Renwick Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 3401 Hennepin Drive, Joliet, Illinois 60435
- CMS Provider Number
- 145694
- Inspections on file
- 44
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Renwick Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain safe and comfortable temperatures for all residents after a power outage and boiler malfunction, resulting in prolonged cold conditions throughout the building. A maintenance director reset the boilers but left after noting the facility was warming, while multiple residents reported being very cold for extended periods, relying on numerous blankets, extra clothing, and room changes. Staff, including CNAs, LPNs, and an RN, acknowledged that the building felt cold, that residents complained, and that they used all available blankets and moved some residents to warmer areas, but they did not consistently notify on-call leadership or maintenance about the ongoing lack of heat. Temperature logs documented readings in the upper 50s to low 60s°F in various areas, and not all residents had body temperatures monitored, despite facility policy requiring notification of administration and maintenance, regular room temperature checks, and observation of residents for adverse effects during loss of heat.
Essential heating equipment was not properly maintained following a power outage, resulting in a period without adequate heat for all residents. The Maintenance Director did not know the boilers required manual resetting after the outage and did not reset all units, and an assistant later had to reset an additional boiler. A heating contractor identified a failed pump motor that was critical for the heat pumps to function and advised immediate replacement, but facility leadership chose to delay the work until normal business hours, despite staff reporting that they were cold. A technician later replaced the defective pump motor and components and confirmed that room temperatures were rising.
Surveyors identified extensive sanitation and hygiene deficiencies in the kitchen, including dirty handwashing stations, stained equipment, spoiled food, and improper staff hygiene practices such as inadequate handwashing and incomplete hair covering. Staff were observed wearing personal clothing in food prep areas and using cracked equipment, while food contact surfaces and storage areas were found with visible residue, stains, and food particles. Facility policies requiring cleanliness and infection control were not consistently followed.
A resident with a history of falls and behavioral challenges was being assisted with toileting when she attempted to pull up her own pants, became unstable, and fell, sustaining a head injury. The staff member assisting did not use a gait belt as required by facility policy, instead attempting to support the resident manually, which was insufficient to prevent the fall.
A resident at high risk for falls, with multiple medical conditions and on blood thinners, was injured after being transferred with a sit to stand lift by a single CNA, despite facility policy requiring two staff for such transfers. The resident fell forward and sustained a bleeding injury to the forehead. The care plan did not specify fall precautions, and staff interviews confirmed the transfer was not performed according to policy.
A resident with moderate cognitive impairment and depression threatened his severely cognitively impaired roommate with a pocketknife, making alarming statements and causing mental distress. Nursing staff moved the threatened resident to another room and later discovered the knife when the resident's family arrived. The facility failed to protect the resident's right to be free from mental abuse, as defined by its own abuse prevention policy.
A resident with schizophrenia and recent elopement attempts was subject to involuntary transfer and discharge procedures initiated by facility staff without the required physician documentation or orders. The DON completed the necessary forms at the direction of corporate staff, but the forms were not signed by a physician and lacked detailed medical justification. Hospital evaluation found no immediate safety concerns, and the resident's medical record did not contain physician progress notes or orders supporting the transfer or discharge.
A resident with hemiplegia and obesity fell from bed during care due to inadequate assistance, resulting in fractures and a knee dislocation. The CNA, working alone, directed the resident to turn onto her affected side, leaving her close to the bed's edge. Despite the resident's care plan requiring two-person assistance, no additional staff were available, leading to the fall and subsequent hospitalization.
A resident with severe cognitive impairment and multiple health issues was injured during a transfer when a CNA used a gait belt instead of the prescribed mechanical lift with two staff members. This improper transfer led to a leg laceration requiring sutures. Facility staff confirmed that the expectation was to follow therapy's recommendations for safe transfers, as outlined in the care plan and facility policy.
The facility failed to maintain sanitary practices during food preparation and service, affecting 92 residents. A cook was observed using a dirty blender and lid, with uncovered facial hair, and storing personal items on prep counters. Uncovered and undated food items were found in storage, and a dietary aide also had uncovered facial hair. Facility policies on food storage and preparation were not adhered to.
The facility failed to follow its Infection Prevention and Control Program, with the ADON not completing infection surveillance tools since October 14, 2024. The Maintenance Director was unaware of the water management plan for legionella, leading to no monitoring of water systems. Staff also neglected hand hygiene and Enhanced Barrier Precautions, with CNAs not wearing gowns or performing hand hygiene between tasks, affecting residents with conditions like ESBL resistance and Candida Auris.
