Ryze West
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5130 West Jackson Boulevard, Chicago, Illinois 60644
- CMS Provider Number
- 145661
- Inspections on file
- 70
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ryze West during CMS and state inspections, most recent first.
Two residents with complex medical and psychiatric histories engaged in a verbal disagreement that escalated to physical abuse in their shared room, with both parties admitting to hitting each other. Staff were aware of verbal conflicts and intervened verbally, but no staff witnessed or intervened in the physical altercation, resulting in a failure to prevent abuse as defined by facility policy.
A resident with multiple medical and behavioral diagnoses alleged physical abuse, stating someone kicked him, but retracted the claim several times. Staff, including an LPN and CNA, were aware of the allegation and their reporting responsibilities. The administrator began an internal investigation but did not report the allegation to the state agency, citing the resident's retraction, which was contrary to facility policy requiring immediate reporting of all abuse allegations.
A resident with multiple comorbidities and moderate cognitive impairment was found lying on a low air loss mattress that was not set according to their actual weight, contrary to facility policy and manufacturer instructions. Staff interviews revealed uncertainty about the correct mattress setting, and the process for updating and labeling the mattress with the resident's weight was not followed, potentially compromising pressure ulcer prevention.
A resident with multiple health conditions, including morbid obesity and a recent tracheostomy, returned from a hospital stay to find her weight loss medication missing. The medication, brought in by family and requiring refrigeration, was unaccounted for due to inconsistent staff practices and lack of documentation. Nursing staff gave conflicting reports about whether the medication was discarded or sent back to the pharmacy, and there was no policy in place for handling or documenting medications brought in by families, resulting in missed doses for the resident.
Multiple residents with complex medical needs experienced repeated exposures to lice and scabies due to the facility's failure to administer prescribed topical medications, document physician notifications, obtain and implement contact precautions, and perform required isolation assessments and deep cleaning. Staff did not consistently follow infection control policies, and there was a lack of documentation and communication regarding treatment and environmental cleaning.
A resident with intact cognition and good discharge potential was not regularly re-evaluated, referred, or provided documented referrals to local agencies for discharge planning. Despite being eligible and expressing a desire to move to assisted living, the resident received no updates or assistance after an initial referral discussion, and staff confirmed there was no record of a formal referral or updated care plan, due in part to recent staff turnover in social services.
A resident with intact cognition and nutritional risks was repeatedly served oatmeal despite documented preferences against it, leading to dissatisfaction and potential health concerns. The error was acknowledged by dietary staff as an oversight, and the facility's policy on respecting dietary preferences was not followed.
A facility failed to coordinate with the state-designated authority for a new PASRR Level I screen for a resident with severe mental disorders before the expiration of their PASRR Level II short-term approval. The resident, diagnosed with cognitive communication deficit, schizophrenia, schizoaffective disorder, and bipolar type, did not receive a new Level I screen as required by the facility's policy, leading to a deficiency in compliance with the PASRR process.
A resident with a history of mood and anxiety disorders consistently refused prescribed psychotropic medications due to distrust in staff, leading to ongoing behavioral issues. Despite the resident's verbal aggression and frequent complaints about mistreatment, the facility failed to include the medication refusal in the care plan, contrary to its policy requiring comprehensive, person-centered care plans.
A fire incident in a facility was caused by a resident's motorized wheelchair with exposed wires, leading to a dangerous situation for three residents. The facility's fire alarm system failed to function, delaying emergency response. The facility did not report the incident to the state or conduct thorough assessments of the residents involved. The maintenance of the wheelchair was left to the resident's family, who performed unauthorized repairs.
A resident involved in a fire incident in her room was not properly assessed or provided with necessary psychosocial interventions. Despite her non-verbal status, she communicated fear and distress, but the facility failed to document social service interventions or revise her care plan. The resident continued to use the same equipment involved in the fire, potentially triggering her trauma.
A facility failed to maintain a resident's motorized wheelchair, leading to a fire caused by exposed wires. The wheelchair, owned by the resident, was not routinely checked by the facility. The fire department identified the wheelchair as the fire's source, and the facility's fire alarm system did not activate, delaying staff response. The resident's son, who maintained the wheelchair, lacked formal training. The facility's policy requires monthly equipment checks, which were not followed for personal equipment.
The facility failed to ensure call light accessibility for two residents, one with paraplegia and moderate cognitive impairment, and another who is legally blind with a history of falls. The call lights were found out of reach, compromising the residents' ability to request assistance. Staff acknowledged the oversight, which contradicts the facility's policy requiring call lights to be within reach.
A resident with paraplegia and bilateral foot drop did not receive a shower since May, contrary to the facility's policy of weekly bathing. Despite being dependent on staff for ADLs, there were no records of the resident receiving a shower or bed bath after being transferred to a different floor. The resident expressed discomfort due to sticky hair, and staff acknowledged the lack of documentation, suggesting bed baths might have been given due to shingles.
A resident with severe cognitive impairment and multiple diagnoses was improperly positioned during dining, leading to a risk of choking and aspiration. The resident was observed in a low Fowler's position while eating, contrary to facility guidelines that emphasize proper positioning to prevent aspiration. Staff interviews revealed inconsistencies in understanding the correct positioning for residents during meals.
A resident with severe dental decay and pain did not have a dental appointment scheduled as ordered by a Nurse Practitioner, due to a communication breakdown in the facility. The resident's care plan and physician orders indicated the need for a dental evaluation and extraction, but the appointment was not made, resulting in continued pain and decay.
A resident with a history of epilepsy experienced a seizure, and the facility failed to follow its policy by not adequately monitoring vital signs during the medical emergency. The LPN did not document the resident's oxygen saturation post-seizure, and the resident was transported to the hospital via private ambulance instead of 911, despite low oxygen levels. The facility's policy requires frequent vital sign checks and physician notification of significant changes, which were not fully adhered to.
A resident with ADHD and depression did not receive his prescribed medication, Dextroamphetamine Sulfate, from 5/15/24 through 5/23/24. Despite the psychiatrist's assessment and prescription, the medication was not administered due to a breakdown in communication and procedure between the psychiatrist, Director of Nursing, and pharmacy. This led to the resident feeling sad, depressed, tired, and refusing care.
The facility failed to ensure proper food safety and sanitation practices, including labeling and dating food items, discarding expired food, and properly sanitizing cooking equipment. Observations revealed spoiled strawberries, dust in refrigerators, and improper sanitization of blender parts, affecting all 176 residents.
The facility failed to ensure that the dumpster was covered, leaving two of the three lids wide open and debris on the ground. The Dietary Manager and Divisional Manager for Laundry and Housekeeping Services acknowledged that the lids should be closed to prevent pests and rodents. Facility policies on garbage disposal and maintaining a clean environment were not followed.
The facility failed to provide an adequate supply of linens, affecting all 180 residents. CNAs frequently ran out of bath towels during shifts, and the par levels for linens were outdated. Despite efforts to order more linens, the issue persisted, with observations confirming a shortage of bath towels on multiple floors.
The facility failed to ensure sufficient CNAs on weekends, affecting resident care. A resident was observed with a long beard and stated that staff did not assist with shaving. The staffing coordinator confirmed frequent weekend call-offs, and records showed the facility did not meet required staffing numbers on multiple days. The DON acknowledged the challenges, and PBJ reports triggered for low weekend staffing.
