The Citadel At Saint Joseph Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Illinois.
- Location
- 659 East Jefferson Street, Freeport, Illinois 61032
- CMS Provider Number
- 145935
- Inspections on file
- 39
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Citadel At Saint Joseph Village during CMS and state inspections, most recent first.
A resident with multiple cardiac and musculoskeletal conditions, recently post-CABG and receiving subacute rehab, was discharged home with documented plans and NP recommendations for continued home health PT, OT, nursing, and a bath aide. Social services documented that in-home services would be arranged through a local home health agency, but the discharge instructions given to the resident stated that no services were contacted and did not list any home health provider. After discharge, the resident and family waited for home health that never arrived and later learned from the home health intake coordinator that no referral had been received from the facility; services were only started after the family contacted the agency and orders were obtained from the physician’s office. This sequence of events shows the facility failed to implement the planned home health referral and did not ensure that post-discharge services were actually arranged.
A resident with recent MI, CABG, and HTN was admitted on a hospital discharge order specifying a Heart Healthy DASH diet and a no added salt diet. The facility entered a no added salt diet and later changed it to a 2–3 g sodium diet, despite the RD acknowledging that the regular menu would exceed 3 g sodium on most days and that the facility did not have a formal DASH diet option. On the first night, the resident was served a large portion of pulled pork with barbecue sauce and visible fat, which she recognized as inconsistent with her low sodium, low fat diet and ate only partially. The RD later stated she would have expected staff to enter a no added salt diet based on the discharge orders and acknowledged that the intended order may have been for both a DASH diet and a no added salt diet.
The facility failed to maintain accurate controlled substance records and documentation for several residents. For a resident receiving PRN hydrocodone-acetaminophen, a narcotic count revealed one missing tablet that was not signed out on the control sheet, and the LPN involved could not explain the discrepancy. Another resident with scheduled and PRN alprazolam had a tablet removed and documented as being used for a different resident, while the MAR did not show administration for the original resident. A third resident had Norco signed out twice on the control sheet without staff signatures and with no corresponding MAR entries. Additionally, four residents’ controlled substance sheets were not signed at the time of administration, even though the LPN later signed them during a narcotic count, contrary to facility policy requiring real-time documentation and accurate shift-to-shift controlled drug counts.
The facility did not honor resident preferences for bacon, a previously available breakfast item, after a change in ownership and guidance from the food service provider. Multiple residents and staff reported frequent requests and complaints about the absence of bacon and other breakfast meats, with documentation in grievance logs and resident council meetings. The dietary manager and registered dietitian confirmed the removal was based on nutritional guidance, and the facility lacked a policy addressing resident menu preferences.
Three residents experienced safety failures, including a laceration from improper catheter management during dressing, unsafe handling of a urinary catheter during ambulation, and a fall during showering due to inadequate supervision and miscommunication about transfer needs. These incidents involved residents with catheters, fall risks, and sensory impairments, resulting in injury and unsafe conditions.
Multiple residents reported that CNAs used personal cell phones during showers and in common areas, leading to feelings of neglect and lack of attention. Resident Council Meeting minutes confirmed ongoing concerns about staff phone use, and the DON acknowledged this as an issue, contrary to facility policy requiring staff to focus on residents and maintain their dignity.
A resident who needed staff assistance for bathing did not consistently receive the required number of showers, with records showing a 13-day gap between showers. The DON confirmed that staff are expected to provide showers twice weekly, but the facility lacked a formal policy on shower frequency.
A resident with visual impairment and a physician order for an ophthalmology consult did not receive a timely follow-up appointment after the original was canceled due to insurance issues. The resident reported worsening vision and had not seen an eye doctor or had vision testing in over a year. Facility records confirmed no rescheduled appointment, and the DON acknowledged the lapse, despite facility policy requiring timely coordination of such services.
A resident with a recent cardiac surgery did not receive daily cleansing of a surgical incision as ordered by the physician. The wound care nurse overlooked the order, and the DON was unaware of its existence, resulting in the order not being entered or followed. The facility's records only showed monitoring of the incision, with no evidence of the required cleansing being performed.
A resident with multiple chronic conditions did not receive medications as ordered when an LPN administered levothyroxine later than the prescribed time and gave two tablets of acetaminophen instead of one. The resident expressed the importance of timely administration due to dietary restrictions, and facility policy requires adherence to prescribed medication times until reviewed by the pharmacist.
Multiple residents did not consistently receive or have documented wound care and weekly skin checks as ordered, with missed treatments and incomplete records noted for wound care, skin protectant applications, and weekly assessments, despite facility policy and staff acknowledgment of their importance.
A discrepancy in a resident's lorazepam count was identified by two nurses, but the missing medication was not reported to administration or authorities as required. The ADON and Administrator confirmed that the incident was not communicated or documented according to facility policy.
A resident with a stage four pressure injury did not receive or have documentation for several ordered wound care treatments, as evidenced by gaps in the Treatment Administration Record and confirmed by the wound care nurse. Facility policy requires documentation of dressing changes, but this was not consistently done.
