Seminary Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Illinois.
- Location
- 2345 North Seminary Street, Galesburg, Illinois 61401
- CMS Provider Number
- 145598
- Inspections on file
- 28
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Seminary Manor during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including acute respiratory failure with hypoxia, PVD, GAD, and BPH, reported that a CNA roughly handled his genital area while placing a urinal, yelled at him to use it despite his objections, and reacted angrily when urine spilled on him and the bed, leaving him feeling blindsided, dumbfounded, concerned, and embarrassed. The facility’s abuse policy required protection from abuse, interviews with involved parties including the resident when able, and documentation of the resident’s condition after an alleged incident, but the resident’s care plan contained no psychosocial interventions, and there was no documented follow-up assessment or care plan revision addressing his psychosocial well-being. Multiple staff, including the ADON, Social Services, and an LPN, acknowledged they had not specifically spoken with the resident about the incident or his feelings, and leadership confirmed there was no documentation of attempts to speak with him about the event.
The facility failed to follow its abuse reporting policy when an allegation that a resident had been roughly handled by a third-shift CNA was not immediately reported to the Administrator/Abuse Coordinator. One resident told his roommate he had been treated roughly and mishandled with a urinal; the upset roommate then reported this to a CNA, who in turn informed an LPN. The CNA and LPN acknowledged awareness of a complaint involving third-shift staff but did not directly notify the Administrator, and Social Services was only told that the resident had a complaint, without mention of abuse. Social Services made unsuccessful attempts to speak with the resident and did not learn the concern involved abuse until the resident’s son later stated it was "elder abuse." The Administrator reported first learning of the allegation hours after staff initially became aware, and the resident stated no one from the facility had come to talk with him about what occurred.
The facility failed to follow its abuse prohibition and reporting policy by not interviewing a resident who was the subject of an abuse allegation and not documenting any attempt to do so. Policy required interviews with all involved parties, including the allegedly abused resident when cognitively able, and documentation of the incident in the medical record. Instead, staff spoke with the resident’s son and another resident, but there was no record of direct contact with the affected resident. The DON and another facility representative confirmed that neither the investigation file nor the resident’s EMR contained evidence of an interview or attempted interview with the resident regarding the alleged abuse.
A resident with a history of behavioral symptoms and moderate cognitive impairment made sexually explicit comments to another cognitively impaired resident in a dining room, telling her he wanted to see and touch her breasts and making other graphic remarks. The recipient of the comments became upset, sought out staff, and reported the incident, stating she did not want other female residents to be similarly harassed and now actively avoids the other resident. Staff confirmed both residents were oriented, and the facility’s own policy prohibits sexual abuse, including sexual harassment, yet the incident was not substantiated as abuse based on a conclusion that the offending resident lacked capacity, despite acknowledgment that he understood basic social rules and could recognize inappropriate comments.
The facility did not return trust fund balances to discharged or deceased residents within the required timeframe and failed to notify residents or their representatives when trust fund accounts approached or exceeded the SSI resource limit. Multiple residents were affected, with some accounts holding significant balances, and staff confirmed that required notifications and refunds were not completed as per policy.
The facility did not hold required quarterly QAA meetings as outlined in its QAPI Plan, with only two meetings documented in the past year and none during the administrator's absence. This failure potentially affected all 97 residents in the facility.
The facility did not properly identify, monitor, or review antibiotic use for several residents, as required by its infection control and antibiotic stewardship policies. Antibiotics and antifungals were administered for various conditions, but the facility's tracking logs and pharmacist reviews failed to document the medications, their indications, or relevant test results. Staff interviews confirmed that ongoing monitoring and accurate record-keeping were not performed.
A resident had an active PRN order for Alprazolam 0.5 mg for generalized anxiety, despite not having received the medication for over a month. The DON confirmed that the order remained in the medical record and should have been discontinued according to facility policy.
A resident's care plan did not include their diagnoses of Atrial Fibrillation and Diabetes or the use of Eliquis and Humalog Insulin, despite these medications being ordered and administered. The Care Plan Coordinator confirmed these omissions during the review.
