Shelbyville Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelbyville, Illinois.
- Location
- 1111 West North 12th Street, Shelbyville, Illinois 62565
- CMS Provider Number
- 145441
- Inspections on file
- 31
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Shelbyville Manor during CMS and state inspections, most recent first.
A facility failed to conduct abuse risk assessments and to implement care-planned non-pharmacological interventions for several cognitively impaired residents with dementia and behavioral disturbances. One resident with severe cognitive impairment was struck on the face by another cognitively impaired resident, yet neither had documented abuse risk assessments. Another resident with Alzheimer’s disease and behavioral disturbance repeatedly engaged in sexually inappropriate and intrusive behaviors toward staff and female residents, including grabbing buttocks and breasts, exposing genitals, entering or attempting to enter female residents’ rooms, and touching or attempting to touch female residents while seated or asleep. Documentation showed that staff responses were often limited to verbal redirection, reminders that behavior was inappropriate, monitoring, and basic assistance with clothing or hygiene, with no consistent evidence that the broader, individualized non-pharmacological interventions listed in the care plan were implemented. A severely cognitively impaired resident was also identified as an alleged victim of breast touching by this behaviorally disturbed resident. Facility staff and leadership acknowledged that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that no specific abuse risk assessment tool was used, despite an abuse prevention policy requiring identification of residents at risk of abusing others or being victims and inclusion of appropriate interventions on care plans.
A resident with CKD, diabetes, chronic pain, and morbid obesity, who was cognitively intact and dependent on staff for ADLs, was care planned to receive showers twice weekly with attention to drying skin folds. Shower records for a given month showed the resident received only four showers and missed two scheduled showers, with no documentation of refusals. The resident reported that staff frequently forgot to provide showers and that she often had to remind them, while the DON confirmed the resident was scheduled and care planned for two showers per week and had missed two showers during that month.
Two residents with dementia, neurological conditions, and multiple psychoactive and anti-seizure medications experienced repeated falls related to inadequate implementation of fall-prevention measures. For one resident, the care plan contained conflicting directions about wheelchair foot pedals, and an intervention to add non-slip material to the wheelchair seat was not documented or in place during observation. For another resident with a history of falls, documentation showed inconsistent or missing information about footwear, and the resident was later observed in a wheelchair wearing regular socks with a foot dangling between foot pedals, despite staff stating that non-slip socks were needed and that the resident attempted to stand without assistance.
A resident with dementia, multiple vitamin deficiencies, and documented dental issues had a physician order for a high‑protein supplement TID with meals and a recorded dislike of chicken. During a lunch meal, the resident was served chicken cordon bleu and did not receive the ordered high‑protein milkshake, even though both the supplement order and the chicken dislike were clearly printed on the diet ticket. The resident reported inconsistent receipt of the milkshakes and reiterated his dislike of chicken, while a CNA, the Dietary Manager, and the DON each confirmed that the meal and supplement provided did not match the documented physician orders and stated food preference.
Two residents with cognitive impairment and high fall risk experienced multiple falls due to the facility's failure to update care plans with appropriate interventions, lack of documentation of required 15-minute checks, and incomplete fall investigations. Staff did not consistently document or implement fall prevention measures, and leadership confirmed the absence of policies for tracking interventions or collecting witness statements.
Several hot water heaters located in resident closets were found with visible mold, rust, and lime build-up, with resident clothing hanging directly above or touching the units. Staff and family members had reported concerns about these unsanitary conditions, but the issues remained unaddressed, and there was no documentation of the concerns in the affected residents' records.
A resident with cognitive impairment and a history of falls was consistently placed in bed with full-length body pillows and a concave mattress to prevent bed exit, but the facility failed to assess or care plan these devices as restraints. Despite multiple falls and a resulting pelvic fracture, there was no documentation of restraint assessment or reassessment, and staff confirmed the interventions were used to restrict movement without proper evaluation.
A resident reported that a male CNA was rough during perineal care, resulting in a bleeding skin tear. Staff observed and documented the injury, and the CNA was identified as present on the unit. Despite the report and facility policy requiring suspension, the alleged staff member was not removed from duty and the incident was not reported to authorities.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff failed to prevent both staff-to-resident and resident-to-resident abuse, including a CNA using profanity and physically handling a resident with dementia, and another resident striking a peer with a plastic object, resulting in injury and pain. Prior disciplinary actions for the CNA and inadequate supervision contributed to these incidents.
A cognitively impaired resident with a high fall risk and multiple diagnoses required substantial staff assistance for transfers but was allowed to self-transfer and self-toilet without supervision. The resident fell while attempting to go to the bathroom alone, resulting in fractures that required emergency surgery. Staff were unaware of the resident's true assistance needs, and the care plan did not include targeted interventions to address self-toileting or increased supervision.
The facility did not transmit MDS assessments to CMS within the required time frames for five residents. Documentation and staff interviews confirmed that the assessments were submitted late or not at all, despite established procedures for timely completion and transmission.
Several residents who were diagnosed with severe mental illness after admission did not receive required Level 2 PASRR assessments. Staff misunderstood the requirements, believing Level 2 PASRRs were only needed for new admissions or significant changes, and failed to complete them when new mental illness diagnoses were made.
Staff failed to follow proper infection control procedures during catheter and incontinence care for multiple residents, including not changing gloves or performing hand hygiene between care tasks, improper cleaning techniques that led to cross-contamination, and not applying barrier cream as required by facility policy.
A resident with severe cognitive impairment and a history of modesty was transported by CNAs to the shower room while inadequately covered, resulting in exposure of multiple body areas in view of other residents and staff. Staff reported undressing the resident in his room for convenience, contrary to facility policy and the resident's known preferences.