A resident's controlled substance records for lorazepam and morphine were not accurately maintained, with a 4 ml discrepancy in lorazepam count and incomplete documentation for a morphine dose. Staff were unable to determine the exact amount of medication in the bottle due to unclear graduation marks, and required procedures for reporting and resolving discrepancies were not followed.
A resident with multiple health issues, including a high fall risk, was injured when a CNA attempted to reposition them alone on a low air loss mattress, contrary to facility policy requiring two staff members. This resulted in the resident falling and sustaining fractures, necessitating hospitalization.
A facility failed to maintain the patency of a resident's CVC, leading to occlusion and replacement. The resident reported that the catheter was not flushed as required, and records showed multiple missed flushes and Heparin locks. Staff interviews revealed inconsistent practices and a lack of specific training for CVC flushing, contributing to the catheter's occlusion.
The facility failed to provide pureed Swiss steak with a smooth, uniform texture for residents on a pureed diet. The cook did not achieve the required consistency, and the Dietary Manager confirmed the gritty texture, which required chewing. The facility's policy mandates a smooth texture for pureed foods.
A facility failed to follow proper sanitation practices during the preparation of pureed diets for residents. A cook used the same spatula and food processor components without adequately washing, rinsing, and sanitizing them between uses, leading to potential cross-contamination. The Dietary Manager confirmed that the facility's policy requires washing, rinsing, and sanitizing kitchenware after each use, which was not followed.
A resident with emotional distress and multiple diagnoses was not treated with dignity by CNAs in a facility. Despite the care plan's emphasis on a warm and calm approach, the resident was told to stop moaning, and her incontinence brief was replaced without her consent, causing distress. The DON confirmed the staff's actions were inappropriate and not in line with the facility's dignity policy.
A facility failed to safely transfer a resident by not using a gait belt, as required by the resident's care plan. A CNA assisted the resident from a wheelchair to a bed without applying a gait belt, lifting the resident under the arm and guiding their hips with her hands. This was contrary to the facility's policy and the resident's care plan, which mandated the use of a gait belt for safety during transfers. Interviews with another CNA and the DON confirmed the necessity of using a gait belt for the resident's safety.
A resident experienced multiple medication administration errors, including incorrect dosing and failure to notify a physician when withholding medication. An LPN withheld Diltiazem without parameters, administered Timolol Maleate incorrectly, gave an incorrect dose of Milk of Magnesia, and omitted Vitamin D3. The facility's error rate was 10.81%, exceeding the acceptable 5% threshold.
A resident with Type 1 diabetes did not receive the correct insulin medications as prescribed by their endocrinologist due to transcription errors at the facility. The resident's After Visit Summary specified changes to their insulin regimen, but the facility's MAR showed incorrect insulin types and dosages were ordered and administered. The error was discovered during a medication audit by an LPN, highlighting the need for accurate medication management.
A resident with multiple health conditions fell and sustained a head injury during a transfer due to a CNA's failure to maintain a hold on the gait belt, contrary to facility procedures. The resident hit her head on an oxygen concentrator, requiring emergency medical treatment. Staff interviews confirmed the expectation of using gait belts during transfers to prevent such incidents.
A resident with dementia experienced escalating agitation due to inappropriate care by multiple staff members in a small space, leading to physical distress and lack of proper documentation. Despite having a care plan that required a calm approach, staff failed to follow guidelines, resulting in a deficiency in care.
A resident sustained a fractured femur during an unsafe transfer by a CNA who was unfamiliar with her needs and did not use a gait belt. The resident's knees buckled, and she was lowered to the floor, later diagnosed with a periprosthetic fracture. The RN noted limited leg movement and discomfort, but the resident was placed in a chair without immediate intervention. The resident, with a history of osteopenia, eventually expired under hospice care.
A facility failed to assess, treat, and document skin damage for a resident, leading to the discovery of foam patches swollen with urine on the resident's body. The resident, who preferred minimal changes, had saturated briefs and liners. CNAs and the wound care RN were unaware of the patches, and further assessment revealed a dried fluid blister and moisture-associated skin damage. The facility's records did not document these issues, indicating a failure to follow skin monitoring policies.
A resident's family requested the discontinuation of scheduled melatonin, to be given only as needed upon family request. Despite this, the resident continued to receive the scheduled dose, leading to increased sleepiness and decreased eating and drinking. The facility failed to inform the NP and update the medication orders accordingly.
The facility failed to treat residents with dignity, as evidenced by reports from three residents. One resident reported that a CNA threw her shoes under her bed, another resident stated that the CNA was rude and unhelpful when she requested assistance to use the bathroom, and a third resident reported that the CNA frequently used inappropriate language. These actions were in violation of the facility's dignity policy.