The facility failed to maintain comfortable room temperatures, affecting six residents who reported inadequate heating in their rooms. Temperatures dropped to 58 degrees Fahrenheit at night, forcing residents to use extra blankets. The issue arose from a contractor's error in the electrical system, delaying the installation of new heating units. The facility's policy for loss of heat was not effectively implemented.
The facility failed to assist six residents with personal hygiene, grooming, and incontinence care. Residents with cognitive impairments and physical limitations were observed with dirty fingernails, overgrown facial hair, and inadequate incontinence care. Despite needing total or extensive assistance, their grooming needs were unmet, highlighting a deficiency in maintaining hygiene and dignity.
The facility failed to provide adequate perineum and catheter care for four residents, increasing the risk of UTIs. One resident was not fully cleaned after incontinence, another's uncircumcised penis and groins were not properly cleaned, a third resident's pubic area and labia were inadequately cleaned, and a resident with a suprapubic catheter did not receive proper catheter care. Facility guidelines for incontinence and catheter care were not adhered to.
The facility failed to label and date opened medications, including insulin and inhalers, to determine expiration dates. Additionally, narcotic medications with broken seals were not discarded as required, posing risks of medication diversion and infection. These deficiencies were identified during inspections of medication storage areas.
The facility failed to serve the correct portion sizes for pureed diets as per the menu guidelines, affecting six residents. The cook substituted pureed chicken for pork and mashed potatoes for rice, and dietary aides used an incorrect scoop size, leading to a deficiency in meeting nutritional needs.
The facility failed to provide necessary splint and therapy services to two residents, leading to a decline in their range of motion (ROM). One resident, with hemiplegia, was not wearing the prescribed hand splint for several days, resulting in a decline in ROM. Another resident, with severe contractures, was observed without a splint, and an occupational therapist recommended splinting and an orthopedic consult. These deficiencies highlight the facility's failure to maintain or improve residents' ROM.
A resident with a history of cerebral infarction and rheumatoid arthritis experienced tooth pain for over six months without receiving recommended extractions. Despite multiple dental visits, no action was taken, leading to significant discomfort and a downgraded diet. Communication issues and financial concerns were noted, with the resident's daughter seeking insurance-covered options.
The facility did not follow its antibiotic stewardship policy, impacting all 92 residents. The ADON, newly appointed as Infection Preventionist, had just started reviewing antibiotic use. The facility lacked documentation for tracking antibiotic use since early September, as confirmed by the Regional Nurse Consultant.
The facility failed to implement proper infection control practices following a COVID-19 exposure, affecting 55 residents. Residents were not tested for COVID-19 despite known positive cases, and the facility did not adhere to its COVID-19 policy. A CNA who tested positive had contact with residents and staff without appropriate precautions. The facility lacked documentation of testing and tracking, resulting in inadequate infection control measures.
The facility failed to maintain a safe and comfortable environment for residents due to a malfunctioning air conditioning system. Despite being notified of the issue, the facility did not take timely action, resulting in high room temperatures and resident discomfort. The facility did not follow its hot weather policy, using inappropriate tools to measure air temperature and failing to provide adequate fluids to residents. The HVAC contractor had informed the facility of underground pipe leaks, but temporary cooling solutions were delayed, affecting all 98 residents.
The facility failed to follow hot weather policies when the air conditioning malfunctioned, resulting in room temperatures exceeding 85°F. The administration did not ensure temperature and humidity were monitored every two hours, and residents were left in hot conditions without water. The facility lacked the necessary equipment to measure air temperatures and humidity, and staff were not informed of the procedures to follow during the malfunction.