A resident with a diagnosis of Major Depressive Disorder with recurrent psychotic symptoms and an Intellectual Disorder was admitted without the facility obtaining a required Level 2 PASRR, despite documentation indicating the need. The administrator reported that Level 2 PASRRs were only being completed after significant changes in status, contrary to facility policy.
A resident with pneumonia and emphysema received oxygen therapy without a complete physician order specifying the flow rate, and a CNA, rather than a licensed nurse, administered the oxygen by turning on the concentrator and setting the rate. The facility's policy requires licensed nurses to administer oxygen and for orders to include all necessary details.
A resident with a history of pain and mobility issues was unable to access her call light and bedside table during the night, resulting in a prolonged period of unmanaged pain. Staff confirmed the items were out of reach, and the nurse did not document the resident's pain level when administering PRN pain medication, contrary to facility policy.
A resident with severe cognitive impairment and multiple behavioral health diagnoses experienced repeated injuries during care due to combative behavior. Staff lacked behavioral health training, and psychiatric services were not in place at the time of the incidents. Injuries were not consistently reported or followed up according to policy, and care plan interventions were not always implemented.
The facility failed to ensure respect and dignity for two residents due to inappropriate communication by a CNA, V4. R2 reported feeling rushed and uncomfortable with V4's demeanor, while R1 felt disrespected and anxious due to V4's frequent room visits and rude manner. Despite the abuse being unsubstantiated, the facility acknowledged V4's inappropriate communication, leading to V4's termination.
A resident with Spastic Paraplegia and other mobility impairments fell from a shower chair when a wheel got caught on the shower curb, resulting in multiple back and neck fractures. The resident required emergency medical treatment and was diagnosed with six vertebral fractures, necessitating pain management and a cervical immobilizer upon return to the facility.
The facility has not employed a Certified Dietary Manager for almost a year, affecting all 80 residents. During a survey, it was confirmed that the position has been vacant for six months, with the Registered Dietician only visiting monthly and reviewing charts remotely weekly. The facility lacks a policy mandating a Certified Dietary Manager, although it is acknowledged that one should be employed.
A facility failed to maintain kitchen equipment in a sanitary condition, risking cross-contamination and food-borne illnesses for 80 residents. Observations included rust and grease buildup on equipment, standing water, and expired food items. Staff confirmed the lack of a cleaning schedule and maintenance issues, violating professional standards for food safety.
A facility failed to maintain resident dignity by not providing timely toileting assistance and allowing staff to engage in personal conversations during meal service. A resident reported waiting long periods for toileting help, leading to incontinence and humiliation. Staff were observed talking about non-work-related topics while assisting residents with severe cognitive impairments during meals, with minimal interaction directed towards the residents. The facility's Administrator acknowledged these as dignity issues.
The facility failed to maintain and store respiratory equipment properly, affecting four residents. Equipment was not dated when changed and was improperly stored, with tubing found on the floor and humidifier bottles on dirty surfaces. Staff confirmed the need for more hygienic practices.
The facility failed to prevent cross-contamination during meal service by not following hand hygiene protocols. A CNA used bare hands to move food on a resident's plate without gloves or hand hygiene, and an LPN assisted two residents without cleaning hands between them. Another CNA handled a resident's drinking cup without hand hygiene. These actions violated the facility's hand washing policy, risking infection spread.
A facility failed to report an allegation of verbal and physical abuse of a resident by a CNA to the Abuse Coordinator. The resident, with multiple medical conditions, was allegedly treated roughly, yelled at, and left in wet clothes. The Administrator was unaware of the incident until later, and the CNA was suspended during the investigation. The facility's policy mandates immediate reporting of such allegations, which was not adhered to.
A resident with Enterocolitis due to Clostridium Difficile did not receive prescribed doses of Fidaxomicin as per physician orders. The MAR showed missed doses on multiple occasions, which was confirmed by an RN. The facility's policy requires adherence to physician orders for medication administration.
A CNA failed to change gloves and perform hand hygiene after contamination with stool while providing catheter care to a resident with multiple medical conditions, including Parkinson's Disease and Bladder-Neck Obstruction. The CNA acknowledged the error, and the IP stressed the importance of proper infection control practices to reduce infection risks.
The facility failed to conduct necessary Psychotropic Medication Assessments for two residents, leading to a deficiency in managing unnecessary medications. One resident with Dementia and Depression had not been assessed in the past year despite being on Citalopram and Olanzapine. Another resident with Depression and Anxiety did not receive an Initial Assessment upon admission while on Buspar and Citalopram. These assessments are essential for the Care Plan and Gradual Dose Reduction Program.
Two residents received meals at a cold temperature due to staff delivering food without covering trays, leading to dissatisfaction and reduced meal consumption. The Nurse Manager acknowledged the lack of a formal policy on covering trays, which contributed to the issue.
A resident with severe cognitive impairment was not served a modified diet as ordered, leading to coughing after consuming un-thickened tomato soup. The CNA feeding the resident and a cook acknowledged the oversight in not thickening the soup, which was required per the resident's dietary order.