Failure to Initiate Home Health Referral at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to initiate a home health referral for a resident who was discharged home, despite documented plans and clinical recommendations for post-discharge services. The resident had multiple significant diagnoses, including fibromyalgia, non-ST elevation myocardial infarction, prior CABG with aortocoronary bypass graft, chronic pain syndrome, muscle wasting and weakness, major depressive disorder, Bell’s palsy, generalized anxiety disorder, and osteoarthritis. The care plan documented that the resident intended a short-term stay with a goal to return to the community, and that facility staff would assist with referrals as needed to meet discharge goals. A facility discharge assessment indicated a planned discharge home under the care of an organized home health service, with active discharge planning and a referral to a local contact agency. Provider documentation prior to discharge consistently indicated the need for continued services after leaving the facility. Nurse practitioner notes stated that, despite the resident’s good participation in subacute rehab and functional improvements, the resident needed to continue with home health PT and OT to improve strength, balance, endurance, and mobility, and to maintain independence with ADLs and decrease fall risk. Social services documented on the day of discharge that the resident requested to leave that day and that she would discharge home with in-home PT, OT, nursing, and a bath aide through a local home health agency, and that she also planned to begin cardiac rehab in July. However, the written discharge instructions given to the resident listed discharge to home with a cardiac diet and home exercise program, noted the resident as independent in all ADLs, and specifically documented “no services contacted,” with no home health agency or physician information included. Post-discharge accounts from the resident and the home health intake coordinator confirmed that no referral was actually sent by the facility at the time of discharge. The resident reported that social services told her home health PT and OT would be set up, but no one contacted her for at least one to two weeks; when her family called the home health agency, they were told no referral had been received. The home health intake coordinator stated that their records showed no referral from the facility and that services were only initiated after the resident’s son contacted the agency, prompting the coordinator to obtain orders directly from the physician’s office. Facility staff interviews indicated that therapy typically recommends home health and that the physician or NP has final authority on referrals, and current social services staff described a process of faxing referrals and expecting confirmation from agencies. The facility’s own policy on resident-initiated discharges requires documentation of discharge planning and arrangements for post-discharge care, but in this case, the documented plan for home health services was not carried out, and the medical record showed no services contacted at discharge.
Failure to Provide Ordered Low Sodium Cardiac Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with the ordered low sodium diet consistent with hospital discharge instructions and physician orders. The resident had significant cardiac history, including myocardial infarction, coronary artery bypass graft surgery, and hypertension, and was cognitively intact. The hospital discharge packet, printed the day before admission, specified a Heart Healthy DASH diet and a No Added Salt diet, with a note that the hospital diet order could be substituted with the facility’s equivalent diet description. Upon admission, the physician’s orders reflected a No Added Salt diet starting on 5/28/25, which was later changed on 6/6/25 to a 2–3 g sodium diet with thin liquids. The Registered Dietitian (RD) stated that at the time of admission the facility only had two sodium-restricted options: a No Added Salt diet (regular diet with no salt packets) and a 2–3 g sodium diet, and that the regular menu would exceed 3 g of sodium on most days. On the night of admission, the resident reported being served a large portion of pulled pork with barbecue sauce and visible fat, which she described as salty and inconsistent with her understanding that she should be on a low sodium and low fat diet. She took a picture of the meal and shared it with her family, stating she ate less than half because she knew she was not supposed to eat it. The RD acknowledged being notified by staff the day after admission that the resident had been served pulled pork and that the resident’s son was unhappy. When later shown the hospital discharge orders, the RD stated she would have expected staff to enter a No Added Salt diet because that was what was ordered and the facility did not have a DASH diet option, and further acknowledged that the intended order may have been for both a DASH diet and a No Added Salt diet. The RD also stated that if the DASH diet’s sodium recommendation was less than 3 g, the facility’s 2–3 g sodium diet would most closely align with that restriction, and confirmed that the purpose of sodium restriction is to minimize swelling and reduce blood pressure.
Inaccurate Documentation and Discrepancies in Controlled Substance Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate records and documentation for controlled medications for multiple residents. For one resident with an order for hydrocodone-acetaminophen (Norco) 5-325 mg every four hours as needed for pain, a narcotic count showed 14 pills remaining in the punch card, while the Controlled Drug Receipt/Record/Disposition Form indicated 15 pills remaining with the last documented dose given several days earlier, leaving one tablet unaccounted for. The LPN who participated in the narcotic count stated she had counted with the previous nurse, did not know why there was a discrepancy, and did not remember administering the medication. Another resident had an order for alprazolam 0.25 mg twice daily and every 12 hours as needed; the controlled drug record showed a tablet removed and documented as given for another resident, while that resident’s MAR did not show administration of alprazolam on that date. For a third resident, the Controlled Drug Receipt/Record/Disposition Form showed Norco signed out twice on the same day without any staff member’s name recorded, and the MAR showed that the resident did not receive Norco on that date. Additionally, controlled substance sheets for four other residents were signed off by the same LPN during a narcotic count, and the LPN stated she had administered the controlled substances but had not signed them out on the controlled substance sheets, even though the MARs showed the medications were scheduled for administration earlier that morning. Staff interviews confirmed that narcotics are supposed to be counted at shift change by two nurses, with one reviewing the book and the other the cart, and that medications should be documented at the time they are given. Facility policies required the individual administering medications to initial the MAR after each administration and mandated end-of-shift controlled substance counts with documentation and reporting of discrepancies to nursing leadership.
