tool was not utilized to determine if the antibiotic was warranted. The Director of Nursing (DON), identified as V2, confirmed that the McGeer's tool is a critical component of the facility's antibiotic stewardship program, intended to ensure antibiotics are prescribed appropriately. The facility's policy, reviewed in June 2024, mandates the use of a surveillance tracking form to document antibiotic usage and outcomes, which was not adhered to in these cases. This oversight indicates a lapse in following established protocols for antibiotic stewardship, potentially impacting the quality of care provided to the residents involved.
Failure to Identify Bed Entrapment Hazard
Penalty
Summary
The facility failed to identify a potential entrapment hazard on a resident's bed, which was observed during a survey. Specifically, the bed and overbed table of a resident were left in a very high position, and the side rails extended approximately five inches on both sides of the bed. This created a risk of the resident rolling over and becoming stuck between the rails. A Licensed Practical Nurse (LPN) confirmed that the bed rails were too far apart from the mattress and bed frame, posing a safety risk. The Director of Nursing (DON) acknowledged that both Maintenance and Nursing staff should ensure there is no space between the bed rail and mattress to prevent injury or entrapment. The facility's policy, dated January 17, 2025, mandates regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment areas.
Failure to Identify and Address Skin Breakdown
Penalty
Summary
The facility failed to identify and address a resident's skin breakdown, resulting in the development of a Stage 3 pressure ulcer. The resident, who was admitted with multiple diagnoses including hemiplegia, hypertension, and respiratory dependence, was at a very high risk for skin breakdown according to assessments. Despite orders for daily and weekly skin checks, the resident's skin issues went unnoticed until a Wound Care Coordinator observed several areas of open, broken, and bloody skin on the resident's buttocks. The resident's care plan aimed to maintain clean and intact skin, but no skin assessments for impaired or open skin were completed since admission. Staff interviews revealed that CNAs providing incontinence care did not notice any skin issues, and the resident's skin was not dressed or treated prior to the discovery of the ulcer. The CNAs did not report any concerns to the nursing staff, and the LPN on duty had not been treating the resident for any skin concerns. The facility's Wound Prevention and Healing policy required skin inspections during showers and as scheduled, but these were not effectively carried out, leading to the oversight of the resident's skin condition.
Failure to Provide Information for Camera Installation in Resident's Room
Penalty
Summary
The facility failed to provide necessary information to a resident's family regarding the installation of a camera in the resident's room, which is a violation of the resident's rights to a dignified existence and self-determination. The resident, who was moderately impaired and required assistance with various activities of daily living, had a care conference on December 5, 2024, where the family expressed the desire to have a camera installed in the resident's room. Despite this request, the facility did not follow through with providing the necessary information or addressing the request in a timely manner. The family member, V31, reported that they had contacted the Director of Social Services, V6, on December 11, 2024, to request information about the camera installation policy, but did not receive a follow-up. The facility's staff, including V5 and V6, were unclear about the status of the request, and the Administrator, V1, was not aware of the request. The facility's policy allowed for cameras, but the request was not addressed within the expected 72-hour timeframe. The lack of communication and follow-up resulted in the failure to honor the resident's rights, as the family was not provided with the necessary information to proceed with the camera installation.
Failure to Provide Scheduled Anxiety Medications
Penalty
Summary
The facility failed to provide a resident with his scheduled anxiety medications as ordered, affecting one resident reviewed for pharmacy services. The resident, who was cognitively intact and had a history of anxiety disorder among other diagnoses, did not receive his prescribed doses of Buspirone, Clonazepam, and Hydroxyzine over several days in December 2024. The resident reported being out of these medications and expressed increased stress due to the lack of medication. Despite communicating with staff and a Nurse Practitioner, the issue was not resolved promptly. Interviews with facility staff revealed a breakdown in the medication reordering process. Licensed Practical Nurses (LPNs) acknowledged the importance of timely reordering to prevent medication shortages, yet the resident's medications were not reordered in time. The Director of Nursing confirmed that communication with the pharmacy began only after the medications had run out, leading to a delay in receiving the necessary medications. The facility's policy required controlled substances to be reordered when a five-day supply remained, but this protocol was not followed, resulting in the deficiency.
Failure to Report and Treat New Pressure Injuries
Penalty
Summary
The facility failed to report and address new skin alterations for a resident with a known history of pressure injuries. The resident, who had multiple diagnoses including a history of pressure injuries, was found to have new facility-acquired pressure injuries on the right hip, specifically a stage 3 and a stage 2 cluster. These injuries were not assessed or treated promptly upon identification, as required by the facility's protocols. During an observation, the resident was found in the same position for an extended period, and a Certified Nurse Assistant (CNA) initially reported no wounds. However, upon further inspection, the CNA discovered open areas on the resident's right hip, which had been observed earlier in the shift but not reported. The CNA then notified a Licensed Practical Nurse (LPN), who was unaware of the wounds until that moment. The LPN assessed the wounds, identified them as pressure injuries, and initiated basic wound care. The Wound Care Nurse (WCN) and Wound Care Aide (WCA) later assessed the wounds, confirming the presence of newly acquired pressure injuries. The facility's policy required immediate reporting and treatment of skin alterations, which was not followed in this case. The resident's care plan and orders emphasized the need for daily skin assessments and prompt notification of wound care staff for any issues, which were not adhered to, leading to the deficiency.
Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
The facility failed to assess and obtain treatment orders for a resident with known skin tears, leading to a deficiency in providing appropriate treatment and care. The resident, who was at risk for skin integrity impairment due to fragile skin and a history of skin tears, was observed with multiple dressings on her extremities. The Wound Care Nurse was unaware of the resident's active wounds and found that the resident did not have treatment orders in her Electronic Medical Record (EMR). The resident's wounds were not assessed or documented by the facility prior to the surveyor's observation. The facility's staff, including the Registered Nurse and Hospice RN, were involved in changing the resident's dressings but did not ensure proper documentation or treatment orders were in place. The Hospice RN did not have access to the facility's EMR and relied on previous dressings for treatment. The Director of Nursing expected staff to assess and report skin abnormalities, but the resident's EMR lacked active wound care orders. The facility's policies required wound assessment and documentation, but these were not followed, resulting in the deficiency.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for six residents, as observed during an environmental inspection. The inspection revealed that the bedroom floors of these residents were dull, dirty, and covered with accumulated dirt, dust, and debris, including small pieces of plastic from personal protective equipment packaging. The floors also had stains and patches of dry, unidentified fluids. Interviews with residents and a family member confirmed the dissatisfaction with the cleanliness of the floors. A housekeeper admitted that some bedrooms had not been swept for days, despite the expectation that floors should be swept and mopped daily. Documentation from Resident Council Meetings from June through August 2025 also indicated ongoing concerns about the need for bedroom and floor cleaning.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living (ADL) for three residents. On September 25, a CNA provided incontinence care to a resident who was found saturated with urine and had a pasty bowel movement, with the last change occurring around 9 AM. Another resident was also found with a saturated brief, with the last change also occurring after breakfast. Both residents' urine was dark in color, indicating a lack of timely care. Additionally, a third resident was observed in bed for an extended period without being offered assistance to get up, despite expressing a desire to do so. The resident reported that staff often made excuses for not assisting her, leading her to stop asking for help. The Director of Nursing confirmed that staff are required to check and change residents every two hours and assist them in getting up unless medically contraindicated. All three residents were noted to be alert and oriented, requiring extensive to total assistance with ADL care.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to monitor and check glucose blood sugar levels for a resident with a known history of Diabetic Ketoacidosis (DKA) and elevated blood sugars. This failure resulted in the resident needing hospitalization for DKA. The resident's blood glucose levels were consistently elevated, ranging from 345 mg/dL to 400 mg/dL, despite routine insulin doses and sliding scale orders. There was no documentation of rechecking the resident's sugar levels after dinner and at bedtime, nor was there any record of notifying the resident's physician about the consistent elevation of sugar levels despite the insulin doses. The resident, who has multiple diagnoses including type 2 diabetes mellitus with ketoacidosis, acute kidney failure, and congestive heart failure, was admitted to the facility after suffering a cardiac arrest. The resident's blood glucose monitoring log showed consistently elevated readings from May 21 to May 22, 2024. On May 23, 2024, the resident's blood sugar level was 600 mg/dL, and he displayed lethargy and slurred speech, leading to hospitalization with a diagnosis of DKA. The hospital report indicated that upon admission, the resident's blood glucose level was 810 mg/dL, and his ketones were very high. Interviews with facility staff and the resident's physician revealed that the standard glucose monitoring for brittle diabetics is 3-4 times a day and as needed. The staff should have rechecked the resident's sugar levels 2 hours after dinner and at bedtime and reported the resident's condition to the physician for potential new orders and medication adjustments. The lack of proper monitoring and communication with the physician contributed to the resident's hospitalization for DKA.
Failure to Implement Physician's NPO Order
Penalty
Summary
The facility failed to implement a physician's order for a resident who was scheduled for eye surgery. The resident, a [AGE] year old female with diagnoses including bilateral cataracts, had a physician's order to be NPO (Nothing by Mouth) from midnight and could only have clear liquids until 6:30 AM, along with specific medications with a sip of water. On the morning of the scheduled surgery, the resident was fed toast and cereal by the staff, leading to the rescheduling of the surgery. Interviews with the resident and various staff members confirmed that the NPO order was not followed, resulting in the delay of the medical procedure. The facility's policy requires Licensed Professional Nurses/Registered Nurses to follow physician orders, which was not adhered to in this instance.
Failure to Maintain Bed Equipment
Penalty
Summary
The facility failed to maintain a resident's bed equipment, specifically the bed control cord, which had approximately two inches of exposed wires. This deficiency was observed on two separate occasions, with the Administrator present during one of the observations. The resident involved is a [AGE] year old female with diagnoses including osteoarthritis, type 2 diabetes, and bilateral cataracts. The resident's daughter also reported the frayed wires. The Director of Maintenance was notified of the issue on the same day as the second observation. The facility's Safe Environment policy mandates maintaining all essential equipment in safe operating conditions, which was not adhered to in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