A resident did not have compression stockings applied as ordered by their physician. Although the treatment record indicated the stockings were on, observation revealed the resident was not wearing them, and a CNA confirmed the omission and located the stockings in the resident's dresser drawer.
A resident with a history of trauma and multiple psychiatric diagnoses did not have potential trauma triggers or emotional support needs identified in their care plan or medical record. Staff confirmed the absence of this documentation, and the facility lacked a trauma-informed care policy.
Two residents developed severe pressure ulcers due to the facility's failure to implement and update care plans with pressure-relieving interventions. One resident developed an unstageable ulcer on the left heel, while another developed a stage three ulcer on the right heel and an unstageable ulcer on the inner ankle. The facility did not conduct required assessments, update care plans, or notify physicians of changes, resulting in severe pain for the residents.
A resident with Congestive Heart Failure and respiratory conditions experienced multiple instances of oxygen deprivation due to the facility's failure to monitor and maintain a continuous oxygen supply. The resident's portable oxygen tanks were not adequately checked or refilled, leading to severe respiratory distress during a medical appointment and at the facility. Interviews revealed issues with equipment maintenance and a lack of proper procedures, contributing to the resident's distress.
The facility failed to change nebulizer and oxygen equipment as per protocol, with two residents' nebulizer equipment not replaced weekly and found un-bagged, and oxygen tubing for two residents not dated or replaced every seven days. Observations showed oxygen equipment improperly stored and dated, indicating a lapse in respiratory care standards.
The facility failed to disinfect wound care supplies after each use, affecting multiple residents. A resident with diabetes and chronic kidney disease received wound care, but the spray bottle used was not disinfected before being returned to the treatment cart. This bottle was used for multiple residents, contradicting the facility's infection control policies.
The facility failed to document justification for duplicative antidepressant therapy for a resident and for reinstating an antipsychotic for another. One resident was put back on Olanzapine after confirmed agitation, but without documented justification. Another resident was on three antidepressants without documented rationale, despite not being a harm to themselves or others.
Failure to Prevent Mental Abuse and Assess Psychosocial Impact After Alleged Rough Handling by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from mental abuse and to follow its own abuse prohibition and reporting policy. The facility’s policy, revised 11/28/19, requires protection from all forms of abuse, staff awareness and correction of inappropriate behaviors such as derogatory language and rough handling, immediate reporting of alleged abuse, interviews with involved parties including the resident when cognitively able, and documentation in the medical record of the nature and extent of any injuries or conditions resulting from the incident. The resident’s care plan contained no documentation regarding psychosocial well-being or related interventions. The resident, admitted with diagnoses including acute respiratory failure with hypoxia, peripheral vascular disease, generalized anxiety disorder, and benign prostatic hyperplasia, reported that early one morning he activated his call light to use the bathroom. A CNA entered, obtained a bedside urinal, and threw it at his groin, then grabbed his penis and pushed it toward the urinal while yelling, “it’s in, go!” The resident stated he told the CNA that his penis was not in the urinal, but she again yelled, “It’s in, use it!” He then urinated and felt urine go all over himself and the bed. He reported that the CNA appeared unhappy about the mess, forcefully closed the curtain between his bed and his roommate’s, and forcefully sat him on the side of the bed. A second CNA entered, observed the first CNA’s anger about the mess, and told the first CNA she would clean it up, after which the first CNA left the room. The resident described feeling blindsided, dumbfounded, concerned, and embarrassed by the incident. Following the incident, there was no documented assessment or care plan revision addressing the resident’s psychosocial well-being related to the alleged abuse. The resident stated that no one from the facility had come to talk to him about what occurred, although they had spoken with his son and another resident. The ADON, Social Service Director, and Social Service/Admission Director each acknowledged they had not spoken with the resident about the incident or his well-being, and the LPN stated she had not discussed anything specific related to the incident with him. The DON confirmed that the resident’s care plan had not been revised to address psychosocial needs after the incident, and the Administrator verified there was no documentation in the medical record or investigation showing attempts to speak with the resident. The Administrator stated he did not see any reason to follow up on the resident’s psychosocial well-being and attributed the resident’s reluctance to talk with staff to potential litigation rather than distress.
Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Prohibition and Reporting policy by not immediately reporting an allegation of abuse involving one resident (R1) to the Abuse Coordinator/Administrator. The facility’s written policy requires any employee or agent who becomes aware of alleged abuse or neglect to immediately report the matter to the Administrator or designee, and specifies that staff must report whenever they hear the word "abuse" or suspect abuse. R1’s face sheet shows he was admitted with diagnoses including acute respiratory failure with hypoxia, peripheral vascular disease, generalized anxiety disorder, and benign prostatic hyperplasia. Despite this policy, multiple staff members became aware that R1 allegedly experienced rough handling by a third-shift CNA but did not promptly notify the Administrator as required. On the morning of 4/15/26, R2 reported to a CNA (V8) that he believed his roommate, R1, had been abused by a third-shift CNA, describing that there were two CNAs, one nice and one not, and that the rough CNA had been very rough with R1 and did something involving a urinal. V8 acknowledged that R2 appeared upset and that she understood this as a concern about possible abuse of R1 by third shift. V8 then reported the concern to an LPN (V6) and accompanied her to the residents’ room. V6 spoke briefly with R1, who stated he had a complaint about a third-shift CNA, and V6 told him she would get Social Services so he would not have to repeat himself. V8 stated she did not know who the Abuse Coordinator was and did not report the allegation to the Administrator. V6 stated she contacted Social Services (V5) only to report that R1 had a complaint, without specifying that it involved alleged abuse. Social Services (V5) reported being told only that R1 had a complaint and made two unsuccessful attempts to speak with him before R1’s son (V15) was brought to her office later that afternoon. V5 stated that the first time she became aware that the issue involved abuse was when V15 came in and stated, "This is Elder Abuse." V6 similarly stated she did not realize it was an abuse allegation until V15 used the term "elder abuse" when she took him to Social Services. The Administrator (V1), who is the Abuse Coordinator, reported that she did not become aware of the allegation until between 3:00 and 4:00 p.m. that day, despite the policy requiring immediate reporting to her when abuse is suspected. R1 stated that no one from the facility had come to talk to him about what occurred, although they had spoken with his son and his roommate. R1’s son also reported that he was not notified by the facility of the abuse allegation and instead learned of it from R1 and R2, and that when police later interviewed R1 and R2, R2 told the police he had reported the incident to the Administrator the morning it occurred. These interviews and record reviews demonstrate that the facility did not implement its abuse reporting procedures as written for this allegation involving R1.
Failure to Interview Resident During Abuse Allegation Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. Facility policy titled "Abuse Prohibition and Reporting (Elder Justice Act)," revised 11/28/19, requires that all alleged abuse be immediately reported to administration, that interviews with all involved parties or potential witnesses be completed, and that statements be obtained from the resident abused or neglected if the cognitive level permits. The policy also requires documentation in the resident’s medical record of the nature and extent of any injuries or conditions resulting from the alleged incident, and related clinical notifications. Despite these requirements, the investigation documentation dated 4/15/26 and the resident’s electronic medical record contained no evidence that the resident was interviewed regarding the allegation of abuse reported on that date. The resident was admitted with diagnoses including acute respiratory failure with hypoxia, peripheral vascular disease, generalized anxiety disorder, and benign prostatic hyperplasia. On 4/24/26 at 3:00 p.m., the resident stated that no one from the facility had come to talk to him about what occurred, and that staff had spoken to his son and another resident instead. On 4/28/26, both the DON (V2) and another facility representative (V1) confirmed there was no documentation in the medical record or the investigation to show that the facility attempted to interview the resident about the alleged abuse. This lack of interview and documentation constituted the failure to respond appropriately to the alleged violation in accordance with facility policy.