Failure to Honor Resident Menu Preferences Regarding Bacon
Penalty
Summary
The facility failed to honor resident preferences regarding menu items, specifically the provision of bacon, which had previously been available to residents before a change in facility ownership. Multiple residents and staff reported that bacon was regularly requested and had been a staple breakfast item prior to the new corporation taking over. After the change in ownership, bacon was removed from the menu, and staff were instructed by the food service provider that bacon would no longer be supplied due to its perceived lack of nutritional value. Observations confirmed that bacon was not present in the facility's food storage areas, and the alternative menu no longer listed bacon-containing items. Residents expressed dissatisfaction and frustration with the removal of bacon, noting that it was a preferred food item and a source of enjoyment during meals. Several residents reported repeatedly requesting bacon and being told it was unavailable, while staff corroborated that complaints about the lack of bacon and breakfast meats were frequent. The facility's grievance log and resident council meeting minutes documented ongoing concerns about the absence of bacon and breakfast meats, indicating that the issue was persistent and widely recognized among residents and staff. The dietary manager and registered dietitian confirmed that the decision to remove bacon was based on guidance from the food service provider, who cited nutritional concerns. Despite acknowledging that bacon could be enjoyed in moderation and posed no danger, the facility did not provide it as an option, even though it was previously available and listed on alternative menus. The administrator stated there was no facility policy addressing menu changes or resident preferences, and the current menu cycle did not include bacon or similar breakfast meats.
Failure to Prevent Accidents and Ensure Safe Catheter and Transfer Practices
Penalty
Summary
The facility failed to ensure resident safety and adequate supervision in three separate incidents involving residents with urinary catheters and fall risks. In the first case, a cognitively intact resident with a urinary catheter was injured when a CNA attempted to dress her by pulling the catheter system through her pants, causing a plastic clip attached to the catheter bag to lacerate her leg. The resident required emergency care and nine sutures to close the wound. The CNA later acknowledged that the catheter bag and tubing should have been managed differently to prevent contact with the resident's skin. In the second incident, a resident with a history of falls and confusion, also with a urinary catheter, was observed during therapy with her catheter drainage bag hanging from her wheelchair while she ambulated with a walker. As the resident walked, the catheter tubing was pulled taut, creating tension and pulling on her leg, as the drainage bag remained attached to the wheelchair behind her. The DON confirmed that the standard of care would be to use a leg bag or to hang the catheter bag from the walker to avoid tension on the tubing during ambulation. The third incident involved a resident with repeated falls, hearing and vision loss, and impaired mobility. During a shower, an agency CNA, who had been told the resident was independent, left her in a wheelchair while retrieving a shower chair. The resident attempted to stand on her own, lost her balance, and was lowered to the floor by the CNA. The CNA was unsure if the resident could hear or see her instructions. The DON stated that staff should verify a resident's transfer status and assistance needs using the care plan or information posted in the resident's room.
Staff Cell Phone Use During Care Undermines Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, as evidenced by staff using personal cell phones while providing care and during resident interactions. Three residents reported that CNAs were on their cell phones during showers, with one resident stating the aide was on her phone and using earphones throughout the shower, making the resident feel unimportant and not attended to. Another resident described a similar experience, where the CNA answered a phone call and engaged in conversation during the shower, leading the resident to feel that her care was less important than the staff member's personal call. A third resident observed staff frequently using their phones in hallways and the dining room, expressing concern about staff availability if assistance was needed. Review of the facility's Resident Council Meeting minutes from April to June indicated ongoing resident concerns about staff cell phone use during work hours. The Director of Nursing confirmed that staff are not permitted to use personal phones while at work, especially during resident care, and acknowledged that this has been an ongoing issue. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of treating residents with respect and focusing attention on them during care, which was not adhered to in these instances.
Failure to Provide Required Showers for Dependent Resident
Penalty
Summary
A resident who required staff assistance and supervision for showering or bathing, as indicated in their care plan, did not consistently receive the required showers. Interview and record review revealed that the resident reported sometimes receiving only one shower per week or none at all, despite being supposed to receive at least two showers weekly. Shower records from 5/1/25 to 7/21/25 showed a gap of 13 days between showers, with the resident receiving a shower on 6/27/25 and not again until 7/11/25. The DON confirmed that staff are expected to offer or provide showers or baths twice a week, but also stated that the facility did not have a policy specifying the frequency of showers or baths.
Failure to Arrange Ophthalmology Appointment for Visually Impaired Resident
Penalty
Summary
A resident with a history of visual impairment, who required eyeglasses, had a physician order for an ophthalmology consult and treatment as indicated. The resident reported that his vision had worsened recently, even while wearing his glasses, and stated that he had not been seen by an ophthalmologist or had his vision tested in over a year. The resident recalled having an appointment scheduled with an eye doctor, but it was canceled, and he was unaware of the reason for the cancellation. Record review showed that the ophthalmology appointment was canceled because the provider did not accept the resident's insurance, and no subsequent appointment was scheduled from the time of cancellation through the review period. The DON confirmed awareness of the canceled appointment and acknowledged that a new appointment had not been arranged. Facility policy required social services to coordinate and arrange for physician-ordered services in a timely manner, but this was not followed in the resident's case.