Failure to Maintain Safe Indoor Temperatures and Monitor Residents During Heating System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe and comfortable indoor temperatures for all 102 residents following a power outage and subsequent heating system malfunction. After a power outage occurred on a Saturday, the Maintenance Director reported that the power was restored within approximately 45 minutes and stated there were no heating issues at that time. The next day, the Administrator notified the Maintenance Director that the heat was not working, and the Maintenance Director manually reset the boiler system, which he stated was required after the outage but had not been done earlier because he was unaware of the need. He reported that after resetting the boilers, the heat began working and temperatures taken throughout the facility showed it was warming up, and he then left the building. Despite this, residents and staff reported that the building remained cold over the weekend and into Monday. One resident stated that heating issues began on Saturday evening when the power went out and that the thermostat in his room read 55–60°F for 18 hours before he was moved to another room on Sunday afternoon. Another resident reported that it was very cold and that his nose was freezing to the touch, and staff provided extra blankets. A third resident’s room temperature was measured at 62.4°F by the Assistant Maintenance staff, and this resident reported that his room had been cold for two to three days, had already had his roommate moved out, and had asked his son to bring winter gloves. Another resident reported that his room was freezing the previous night, that he had 10 blankets on to stay warm, and that multiple people attempted but were unable to fix the heater in his room. A fifth resident reported that the heat was not working, that he used four blankets and two pairs of pants to stay warm, and that he remained in his room during this time. Staff interviews and facility records further demonstrated that the facility did not adequately monitor or respond to the cold conditions. A CNA reported working a morning shift when the building was cold, wearing her winter jacket while assisting residents in the dining room, and hearing residents complain of the cold; she stated that residents were moved to warmer areas but that she did not obtain temperatures on any residents. An LPN working a 12-hour day shift stated the facility was cold when she arrived and that she only took body temperatures on residents who could not verbalize if they were cold. An RN working the night shift reported that the facility felt cold when she arrived, that the previous shift had told her it was getting colder throughout the day, and that she instructed CNAs to add clothing and blankets and repositioned a resident’s bed away from a window, but she did not call anyone about the cold. Another LPN working night shifts over three days stated that heating issues started Saturday night, that staff were told maintenance had done everything possible, and that although it was cold on subsequent nights, she did not notify anyone on Sunday night. Temperature logs for the day of January 19 showed multiple readings below typical comfort levels, with recorded temperatures ranging from as low as 57.8°F to 71.4°F at various times between 8:00 AM and 6:00 PM. The Maintenance Director stated he was not notified by staff or administration on Sunday night into Monday morning that the heat was not working properly and that he did not become aware of the ongoing heating problem until he arrived Monday morning. The Assistant DON, who was the on-call nursing manager Sunday night, reported receiving no calls about the heat not working, and the Administrator similarly reported receiving no calls about the cold conditions that night, while stating that staff should have notified him or the Maintenance Director. The DON stated that staff began taking resident temperatures on Monday evening and acknowledged that not all residents’ temperatures were checked and that all residents should have been monitored, including on Sunday night if staff felt the facility was cold. The facility’s written policy on “Loss of Heat During Cold Weather” required that staff be oriented and educated to procedures for individual room heat malfunction and loss of heat to the entire facility. For individual room malfunctions, the policy directed staff to notify maintenance and to check room temperatures as needed, sampling at least every two hours when residents were in the room, and recommended moving residents if room temperatures fell below 55°F for 12 hours or more. For loss of heat to the facility, the policy required notification of the Administrator and Maintenance Department and observation of residents for signs of adverse effects of cooler temperatures. The report indicates that the facility did not document monitoring of all residents for signs and symptoms of hypothermia, including temperature checks, during the period when the facility lacked adequate heat on Sunday night and Monday, and that staff did not consistently follow the notification and monitoring procedures outlined in the policy.
Failure to Maintain Essential Heating Equipment After Power Outage
Penalty
Summary
Failure to maintain essential heating equipment occurred after a facility-wide power outage that affected all 102 residents. The Maintenance Director reported that power was lost for approximately 45 minutes on a Saturday and was restored before he arrived, and he did not identify any heating issues at that time. The following day, the Administrator notified him that the heat was not working, and he then realized the facility’s boiler system required a manual reset after the outage, which he had been unaware of. An Assistant Maintenance staff member later confirmed that the Maintenance Director did not reset all boilers and that he himself had to manually reset one boiler supplying heat to the Administrator’s office. The Administrator acknowledged that the Maintenance Director, who had started working at the facility the previous month, could not be trained on all aspects of the building and stated that he should have contacted the regional maintenance team after the power outage to determine any additional required tasks. A heating company technician visited the facility on Sunday due to lack of heat and determined that a new motor and spring coupler were needed for the pump, documenting that the pump motor was a pivotal component for the heat pumps to work and needed immediate replacement. The technician recorded that the customer chose to wait until the next day during normal business hours, stating that the building temperature had risen and they preferred to delay the work. On Monday, the Maintenance Director reported that staff were complaining of being cold, and the regional maintenance team identified that the water pump was failing. A heating company technician arrived that afternoon with a replacement pump motor, confirmed the existing motor was bad, and ultimately installed a new motor and spring coupler later that evening after obtaining a functional replacement. The technician documented remaining on-site until staff were comfortable that room temperatures were rising, indicating that essential heating equipment had not been maintained in safe operating condition for a period following the outage.