Failure to Protect Resident From Sexual Harassment by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual harassment by another resident, as required by its abuse prohibition policy. The facility’s policy, revised 11/28/19, states that residents must be protected from all forms of abuse, including sexual abuse and sexual harassment. One resident (R1) had a documented history and care plan problem area for multiple behavioral symptoms, including delusions, exit seeking, physical and verbal behaviors toward others, rejection of care, and making inappropriate comments toward female staff during care. R1’s cognitive status was documented as moderately impaired with a score of 10/15 on the MDS. Another resident (R2), with a cognitive score of 11/15 and no care plan problem areas indicating a history of making false allegations, reported that R1 made sexually explicit comments to her. On the morning of 1/8/26, R2 and R1 were both in the north dining room early, as R1 often went there for coffee and R2 had not been sleeping well and was also up early. R2 reported that R1 told her he wanted to see and touch her breasts in a sexual manner and made other graphic remarks. R2 stated she told R1 to stop talking to her that way, and he stopped immediately. R2 became upset, wheeled herself through the hallway looking for staff, and called out for help to report that R1 was making inappropriate comments and that she did not want other female residents to be harassed. Staff, including a CNA and an RN, responded to R2’s call, and R1 was escorted away from the area. During subsequent interviews, R2 consistently recalled the incident and reiterated that she was upset by R1’s comments and now makes a point to avoid him. Staff who knew both residents stated that both R1 and R2 were oriented to time, place, and purpose. The administrator later determined that the incident was not substantiated abuse based on a conclusion that R1 lacked capacity to understand his actions, despite also acknowledging that R1 understood basic social rules, could recognize that certain comments were inappropriate, and could follow simple directions or redirections. The facility’s determination that abuse was not substantiated, in the context of a credible report of sexually explicit comments and R1’s known history of inappropriate verbal behaviors, reflects the failure to ensure R2’s right to be free from sexual harassment by another resident.
Failure to Timely Refund Resident Trust Funds and Notify of SSI Resource Limit Exceedance
Penalty
Summary
The facility failed to return resident trust fund balances within the required 30-day period after discharge or death for 46 residents. Record review and interviews confirmed that multiple residents had remaining balances in their trust fund accounts that were not refunded in accordance with facility policy and state/federal regulations. Documentation showed that these balances ranged from small amounts to over a thousand dollars, and there was no evidence that the funds were returned to the residents or their representatives within the specified timeframe. The facility's own admission contract and trust fund policy require timely refunds, but these were not followed, as confirmed by both the administrator and business office staff. Additionally, the facility did not provide required notifications when resident trust fund balances approached or exceeded the Supplemental Security Income (SSI) resource limit. Three residents had trust fund balances that exceeded the SSI resource limit, but there was no documentation that the residents, their legal representatives, or social services were notified as required by facility policy. The business office manager was unaware of the SSI resource limit, and the administrator confirmed the lack of notification. These failures were identified through review of facility records and interviews with staff.
Failure to Hold Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct quarterly Quality Assessment and Assurance (QAA) meetings as required by its QAPI Plan, which specifies that the committee must meet on a quarterly basis. Record review showed that only two QAA sign-in sheets were available for the past year, dated March and April, with no documentation of meetings prior to March. The administrator confirmed that QAA meetings were not held during her temporary absence starting in July, and no additional sign-in sheets could be located. This lapse in holding required QAA meetings has the potential to affect all 97 residents residing in the facility, as documented on the CMS form 671.
Failure to Monitor and Review Antibiotic Use for Multiple Residents
Penalty
Summary
The facility failed to identify, monitor, and review antibiotic use for all five residents reviewed for antibiotic stewardship, as required by their Infection Control and Antibiotic Stewardship policies. The policies specify that the Infection Control Committee is responsible for surveillance, review, and analysis of infections, as well as maintaining a system for reporting and evaluating antibiotic use. However, the facility's Infection Tracking Logs for multiple months did not include required information such as the antibiotics administered, their indications for use, or the results of relevant cultures and laboratory tests for several residents who were receiving antibiotics or antifungals. For example, one resident was on a maintenance dose of Macrodantin for a history of urinary tract infections without a documented stop date, and this was not tracked in the Infection Tracking Log or evaluated by the pharmacist. Another resident received Macrobid prophylactically and later multiple courses of Levofloxacin for urinary tract infections, but the logs did not document the antibiotics, their indications, or the results of diagnostic tests. Additional residents received various antibiotics and antifungals for conditions such as cough, skin eruptions, pneumonia, and cystitis, but the facility failed to document these treatments and their appropriateness in both the Infection Tracking Log and the Pharmacist's Summary of Recommendations. Interviews with facility staff confirmed that ongoing monitoring of residents on prophylactic antibiotics was not performed after initial initiation, and that the tracking system was incomplete and inaccurate. The Assistant DON/Infection Preventionist acknowledged that the logs did not track culture or test results, were not comprehensive, and that the pharmacist's reviews were not inclusive of all antibiotic or antifungal use. The Administrator also stated that the facility struggled with entering and ensuring the accuracy of required infection information in the new tracking system.