Failure to Implement Abuse Risk Assessments and Non-Pharmacological Interventions for Dementia-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatments, services, non-pharmacological interventions, and abuse risk assessments for residents with dementia and severe cognitive impairment, particularly in relation to resident-to-resident and resident-to-staff incidents. Several residents were identified as having dementia or Alzheimer’s disease with behavioral disturbances, and Minimum Data Set (MDS) assessments documented severe or moderate cognitive impairment. Despite this, the medical records for some residents, including those involved in incidents, did not contain abuse risk assessments to determine whether they were at risk of being victims or perpetrators of abuse. One resident with dementia and severe cognitive impairment was involved in an incident where another cognitively impaired resident put a hand on her face; a CNA witness described the action as the second resident appearing to get mad and smacking the first resident, with apparent contact to the cheek under the eye. Neither resident’s record contained a documented risk assessment for abuse risk as victim or perpetrator. Another resident with Alzheimer’s disease and dementia with behavioral disturbance exhibited a pattern of sexually inappropriate and intrusive behaviors over an extended period, including grabbing the buttocks, breasts, and attempting to kiss CNAs, exposing genitals in public areas, walking naked in hallways, urinating and defecating outside the bathroom, following female residents to their rooms, entering or attempting to enter female residents’ rooms, and attempting or making physical contact with female residents while they were seated or asleep. Nursing progress notes repeatedly documented these behaviors and, in many instances, either documented no intervention or only minimal verbal redirection, reminders that the behavior was inappropriate, or simple monitoring. The same resident’s care plan identified behavioral problems directed at others and an inability to differentiate socially appropriate from inappropriate behaviors, and it listed multiple non-pharmacological interventions such as specific redirection strategies, engagement in activities of interest, and one-to-one supervision. However, there was no documented evidence that staff implemented these listed non-pharmacological interventions beyond repeated verbal redirection, monitoring, and occasional direction to watch a movie or have a snack. Another severely cognitively impaired resident was documented as the alleged victim of breast touching by the behaviorally disturbed resident, and was observed during the survey sitting in the dementia unit day room covered with a blanket, unlike other residents. Multiple staff, including CNAs, RNs, LPNs, and care plan staff, reported either not witnessing the inappropriate behaviors firsthand or only having hearsay knowledge, and facility leadership and care planning staff confirmed that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that the electronic record system did not provide an actual abuse risk assessment. The facility’s own Abuse Prevention policy called for special attention to identifying behaviors that increase a resident’s potential for abusing others or being a victim, and for including appropriate interventions on care plans and communicating them to direct care staff, but the documentation showed that these expectations were not met for the residents involved. Throughout the documented period, the resident with Alzheimer’s disease and behavioral disturbance continued to display sexually inappropriate and intrusive behaviors toward staff and female residents, including repeated touching or attempts to touch staff and residents, making sexual comments, and exposing himself in public areas. Progress notes showed that staff responses were often limited to telling the resident the behavior was inappropriate, redirecting him, assisting with clothing or hygiene after episodes of disrobing or incontinence, or simply monitoring him, with no consistent documentation of the broader, individualized non-pharmacological interventions outlined in the care plan. Additionally, the facility did not document completion of the ordered referral to a geriatric psychiatric hospital for this resident. Social services and care plan staff acknowledged that they were not aware of specific abuse or neglect risk assessment tools being used, and that the existing social history assessment was not designed to evaluate resident-to-resident or staff-to-resident abuse risk, despite the facility’s written policy requiring identification of such risks and inclusion of appropriate interventions on care plans.
Failure to Provide Scheduled Twice-Weekly Showers to Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers twice weekly to a dependent resident, resulting in missed showers without documented refusals. The resident had chronic kidney disease, diabetes, chronic pain, and morbid obesity, and was cognitively intact with a Brief Interview of Mental Status score of 14 out of 15. The resident’s care plan, initiated on 03/14/2025, specified that the resident was to receive showers twice weekly and requested that staff ensure she was dry and that skin folds were patted dry. Shower documentation for February 2026 showed the resident received showers on 2/3/26, 2/10/26, 2/18/26, and 2/21/26, with no documentation that the resident declined showers between 2/3/26 and 2/10/26 or between 2/10/26 and 2/18/26, indicating two missed showers. The resident reported that staff almost weekly forgot to provide showers, that she often had to remind them, and that sometimes staff did not have time until later in the day, and the DON confirmed the resident was scheduled and care planned for two showers per week and had missed two showers in February 2026. These findings show that the facility did not follow the resident’s care plan and scheduled bathing routine, and did not document any refusals or other reasons for the missed showers, despite the resident’s dependence on staff for activities of daily living and her expectation of two routine showers per week on specific days.
Failure to Implement and Communicate Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and consistently follow fall-prevention interventions as outlined in residents’ care plans. One resident with dementia, multiple neurological conditions, and on numerous psychoactive and anticonvulsant medications had a history of falls from bed and from a wheelchair. After falls in which the resident became entangled with wheelchair foot pedals and struck her head, the interdisciplinary team determined that the wheelchair foot pedals should be removed and non-slip material placed on the wheelchair seat. However, the resident’s care plan contained conflicting information: the Resident Care Information section continued to require bilateral foot pedals on a high-back reclining wheelchair, while the Fall Risk section directed that the foot pedals be removed. The non-slip material intervention was not documented in the care plan. During observation, the resident was transferred into her wheelchair with no non-slip material present on the seat or under the padded cushion, despite the team’s prior decision to use it. A staff member later acknowledged carrying non-slip material intended for this resident’s wheelchair and stated she had revised the care plan to include it, but the care plan still listed foot pedals in one section and removal of foot pedals in another. The staff member also confirmed that the intervention to remove the foot pedals should have been revised in the Resident Care section of the care plan, and the administrator stated that care plan interventions recommended by the interdisciplinary team are expected to be implemented into the care plan. A second resident with encephalopathy, dementia with agitation and psychotic disturbance, Parkinsonism, seizures, osteoporosis, and other conditions, and who was receiving anti-Parkinson’s, antipsychotic, and multiple anti-seizure medications, experienced multiple falls in her room. Documentation showed one fall occurred when the resident was barefoot and looking for a bathroom, another when she was wearing non-skid slippers, and additional falls occurred with an orthopedic boot in place or with no documentation of footwear. Observation later found this resident seated in a high-back wheelchair with regular dress socks and her left foot dangling between the two foot pedals. A LPN stated the resident attempts to stand without assistance and should be wearing non-slip socks, and the DON indicated she would need to determine the status of non-slip socks for this resident, noting recent use and discontinuation of an orthopedic boot and initiation of hospice services.