Widespread Sanitation and Hygiene Failures in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food preparation and sanitation. The kitchen hand washing sink was heavily stained with black residue, and food spatter and particle residue were present on the hand soap and sanitizer dispensers. Dust and stains were also found on the paper towel dispenser and garbage bin. Walls above food prep areas had yellow stains and food spatter, and the deep freezer contained a large box of bagels with a red sticky substance, as well as red spatter on the freezer doors. The ice machine had dark stains and buildup on both the interior and exterior, and the food prep sink faucet was covered in thick white stains. A box of apples stored under the prep table contained multiple rotted apples. Staff were observed failing to follow proper hygiene and infection control practices. One cook touched his mouth and continued handling dishware and meal prep without performing hand hygiene. Another dietary aide wore a personal coat in the kitchen and handled a personal cup in the food prep area. Staff were also seen with hairnets that did not fully cover their hair, and one cook repeatedly touched his lips and placed his hand in his pockets without washing hands before returning to food preparation. The dietary manager and consultant confirmed the presence of visible dust, particles, and stains on various kitchen surfaces and acknowledged the need for improved cleaning practices. Additional observations included cracked and leaking food processor equipment, heavily stained walls and basins, food particles and grease on shelves and stoves, and dirty dish racks and plate warmer cabinets. Beverage pitchers and clean cups were found with thick food particles and stains. The dietary manager stated that hairnets should fully cover hair, outside clothing should not be worn in the kitchen, and all kitchen equipment and surfaces should be clean. Facility policies required thorough cleaning and sanitizing of all kitchen areas and equipment, proper food storage, and strict hand hygiene, but these were not consistently followed.
Failure to Use Gait Belt During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement required safety and fall prevention interventions during the transfer of a resident with a significant history of falls and multiple behavioral and medical conditions, including dementia, seizures, and muscle disorder. The resident, who was known to be noncompliant with care and at risk for falls, was being assisted to the toilet in the shower room. During the transfer from the toilet back to the wheelchair, the resident insisted on pulling up her own pants, became unstable, and fell, resulting in a head injury. Observations confirmed visible bruising above the resident's left eyebrow following the incident. Interviews and record reviews revealed that the staff member assisting the resident did not use a gait belt during the transfer, despite facility policy requiring gait belt use for residents at risk for falls and those needing assistance during transfers. The staff member attempted to support the resident by placing her arms around the resident's back, but was unable to prevent the fall. The facility's policy and statements from supervisory staff confirmed that gait belts are mandatory for such transfers, and the failure to use this safety device directly contributed to the incident.
Failure to Provide Adequate Supervision During High-Risk Transfer
Penalty
Summary
A deficiency occurred when a resident at high risk for falls, with a history of cerebral infarction, dementia, depression, hypertensive heart disease, and protein-calorie malnutrition, was transferred using a sit to stand lift by a single CNA, contrary to facility policy requiring two staff members for such transfers. During the transfer from chair to bed, the resident fell forward and struck her head on the machine, resulting in a bleeding injury to her left eyebrow, which was exacerbated by her use of blood thinners. The resident's care plan did not specify any fall precautions, despite her high fall risk status as indicated in her assessment. Interviews with staff confirmed that the CNA performed the transfer alone and that the facility's policy mandates two staff for sit to stand lift operations. The incident was documented in progress notes, and the DON acknowledged that the transfer was not conducted according to policy. The facility's policy, revised in 2008, clearly states that two staff members are required for the use of portable lifts, but this protocol was not followed in this instance.
Failure to Protect Resident from Mental Abuse Following Threatening Incident
Penalty
Summary
A resident with moderate cognitive impairment and a history of depression was involved in a verbal altercation with his roommate, who has severe cognitive impairment. During the incident, the roommate alleged that the resident threatened him with a small pocketknife. Nursing staff responded by moving the roommate to another room for safety and conducted a room check, but did not initially find a knife. The resident refused a body check at that time. Later, when the resident's family arrived, the resident produced a small knife from his sock, which was then confiscated. Progress notes indicated that the resident was found agitated, holding a knife, and making alarming statements about having killed before and being willing to do so again. The facility's abuse prevention policy defines threats of harm as verbal abuse and mental abuse, including intimidation and threats of punishment. The facility failed to protect the resident's right to be free from mental abuse, as the threatening behavior was not immediately identified or addressed, resulting in a deficiency.