Failure to Discontinue Unnecessary PRN Psychotropic Medication
Penalty
Summary
The facility failed to discontinue a PRN (as needed) psychotropic medication, Alprazolam 0.5 mg, for one resident as required by facility policy and procedures. The resident had an active physician order for Alprazolam to be administered twice daily as needed for generalized anxiety, with the last documented administration occurring over a month prior to the survey. Despite the lack of recent use, the medication order remained active in the resident's medical record. The Director of Nursing confirmed that the PRN order for Alprazolam was still present and acknowledged it should have been discontinued in accordance with facility protocols to prevent unnecessary medication use.
Care Plan Omission for Anticoagulant and Insulin Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's medical needs. Specifically, for one resident, the care plan did not include the diagnoses of Atrial Fibrillation and Diabetes, nor did it address the administration of Eliquis, a blood thinner, and Humalog Insulin, both of which were ordered by the physician and being administered according to the Medication Administration Record. The Care Plan Coordinator confirmed that these diagnoses and medications were missing from the resident's care plan and acknowledged the oversight during the surveyor's review.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive leg compression stockings as ordered by their physician. The physician's orders specified that Tubi Grips (compression stockings) were to be applied to both lower extremities in the morning and removed at bedtime. The resident's treatment administration record indicated that the Tubi Grips were on, but during an observation in the activity area, the resident was found without Tubi Grips, socks, or shoes. A certified nurse aide confirmed responsibility for applying the Tubi Grips, acknowledged that the resident was not wearing them, and verified that the stockings were available in the resident's dresser drawer but had not been applied as required.
Failure to Identify and Address Trauma Triggers in Resident Care Plan
Penalty
Summary
The facility failed to provide trauma-informed care for one resident with a history of significant trauma, including childhood separation, time in an orphanage, sexual assault, and experiencing a tornado. The resident's diagnoses included Generalized Anxiety Disorder, Psychotic Disturbance, Mood Disturbance, Major Depressive Disorder, and Hallucinations. Despite this history, the resident's social assessment and care plan did not identify or document any potential triggers or emotional support needs related to past trauma. Interviews with facility staff confirmed that the care plan and medical record lacked this information, and it was also noted that the facility did not have a policy on trauma-informed care.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate pressure ulcer prevention and treatment protocols for two residents, R1 and R2, leading to the development and worsening of pressure ulcers. R1, who was admitted with a left femur fracture and other mobility issues, developed an unstageable pressure ulcer on the left heel six days after admission. The facility did not conduct weekly Braden Scale assessments as required, and R1's care plan was not updated to include interventions for the newly developed pressure ulcer. Additionally, R1's wound was incorrectly categorized as a stage one pressure injury, and there was a lack of consistent wound assessment and documentation. R2, who was severely cognitively impaired and diagnosed with chronic congestive heart failure and cerebrovascular disease, developed a stage three pressure ulcer on the right heel and an unstageable pressure ulcer on the inner ankle. The facility failed to update R2's care plan with pressure-relieving interventions after R2 was identified as high risk for pressure ulcers. Furthermore, there was inadequate documentation and notification to the physician regarding the condition and treatment of R2's pressure ulcers, resulting in severe pain for R2. The facility's staff, including the wound nurse and care plan coordinator, admitted to being behind on assessments and care plan updates. There was also a lack of communication with the physician regarding changes in the residents' wound conditions. These deficiencies highlight the facility's failure to adhere to its own pressure ulcer prevention and treatment protocols, leading to the development and worsening of pressure ulcers in residents R1 and R2.