Failure to Follow Physician's Wound Care Orders for Surgical Incision
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician's orders for a resident who was admitted with multiple complex medical conditions, including recent cardiac surgery. The resident's hospital discharge instructions specifically ordered daily cleansing of a surgical incision with soap and water, monitoring for signs of infection, and avoiding lotions or ointments on the site. However, upon review of the resident's electronic Treatment Administration Record (eTAR) and medical record, there was no evidence that an order to wash the incision daily was entered or carried out during the resident's stay. The only documented intervention was monitoring the incision site, with no record of actual cleansing as directed by the physician's order. Interviews with facility staff revealed that the wound care nurse overlooked the order to wash the incision daily and did not ensure the order was entered or followed. The Director of Nursing was unaware of the wound care order and stated that such orders are typically managed by the wound care nurse, who coordinates with the facility's wound care physician or nurse practitioner. The facility's policy requires that treatment orders specify the treatment, frequency, and duration, and that a current list of orders be maintained in each resident's clinical record. This process was not followed, resulting in the omission of the required wound care for the resident.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident. The resident, who had multiple diagnoses including fibromyalgia, heart disease, hypothyroidism, and major depressive disorder, had a physician's order for levothyroxine to be given at 7:00 AM and acetaminophen 500 mg, one tablet by mouth four times daily. During a morning medication pass, an LPN administered the levothyroxine later than the prescribed time and gave two tablets of acetaminophen instead of the ordered one tablet. The resident later stated that she needs to take her levothyroxine at 7:00 AM because she has to wait to eat. The facility's policy requires staff to follow prescribed medication times until reviewed by the facility pharmacist and discussed with the resident or responsible party.
Failure to Provide and Document Ordered Wound Care and Weekly Skin Checks
Penalty
Summary
The facility failed to provide wound and skin treatments as ordered and did not consistently perform or document weekly skin checks for multiple residents. Four out of five residents reviewed for improper nursing care were affected. For example, one resident with skin infections, morbid obesity, and congestive heart failure reported receiving leg wound care only one to two times per week, despite orders for more frequent treatments. Treatment Administration Records (TARs) for this resident showed missed documentation of both wound care and weekly skin checks on several ordered dates. Another resident with non-pressure wounds to the right upper buttock and left lower leg stated that wound care was only provided once a week during physician rounds, even though daily and three-times-weekly treatments were ordered. Documentation for this resident also showed missed skin checks and wound treatments on multiple dates. Additional residents had orders for protective skin preparations to be applied to their heels twice daily, but the TARs indicated numerous missed or undocumented applications and weekly skin checks. Staff interviews confirmed that the purpose of weekly skin checks is to identify skin concerns early and that wound care is essential for healing and infection prevention. The facility's own policy required weekly general skin checks with documentation in the medical record, but records showed this was not consistently done. The findings demonstrate a pattern of missed or undocumented wound care and skin checks, contrary to physician orders and facility policy.
Failure to Report Missing Controlled Substance
Penalty
Summary
The facility failed to identify and report the diversion of a resident's controlled substance, specifically lorazepam. According to the medication administration record and controlled drug count sheet, a discrepancy of 4.0 ml of lorazepam was noted during a routine count, with two nurses signing off on the correction. Despite this discrepancy, there was no documentation or evidence that the missing medication was reported to facility administration or to the appropriate authorities. Interviews with nursing staff revealed that one nurse believed the other would report the issue, but neither confirmed that a report was made. The Assistant Director of Nursing confirmed that the missing lorazepam had not been reported, and the new Administrator, who also serves as the abuse coordinator, stated she was not made aware of the incident. The facility's policy requires prompt reporting of any suspected abuse, neglect, or misappropriation of resident property, including controlled substance discrepancies, to local, state, and federal agencies. The failure to report the missing lorazepam as required by policy and regulation resulted in a deficiency related to the timely reporting of suspected theft or diversion of a resident's medication.
Failure to Document and Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide and document ordered wound care treatments for a resident with a stage four pressure injury located above the buttocks. Review of the resident's Treatment Administration Records (TAR) for April and May showed that several evening wound care treatments were not documented as completed, specifically on 4/29, 4/30, and 5/10. The wound care nurse confirmed that if wound care is not documented, it is considered not done, and any refusals or absences should be noted in the TAR. The facility's policy requires that the date and time of dressing changes be recorded in the resident's medical record or treatment sheet. At the time of observation, the wound appeared as previously described, with a red wound bed and no active drainage.