Failure to Provide Ordered High-Protein Supplement and Honor Food Dislike
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered high‑protein supplement and to honor a documented food dislike for a resident with multiple nutritional deficiencies and moderate cognitive impairment. The resident’s diagnoses include unspecified dementia with moderate cognitive impairment, vitamin D, E, and ascorbic acid deficiencies, and a disorder of teeth and supporting structures. A dietary physician order dated February 4, 2026, specifies that the resident is to receive a regular high‑protein supplement three times daily with meals at 7:30 a.m., 12:00 p.m., and 5:30 p.m. The same physician order/meal ticket also documents that the resident dislikes chicken. On observation at a lunch meal, the resident was served chicken cordon bleu as the entrée and did not receive the ordered high‑protein milkshake supplement, despite both the supplement and the chicken dislike being clearly documented on the physician order/meal ticket. The resident later stated that he does not like chicken, but ate the entrée because the ham inside made it more tolerable, and reported that he enjoys the high‑protein milkshakes but does not receive them consistently at every meal as ordered. A CNA confirmed that the resident did not receive the high‑protein milkshake and was given chicken in error, acknowledging that both the supplement and the chicken dislike were on the ticket. The Dietary Manager confirmed that chicken was listed as a dislike and that the high‑protein supplement was ordered three times daily, and acknowledged that the kitchen staff missed adding the supplement. The DON also confirmed that the physician order/dietary ticket documented the chicken dislike and the high‑protein milkshake order.
Failure to Update Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to update and implement fall interventions in the care plans for residents identified as high fall risks, and did not conduct thorough fall investigations. One resident with diagnoses including dementia, psychotic disturbance, and diabetes was documented as moderately cognitively impaired and required supervision for most activities of daily living. Despite being identified as a high fall risk, this resident experienced multiple falls, some unwitnessed, and the care plan was not consistently updated with new interventions following each incident. Staff involved in the falls were not asked to provide witness statements, and management did not systematically document or investigate the circumstances of each fall. Another resident, severely cognitively impaired with diagnoses such as encephalopathy, dementia, and repeated falls, also experienced an unwitnessed fall. The care plan for this resident included an 'alternate call light' intervention, which required staff to visualize the resident every 15 minutes. However, staff interviews revealed that these checks were not documented, and there was no way to verify that the intervention was consistently implemented. Staff could not confirm the last time the resident was visualized prior to the fall, and documentation in the medical record was found to be inaccurate regarding the timing of checks. Facility leadership confirmed that there was no policy or system in place to document 15-minute checks or to keep separate files for fall investigations. The only documentation available was in the electronic medical record, and there was no established process for collecting or reviewing witness statements from staff involved in falls. The lack of documentation and follow-through on care plan interventions and investigations contributed to the facility's failure to ensure a safe environment and adequate supervision to prevent accidents.
Unsanitary Hot Water Heaters in Resident Closets
Penalty
Summary
The facility failed to maintain sanitary conditions for hot water heaters located in resident closets, affecting six residents reviewed for physical environment. Observations revealed that several hot water heaters in resident closets had visible lime build-up, rust, and black mold on the units, surrounding floors, and walls. Residents reported that their clothes, which hung directly above or touched the water heaters, became very warm, and some expressed concerns about potential health risks due to the presence of mold and lime build-up. One resident's family member had previously reported concerns about mold and lime build-up to facility staff, but there was no documentation of this concern in the resident's electronic medical record, nor evidence that the issue was addressed. Interviews with staff, including the DON, Maintenance Director, and Custodian, confirmed awareness of the unsanitary conditions and the presence of water heaters in multiple resident closets. Staff acknowledged that some water heaters were in poor condition, with visible mold, rust, and lime build-up, and that resident clothing was in direct contact with the units. Despite these concerns being reported by residents and family members, and staff being aware of the issues, the unsanitary conditions persisted at the time of the survey.
Failure to Assess and Care Plan Use of Body Pillows and Concave Mattress as Restraints
Penalty
Summary
The facility failed to identify and assess the use of full body pillows and a concave mattress as physical restraints for a resident with cognitive impairment and a high risk for falls. Observations showed that the resident was consistently positioned in bed with full-length body pillows placed along both sides of the body, under a fitted sheet, on top of a concave mattress. Staff interviews confirmed that these interventions were used specifically to prevent the resident from getting out of bed, yet there was no documentation of a restraint assessment or inclusion of these interventions in the resident's care plan. The resident's medical record indicated a history of falls, cognitive impairment, and unsteady gait. Progress notes and post-fall documentation revealed multiple incidents where the resident exited the bed and ambulated unsupervised, despite the presence of body pillows and a concave mattress. On several occasions, the resident was found on the floor after attempting to self-transfer, and ultimately sustained a left pelvic fracture following a fall when the body pillows were in place. There was no evidence in the medical record of an assessment or reassessment for the use of these devices, even after falls occurred. Staff, including CNAs, an LPN, and the DON, acknowledged that the body pillows were intended to restrict the resident's ability to get out of bed and that no formal assessment or care plan intervention had been completed for their use. The facility's own restraint policy required an assessment prior to the use of any restraint and regular reassessment, but this was not followed. The hospice nurse practitioner also noted that the combination of body pillows and a concave mattress increased the resident's risk for injury by creating additional obstacles to safe bed exit.