The facility failed to ensure smoking materials were given to designated staff, complete timely smoking assessments, and develop comprehensive care plans for smoking. Residents were observed keeping smoking materials inside the facility, contrary to policy, and smoking assessments and care plans were either missing or outdated.
The facility failed to ensure narcotic medications were administered according to physician orders, maintain accurate narcotic counts at shift changes, and document the administration of ordered narcotic medications for two residents. Discrepancies in the amounts of Morphine Sulfate remaining in the bottles were not identified or addressed promptly by the LPNs responsible.
The facility failed to follow infection control practices, including improper hand hygiene and PPE doffing procedures, affecting residents under Enhanced Barrier Precautions. Observations revealed staff not adhering to policies, leading to potential infection risks.
The facility failed to repair a hole in the ceiling and replace missing or stained ceiling tiles in the dining room, and failed to maintain the walls in residents' rooms in good repair. Residents expressed concerns about leaks and the lack of timely repairs. The Maintenance Director acknowledged the issues and stated that repairs were ongoing due to years of neglect and limited staff.
The facility failed to follow its policy for determining and assessing a resident's ability to self-administer medications, did not obtain a physician's order, and did not implement a care plan for one resident. The resident, with multiple diagnoses, was found using medications without proper assessment or documentation.
A resident reported theft, neglect, and bullying to a surveyor, but an LPN failed to report these allegations to the administrator as required by facility policy. The administrator was unaware of the allegations until informed by the surveyor the following day, after which an investigation and report were initiated.
The facility failed to refer a resident for a required Level II PASARR evaluation despite the resident's diagnoses of Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation. The Social Service Director admitted that the necessary PASARR Level I screen was only submitted after the surveyor's inquiry, revealing a lapse in compliance with federal and state regulations.
The facility failed to assist a resident with personal hygiene, specifically shaving, and did not provide adequate communication support in another resident's primary language. The deficiencies were identified through observations, interviews, and record reviews, revealing lapses in following care plans and facility policies.
A facility failed to identify and address a resident's skin lesions, resulting in unaddressed wounds and discomfort. The Wound Nurse was unaware of the current wounds, and despite a Bacitracin ointment order, the resident had not received the cream. The Infection Prevention Nurse confirmed the ointment should have arrived the same day it was ordered, but it had not. The facility's policy on skin care prevention was not followed.
The facility failed to provide a resident with a pressure redistribution mattress as ordered, despite the resident being at very high risk for skin breakdown. The resident, who had multiple diagnoses and a history of pressure ulcers, was observed without the required air mattress, contrary to the care plan and facility policy.
The facility failed to provide physician-ordered nutritional supplements and double portions to two residents, despite these items being in stock. Staff confirmed that the supplements and increased portions were not included on the meal trays as required, potentially impacting the residents' nutritional status and weight management.
The facility failed to provide the total volume of prescribed gastrostomy tube feeding for two residents, as observations and interviews revealed discrepancies in the administration and documentation of the tube feeding volumes, leading to a deficiency in meeting the residents' nutritional needs.
The facility failed to follow physician orders for administering the correct oxygen flow rate for two residents. One resident with multiple respiratory diagnoses was observed with oxygen set below the prescribed rate, and another resident with similar conditions also had oxygen set below the prescribed rate. Both residents denied changing the flow rate, and their records lacked orders or assessments for self-administration.
A facility failed to ensure a psychiatrist documented their assessment and completed the necessary prescription process for a resident's ADHD medication. This led to the resident not receiving the medication for nine days, causing significant distress and a decline in their condition. Interviews revealed a breakdown in communication and procedure among the psychiatrist, DON, and nursing staff.
The facility failed to follow its policy regarding psychotropic medications for three residents, including not obtaining informed consent, not ensuring PRN medications had a duration of no longer than 14 days, not attempting Gradual Dose Reduction (GDR), and not completing AIMS tests in a timely manner.
A resident was administered 4 units of Humalog Insulin one hour before the meal instead of with the meal as prescribed. The LPN acknowledged the error, and the Director of Nursing confirmed that this practice could lead to severe consequences such as hypoglycemia.
The facility failed to ensure medications were properly labeled when opened, expired medications were removed from the medication cart and medication room, and medications for discharged residents were removed from the medication cart. Expired medications were found in the fourth-floor medication cart and room, and medications without open dates were observed in the second-floor medication cart. The DON confirmed that nurses are responsible for checking expiration dates daily and removing expired medications.
A resident with legal blindness and schizophrenia became agitated and inadvertently scratched another resident in a wheelchair, leading to an altercation. The facility's measures were insufficient to prevent the incident, despite known behavioral issues.
A resident with a history of stroke and other health issues was found to have a fractured arm initially misdiagnosed as cellulitis. Despite the discovery of the fracture, the facility administrator did not report the injury to the regional office, as it was not deemed suspicious. This failure to report constitutes a deficiency in following the facility's abuse policy and prevention program.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent two residents from physically abusing one another. One resident, a female with diagnoses including diabetes, COPD, schizoaffective disorder, and heart failure, reported being verbally and physically attacked by her roommate, who has diagnoses including COPD, dementia, and mood disturbance. The incident began with a verbal disagreement that escalated to physical violence, with one resident stating she was hit in the head and face by her roommate. The other resident confirmed that both parties hit each other during the altercation, which occurred in their shared room without staff present. Staff interviews revealed that although staff were aware of ongoing verbal disagreements between the two residents and intervened at least once to separate them, they did not witness the physical altercation. Staff responses included calling a nurse to the scene and sending one resident out of the facility, but no staff member reported seeing or being informed of the physical abuse at the time. The facility's abuse policy defines physical abuse as the infliction of injury by non-accidental means, including hitting, slapping, or kicking, which was not prevented in this case.
Failure to Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse made by a resident who had multiple complex diagnoses, including heart failure, diabetes, substance abuse, and schizoaffective disorder. The resident alleged that someone had kicked him, but immediately retracted the statement multiple times, both to facility staff and emergency responders. Staff members, including an LPN and a CNA, confirmed that the resident made and then retracted the allegation, and neither witnessed any abuse. Both staff members stated they were trained on abuse reporting and were aware of the procedures for reporting such incidents to the administrator. The administrator, who also serves as the abuse coordinator, was informed of the resident's escalating behaviors and the abuse allegation after the fact. She initiated an internal investigation but did not report the allegation to the state agency, citing the resident's retraction as the reason. Review of facility records confirmed that no report was made to the state agency regarding this allegation, despite facility policy requiring immediate external reporting of all abuse allegations, regardless of retraction. The deficiency centers on the facility's failure to report the initial allegation as required by policy and regulation.
Incorrect Low Air Loss Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a low air loss mattress was set to the correct setting according to the wound care prevention protocol for a resident with multiple comorbidities and moderate cognitive impairment. The resident was readmitted with diagnoses including hypertension, diabetes, subdural hemorrhage, disc degeneration, epilepsy, anemia, malnutrition, and hepatic encephalopathy, and was identified as being at moderate risk for pressure ulcers. Upon admission, the resident had moisture-associated skin damage (MASD) to the sacrum and was assessed as chairfast and incontinent, with a care plan in place for pressure relief interventions, including the use of a low air loss mattress. During observation, the resident was found lying on a low air loss mattress set at 320, which did not correspond to the resident's actual weight, which was significantly lower. Interviews with staff revealed uncertainty about the resident's weight and the correct mattress setting. The LPN was unsure of the resident's weight and acknowledged that the mattress should be set based on weight, while the wound care technician confirmed that the setting was incorrect and planned to update the label with the correct weight. The wound care nurse also stated that the mattress should be set according to the resident's weight and that the current setting was too firm, potentially compromising the intended pressure relief. Facility policy and the manufacturer's instructions both require that the low air loss mattress be set according to the resident's weight to ensure proper pressure redistribution and skin protection. The failure to set the mattress correctly was observed and confirmed by multiple staff members, and the process for ensuring correct settings, including labeling and regular checks, was not followed at the time of the survey. This lapse had the potential to affect the resident's skin integrity and the effectiveness of the pressure ulcer prevention protocol.