Failure to Obtain Required Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the required physician documentation was included in the medical record to support a resident's transfer and discharge rights. A resident with a history of schizophrenia and elopement behaviors was admitted to the facility and, shortly after admission, attempted to leave the facility twice. Following these incidents, facility staff initiated a Petition for Involuntary/Judicial Admission and a Notice of Involuntary Transfer or Discharge (IVD), citing the safety of individuals in the facility as the reason for the proposed transfer or discharge. However, the forms were completed by the Director of Nursing at the instruction of corporate personnel, and not by a physician. The IVD form indicated that the transfer was not an emergency, and the petition lacked detailed physician input or signature. Review of the resident's medical record and hospital documentation revealed that there were no physician orders for the involuntary psychiatric admission or for discharge. The hospital evaluation found no acute psychiatric or medical condition requiring intervention, and the petition from the facility was deemed invalid due to the lack of clear immediate safety concerns and improper completion. Additionally, the resident's electronic medical record contained no progress notes from a nurse practitioner or physician regarding the need for involuntary discharge or psychiatric admission, and behavioral monitoring documentation by CNAs was incomplete, only noting the resident as "not available." Facility policy requires physician confirmation and documentation in the medical record to support emergency transfers or discharges, as well as clear documentation of the danger posed by the resident. In this case, the required physician documentation and orders were absent, and the forms were not properly completed or signed by a physician, resulting in a failure to meet regulatory requirements for transfer and discharge rights.
Resident Falls Due to Inadequate Assistance During Bed Repositioning
Penalty
Summary
The facility failed to ensure a resident was positioned safely in bed during routine care, resulting in a fall and significant injuries. The resident, who had a history of hemiplegia, hemiparesis, rheumatoid arthritis, and obesity, was being cared for by a CNA who was alone in the room. The CNA directed the resident to turn onto her right side, which was her affected side, for peri-care. During this process, the resident's lower extremities slid off the bed, causing her to fall to the floor and sustain fractures and a knee dislocation. The incident occurred when the CNA, who was on the opposite side of the bed, reached over to the nightstand, leaving the resident closer to the edge of the bed. The resident attempted to alert the CNA that she was slipping, but the CNA was unable to prevent the fall. The CNA had previously cared for the resident with assistance from other staff members, but no additional help was available at the time of the incident. The resident's care plan indicated that she required assistance from two staff members for bed mobility due to her size and hemiplegia. Following the fall, the resident was assessed by a nurse and sent to the hospital for evaluation and treatment. Diagnostic imaging confirmed a posterior dislocation of the right tibial prosthesis, a proximal right tibial fracture, and a right periprosthetic femur fracture. The resident's care plan and CNA charting indicated that she was dependent on assistance for bed mobility, requiring two staff members for safe repositioning, which was not adhered to during the incident.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to adhere to therapy's recommendations for the safe transfer of a resident, resulting in an injury. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and peripheral vascular disease, required substantial assistance for transfers as per their care plan. The care plan specified the use of a mechanical lift with two staff members for transfers. However, on September 28, 2024, a CNA transferred the resident alone using a gait belt, contrary to the prescribed method. During this improper transfer, the resident's leg was scraped against the wheelchair, causing a laceration that required six sutures. Interviews with facility staff, including the Director of Rehab and a Nurse Practitioner, confirmed that the expectation was for staff to follow therapy's recommendations for safe transfers. The facility's policy also mandated the use of mechanical lifting devices for residents needing a two-person assist, except in emergencies. The incident report indicated that the resident was on anticoagulants, which could have contributed to the severity of the bleeding. The failure to follow the established transfer protocol directly led to the resident's injury.