Failure to Protect Residents Following Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to protect residents from further abuse by staff following an allegation of staff-to-resident abuse. Specifically, a resident reported to CNAs that a male CNA was rough while cleaning the perineal area during a shower, resulting in a 2 cm by 1 cm open area with bleeding on the scrotum. The incident was documented in nursing notes, and the resident's family and the administrator were notified. Multiple staff interviews confirmed that the resident reported the male CNA was rough, and that the injury was observed and reported to nursing staff. The CNA in question was identified as the only male CNA working on the resident's hallway during the relevant shift, and assignment records confirmed his presence on the unit with the resident and other residents. Despite the resident's report and staff observations, the administrator did not consider the incident to be an abuse allegation and did not report it to the state health department. The alleged perpetrator was not suspended pending investigation, contrary to the facility's own abuse prohibition and reporting policy, which requires immediate suspension of any employee alleged to have committed abuse. The CNA continued to work on the unit with other residents after the allegation was made, and no immediate protective measures were implemented.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent incidents of both staff-to-resident and resident-to-resident abuse, affecting two residents. In one incident, a Certified Nursing Assistant (CNA) used profanity and physically handled a resident with severe cognitive impairment and dementia by placing hands on the resident's shoulders to restrict movement in a wheelchair. A family member witnessed the CNA aggressively jerking the wheelchair and using profane language toward the resident. The CNA had a documented history of prior disciplinary actions for similar behaviors, including previous use of profanity in the presence of residents and leaving residents unsupervised. In a separate incident, a resident with a history of verbal and physical aggression entered another resident's room despite being told not to by both a CNA and the resident. The aggressive resident picked up a plastic bubble wand and struck the other resident on the head and face, resulting in a significant bump, bruising, dizziness, and a high level of pain. The CNA present was unable to immediately intervene as he was providing care to another resident at the time. Both incidents demonstrate a lack of adequate supervision and failure to enforce abuse prevention policies. The facility's own documentation and staff interviews confirm that the abuse occurred and that the affected residents suffered physical and emotional harm as a result. The facility's policies prohibit such abuse, but repeated violations and insufficient supervision contributed to the deficiencies.
Failure to Provide Safe Transfer and Supervision for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of falls and multiple diagnoses, including dementia, muscle wasting, and difficulty walking, was admitted to the facility and assessed as high risk for falls. The resident required substantial to maximal staff assistance with transfers, as documented in both the physical therapy evaluation and the certified nursing assistant task sheet. Despite these documented needs, staff failed to provide the necessary assistance, and the resident was allowed to self-transfer and self-toilet without supervision. On the day of the incident, the resident was found on the floor in his room, having attempted to go to the bathroom independently. The environment was free of clutter, and the call light was not activated. The resident reported tripping over his heel while trying to reach the bathroom, which was approximately eight feet away from where he was found. He sustained severe injuries, including fractures to the left shoulder and left hip, requiring emergency medical attention and surgical intervention. Staff interviews revealed a lack of awareness regarding the resident's need for assistance and a misunderstanding of his level of independence, despite clear documentation of his high fall risk and need for staff support. Additionally, the facility failed to implement targeted post-fall interventions to address the root cause of the resident's self-toileting behavior. The care plan did not include increased toileting assistance or supervision prior to the incident, and staff did not recognize or act upon the resident's history of impulsivity and previous falls. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the level of supervision and assistance required to prevent accidents.
Failure to Timely Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) Resident Assessment Instruments to the Centers for Medicare and Medicaid Services (CMS) within the required time frames for five residents. Specifically, the MDSs for these residents had Assessment Reference Dates (ARDs) in February, but the submissions were not completed until late April, well beyond the regulatory deadlines. In one case, an MDS was still not completed or transmitted as of the end of April. The facility's CMS Submission Reports confirmed the late submissions, and the MDS Coordinator acknowledged the delays during an interview. The MDS Coordinator explained the required timing process, which allows 14 days after the ARD to complete the assessment, 7 days to code the MDS, and an additional 7 days to transmit the data to CMS. Despite this process, the MDSs for the affected residents were not transmitted within the required time frames, as confirmed by both documentation and staff interview. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Complete Level 2 PASRR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to obtain Level 2 Pre-admission Screening and Resident Review (PASRR) assessments for four residents who were diagnosed with severe mental illness after admission. In each case, the residents were initially admitted with no indication of mental illness or developmental disability, as documented by their original Level 1 PASRR screenings. However, subsequent diagnoses of severe mental illnesses such as Psychotic Disorder with Delusions, Bipolar Disorder, Psychosis, and Schizoaffective Disorder were made after admission. Despite these new diagnoses, there was no documentation of Level 2 PASRR assessments being completed for these residents in their comprehensive medical records. Interviews with facility staff revealed a misunderstanding of PASRR requirements, with staff believing that Level 2 PASRRs were only necessary for new admissions or in cases of significant change, rather than when a new mental illness diagnosis was made after admission. The facility's own policy required a Level 2 PASRR for residents with new mental illness diagnoses, but this was not followed. As a result, the facility did not coordinate appropriate assessments or referrals for services as required for residents with newly identified severe mental illnesses.