Failure to Document and Account for Resident's Medication Brought in by Family
Penalty
Summary
The facility failed to ensure a system was in place for the documentation and disposition of a resident's medication, resulting in the resident's weight loss medication being unaccounted for. The resident, who had a complex medical history including morbid obesity, depression, lymphedema, hypothyroidism, and a recent tracheostomy, was readmitted to the facility after a hospital stay. The resident reported that her weight loss medication, which was brought in by her family and required refrigeration, was missing upon her return. She stated that she had two doses left, but staff could not locate them, and she subsequently missed two doses. Multiple staff interviews revealed confusion regarding the handling and documentation of medications brought in by family members, with some staff stating that medications are typically sent back to the pharmacy or discarded when a resident is hospitalized, but no clear documentation or process was followed in this case. Nursing staff provided inconsistent accounts regarding the disposition of the medication. Some staff indicated that medications not classified as controlled substances, such as the resident's injectable weight loss medication, were discarded without documentation, while others were unaware of the medication's origin or storage requirements. One LPN admitted to discarding the medication after a period of time, along with other medications, but did not document this action. There was also a lack of clarity about whether the medication should have been returned to the family, kept in a secure location, or sent back to the pharmacy, and no records were maintained to track the medication's disposition. The Director of Nursing and the Administrator both acknowledged the absence of a policy regarding the handling and documentation of medications brought in by family members. The Administrator confirmed that there was no existing policy on medication disposition, and staff were not aware that the medication in question had been provided by the resident's family. The lack of a clear process and documentation led to the medication being unaccounted for and the resident missing prescribed doses.
Failure to Administer Ordered Treatments and Implement Infection Control for Lice and Scabies
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in response to multiple cases and exposures of lice and scabies among residents. Specifically, the facility did not administer ordered topical medications for lice and scabies as prescribed, and there was a lack of documentation regarding the administration of these medications. In several instances, the medication was not available at the scheduled time, and there was no evidence that the responsible staff notified the physician or nurse practitioner about the delay or non-administration. Additionally, there was no documentation of required isolation assessments or infection criteria evaluations for residents exposed to or diagnosed with lice and scabies prior to May, despite multiple exposures and symptoms being reported and observed by staff and residents. The facility also failed to obtain and document physician orders for contact precautions for affected residents at the time of exposure or diagnosis. Contact precautions were not consistently implemented or documented, and staff did not always follow facility policy regarding the use of personal protective equipment (PPE) and isolation procedures. Furthermore, the facility did not ensure that deep cleaning of resident rooms was performed in conjunction with treatment, as recommended by medical providers. There were inconsistencies in the cleaning of launderable and non-launderable items, and privacy curtains with visible stains were not always removed or laundered during deep cleaning, as reported by both residents and housekeeping staff. Residents involved in these deficiencies included individuals with significant medical histories, such as immunodeficiency, chronic illnesses, and cognitive impairments. These residents experienced repeated exposures and infestations, with one resident reporting psychosocial harm due to the ongoing situation. Staff interviews revealed a lack of clarity and follow-through regarding infection control protocols, medication administration, and communication with medical providers. The facility did not have a dedicated infection preventionist for a period during which these events occurred, further contributing to lapses in infection control practices.
Failure to Re-Evaluate and Document Discharge Planning for Resident
Penalty
Summary
The facility failed to regularly re-evaluate, refer, and document referrals to local contact agencies for discharge planning and assessment for one resident. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and osteoarthritis, was found to have intact cognition and required only supervision or minimal assistance with activities of daily living. Despite being assessed as having good discharge potential and expressing a desire to be discharged to an assisted living facility, the resident reported not receiving updates or assistance regarding discharge planning after an initial referral discussion with a previous social worker. The resident stated he had not been informed of any progress or timeline for discharge and was concerned about having nowhere to go if the facility did not assist him. Staff interviews revealed that the social services department had experienced significant turnover, with most social workers having left and a new team recently starting. The Social Services Director confirmed that there was no record of a referral for discharge assessment in the facility's referral tool, despite the resident's eligibility and readiness for community discharge. The resident's care plan and assessments had not been updated as required, and there was a lack of ongoing communication and documentation regarding discharge planning, contrary to facility policy and standard practice.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences by repeatedly serving oatmeal instead of grits, despite the resident's clear dislike and reported allergic reaction to oatmeal. The resident, who has an intact cognitive status with a BIMS score of 15, expressed dissatisfaction and concern about receiving oatmeal, which was documented as a dislike on their meal ticket and dietary preference sheet. The resident's care plan highlighted nutritional risks due to their medical conditions, including moderate protein-calorie malnutrition and a history of weight loss, necessitating careful attention to dietary preferences. During a survey, the resident reported to the surveyor that they had informed both nursing and dietary staff about their preference against oatmeal, yet the issue persisted. On the day of the survey, the resident was again served oatmeal, which was confirmed by the surveyor upon inspection of the breakfast tray. The dietary aides acknowledged the error, attributing it to an oversight during meal preparation, and corrected it by providing grits. The facility's policy mandates that resident dietary preferences be documented and respected, but this was not adhered to in this instance, leading to the deficiency.
Failure to Coordinate PASRR Screening for Resident
Penalty
Summary
The facility failed to coordinate with the appropriate state-designated authority to refer a resident with a severe mental disorder for a new PASRR Level I screen before the expiration of the resident's PASRR Level II short-term approval. This oversight affected one resident out of four reviewed for resident rights in a total sample of 20 residents. The deficiency was identified during an interview and record review, where it was revealed that the social services department, responsible for following up with the PASRR process, did not track the expiration date of the PASRR Level II approval for the resident. The resident in question, a [AGE] year-old individual, has diagnoses including cognitive communication deficit, schizophrenia, schizoaffective disorder, and bipolar type. The resident's PASRR Level II outcome document indicated a short-term approval without specialized services, which was set to end on February 27, 2025. The facility's policy requires a new Level I screen to be submitted no later than 10 days before the short-term approval ends. However, there was no documentation showing that a new Level I screen was conducted since the PASRR Level II expired, indicating a lapse in the facility's compliance with the PASRR process.