Failure to Maintain Accurate Controlled Substance Records and Procedures
Penalty
Summary
The facility failed to maintain accurate records and procedures for controlled substances, specifically lorazepam and morphine, for one resident. The medication administration record showed that lorazepam was to be administered as needed, and the controlled drug count sheet indicated a discrepancy of 4 ml, with the count being corrected from 28.0 ml to 24.0 ml by two nurses. One nurse stated she noticed the discrepancy during the shift count and signed off on the correction, believing the other nurse would report it, but was unaware of what happened to the missing medication. The Assistant Director of Nursing confirmed that the nurse should not have signed off on the count and should have notified a nurse manager, and was not aware of the discrepancy until it was brought to her attention during the survey. Additionally, the physical bottle of lorazepam had unclear graduation marks, making it difficult for staff to accurately measure the remaining medication. For the same resident, the morphine count sheet showed a dose was documented as given without a date, time, amount left, or nurse signature. The nurse on duty stated she had not dispensed any morphine and that discrepancies should be reported to administration. The Assistant Director of Nursing was not aware of the incomplete documentation and stated it should have been identified and addressed at shift change. The facility's policy required controlled substances to be counted at each shift change, with discrepancies reported to the Director of Nursing or designee, and for the outgoing nurse to remain until the issue was resolved.
Failure to Safely Reposition Resident Leads to Injury
Penalty
Summary
The facility failed to safely reposition a resident in bed, leading to the resident experiencing multiple fractures and requiring hospitalization. The resident, who was admitted with diagnoses including fibromyalgia, morbid obesity, spinal stenosis, cervical spine fusion, major depressive disorder, repeated falls, and pain, required substantial assistance for bed mobility. Despite this, a CNA attempted to reposition the resident alone on a low air loss mattress, contrary to the facility's policy requiring two staff members for such tasks. This resulted in the resident falling off the bed and sustaining significant injuries, including a humerus shaft fracture, a laceration on the leg, and a pubic ramus fracture. Interviews revealed that the CNA was unaware of the policy requiring two staff members for repositioning residents on low air loss mattresses. The Assistant Director of Nursing confirmed that the incident could have been prevented if the policy had been followed. The resident expressed that the CNA was in a hurry and that the accident was unnecessary, indicating that the CNA's actions were not in line with the required care plan. The incident highlights a lapse in adherence to safety protocols, which directly contributed to the resident's injuries.
Failure to Maintain Patency of Central Venous Catheter
Penalty
Summary
The facility failed to provide physician-ordered interventions to maintain the patency of a Central Venous Catheter (CVC) for a resident, resulting in the occlusion and subsequent need for replacement of the catheter. The resident, who is cognitively intact, reported that the catheter was not being flushed as required, leading to repeated clogging. Observations revealed that the catheter had dark red blood in the tubing, and the resident confirmed that the line had not been flushed on the day of observation. Interviews with nursing staff indicated a lack of consistent practice in flushing the CVC, with some staff members not performing the procedure and others documenting flushes that were not actually conducted. The Medication Administration Records for November and December showed multiple instances where the prescribed Normal Saline flushes and Heparin locks were not administered as ordered. A narrative from a medical doctor confirmed that the catheter was filled with clots, indicating improper flushing and locking practices. The Director of Nurses acknowledged the absence of specific training for CVC flushing, relying instead on a computer program for instruction. This lack of training and adherence to protocol contributed to the catheter's occlusion and the need for its replacement.
Failure to Ensure Proper Texture of Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed Swiss steak was prepared to a smooth, uniform texture as required for residents on a pureed diet. During an observation, the cook, identified as V11, was seen pureeing Swiss steak for lunch but did not achieve the desired consistency similar to mashed potatoes. The pureed Swiss steak appeared slightly chunky, and V11 did not perform a taste test to verify the texture. A test tray provided by the facility revealed that the pureed Swiss steak was gritty with small granules, necessitating chewing before swallowing. The Dietary Manager, V6, confirmed the gritty texture and noted that staff should taste test the product every time before completing the puree. The facility's policy on Modified Texture Foods states that foods requiring modification to a puree texture should have a smooth texture.