Failure to Prevent Cross-Contamination During Catheter and Incontinence Care
Penalty
Summary
Staff failed to provide appropriate catheter and incontinence care for multiple residents, resulting in cross-contamination and improper infection control practices. One resident with an indwelling urinary catheter for obstructive uropathy was observed with cloudy, sediment-laden urine and a soiled catheter insertion site. During catheter care, a CNA cleaned the resident's penis in the wrong direction, causing cross-contamination at the catheter insertion site, and failed to adequately clean the soiled catheter. The DON confirmed the improper technique and acknowledged the cross-contamination. Another resident, dependent on staff for all activities of daily living and with a diagnosis of neuromuscular dysfunction of the bladder, received perineal and catheter care from two CNAs. One CNA did not change gloves or perform hand hygiene after cleaning the front perineal area before moving to the rear, and a contaminated drainage bag cover was placed back over the urinary drainage bag after falling to the floor. Barrier cream was not applied after perineal care, contrary to facility policy. The DON confirmed that gloves should have been changed, hand hygiene performed, and a new drainage bag cover used. A third resident, severely cognitively impaired and dependent on staff, was provided incontinence care by two CNAs. After cleansing urine and feces from the resident's buttocks, a clean incontinence brief was applied without changing gloves or performing hand hygiene. The CNA later acknowledged the lapse, and the DON confirmed that hand hygiene should have been performed after incontinence care and before applying a new brief.
Resident Dignity Compromised During Shower Transfer
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and severe cognitive impairment was observed being transported by two CNAs from his room to the shower room while reclined in a mesh slatted shower chair. The resident was only covered by a thin bath blanket, leaving his left shoulder, trunk, buttock, and thigh visible. During this transfer, the resident was pushed past the nurse's station where other residents and staff were present, resulting in exposure. Interviews revealed that staff routinely undressed the resident in his room before transporting him to the shower room, citing the difficulty of transferring him once inside the shower room. The resident's Power of Attorney stated that the resident, a former minister with a history of modesty, would not have appreciated being unclothed in public. The facility's administrator confirmed that residents should be appropriately covered during transfers and that the shower room could accommodate necessary equipment for dressing or undressing. Facility policy requires residents to be treated with dignity and respect, which was not upheld in this instance.
Failure to Complete Required Level 2 PASRR for Resident with Intellectual Disability
Penalty
Summary
The facility failed to obtain a required Level 2 Pre-admission Screening and Resident Review (PASRR) for one resident who was diagnosed with Major Depressive Disorder with recurrent psychotic symptoms and documented as having an Intellectual Disorder. The resident's face sheet confirmed the diagnosis, and the Level 1 PASRR indicated the presence of an Intellectual Disorder. However, there was no documentation that a Level 2 PASRR had been completed for this resident. The administrator stated that the facility had only been completing Level 2 PASRRs when there was a significant change in status and was not aware that a Level 2 PASRR was required for all residents with an Intellectual Disability, as outlined in the facility's own policy.
Incomplete Oxygen Order and Unlicensed Administration
Penalty
Summary
A deficiency occurred when the facility failed to transcribe the complete physician order for oxygen administration for a resident with diagnoses including pneumonia, emphysema, and a stage II sacral pressure ulcer. The physician order sheet for the resident documented oxygen therapy but left the prescribed liter flow rate blank. During an observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was not turned on. The resident reported not receiving oxygen, prompting a certified nursing assistant (CNA) to turn on the concentrator and set the flow rate to two liters per minute. A registered nurse (RN) verbally confirmed the rate from across the bed after the CNA had already set it. The facility's policy requires that only licensed nurses administer oxygen and that physician orders specify details such as when to use, how often, the liter flow, and the delivery method. The administrator confirmed that the order should have included the oxygen rate and that only licensed nurses are permitted to administer oxygen, in accordance with facility policy and standard practice. The failure to transcribe the complete order and to ensure a licensed nurse administered the oxygen led to the deficiency.
Failure to Maintain Call Light Accessibility Resulting in Delayed Pain Management
Penalty
Summary
A deficiency occurred when a resident with a history of pain, osteoporosis, difficulty walking, and muscle atrophy was unable to access her call light and bedside table during the night. The resident, who was cognitively intact, reported that she experienced severe leg pain while in bed and was unable to summon assistance because the call light was out of reach. She attempted to call out for help, but her voice was too soft to be heard, and she did not have a roommate to assist her. As a result, she remained in pain for several hours until the morning, when she reported the incident to a nurse. Documentation showed that the resident had a PRN order for Tramadol for pain, but the nurse who administered the medication in the morning did not document the resident's pain level as required by facility policy. Interviews with staff confirmed that the call light and bedside table were out of reach during the night, and that this information was communicated among staff members. Facility policies required that call lights be accessible at all times and that pain assessments be documented every shift, but these procedures were not followed in this instance.
Failure to Provide Behavioral Health Services and Training Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide necessary behavioral health care and services, as well as behavioral health services training, for a resident with significant behavioral health needs. The resident, who was diagnosed with Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and violent behavior, was severely cognitively impaired and dependent on staff for all activities of daily living. Despite documented care plan interventions instructing staff to ensure safety and re-approach the resident with different staff when physical behaviors occurred, the resident experienced multiple incidents of combative behavior during care, resulting in several skin tears and minor injuries. These injuries occurred during routine care activities such as bedtime care, transfers, and shower preparation, with staff sometimes failing to follow recommended interventions such as walking away or seeking assistance. Additionally, the facility did not have psychiatric services available until after several of these incidents had occurred, and the resident had not yet been seen by the psychiatric nurse practitioner. Staff had not received training on behavioral health or on providing care for residents with behavioral issues. Furthermore, required follow-up procedures were not consistently followed, as some injuries were not reported or investigated according to facility policy, resulting in missed opportunities for skin evaluations and appropriate notifications. The facility's policy on PASRR was not fully implemented, as recommendations from Level 2 screens and significant changes in status were not consistently incorporated into the care plan.