Failure to Address Medication Refusal in Resident Care Plan
Penalty
Summary
The facility failed to provide a person-centered care plan for a resident with behavioral concerns who refused psychotropic medication. The resident, who has a medical history of mood affective disorder, anxiety disorder, cocaine abuse, bipolar disorder, and manic severe disorder, was noted to have intact cognition with a BIMS score of 15. Despite being prescribed Hydroxyzine and Seroquel to manage anxiety, agitation, and bipolar disorder, the resident consistently refused these medications. The refusal was attributed to a lack of trust in the staff administering the medication. The resident's behavioral issues included verbal aggression towards staff and peers, leading to an involuntary discharge and subsequent readmission. Interviews with facility staff and the resident's case manager revealed that the resident frequently complained about mistreatment and lack of respect, although no physical abuse was reported. The Director of Nursing acknowledged the resident's verbal aggression and frequent room changes, attributing the behavior to the refusal of psychotropic medication. Upon review, it was found that the resident's care plan did not address the issue of medication refusal, which was a significant oversight given the resident's ongoing behavioral concerns. The facility's care plan policy mandates the development of a comprehensive, person-centered care plan for each resident, which was not adhered to in this case.
Fire Incident Due to Faulty Wheelchair and Alarm System Failure
Penalty
Summary
The facility failed to ensure the safety of residents by not properly assessing and maintaining a motorized wheelchair, which led to a fire incident involving three residents. The fire occurred in a resident's room, where the motorized wheelchair was suspected to have caused the fire due to exposed wires and a potential spark. The resident using the wheelchair, who had severe cognitive impairment and multiple medical conditions, was unable to move the wheelchair during the incident, resulting in a dangerous situation. The fire alarm system in the facility did not function properly during the incident, as no alarms sounded, and the fire department was not automatically notified. This failure in the alarm system delayed the response to the fire, increasing the risk to the residents involved. Staff members had to manually call 911 and evacuate the residents from the room. The facility's maintenance director initially misidentified the cause of the fire, attributing it to an electrical outlet, before later acknowledging the wheelchair as the source. The facility did not conduct a thorough investigation or report the incident to the state health department, as it was not considered an unusual occurrence by the administration. Additionally, the residents involved were not adequately assessed for potential injuries or smoke inhalation following the incident. The facility's policy on wheelchair maintenance was unclear, and the responsibility for maintaining the resident's wheelchair was left to the resident's family, who performed unauthorized repairs that may have contributed to the fire.
Failure to Address Resident's Psychosocial Needs After Fire Incident
Penalty
Summary
The facility failed to properly assess and implement interventions for a resident who experienced a fire incident in her room. The resident, who has a history of major depressive disorder and other significant medical conditions, was involved in a fire that occurred in her room. The fire was reportedly sparked by her motorized wheelchair, which was not functioning properly. Despite the resident's non-verbal status, she was able to communicate her fear and distress through gestures, indicating that she was scared during and after the incident. The facility did not adequately address the resident's psychosocial needs following the traumatic event. There was no documentation of social service interventions or monitoring of the resident's emotional state in the days following the fire. The resident's care plan was not reviewed or revised to reflect her status and needs after the incident. Additionally, the resident continued to use the same motorized wheelchair and bed that were involved in the fire, which could serve as triggers for her trauma. Interviews with facility staff, including the Social Service Director and a Licensed Clinical Social Worker, revealed that the resident's involvement in the fire was recognized as a potentially traumatizing event. However, there was no evidence that psychotherapy or other supportive measures were provided to help the resident process her emotions. The lack of timely and appropriate interventions highlights a deficiency in the facility's response to the resident's psychosocial needs after the fire incident.
Failure to Maintain Resident's Motorized Wheelchair Leads to Fire
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, specifically regarding a motorized wheelchair owned by a resident. The Director of Maintenance, V5, stated that the facility does not conduct routine checks on residents' electric wheelchairs, as they are owned by the residents and not the facility. This lack of maintenance led to a fire incident involving a resident's motorized wheelchair, which was identified as the source of the fire by the Chicago Fire Department. The fire was caused by exposed wires on the wheelchair's cord, which ignited nearby combustible materials. On the day of the incident, the resident's son, V41, had replaced the electronic charger for the wheelchair and was responsible for its maintenance. However, the son lacked formal training in wheelchair repair, relying on his experience with motorcycles. The fire occurred when the wheelchair was being charged using an extension cord, which melted and contributed to the fire. The facility's fire alarm system did not activate, delaying the staff's awareness of the fire. Emergency Medical Technicians present at the scene assisted in evacuating the resident and extinguishing the fire. The fire department's investigation confirmed that the fire was electrical in nature, likely due to the damaged cord on the wheelchair. The facility's policy requires monthly surveillance of resident rooms and equipment, but this was not adhered to for the resident's personal equipment. The report highlights the need for proper maintenance and inspection of personal equipment to prevent such incidents. The motorized wheelchair was not inspected by a qualified technician after the fire, raising concerns about its safety for future use.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a deficiency in the quality of care. For one resident, the call light was found on top of three pillows on the nightstand, out of reach. This resident, who has a history of paraplegia, major depressive disorder, and moderate cognitive impairment, expressed that she could not reach her call button and felt that it had been taken away from her. A Certified Nursing Assistant confirmed that the call light was not within reach and repositioned it appropriately. Another resident, who is legally blind and has a history of falls, was found with the call light attached to the lowest part of the bed rail, making it inaccessible. On a subsequent observation, the call light was found on the floor. This resident, who is cognitively intact, expressed a need for assistance but was unable to reach the call light. A Licensed Practical Nurse acknowledged that the call light should not have been on the floor and stated that it might have slipped off the resident. The facility's policy mandates that call lights should always be within reach of residents, especially those who are vulnerable or have specific needs.
Failure to Provide Scheduled Bathing for Resident
Penalty
Summary
The facility failed to adhere to its policy of providing a shower or bath to residents at least once a week, as evidenced by the case of a resident with paraplegia and bilateral foot drop. This resident, who is dependent on staff for activities of daily living, reported not having received a shower since May, despite being scheduled for showers twice a week. Observations and interviews revealed that there were no records of the resident receiving a shower or bed bath since being transferred to a different floor of the facility. The resident expressed discomfort due to her hair being sticky and difficult to manage, indicating a lack of proper hygiene care. The facility's bathing policy requires that all residents be offered a bath or shower at least once a week, with more frequent bathing as needed. However, the records reviewed did not show any documentation of the resident receiving the required care. The staff, including the restorative nurse and the wound nurse, acknowledged the absence of shower records and suggested that bed baths might have been given due to the resident's shingles. Despite this, the necessary documentation was not completed, and the resident's hygiene needs were not adequately met, as confirmed by the facility administrator.
Improper Positioning During Dining
Penalty
Summary
The facility failed to provide proper positioning for a resident during dining, which posed a risk for choking and aspiration. The resident, who has severe cognitive impairment and multiple diagnoses including hemiplegia, aphasia, and anxiety disorder, was observed in a low Fowler's position while attempting to eat lunch. This position was inappropriate for eating, as confirmed by a Licensed Practical Nurse (LPN) who noted the potential for choking or aspiration. Despite the resident's care plan indicating a need for assistance with dining and proper positioning, the resident was left in a reclined position, leading to coughing during the meal. Staff interviews revealed inconsistencies in understanding the correct positioning for residents during meals, with some staff indicating a 90-degree upright position and others suggesting a semi-Fowler position. The facility's policy and in-service education documents emphasize the importance of proper positioning to prevent aspiration and promote optimal intake. However, these guidelines were not followed in the case of the resident, resulting in a deficiency in care during the dining experience.