Sanitary Practices Deficiency in Food Preparation and Service
Penalty
Summary
The facility failed to adhere to sanitary practices during food preparation and service, affecting 92 residents who receive meals from the facility kitchen. During an observation, a cook was seen washing a blender in a prep sink that contained food debris and a brownish substance. The cook, who had an uncovered beard, placed the washed lid inside the same dirty sink and used it on the blender, which still had food debris. The cook expressed frustration when informed that the blender and lid needed to be rewashed. Additionally, the cook's phone was on the main prep counter, which also had an opened box of cream of wheat. In the walk-in cooler, several bowls of pudding-like items were uncovered and stored on a rack, along with undated containers of various foods, some of which were past their use-by dates. The reach-in freezer contained an open packet of frozen breaded chicken. Multiple washed domed lids were stacked on a counter with dust and food debris, and some lids still had food and dust on them. A dietary aide with uncovered facial hair was also observed working in the kitchen, and the food service manager from another facility confirmed that dietary staff with facial hair should wear a beard cover. The facility's policies on food storage and preparation were not followed, contributing to the deficiency.
Infection Control and Water Management Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, as evidenced by the lack of infection surveillance and documentation. The Assistant Director of Nursing (ADON), who assumed the role of Infection Preventionist on October 14, 2024, admitted to not having completed any infection surveillance tools since taking over the position. This lapse in surveillance was confirmed by the Regional Nurse Consultant, who noted the absence of Infection Screening Evaluations for resident infections from September 1, 2024, to the present. The facility's policy mandates a system for preventing, identifying, reporting, investigating, and controlling infections, which was not followed. The facility also neglected its water management plan for legionella, as the Maintenance Director, who started on October 7, 2024, was unaware of the plan and had not conducted any monitoring. The facility's water management plan requires daily temperature checks of the hot water tank and weekly checks of chlorine or bromine levels, none of which were documented. The Administrator confirmed that the previous maintenance director also did not perform these necessary checks, indicating a systemic failure in following the water management plan. Additionally, there were multiple instances of staff failing to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies. Certified Nursing Assistants (CNAs) were observed providing care without performing hand hygiene between tasks or wearing the required personal protective equipment, such as gowns, when caring for residents on EBP. Specific cases included residents with conditions like ESBL resistance and Candida Auris, where staff did not adhere to the necessary precautions, potentially compromising infection control efforts.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable room temperature for residents, compromising their right to a safe and homelike environment. Six residents reported issues with heating and cooling in their rooms, with temperatures dropping as low as 58 degrees Fahrenheit at night. Residents resorted to using extra blankets and clothing to stay warm. Observations confirmed discrepancies in room temperatures, with facility thermometers showing different readings than residents' personal thermometers. The facility's Maintenance Director acknowledged that room temperatures should not fall below 70 degrees Fahrenheit. The facility's Administrator and Vice President of Operations explained that the issues stemmed from a previous contractor's error in stripping the electrical system, which required reinstallation. New heating and cooling units were being installed, but some rooms were not yet connected. The 100 hallway was particularly affected, with delays due to damaged heat pumps. The facility had a policy for loss of heat during cold weather, but it was not effectively implemented, leading to discomfort for the residents.
Deficiency in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene, grooming, and incontinence care for six residents who required such support. Resident 13, with severe cognitive impairment and limited mobility, was observed with dirty fingernails despite needing total assistance with personal hygiene. Similarly, Resident 25, also severely cognitively impaired, had long, jagged fingernails with black substances underneath and overgrown chin hair, indicating a lack of grooming assistance. Resident 76, who is cognitively intact but has impaired range of motion, reported requesting nail care assistance without receiving it, resulting in long, dirty fingernails. Resident 23, with severe cognitive impairment and hemiplegia, was found with overgrown, dirty fingernails and facial stubble, despite requiring total assistance for ADLs. Resident 56, who needs extensive assistance, was found in a room with a strong urine odor and expressed a desire for facial hair removal, which was not addressed. Resident 71, with cognitive impairment, was found tearful and improperly dressed, with dirty fingernails, overgrown facial hair, and fecal smears on her body. Despite being assisted with dressing and incontinence care, her grooming needs were not met. The facility's failure to provide adequate ADL care, including nail and facial care, was acknowledged by the Director of Nursing, highlighting a deficiency in maintaining residents' hygiene and dignity.