Improper Sanitation Practices in Pureed Diet Preparation
Penalty
Summary
The facility failed to ensure proper sanitation practices were followed in the preparation of pureed diets for four residents. During an observation, a cook was seen using a spatula and food processor components without adequately washing, rinsing, and sanitizing them between uses. The cook used the same spatula to transfer different food items, such as Swiss steak, mashed potatoes, and broccoli, without proper cleaning, which could lead to cross-contamination. The Dietary Manager confirmed that the cook should have used either new containers with lids and blades for each food item or should have washed, rinsed, and sanitized each component before reuse. The facility's policy on cleaning food and nonfood contact surfaces requires that kitchenware and food-contact surfaces be washed, rinsed, and sanitized after each use to prevent cross-contamination. This policy was not adhered to during the preparation of pureed diets for the residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat a resident, identified as R9, in a dignified manner, as observed during a survey. R9, who was admitted with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and generalized anxiety disorder, was noted to have emotional and spiritual distress due to hopelessness and lack of family support. The care plan for R9 emphasized the need for staff to approach her warmly, positively, and calmly, offering reassurance before initiating care. However, on December 9, 2024, R9 was observed moaning and asking to go to bed, with her moans audible across the hall. When two CNAs, V8 and V9, entered her room, V8 told R9 to stop moaning, stating, "Nobody wants to hear that," while V9 loudly informed R9 that they were going to replace her incontinence brief, causing R9 to wince. The Director of Nursing (DON), identified as V2, confirmed that R9 was not hard of hearing and could hear without someone speaking close to her ear. V2 acknowledged that the responses from V8 and V9 were inappropriate and not in line with the facility's policy on dignity, which requires staff to speak respectfully to residents at all times. The facility's Quality of Life-Dignity policy, revised in December 2021, mandates that each resident be cared for in a manner that promotes dignity, respect, and individuality, and that staff should address residents by their name of choice rather than by room number, diagnosis, or care needs.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to safely transfer a resident by not using a gait belt during a transfer, as required by the resident's care plan. The care plan specified that a gait belt should be used for all transfers with the assistance of one person. On December 9, 2024, a Certified Nursing Assistant (CNA) assisted the resident from a wheelchair to a bed without applying a gait belt, instead lifting the resident under the arm and guiding their hips with her hands. This action was contrary to the facility's policy and the resident's care plan, which both mandated the use of a gait belt for safety during transfers. Interviews with another CNA and the Director of Nursing confirmed that the use of a gait belt is necessary for the resident's safety during transfers.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.81%, which is above the acceptable threshold of 5%. This deficiency was observed in one of the three residents during a medication pass. Specifically, a Licensed Practical Nurse (LPN) did not administer Diltiazem to a resident with hypertension, despite the absence of hold parameters in the order. The LPN decided to withhold the medication due to the resident's pulse being less than 70, but failed to notify the physician about this decision. Additionally, the LPN administered Timolol Maleate eye drops incorrectly by applying them to both eyes instead of just the left eye as ordered. The LPN also administered Milk of Magnesia on a day it was not due and gave a double dose. Furthermore, the LPN did not administer Vitamin D3 as ordered. The Director of Nursing confirmed that all medications should be given as ordered and that any deviations should be communicated to the physician for approval.
Significant Medication Error Due to Incorrect Insulin Transcription
Penalty
Summary
The facility failed to ensure that a resident received the correct insulin medications as prescribed by their endocrinologist, resulting in a significant medication error. The resident, who has Type 1 diabetes mellitus with polyneuropathy, reported that the facility did not accurately transcribe her insulin orders following an endocrinology appointment. The After Visit Summary from the endocrinologist specified changes to the resident's insulin regimen, including adjustments to the doses of Basaglar (long-acting insulin) and Novolog (short-acting insulin). However, the facility's September Medication Administration Record (MAR) showed that incorrect insulin types and dosages were ordered and administered to the resident until the error was identified and corrected at the end of the month. The Director of Nursing acknowledged that the nurses should have followed the medication orders on the After Visit Summary when transcribing new orders. It was noted that Novolog and Novolin N are different types of insulin and are not interchangeable, highlighting the importance of accurate transcription and understanding of medication types. The Licensed Practical Nurse responsible for medication audits discovered the error during her end-of-month review, which led to the correction of the resident's insulin orders. This incident underscores the critical need for precise medication management and adherence to prescribed treatment plans in the facility.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a fall and head injury. The incident involved a resident who was being assisted by a CNA to transfer from a bed to a wheelchair. The resident, who had a history of chronic kidney disease, morbid obesity, anxiety, insomnia, persistent atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, generalized weakness, and gait abnormalities, required partial to moderate assistance for transfers. Despite the care plan indicating the use of a gait belt and walker, the CNA did not maintain a hold on the gait belt during the transfer, leading to the resident losing balance and falling. The resident fell forward and hit her head on an oxygen concentrator, resulting in a laceration that required emergency medical attention, including 6 staples and 2 sutures. The CNA admitted to not having a hold on the gait belt at the time of the fall, which is against the facility's procedures that require staff to maintain contact with the gait belt to assist residents safely. The incident report inaccurately documented that a gait belt was used during the transfer, although the CNA's account and the resident's statement indicated otherwise. Interviews with facility staff, including a nurse, occupational therapist, nurse practitioner, and the Director of Nursing, confirmed the expectation that gait belts should be used and held during transfers to prevent falls and reduce injury risk. The facility's procedures emphasize the importance of using gait belts to ensure resident safety during transfers, highlighting a failure in adherence to these protocols in this incident.
Deficiency in Dementia Care Leads to Resident Agitation
Penalty
Summary
The facility failed to provide appropriate care to a resident with dementia, leading to escalating agitation. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was involved in an incident where four staff members attempted to assist him in the bathroom. The resident's family expressed concerns about the number of staff involved and the manner in which care was provided, noting that the resident became overwhelmed and agitated due to the loud and multiple instructions given by the staff. The resident was found with bruises and a bump on his head the following day, which the family believed were related to the incident. On another occasion, video footage showed two CNAs providing incontinence care to the resident, who was visibly agitated and in pain. The CNAs continued to provide care despite the resident's resistance and complaints of pain, without giving him time to calm down. The resident's care plan indicated that he required a calm approach and time to process instructions, but these guidelines were not followed during the care provided. The facility's staff did not document the incidents in the resident's progress notes, and there was no dementia care policy in place. The resident's psychiatric provider noted that he had been experiencing agitation and aggression since moving to the facility, with attempts at redirection often escalating his agitation. The facility's Director of Nursing and Administrator acknowledged that the presence of multiple staff members during care was overwhelming for the resident and that additional dementia care training was needed. Despite the facility's efforts to provide dementia care in-services, the incidents highlighted a deficiency in the care provided to the resident with dementia.