Failure to Schedule Dental Appointment for Resident with Severe Decay
Penalty
Summary
The facility failed to schedule a dental appointment for a resident with severe dental decay, as ordered by a Nurse Practitioner. The resident, who is dependent and has multiple diagnoses including essential hypertension and respiratory failure, was observed expressing the need for a tooth extraction due to pain and decay. Despite the resident's care plan and physician orders indicating the need for a dental evaluation and extraction, the appointment was not scheduled, resulting in continued pain and decay for the resident. Interviews with facility staff revealed a breakdown in communication and scheduling processes. The Restorative Nurse acknowledged the presence of the dental order in the resident's chart but noted it was not scheduled due to its absence on the communication board. The staff member responsible for scheduling appointments stated that they rely on the communication board to know when to schedule appointments, indicating a lack of verbal communication or alternative methods to ensure appointments are made. The facility's policy on dental services was not adhered to, leading to the deficiency identified by the surveyors.
Failure to Monitor Vital Signs During Medical Emergency
Penalty
Summary
The facility failed to follow its policy and adequately monitor vital signs during a medical emergency involving a resident who experienced a seizure. The Licensed Practical Nurse (LPN) observed the resident shaking in bed and noted high vital signs, which was unusual given the resident's typical low blood pressure. The doctor was contacted and instructed that the resident be sent to the hospital. However, the resident was transported via private ambulance rather than 911, as the doctor was informed that the resident was stable. The LPN did not take a full set of vital signs after the seizure, as required by the facility's policy, and the resident's oxygen saturation was not documented post-seizure. The resident, who has a history of dementia, epilepsy, and traumatic brain injury, experienced a seizure that lasted approximately two minutes. The LPN noted that the resident's oxygen saturation was 90% on room air, which was lower than the resident's usual readings. The paramedics later recorded an oxygen saturation of 88% and placed the resident on oxygen. The facility's emergency management policy requires vital signs to be taken every 10-15 minutes during a medical emergency until the resident is stable or transferred, which was not adhered to in this case. Additionally, the policy mandates notifying the resident's physician of significant changes in condition, which may not have been fully communicated regarding the resident's oxygen saturation levels.
Failure to Administer Prescribed Medication for ADHD
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with ADHD, depression, and other medical conditions. The resident, a 28-year-old male, was admitted with a physician's order for Dextroamphetamine Sulfate (Adderall) to manage his ADHD. Despite the psychiatrist's assessment and prescription on 5/15/24, the medication was not administered from 5/15/24 through 5/23/24. This lapse led to the resident feeling sad, depressed, tired, and refusing care, as documented in multiple nursing notes and confirmed by the resident's own statements. The psychiatrist, who assessed the resident on 5/15/24, confirmed that the medication was necessary and completed the required forms for the pharmacy. However, the Director of Nursing assumed the psychiatrist had faxed the prescription, which did not happen. The nursing staff failed to follow up adequately with the pharmacy or the psychiatrist, resulting in the resident not receiving his medication. The resident repeatedly expressed his distress and the negative impact of not receiving his medication, but the issue remained unresolved until 5/23/24. Interviews with the psychiatrist, Director of Nursing, and nursing staff revealed a breakdown in communication and procedure. The psychiatrist was unaware that the medication had not been delivered, and the Director of Nursing did not verify the prescription's status with the pharmacy. The facility's policy on controlled substances was not followed, leading to the resident's continued suffering and refusal of care. The deficiency was evident through the resident's deteriorating mental and physical state, as well as the documented failure to administer the prescribed medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, which has the potential to affect all 176 residents. During an initial kitchen tour, it was observed that food items were not labeled and dated with an opened and use-by date. Specifically, an opened case of fresh strawberries was found shriveled and covered in a white, light gray fuzzy material, indicating spoilage. Additionally, black/dark gray dust-like material was observed covering the refrigerator fan covers and ceiling, which could potentially contaminate the food. An opened gallon of barbeque sauce was also found without an open or use-by date, making it difficult for staff to track its usability. The facility's policy requires all refrigerated food to be used within seven days of opening, regardless of the manufacturer's use-by date, but this was not adhered to in practice. Furthermore, the facility failed to properly sanitize cooking equipment according to the manufacturer's directions. During the preparation of pureed food items, it was observed that the blender container, lid, and blade were not submerged in the sanitizing solution for the required 60 seconds. Instead, the items were only dipped for 10 to 16 seconds, which is insufficient for proper sanitation. The Dietary Manager confirmed that the items need to be left in the sanitizing solution for a full minute to ensure they are fully sanitized. The facility's policies on labeling, dating, and sanitizing were not followed, leading to potential cross-contamination and food safety issues.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. During an observation, it was noted that two of the three lids on a large dumpster were wide open, and there was debris and trash on the ground around the dumpster. The Dietary Manager acknowledged that the lids should not be left open as it allows birds and insects to access the garbage. Additionally, the Divisional Manager for Laundry and Housekeeping Services confirmed that the lids must be closed to prevent rodents from getting into the dumpster and potentially leading a trail to the building. The facility's policies on garbage disposal and maintaining a clean and sanitary environment were not followed, as evidenced by the open dumpster lids and surrounding debris.
Inadequate Supply of Linens
Penalty
Summary
The facility failed to provide an adequate supply of linens to meet the needs of residents and staff, affecting all 180 residents. On multiple occasions, it was observed that there were no bath towels available on the CNA carts on the 2nd floor. Interviews with CNAs revealed that they often run out of towels during their shifts and have to wait for the laundry room to supply more. The laundry aides confirmed that linen carts are sent to the floors at the start of each shift, but staff sometimes have to wait for linens if the laundry has accumulated and is not yet clean. The par levels for linens were outdated, and the facility did not have enough bath towels in stock to meet the needs of the residents. The Division Manager of Laundry Services acknowledged that the par levels on the Daily Linen Delivery document were outdated and that the facility did not have enough bath towels. The manager also mentioned that linens are sometimes thrown away by staff or not sent down to the laundry room, contributing to the shortage. Observations of the linen overstock area confirmed that there were no bath towels available, only flat sheets, fitted sheets, and washcloths. The Daily Linen Delivery documents reviewed for a week showed that the facility consistently did not meet the minimum count of linens required for resident care. Despite the administrator's efforts to order additional linens and borrow from a sister facility, the issue persisted. On the following day, it was observed that the second floor had no bath towels, and the third and fourth floors had only a limited number of bath towels and washcloths. CNAs reported that residents sometimes hide towels due to the frequent shortages. The administrator was made aware of the ongoing issue but the problem remained unresolved at the time of the survey.
Inadequate CNA Staffing on Weekends
Penalty
Summary
The facility failed to ensure sufficient certified nursing assistants (CNAs) on weekends to meet the needs of the residents. This deficiency was identified through interviews, record reviews, and observations. On one occasion, a resident was observed with a long beard and stated that staff did not offer or assist him with shaving. The staffing coordinator confirmed that the facility does not use agency staff and that weekends are particularly challenging due to frequent call-offs. The facility's daily schedule and Payroll Based Journal (PBJ) reports showed that the facility did not meet the required staffing numbers on multiple days, particularly on weekends. The Director of Nursing (DON) and other staff members acknowledged the staffing challenges, especially on weekends, and mentioned that nursing managers often work on the floor to fill in gaps. Despite these efforts, the facility's staffing policy and facility assessment tool indicated that the required number of CNAs per day was not consistently met. The PBJ report for the fiscal year 2024 also triggered for excessively low weekend staffing, further highlighting the issue. The facility's census report showed 180 residents, indicating a significant impact due to the staffing deficiencies.