Failure to Ensure Respect and Dignity for Residents
Penalty
Summary
The facility failed to ensure the right of being treated with respect and dignity for two residents, R1 and R2, as part of an abuse investigation. For R2, the investigation revealed that a Certified Nurse's Assistant (CNA), V4, allegedly made inappropriate comments suggesting that no one liked R2 and that no one wanted to answer R2's call light. Although the abuse was deemed unsubstantiated due to R2's hearing difficulties, R2 reported feeling rushed and uncomfortable with V4's demeanor, describing V4 as unwilling to engage and perform care tasks willingly. The Director of Nursing (DON) acknowledged the issue and had previously educated V4 on communication and care delivery. In the case of R1, the investigation documented that V4 was reported to have entered R1's room frequently, causing discomfort and anxiety. R1 described V4 as having a rude and abrupt manner, making R1 feel disrespected and as if R1 was on V4's time. The Social Service Director and the DON were informed of these concerns, and it was noted that this was the second complaint regarding V4's verbal interactions with residents. Despite the abuse being unsubstantiated, the facility recognized V4's inappropriate communication style, leading to the decision to terminate V4's employment.
Resident Falls from Shower Chair, Sustains Multiple Fractures
Penalty
Summary
The facility failed to safely transport a resident after a shower, resulting in a traumatic fall. The resident, who has a medical history of Spastic Paraplegia, Abnormal Posture, Difficulty in Walking, and Muscle Wasting and Atrophy, is completely dependent on staff for all activities of daily living and uses a wheelchair for mobility. On the day of the incident, a Certified Nurse Aide was moving the resident on a shower chair when a wheel became caught on the shower curb, causing the resident to fall to the ground. This fall resulted in multiple back and neck fractures, requiring emergency medical evaluation and treatment at two hospitals. The resident was diagnosed with six fractures in the thoracic, lumbar, and cervical vertebrae and received intravenous morphine for severe pain at a regional trauma center. The resident remained an inpatient at the trauma center for several days before returning to the facility with orders for analgesic pain medication and a rigid cervical immobilizer. Prior to the fall, the resident had only taken a single dose of acetaminophen for pain in September, but after returning to the facility, the resident required pain medication nearly every day.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager, which has the potential to affect all 80 residents residing in the facility. During the survey conducted from June 4 to June 7, 2024, no Certified Dietary Manager was observed in the dietary department. On June 4, 2024, a dietary aide mentioned that the facility had not had a dietary manager for almost a year. The facility administrator confirmed on June 5, 2024, that the position had been vacant for six months, although an offer had been made to a prospective candidate. The administrator also stated that the Registered Dietician is onsite monthly and reviews resident charts remotely every week, but is not present full-time. The facility does not have a policy mandating a Certified Dietary Manager, but it is acknowledged that one is supposed to be employed.
Unsanitary Kitchen Conditions and Expired Food in LTC Facility
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illnesses affecting all 80 residents. During a kitchen tour, several deficiencies were observed, including a commercial ice machine with rust buildup, a rust-covered metal shelf under a leaking coffee maker, and standing water under a juice dispenser with rusted shelves. Additionally, expired food items were found in storage, such as lime juice and instant cheese mix, which were not disposed of in a timely manner. The facility also lacked a cleaning schedule for kitchen equipment, leading to significant grease and charcoal-like buildup on grills, stoves, and ovens. Further observations revealed a rusted and malfunctioning commercial can opener, and a dishwashing station with cracked and chipped caulking. These issues were confirmed by the facility's staff, who acknowledged the need for maintenance and cleaning. The facility's policy on cleaning and sanitizing work surfaces and equipment was not adequately followed, contributing to the unsanitary conditions. The report highlights the facility's failure to adhere to professional standards for food storage, preparation, and equipment maintenance, posing a risk to resident health and safety.
Failure to Maintain Resident Dignity in Toileting and Meal Assistance
Penalty
Summary
The facility failed to honor residents' right to dignity by not providing timely toileting assistance and engaging in inappropriate staff behavior during meal service. A resident, identified as R62, reported having to wait for long periods for staff assistance with toileting, resulting in episodes of incontinence and feelings of humiliation. Despite being continent of bowel and bladder, R62 required assistance from two staff members for transfers and ambulation due to decreased strength. The facility's policy on call light response was not adhered to, as the resident's call light was not answered promptly, leading to the resident being left in soiled conditions. Additionally, during meal service, staff members were observed engaging in personal conversations unrelated to resident care while providing feeding assistance to residents with severe cognitive impairments. Staff, including an MDS Coordinator and CNAs, were noted to be talking amongst themselves about off-work activities, rather than interacting with the residents they were assisting. This behavior was observed across multiple tables in the dining room, with minimal communication directed towards the residents, who were given only short instructions related to eating. The facility's failure to engage with residents during meal times and the delay in responding to toileting needs were acknowledged by the facility's Administrator/Registered Nurse as dignity issues. The facility's Residents' Rights Pamphlet emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances. The report highlights the need for staff to focus on resident interaction and timely response to care needs to maintain the dignity and quality of life of the residents.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a clean and sanitary manner, affecting four residents who required respiratory or oxygen therapy. The facility's policy mandates that oxygen equipment, such as cannulas, masks, and tubing, should be exchanged every seven days and stored off the floor in a sanitary manner. However, observations revealed that the equipment was not dated when changed and was improperly stored. For instance, one resident's oxygen tubing was found laid over the bed and bed frame without a bag for sanitary storage, while another resident's tubing was on the floor and bed without proper storage. Additionally, a resident's oxygen humidifier bottle was found sitting on a dirty floor, and the nebulizer face mask of another resident was dated several months prior and placed on top of a dirty sock without being stored in a bag. These observations were confirmed by the facility's staff, including a nurse manager and an infection preventionist, who acknowledged that the equipment should be stored in a more hygienic manner and dated appropriately. The failure to adhere to these standards compromised the sanitary conditions required for respiratory care.