Failure to Ensure Continuous Oxygen Supply for Resident
Penalty
Summary
The facility failed to adequately monitor and ensure a continuous supply of oxygen for a resident diagnosed with Congestive Heart Failure and other respiratory conditions. The resident, who was cognitively intact, was admitted with a need for continuous supplemental oxygen. However, the facility did not maintain the resident's oxygen supply as ordered by the physician, leading to multiple instances where the resident was without oxygen for significant periods. This resulted in the resident experiencing severe respiratory distress, including chest pain and shortness of breath. The report details specific incidents where the resident's portable oxygen tank ran out, both during a medical appointment and at the facility. During a visit to a nephrologist, the resident's oxygen tank was empty, causing the resident's oxygen saturation to drop to 80 percent, and the resident exhibited symptoms of cyanosis and slurred speech. The facility's transport staff was not adequately trained or equipped to handle the resident's oxygen needs, leading to a delay in providing a replacement tank. Another incident occurred during dinner at the facility, where the resident's oxygen tank again ran empty, and it took an extended period for staff to provide a new tank. Interviews with staff and family members revealed a lack of proper procedures and equipment maintenance, contributing to the resident's distress. The facility's oxygen tanks were reported to be old and unreliable, with some gauges not functioning correctly. Additionally, there was no consistent schedule for checking and refilling the oxygen tanks, and the resident's care plan did not address their oxygen needs. The facility's failure to ensure a continuous oxygen supply and perform necessary assessments after these incidents highlights significant deficiencies in the care provided to the resident.
Failure to Maintain Proper Respiratory Care Protocols
Penalty
Summary
The facility failed to adhere to its own protocols for respiratory care, specifically regarding the timely replacement and proper storage of nebulizer and oxygen equipment. For two residents, the nebulizer mask and tubing were not changed every seven days as required. One resident's nebulizer equipment was found on a nightstand, un-bagged, and dated over a month prior, while a registered nurse confirmed the equipment should be changed weekly and stored in a bag between uses. Additionally, the oxygen tubing for two residents was not replaced every seven days, as evidenced by the tubing being dated several months prior or having no date at all. Further observations revealed that oxygen tubing and nasal cannulas for two residents were found on the floor, connected to oxygen tanks, and running without proper dating. These residents were not present in their rooms at the time of observation, and when seen later, they were using oxygen tanks with tubing that also lacked date markings. These findings indicate a failure to maintain proper respiratory care protocols, potentially compromising the residents' health and safety.
Failure to Disinfect Wound Care Supplies
Penalty
Summary
The facility failed to ensure that wound care supplies were disinfected after each resident's wound care, which has the potential to affect multiple residents receiving wound care. The facility's Standard Precautions policy and Wound Care policy emphasize the importance of following standard precautions during wound care to prevent the transmission of infectious agents. However, during an observation, it was noted that the wound cleanser spray bottle used for a resident's wound care was not disinfected before being returned to the treatment cart. This spray bottle was used for multiple residents, which contradicts the facility's policy and increases the risk of cross-contamination. The deficiency was observed during the wound care of a resident with diagnoses including insulin-dependent diabetes and chronic kidney disease. The resident's treatment involved cleaning and dressing a pressure ulcer on the left buttock. After the wound care was completed, the wound nurse returned the spray bottle to the treatment cart without disinfecting it. The Director of Nurses confirmed that these bottles are considered community property and are used for multiple residents' wound care, further highlighting the facility's failure to adhere to its own infection control policies.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to document justification for the use of duplicative antidepressant therapy for one resident and failed to document the justification for reinstating an antipsychotic for another resident. One resident was initially prescribed Olanzapine for dementia with delusions and agitation, but the medication was discontinued following a pharmacy review due to a lack of documented behaviors justifying its use. However, the resident was later put back on Olanzapine after exhibiting agitation and accusations of missing clothing, which were confirmed to be true events rather than delusions. Despite this, the facility did not document the justification for reinstating the antipsychotic medication. Another resident was prescribed three different antidepressants: Mirtazapine, Bupropion HCL, and Sertraline. The Director of Nursing, responsible for managing psychotropic medications, was unable to provide a documented reason for the resident taking multiple antidepressants, and it was confirmed that the resident was not a harm to themselves or others. This lack of documentation for the use of multiple antidepressants constitutes a deficiency in the facility's management of psychotropic medications.
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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