Failure to Manage Smoking Materials and Assessments
Penalty
Summary
The facility failed to ensure that smoking materials, including cigarettes and lighters, were given to designated staff, complete smoking assessments in a timely manner, and develop comprehensive care plans for smoking. These failures potentially affected four residents reviewed for smoking. Observations revealed that residents were keeping smoking materials with them inside the facility, contrary to the facility's smoking policy. For instance, one resident was observed with a lighter on her bed, and another resident had a pack of cigarettes in his pocket. Both residents stated they were keeping their smoking materials with them, which is against the facility's policy that prohibits residents from possessing smoking materials inside the building. The Social Service Director (SSD) confirmed that smoking assessments are supposed to be done within 48-72 hours upon admission and then quarterly or as needed. However, the review of electronic health records showed that smoking assessments and care plans were either missing or outdated for the residents involved. For example, one resident's last smoking assessment was completed several months ago, and another resident did not have a smoking assessment or care plan documented in their electronic health record. The SSD acknowledged that without timely smoking assessments, the facility could not determine if residents were safe to smoke independently or needed supervision. During a Resident Council Meeting, another resident was observed with a lighter and a carton of cigarettes in their pocket. This resident's smoking risk assessment and care plan were also outdated, and the care plan indicated that the resident had unsafe smoking issues related to behavior. The facility's smoking policy clearly states that all residents who desire to smoke must be assessed by the interdisciplinary team and that possessing smoking materials inside the building is prohibited. The failure to adhere to these policies and procedures could lead to significant safety hazards within the facility.
Narcotic Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure narcotic medications were administered in accordance with physician orders, maintain accurate narcotic counts at the change of shift, and document the administration of ordered narcotic medications for two residents. Specifically, for one resident, the narcotic reconciliation review revealed discrepancies in the amount of Morphine Sulfate Oral Solution remaining in the bottle compared to the documented amount on the narcotic sheet. The Licensed Practical Nurse (LPN) responsible for the medication cart did not notice the discrepancy during the shift change count. Similarly, for another resident, the amount of Morphine Sulfate remaining in the bottle was less than the documented quantity, and the LPN did not notice this discrepancy during the shift change count either. Both instances indicate a failure to adhere to proper procedures for narcotic administration and documentation. The Director of Nursing (DON) confirmed that narcotics are supposed to be counted at the change of shift by two nurses, and any discrepancies should be reported immediately. However, the discrepancies in the narcotic counts for the two residents were not identified or addressed promptly. The facility's policy on controlled substances requires accurate record-keeping and immediate reporting of any discrepancies, but these procedures were not followed, leading to the identified deficiencies. The facility provided updated Controlled Substances Proof of Use forms and conducted in-service education on proper medication labeling, storage, and controlled substances handling, but these actions were taken after the deficiencies were identified.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow professional standards of practice and facility policy to prevent and control infection in the provision of patient care. A CNA was observed not performing hand hygiene after handling breakfast trays in rooms with Enhanced Barrier Precautions (EBP) signage. Additionally, a resident with a PICC line did not have EBP signage on their door, and another resident's room had improper placement of a PPE disposal bin, leading to incorrect doffing procedures. The Infection Prevention Nurse confirmed that staff should don PPE before entering rooms and doff PPE in the doorway, but observations showed this was not being followed. The Infection Prevention Nurse also reported that the facility had a 4.21% healthcare-acquired infection rate last month, primarily due to UTIs and soft tissue/wound infections. The facility's policy on EBP requires gown and gloves during high-contact resident care activities and mandates hand hygiene before and after entering rooms. Despite these policies, staff were observed not adhering to proper infection control practices, such as not performing hand hygiene between rooms and doffing PPE inappropriately.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to repair a hole in the ceiling and replace missing or stained ceiling tiles in the first-floor dining room, and failed to maintain the walls in residents' rooms in good repair. During a facility tour, a missing ceiling tile and four ceiling tiles with brown stains were observed in the dining room, along with peeling plaster and a large yellow garbage can positioned to catch water from a leak. Residents expressed their concerns about the leaks and the lack of timely repairs. Additionally, holes and damaged walls were observed in the rooms of three residents, with the Maintenance Director acknowledging the issues and stating that repairs were being made floor by floor due to years of neglect and limited maintenance staff. The Maintenance Director, who started working at the facility in January, confirmed that there were seven leaks in the facility and that repairs were ongoing. However, the surveyor noted that the issues in the dining room and residents' rooms had not been addressed promptly. Work orders and the facility's preventive maintenance plan indicated that inspections and repairs should be conducted regularly, but the observed conditions suggested that these measures were not effectively implemented. The facility's failure to maintain a safe, clean, and comfortable environment for residents was evident in the observed deficiencies.
Failure to Follow Policy for Self-Administration of Medications
Penalty
Summary
The facility failed to follow its policy and procedure for determining and assessing a resident's ability to self-administer medications. Specifically, the facility did not obtain a physician's order for medication self-administration, nor did it implement a person-centered care plan addressing self-administration of medications for one resident. The resident, who has diagnoses including colon cancer, auditory hallucinations, major depressive disorder, and mild cognitive impairment, was found with wound dressings and a bottle of multivitamins in their drawer, which they stated they used daily without proper assessment or documentation by the facility staff. The Director of Nursing confirmed that the facility's process requires a nurse to assess the resident's capability to self-administer medications, provide education, and obtain a physician's order. However, a review of the resident's electronic health records showed no documentation of such an assessment, education, or physician's order. Additionally, the resident's care plan did not address medication self-administration. This oversight indicates a failure to adhere to the facility's policy titled 'Self Administration of Medications and Treatments,' which mandates a thorough assessment and documentation process before allowing residents to self-administer medications.
Failure to Report Resident's Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to follow its policy in reporting an abuse and neglect allegation made by a resident. On 05/21/24, a resident approached a surveyor and reported that money and personal items were being stolen and that they were being neglected and bullied by staff. An LPN who was present did not report the allegation to the administrator as required by the facility's policy. The administrator, when interviewed the following day, confirmed that they had not been made aware of the resident's allegations and outlined the facility's procedure for handling such reports, which includes immediate notification and investigation. The administrator was informed of the resident's allegations during the interview and subsequently initiated an investigation and reported the incident to the state within the required timeframe. The facility's policy mandates that any incident, allegation, or suspicion of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be reported immediately to the administrator or compliance officer. The failure to report the resident's allegations promptly represents a breach of this policy. The resident reiterated their claims of missing money, unreceived checks, and bullying during a meeting with the administrator and the surveyor. The administrator then took steps to document and report the incident as per the facility's policy, but the initial delay in reporting by the LPN constituted a deficiency in the facility's adherence to its abuse prevention and reporting protocols.
Failure to Conduct Timely PASARR Level II Assessment
Penalty
Summary
The facility failed to refer a resident (R3) to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation. R3's initial screen, completed by the state-designated authority, indicated a reasonable basis for suspecting a developmental disability or mental illness. Despite this, the facility did not request a PASARR Level II assessment until prompted by the surveyor. R3's diagnoses included Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation, all of which necessitate a Level II assessment according to the facility's Social Service Director (V16). V16 admitted that the PASARR Level I screen was only submitted the day before the surveyor's inquiry, revealing a lapse in the facility's compliance with federal and state regulations regarding timely PASARR evaluations. The facility's policy mandates that Level I and Level II PASARR documents be requested prior to a resident's arrival. However, V16 acknowledged that the facility was in the process of auditing to identify residents needing Level II assessments, indicating a systemic issue. The failure to conduct timely PASARR Level II assessments was further evidenced by the fact that R3 had been living at the facility for an extended period without the necessary evaluation. This deficiency highlights a significant oversight in the facility's adherence to regulatory standards designed to ensure appropriate care for residents with mental health and developmental disabilities.