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to prevent cross-contamination during meal service by not adhering to proper hand hygiene protocols. This deficiency was observed in multiple instances involving five residents. For instance, a Certified Nurse Aide (CNA) used her bare hands to move food on a resident's plate without using gloves or performing hand hygiene. This resident had a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) and other medical conditions, making infection control crucial. Additionally, a Licensed Practical Nurse (LPN) assisted two residents with eating without using hand hygiene or alcohol-based hand rub (ABHR) between assisting each resident. This included an incident where a piece of food fell onto the LPN's wrist, and the LPN continued to assist another resident without cleaning her hands. Another CNA was observed assisting two residents with their meals, using her hands to reposition herself and then handling a resident's drinking cup without performing hand hygiene. The facility's policy on hand washing, which emphasizes the importance of hand hygiene in preventing the spread of infections, was not followed. These actions demonstrate a failure to adhere to infection prevention protocols, potentially exposing residents to cross-contamination and infection risks.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse of a resident by a staff member to the Abuse Coordinator. This deficiency involved a resident with medical diagnoses including Postural Kyphosis, Hypertension, Anxiety Disorder, Altered Mental Status, Dysuria, Overactive Bladder, Open Angle Glaucoma, Corneal Edema, and Macular Degeneration. The resident's Power of Attorney alleged that a Certified Nurse Aide was rough during care, yelled at the resident, and left them in wet clothes after a shower. The facility's Administrator was unaware of the incident until a later date, indicating a failure in the reporting process. The Director of Nurses confirmed that the aide received a written warning and was suspended during the investigation, which overlapped with the aide's vacation time. The facility's policy requires immediate reporting of alleged abuse or neglect to the Administrator or Director of Nurses, which was not followed in this case.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with Enterocolitis due to Clostridium Difficile. The resident's care plan required the administration of antibiotics as ordered, specifically Fidaxomicin 200 mg twice daily for ten days. However, the Medication Administration Record (MAR) revealed that the antibiotic was not administered on several occasions, including the PM dose on the day of discharge, and doses on subsequent days. A registered nurse confirmed these omissions, acknowledging that the medication was not given as prescribed. The facility's Medication Administration Policy mandates that medications deemed necessary by the physician should be provided to stabilize the resident's condition.
Failure in Infection Control During Catheter Care
Penalty
Summary
The facility failed to prevent cross-contamination during urinary catheter care for a resident identified as R55. R55 has multiple medical diagnoses, including Parkinson's Disease, Malignant Neoplasm of Prostate, and Bladder-Neck Obstruction, and is dependent on staff for personal hygiene and toileting. On a specific date, a Certified Nurse Aide (CNA), identified as V11, provided urinary catheter care to R55 without changing gloves or performing hand hygiene after the gloves were contaminated with stool. The CNA continued to use the contaminated gloves to clean the urinary catheter tubing, which is a breach of proper infection control practices. The CNA acknowledged the mistake, stating that gloves should have been changed after providing bowel incontinence care and before performing catheter care. The Infection Preventionist (IP), identified as V9, emphasized the importance of hand hygiene in reducing infection risks and confirmed that staff should change gloves when they become contaminated. This incident highlights a failure in adhering to infection control protocols, potentially increasing the risk of infection for the resident.
Failure to Conduct Psychotropic Medication Assessments
Penalty
Summary
The facility failed to complete necessary Psychotropic Medication Assessments for two residents, leading to a deficiency in managing unnecessary medications. One resident, diagnosed with Dementia with Behavioral Disturbances and Depression, was prescribed Citalopram and Olanzapine but had not undergone a Psychopathological Observation in the past year. Another resident, diagnosed with Depression and Generalized Anxiety, was prescribed Buspar and Citalopram but did not receive an Initial Psychopathological Observation upon admission, despite being on these medications. These assessments are crucial for creating a data base for the Care Plan and Gradual Dose Reduction Program, as outlined in the facility's Psychopharmacological Drug Usage Procedure.
Failure to Serve Meals at Palatable Temperature
Penalty
Summary
The facility failed to provide meals at a palatable temperature for two residents, R51 and R52, as observed during a survey. Both residents were on a regular consistency diet as per their Physician Order Sheets. On the day of observation, R51 reported that her food was cold by the time it reached her room, and she only consumed about 10% of her lunch. Similarly, R52 also complained about the cold temperature of her meal, consuming only 25% of it. Both residents expressed dissatisfaction with the cold gravy on their beef cutlet. The deficiency was further highlighted by the actions of staff member V24, who delivered meals to both residents without covering the trays, which likely contributed to the meals being served cold. V24 acknowledged that covering trays could be beneficial, as there were frequent complaints about cold food. The Nurse Manager, V3, confirmed that meal trays should be covered during delivery to maintain temperature, although there was no formal policy in place. This lack of action in covering the food trays led to the residents receiving meals that were not at an appetizing temperature.
Failure to Provide Modified Diet as Ordered
Penalty
Summary
The facility failed to serve a modified diet as ordered for a resident with severe cognitive impairment. The resident's physician order specified a liquidized diet with nectar thick liquids. However, during a meal observation, a Certified Nursing Assistant (CNA) fed the resident pureed food thickened to a nectar consistency and a watered-down tomato soup that was not thickened as required. The resident began coughing immediately and repeatedly after consuming the un-thickened soup. A Licensed Practical Nurse (LPN) present at the scene instructed the CNA to pause feeding. The CNA acknowledged that the tomato soup was too thin and that the kitchen was responsible for thickening the resident's drinks. A cook later admitted to missing the step of thickening the soup while training another cook, despite knowing it was necessary.
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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