Inadequate Perineum and Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide adequate perineum and catheter care to prevent potential urinary tract infections (UTIs) for four residents. One resident, who is cognitively impaired and requires assistance with toileting, was found with fecal matter on her hands and thighs. The CNA assisting her did not clean the frontal perineum and left fecal matter on her thigh. Another resident, who is cognitively impaired and requires total assistance for toileting, was not properly cleaned as the CNA did not retract his uncircumcised penis or clean the inner folds of his groins. A third resident, who is alert and oriented but requires total assistance for toileting, was not properly cleaned as the CNA did not clean the pubic area or the inner folds of the labia. Lastly, a resident with a suprapubic catheter due to neurogenic bladder was not provided with proper catheter care, as the CNA did not clean the catheter tube. The facility's guidelines for incontinence and catheter care were not followed, contributing to the potential risk of UTIs.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and date medications once they were opened, which is necessary to determine their expiration dates. This deficiency was observed in several residents' medications, including Insulin Lispro Kwik Pen, Insulin Glargine-YFGN, and Novolin R Flex Pen, which were opened but not dated. Additionally, Incruise Ellipta inhalers for two residents were also opened and not dated, contrary to the manufacturer's guidelines that specify a discard period after opening. These lapses in labeling and dating medications were identified during inspections of the medication room and carts in various halls of the facility. Furthermore, the facility did not appropriately handle narcotic medications with broken seals. During the inspection, it was found that several narcotic medications, such as Norco and Tramadol tablets, had broken seals that were taped over instead of being discarded as per the facility's policy. The Director of Nursing confirmed that staff are required to discard narcotic medications with broken seals to prevent medication diversion and ensure infection control. The facility's policy mandates the immediate removal and proper disposal of medications in containers that are cracked, soiled, or without secure closures, which was not adhered to in these instances.
Failure to Follow Prescribed Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for pureed diets as outlined in their menu spreadsheets. This deficiency was observed in six residents who were on pureed diets. The Spring Summer Menu 2024 specified the use of a #8 scoop for pureed carrot raisin rice and pureed broccoli, and a #6 scoop for pureed pork chop with apples. However, during meal preparation, the cook substituted pureed chicken for pork chop and mashed potatoes for pureed rice, citing resident preferences. The dietary aides used a #10 scoop, which was not in accordance with the menu specifications, to serve the pureed meat, broccoli, and mashed potatoes. The dietitian confirmed that the correct scoop size is crucial for ensuring the residents receive the appropriate amount of protein and nutrients. The facility's diet order listing confirmed that the six residents were on pureed diets, yet they received meals that did not match the planned menu in terms of both content and portion size. This deviation from the menu and portion guidelines led to the deficiency noted by the surveyors.
Failure to Provide Splint and Therapy Services for ROM Maintenance
Penalty
Summary
The facility failed to assess and provide necessary splint and therapy services to residents, leading to a deficiency in maintaining or improving their range of motion (ROM). One resident, with a history of hemiplegia and hemiparesis following a cerebral infarction, was observed without the prescribed splint for her left hand and wrist over several days. Despite having an active order for a hand orthotic to manage contracture, the resident reported not wearing the splint for at least two days, and staff did not apply it during the observed period. The occupational therapist later confirmed a decline in the resident's ROM, indicating a need for further evaluation and therapy. Another resident, with multiple medical diagnoses including hemiplegia and muscle atrophy, was observed with severe contractures in the right upper extremity, including the shoulder, elbow, and wrist. The resident's hand was flaccid, and fingernails were digging into the skin, yet no splint was applied. An occupational therapist evaluated the resident and noted severe contractures, recommending gentle splinting and an orthopedic consult for potential surgical intervention. These observations and evaluations highlight the facility's failure to provide appropriate care and interventions to prevent further reduction in ROM for these residents. The lack of timely application of prescribed splints and the absence of necessary therapy services contributed to the decline in the residents' conditions, as documented by the occupational therapist.