Failure to Assist with Personal Hygiene and Provide Adequate Communication Support
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident was assisted or supervised with personal hygiene, specifically shaving. The resident, admitted with multiple diagnoses including alcohol dependence, esophagitis, and bipolar disorder, was observed with a long beard and stated that staff did not offer or assist him with shaving. The resident expressed a desire to have his beard shaved off, but the assigned CNA admitted that she did not offer to shave the resident and was not informed that he wanted to be shaved. The Director of Nursing confirmed that all residents should receive ADL care, including grooming and shaving, and that such care should be documented if provided or refused. The resident's care plan indicated a need for supervision to limited assistance with personal hygiene, but this was not followed as per the facility's policy for activities of daily living dated February 2023, which requires residents' facial hair to be shaved if necessary and appropriate per personal preference. The facility also failed to follow its policy and standards of professional practice in providing care and communication in a resident's primary language. The resident, who primarily speaks Spanish, was found to be at risk for complications with communication. Staff initially stated that the resident points to what he wants, but later mentioned the use of an app and a restorative aide for communication. The resident confirmed that he relies on a restorative aide, housekeeper, or another resident who speaks Spanish to help him communicate. The care plan for this resident included the use of communication cards/board, but no such tools were observed in the resident's room. The facility's policy on communication dated January 2023 mandates that reasonable steps be taken to ensure meaningful communication with persons with limited English proficiency (LEP). The facility's failure to assist with personal hygiene and to provide adequate communication support in the resident's primary language were identified as deficiencies. These actions and inactions affected the quality of care provided to the residents, as documented in the observations, interviews, and record reviews conducted by the surveyors.
Failure to Address Resident's Skin Lesions
Penalty
Summary
The facility failed to identify and address an alteration in skin integrity for one resident, resulting in unaddressed skin lesions and resident discomfort. On 05/21/24, the resident was observed with multiple round lesions on the left arm, upper back, and legs, some of which were open, red, and bleeding. The resident expressed discomfort due to these lesions. The Wound Nurse was unaware of the current wounds and had previously stopped following the resident's wound care. Despite a Bacitracin ointment order being placed on 05/22/24, the resident had not received the cream by the following day, and the nursing staff were unsure about the medication process. The Infection Prevention Nurse confirmed that the Bacitracin ointment should have arrived the same day it was ordered, but it had not. The Wound Nurse and Infection Prevention Nurse evaluated the resident and initiated a treatment order, including a dressing for the left arm and upper back. The facility's policy on skin care prevention requires all nursing staff to evaluate residents for changes in their skin condition, which was not adhered to in this case, leading to the deficiency.
Failure to Provide Ordered Pressure Redistribution Mattress
Penalty
Summary
The facility failed to follow the care plan for a resident (R90) by not providing a pressure redistribution mattress or low air loss mattress as ordered, and did not complete an assessment to identify the resident's risk for pressure ulcers in a timely manner. R90 was admitted with multiple diagnoses, including hemiplegia, diabetes, severe malnutrition, and a history of pressure ulcers. On observation, R90 was found lying in bed without the ordered air mattress, despite having an active order for it and being at very high risk for skin breakdown as indicated by a Braden scale score of 9. The resident's care plan also documented the need for a pressure redistribution mattress due to risk factors such as incontinence, immobility, and diabetes. The wound nurse (V17) confirmed that skin checks and assessments are done upon admission and that preventive measures, including air mattresses, should be in place if ordered. The Director of Nursing (V2) also stated that all physician orders should be followed. Despite these protocols, the resident did not have the required air mattress, which was crucial for preventing further skin breakdown. The facility's policy for skin care prevention mandates the use of pressure-reducing mattresses for residents who are bed-bound, which was not adhered to in this case.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered oral nutritional supplements and other nutrition interventions to two residents. During an initial kitchen tour, it was observed that Magic Cup supplements and whole milk were in stock. However, during meal observations, one resident did not receive double portions or the Magic Cup supplement as ordered, and another resident did not receive the Magic Cup or whole milk as specified in their meal ticket. Interviews with staff confirmed that these items should have been provided according to the residents' dietary plans, but they were not included on the meal trays during service. One resident, who has a history of weight loss and is on a mechanical soft diet with double portions and Magic Cup supplements, did not receive the required double portions or the Magic Cup during lunch. This resident's weight has been stable due to these interventions, and the failure to provide them could interfere with their weight maintenance. Another resident, who has a significantly low BMI and is on a mechanical soft diet with whole milk and Magic Cup supplements, did not receive the Magic Cup or whole milk during lunch. This resident has experienced unplanned weight loss and requires these supplements to promote weight gain. The facility's dietary policies state that supplements and increased portions should be provided as ordered by the physician or registered dietitian. The failure to adhere to these orders was confirmed through staff interviews and record reviews. The dietary director and diet technician acknowledged that the supplements and double portions were not provided as required, which could potentially impact the residents' nutritional status and weight management.
Failure to Administer Prescribed Tube Feeding Volumes
Penalty
Summary
The facility failed to provide the total volume of prescribed gastrostomy tube feeding as ordered by the physician for two residents. Observations revealed that the tube feeding bottles for both residents were hung the previous day and were not replaced or supplemented to meet the prescribed volume. Specifically, one resident's tube feeding was observed to be infusing at 65 ml per hour, but the total volume administered was less than the prescribed 1300 ml per day. Similarly, the second resident's tube feeding was infusing at 75 ml per hour, but the total volume administered was less than the prescribed 1500 ml per day. Interviews with the nursing staff confirmed that the tube feedings were turned off from 10 AM to 2 PM daily, and the bottles were not replaced or supplemented to ensure the residents received the full prescribed volume. The Director of Nursing stated that the nurses should follow the tube feed order as prescribed and document the volume infused in the Medication Administration Record (MAR). The Registered Dietitian emphasized the importance of administering the full volume to meet the residents' nutritional needs, especially since one resident was entirely dependent on tube feedings for nutrition and hydration. The MAR entries for both residents showed discrepancies in the total volume of tube feeding administered, consistently falling short of the prescribed amounts. The facility's policy on tube feeding requires continuous feedings based on individual resident needs and documentation of the intake on the MAR. However, the observations and interviews indicated that the policy was not followed, leading to the deficiency in providing the prescribed tube feeding volumes for the residents involved.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow residents' care plans and physician orders for administering the correct oxygen flow rate for two residents. Resident R39 was observed using oxygen via nasal cannula with the flow rate set to 1.5 liters per minute (LPM) on one occasion and 1 LPM on another occasion, despite having a physician order for 2-3 LPM. R39, who has diagnoses including Chronic Respiratory Failure with Hypoxia, Asthma, Obstructive Sleep Apnea, Pulmonary Hypertension, and Acute on Chronic Systolic Congestive Heart Failure (CHF), denied changing the flow rate and stated that the nurse sets it up. R39's electronic health records did not have an order or assessment for self-administration of oxygen, and the care plan indicated that oxygen should be administered per physician orders. Similarly, Resident R148 was observed receiving oxygen via nasal cannula with the flow rate set to 1.5 LPM, despite having a physician order for continuous oxygen at 2-4 LPM. R148, who has diagnoses including Unspecified Systolic (Congestive) Heart Failure, COPD, Asthma, and Dyspnea, also denied changing the flow rate and stated that the nurses set it up. R148's electronic health records did not have an order or assessment for self-administration of oxygen, and the care plan indicated that oxygen should be administered per physician orders. The facility's policy on oxygen therapy requires a physician order specifying the amount of oxygen to be administered, the route of administration, and the indication of use, which was not followed in these cases.