Resident Injury Due to Unsafe Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a fractured femur. During a transfer from bed to chair, the resident's knees buckled, and the CNA lowered her to the floor. The CNA did not use a gait belt and was unfamiliar with the resident's transfer needs, assuming she required only one-person assistance. The resident was lowered to the floor and later assessed by an RN, who noted the resident's ability to move her legs, albeit weakly, and reported some pain in the right leg. Despite these observations, the resident was placed in a chair without further immediate intervention. The resident was later diagnosed with a periprosthetic fracture of the distal femur at a local hospital. The radiologist noted that the fracture pattern suggested a twisting motion and some energy involved, which typically results from a fall rather than causing one. The resident had a history of osteopenia, which may have contributed to the injury. The RN on the following shift noted the resident's discomfort and limited knee movement, indicating a potential injury. The resident's condition deteriorated, and she eventually expired under hospice care in the facility.
Failure to Assess and Document Skin Damage
Penalty
Summary
The facility failed to properly assess, treat, and document skin damage for a resident, identified as R1, who was part of a sample reviewed for skin alterations. On July 31, 2024, during a perineal care session, certified nursing assistants (CNAs) V4 and V5 discovered foam patches on R1's coccyx, left anterior thigh, and outer left knee, which were swollen with urine. R1 was unaware of the patches and expressed a preference to be changed only once per shift, which contributed to her brief and liner being saturated with urine. The CNAs did not remove the patches, as they were unsure of what was underneath and did not want to expose R1's skin. The registered nurse (RN) responsible for wound care, V6, was also unaware of the patches and noted that R1 had returned from the hospital recently, with her skin previously in good condition. Upon further assessment, V6 found no open areas under the patch on R1's buttocks but identified a dried fluid blister under the patch on her left knee and moisture-associated skin damage (MASD) on her right inner thigh. The facility's records, including R1's electronic medical record and admission skin assessment sheet, did not document any open areas on R1's inner thigh or left knee at the time of her readmission from the hospital. The facility's policy on skin identification and monitoring requires licensed nursing staff to evaluate skin integrity upon admission and when significant changes occur, but this was not adequately followed, leading to the deficiency.
Failure to Follow Resident's Medication Choice
Penalty
Summary
The facility failed to ensure a resident's medication choice was followed, specifically for melatonin administration. The resident's family had requested that the scheduled melatonin dose be discontinued and only given as needed upon family request. Despite this, the resident continued to receive the scheduled dose. The Director of Nursing (DON) was unaware of who printed or reviewed the medication orders with the family, and the Nurse Practitioner (NP) was not informed of the family's request. The resident's Medication Administration Record (MAR) showed that the resident received melatonin on multiple occasions, contrary to the family's instructions. The resident's Power of Attorney (POA) confirmed that they had communicated the request to discontinue the scheduled melatonin to the nurse on duty, who assured them that the doctor would be informed and the orders would be changed. However, this change was not implemented, and the resident continued to receive the medication, leading to increased sleepiness and decreased eating and drinking. The facility's Resident Rights Policy states that residents are entitled to exercise their personal and legal rights, which was not upheld in this case.
Failure to Treat Residents with Dignity
Penalty
Summary
The facility failed to treat residents in a dignified manner during care, as evidenced by the experiences of three residents (R1, R2, and R3). R1, who has vascular dementia, anxiety, depression, type 2 diabetes mellitus, and difficulty walking, reported that CNA V9 threw her shoes under her bed where she could not reach them. This incident was corroborated by another CNA, V6, who found the shoes under the bed and reported the incident to the administrator, V1. R2, who has anxiety disorder, depression, chronic pain, and weakness, and is assessed as a moderate fall risk, reported that V9 was rude and unhelpful when she requested assistance to use the bathroom. R2 stated that V9 initially refused to help her and only assisted after she insisted on her need for help due to her fall risk. R3, who has arthritis, cellulitis of the lower extremities, and muscle weakness, reported that V9 frequently used inappropriate language, including swearing, while at work, which she found undignified and unprofessional. The facility's dignity policy and procedure, revised in April 2024, emphasizes that each resident should be cared for in a manner that promotes dignity, respect, and individuality. The policy specifically states that associates should not handle or move a resident's personal belongings without permission. The care plans for R1 and R2 highlight their need for additional attention, reassurance, and assistance with activities of daily living due to their medical conditions. Despite these guidelines, the actions of CNA V9, as reported by the residents and corroborated by staff, indicate a failure to adhere to the facility's dignity policy, resulting in undignified treatment of the residents involved.
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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