Failure to Address Resident's Dental Pain and Required Extractions
Penalty
Summary
The facility failed to follow up on dental care recommendations for a resident experiencing tooth pain for over six months, requiring tooth extractions. The resident, an elderly female with a history of cerebral infarction, rheumatoid arthritis, and polyneuropathy, reported persistent mouth and tooth pain. Despite being seen by a dentist three times, no action was taken to address her broken teeth, which caused her significant discomfort and difficulty chewing. Observations noted that the resident had few teeth remaining, with black substance around the base of her upper teeth and a stub on her lower gum. The resident's diet was downgraded to a mechanical soft diet due to her chewing difficulties, as noted in an email from the Social Service Director. A dental assessment recommended extractions of specific teeth due to pain and inflammation, but no extractions were performed. Communication between the Director of Nursing and the business office manager highlighted ongoing concerns about the resident's dental issues and financial considerations for treatment. Despite the resident's repeated complaints and a nursing note indicating her desire to visit the dentist, the facility's administrator was unaware of any extractions in the past six months. The resident's daughter was informed of the situation but declined to pay for the extractions, seeking alternatives covered by insurance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its policy for antibiotic stewardship, affecting all 92 residents. The Assistant Director of Nursing, who assumed the role of Infection Preventionist on October 14, 2024, acknowledged that she had only just begun reviewing which residents were on antibiotics. The Regional Nurse Consultant confirmed that the Infection Preventionist nurse is responsible for the Infection Prevention and Control Program, including the antibiotic stewardship program. However, the facility lacked documentation to demonstrate tracking of antibiotic use from September 1, 2024, to the present.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection control practices following a COVID-19 exposure, affecting 55 residents. On multiple occasions, residents reported not being tested for COVID-19 despite being informed of positive cases within the facility. The facility did not display a sign indicating outbreak status at the entrance, and the Infection Preventionist Nurse admitted to prematurely removing the outbreak status sign. The facility's COVID-19 policy, which mandates testing and precautions following exposure, was not adhered to. A certified nursing assistant (CNA) who tested positive for COVID-19 had been in contact with residents and staff without appropriate precautions being taken. The CNA reported feeling unwell during her shift and later tested positive for COVID-19. Despite this, the facility did not conduct timely testing of residents and staff who were potentially exposed. The Infection Preventionist Nurse acknowledged the failure to test all potentially exposed residents and staff, citing difficulties in tracking and documentation. The Director of Nursing and Acting Administrator confirmed that the facility's policy required testing and transmission-based precautions for exposed individuals, which were not implemented. The facility lacked documentation of testing and tracking for the affected residents and staff, and the testing that was conducted was insufficient and delayed. The facility's failure to follow its COVID-19 policy and state guidelines resulted in inadequate infection control measures during the outbreak.
Facility Fails to Maintain Safe Environment Due to Malfunctioning Air Conditioning
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents due to a malfunctioning air conditioning system. The issue began when the facility was notified by their HVAC contractor that there would be no heating or cooling capacity without necessary repairs. Despite this notification, the facility did not take timely action to address the problem, resulting in room temperatures reaching as high as 91 degrees Fahrenheit. Residents expressed discomfort and distress due to the heat, with some removing clothing to cool off and others complaining of difficulty sleeping. The facility did not follow its own hot weather policy, which required measuring room temperatures and humidity levels every two hours when the air conditioning was not functioning properly. Instead, the Maintenance Director used an infrared temperature gun, which is not suitable for measuring air temperature, leading to inaccurate assessments of the indoor environment. Additionally, staff did not ensure that residents had access to adequate fluids, further compromising their comfort and safety. The facility's failure to address the air conditioning issues promptly and effectively affected all 98 residents. The HVAC contractor had informed the facility of underground pipe leaks that prevented the system from functioning, but the facility delayed authorizing temporary cooling solutions. The facility's lack of proper monitoring and failure to implement high-temperature procedures as outlined in their policies contributed to the ongoing discomfort and potential health risks for the residents.
Failure to Adhere to Hot Weather Policies During AC Malfunction
Penalty
Summary
The administration of the facility failed to provide adequate oversight and leadership to ensure compliance with hot weather policies and procedures when the air conditioning system was not functioning properly. The facility's administrator, V1, was aware of the malfunctioning air conditioning but did not ensure that temperature and humidity levels were being monitored as required by the facility's policy. The facility did not have the necessary equipment to measure air temperatures and humidity, and the staff was not informed about the need to check these levels every two hours during the malfunction. Observations revealed that room temperatures in the facility were consistently above 85 degrees Fahrenheit, with some areas reaching as high as 91 degrees. Residents expressed discomfort due to the heat, and there were instances where residents were in common areas without access to water, and no staff was present to assist them. The facility's policies required that temperatures and humidity be monitored regularly and that residents be relocated to cooler areas if necessary, but these procedures were not followed. The facility's failure to adhere to its hot weather and extreme high temperature guidelines resulted in prolonged exposure of residents to excessive heat. The administration did not notify the State Agency about the air conditioning issues, and the facility continued to use common areas like the dining room despite high temperatures. The lack of proper monitoring and response to the heat conditions posed a risk to the health and well-being of the 98 residents in the facility.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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