Failure to Document and Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that the physician documented in the resident's clinical record their assessment, current condition, and medical problems for each visit. Specifically, the psychiatrist did not document their assessment of a resident who was prescribed Dextroamphetamine Sulfate for ADHD. This lack of documentation led to the resident not receiving the prescribed medication for nine days. The resident, who has a medical history including ADHD, depression, and paraplegia, reported feeling sad, depressed, tired, disorganized, and unwilling to move around due to not receiving the medication. The psychiatrist assessed the resident and prescribed the medication, but did not complete the necessary documentation or ensure the prescription was faxed to the pharmacy. The Director of Nursing believed the psychiatrist had completed the prescription and faxed it, but this was not verified. The nursing staff did not follow up adequately to ensure the medication was delivered, leading to the resident's continued lack of medication. Interviews with the resident, psychiatrist, and nursing staff revealed a breakdown in communication and procedure. The psychiatrist did not document the assessment or follow up on the prescription, and the nursing staff did not verify the prescription was received by the pharmacy. This resulted in the resident experiencing significant distress and a decline in their condition due to the lack of medication.
Failure to Follow Psychotropic Medication Policies
Penalty
Summary
The facility failed to follow its policy regarding the use of psychotropic medications for three residents. Specifically, the facility did not obtain informed consent for psychotropic medication use, ensure PRN psychotropic medications had a duration of no longer than 14 days, attempt Gradual Dose Reduction (GDR) for psychotropic medication use, or complete AIMS (Abnormal Involuntary Movement Scale) tests in a timely manner. These failures were identified during interviews and record reviews and could potentially affect residents reviewed for unnecessary psychotropic medication use in a sample of 35. One resident, admitted with multiple diagnoses including schizoaffective disorder and major depressive disorder, had active orders for FLUoxetine and QUEtiapine. However, there was no documentation of an AIMS assessment or GDR evaluation in the resident's electronic health record (EHR). The consultant pharmacist's medication regimen review recommended an AIMS test, but it was not completed until the survey date. The resident's care plan included monitoring for side effects and adverse reactions, but there was no evidence of GDR documentation. Another resident, admitted with diagnoses including unspecified dementia and bipolar disorder, had orders for Mirtazapine and Olanzapine. The resident's EHR did not contain recent consent forms for psychotropic medications, and the consultant pharmacist's medication regimen reviews did not include recommendations until the survey date. The resident's care plan included goals to remain free of drug-related complications and to consult with the pharmacy and MD for dosage reduction when clinically appropriate. A third resident, admitted with diagnoses including major depressive disorder and anxiety disorder, had multiple psychotropic medications ordered, but there was no recent GDR documentation. The consultant pharmacist's medication regimen review recommended AIMS tests and reminded that PRN psychotropic orders are only valid for 14 days unless otherwise stated.
Failure to Administer Insulin with Meals
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a Licensed Practical Nurse (LPN) administered 4 units of Humalog Insulin to a cognitively intact resident one hour before the meal was served, instead of with the meal as prescribed. This action was observed by a surveyor, and the LPN acknowledged that the insulin should have been administered with the meal to prevent hypoglycemia, as Humalog is a fast-acting insulin. The resident's electronic Medication Administration Record (eMAR) and Physician Order Sheet (POS) both indicated that the insulin should be administered with meals. The Director of Nursing confirmed that the expectation is for nurses to administer Humalog Insulin with meals, and failing to do so is a medication error that could lead to severe consequences such as hypoglycemia, coma, or death. The resident also reported that they do not usually receive their insulin with meals, even though it is supposed to be administered that way.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled when opened, expired medications were removed from the medication cart and medication room, and medications for discharged residents were removed from the medication cart. During an inspection, expired medications were found in the top drawer of the fourth-floor medication cart and the fourth-floor medication room. Additionally, medications that were opened without an open date were observed in the second-floor medication cart. The Licensed Practical Nurses (LPNs) acknowledged the presence of expired medications and stated that they would dispose of them and notify the manager. The Director of Nursing (DON) confirmed that nurses are responsible for checking expiration dates daily and removing expired medications to prevent potential harm to residents. The report also noted that medications for discharged residents were not removed from the medication cart, contrary to the facility's policy. The DON stated that medications should be sent with the resident upon discharge and should not remain in the medication cart. The facility's policy on medication storage emphasizes the importance of storing medications safely, securely, and properly, and mandates the immediate withdrawal and disposal of outdated or deteriorated drugs. Despite these policies, the survey revealed lapses in adherence, leading to the presence of expired and improperly labeled medications in the facility.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an altercation between two residents. Resident R11, who suffers from legal blindness, schizophrenia, and altered mental status, became agitated while walking with an activity aide. During this episode, R11 began flailing his arms and inadvertently scratched Resident R12, who was seated in a wheelchair in the dining area. R12 sustained superficial scratches to the face, which were treated with first aid and monitored by the wound care team. R12 expressed that he felt safe and understood that the incident was accidental. The incident occurred when the activity aide attempted to redirect R11, who was already agitated about his trust fund. R11 started swinging his arms after nearly tripping over a cord, hitting the activity aide and then grabbing R12 by the neck. The situation escalated until other residents and staff intervened to separate the two. R11 was placed on 1:1 supervision and later sent to a community hospital for psychiatric evaluation. The facility's investigation concluded that the incident was accidental and not intentional abuse. R11's care plan documented his history of resisting care and impaired memory and decision-making abilities. Despite these known issues, the facility's actions to manage R11's behavior were insufficient to prevent the altercation. The facility's abuse prevention policy affirms residents' rights to be free from abuse, yet the measures in place failed to protect R12 from harm during R11's behavioral episode.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the regional office, affecting one resident. The resident, a male with a history of stroke, aphasia, major depressive disorder, adult failure to thrive, and anxiety, was noted to have swelling, redness, pitting edema, and warmth in his right contracted arm. Initially, the staff and nurse practitioners believed the symptoms were due to cellulitis and treated him with antibiotics. However, an x-ray later revealed a fracture of the distal humerus, leading to the resident being sent to a local hospital. Despite the discovery of the fracture, the facility administrator did not report the injury to the regional office, as it was not deemed suspicious due to the resident's poor health and history of old fractures. The investigation included statements from staff, x-ray results, and hospital findings, but the injury was not reported as required by the facility's abuse policy. The policy states that an injury should be classified as an injury of unknown source if the source was not observed or explained and is suspicious due to its extent, location, or number of injuries. The nurse practitioner and staff did not find the injury suspicious, attributing it to the resident's overall poor health and potential pathological fracture. However, the failure to report the injury to the regional office constitutes a deficiency in following the facility's abuse policy and prevention program.
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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