Warren Barr Gold Coast
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 66 West Oak Street, Chicago, Illinois 60610
- CMS Provider Number
- 145336
- Inspections on file
- 42
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Warren Barr Gold Coast during CMS and state inspections, most recent first.
A resident with bilateral knee osteoarthritis and intact cognition reported receiving only a few PT sessions over more than a month despite a physician order and PT plan of care for 2–3 sessions per week. The resident stated that a therapist came once and did not return that week and that staff told her she was not on the therapy schedule when she asked to get up for therapy. Record review confirmed only three PT encounters during the ordered treatment period, while the Therapy Director acknowledged that the ordered PT frequency was not met, contrary to the facility’s policy requiring therapists to follow physician-approved plans of care and ordered frequency and duration.
A resident with a history of traumatic subarachnoid hemorrhage, stroke with hemiplegia, falls, and syncope reported that a CNA hit or bumped her head on the bed and also punched her face during incontinence care. Nursing staff, including an RN and the DON, assessed the resident’s head and skin and completed incident, risk management, and pain assessment forms, finding no visible injury or pain on palpation. However, despite the resident’s clear report of a head impact and the facility’s policy and leadership statements that any suspected or reported head injury requires neurological checks for 72 hours, no neuro assessment or neuro checks were initiated or documented in the resident’s records, resulting in a failure to provide appropriate treatment and care after a reported head injury.
The facility assigned only one LPN per floor to two LTC units, each with 35 to 38 residents, resulting in delayed medication administration and inadequate attention to resident needs. Both LPNs reported being overwhelmed, and the staffing coordinator confirmed the reduced nurse staffing was directed by the DON, despite ongoing complaints from nursing staff. The DON acknowledged implementing the change and recognized that the assignments were overwhelming.
Due to recent staffing changes that reduced the number of nurses per floor, multiple residents did not receive their prescribed medications within the required time window. Both LPNs assigned to the third and fourth floors reported difficulty completing the morning med pass on time, and the eMAR system showed numerous overdue medications. Facility policy requires medications to be administered within one hour before or after the scheduled time, but this was not achieved for a significant number of residents.
A resident's legal representative was not provided timely access to the resident's medical records despite submitting a valid surrogate decision form, as required by facility policy. The records were withheld due to miscommunication and failure to properly review the submitted documentation, resulting in a significant delay before the records were released.
A resident with intact skin and multiple medical conditions was admitted to a facility and developed pressure ulcers due to inadequate repositioning and skin checks. Despite being non-ambulatory and requiring assistance, the facility failed to consistently implement a turning schedule, leading to the worsening of the resident's condition and subsequent hospitalization.
Staff used incorrect serving utensils for portioning grits, oatmeal, and pureed toast, resulting in residents not receiving the full food portions specified on the menu and meal tickets. The cook and Dietary Director confirmed that the correct utensils were not used, and the facility's portion control guides and policies were not followed.
Two residents, both cognitively intact and able to express their needs, were not notified or invited to participate in daily activities despite their interest and care plan goals. Staff interviews and observations confirmed that activity sessions occurred without these residents being informed or encouraged to attend, in violation of facility policy requiring daily engagement based on resident interests.
The facility failed to follow proper sanitation and food storage practices, with unlabeled food items found in storage areas and a malfunctioning dishwasher that did not reach the required sanitization temperature. Additionally, improper sanitization practices were observed in the kitchen's three-compartment sink, contributing to inadequate hygiene standards.
The facility failed to complete and transmit a resident's discharge assessment to CMS within the required 14-day period. The MDS/Clinical Coordinator acknowledged the oversight, noting the assessment was overdue by 122 days. Facility documentation confirmed the assessment should have been completed within 14 days.
A resident with schizoaffective disorder, anxiety, and depression was not referred for a PASARR Level II assessment due to incorrect documentation from the hospital and oversight by the facility's admission staff. The facility's DON acknowledged the need for evaluation to monitor the resident's behavior and medications, highlighting a deficiency in the assessment process.
The facility failed to properly use low air loss mattresses for three residents, with incorrect weight settings and excessive layers between the residents and mattresses. Staff provided conflicting information on the appropriate number of layers, potentially compromising pressure ulcer prevention and care.
The facility failed to maintain accurate records of controlled substances, leading to discrepancies in medication counts for several residents. An agency nurse found an unaccounted Hydromorphone tablet in a medication cart, and another nurse admitted to not signing the narcotic book, contributing to the discrepancies. The DON confirmed that all narcotics should be documented on a controlled substance sheet.
The facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate. Two residents were affected: one received Vancomycin at an incorrect infusion rate, and another received an incorrect dosage of Vitamin D. The errors were due to staff not following prescribed medication administration procedures.
The facility failed to ensure that residents had access to functioning call lights, which are essential for requesting assistance. One resident's call light was not within reach, another's was non-functional, and a third's was found on the floor. These oversights occurred despite facility policies requiring call lights to be accessible and operational at all times.
A resident with hemiplegia and hemiparesis experienced significant tooth pain and anxiety due to the facility's failure to include dental care in her care plan. Despite a dentist's recommendation for tooth extraction, the care plan was not updated for over a month, affecting the resident's ability to eat and contributing to her depression. The facility did not adhere to its policy of updating care plans within seven days of assessment.
The facility failed to implement fall precautions for two residents at high risk for falls. One resident's bed alarm pad was incorrectly placed, and the assigned CNA was on a break without proper monitoring. Another resident's bed alarm was not plugged in, and the CNA was unaware of the requirement. Both residents had care plans indicating fall risks, but interventions were not properly executed.
A resident with end-stage renal disease did not receive prescribed Midodrine before dialysis sessions, despite physician orders and reminders to nursing staff. The nurse responsible did not administer the medication, citing high blood pressure, and failed to document the administration or reason for not administering it. The facility did not adhere to its medication pass and hemodialysis care policies.
Failure to Provide Ordered Physical Therapy Services as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services, specifically physical therapy, as ordered by a physician for one cognitively intact resident with bilateral primary osteoarthritis of the knees. The resident reported that for over a month she had received very little rehabilitation therapy despite being told by her physician that she would be referred to therapy. She stated that one therapist came once and did not return that week, and that since March she had only two or three therapy sessions. On the day of interview, she asked a CNA if she was scheduled to get up for therapy, as she required assistance to get out of bed, and was told she was not on the therapy schedule. The resident expressed that she believed therapy would help with her arthritis and knee pain. Record review showed that the resident had a physician order and PT plan of care for physical therapy 2–3 times per week for 41 days beginning in mid-March, based on an evaluation documenting balance deficits, decreased functional capacity, pain, strength impairments, and a need for skilled PT to improve mobility and safety. PT encounter notes showed only three visits (evaluation and two treatment sessions) over this period. The Therapy Director confirmed that the resident was evaluated in mid-March and seen for treatment on two subsequent dates, and acknowledged that, based on the visits provided, the physician’s order for 2–3 sessions per week was not followed. The facility’s own policy required therapists to follow physician-approved plans of care and deliver services per the ordered frequency and duration, but this did not occur for this resident.
Failure to Perform Neuro Checks After Reported Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological monitoring after a resident reported a head injury. The resident had diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness (subsequent encounter), history of falling, syncope and collapse, asthma, hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side, atherosclerotic heart disease, and type 2 diabetes mellitus. The resident was cognitively intact with a BIMS score of 14 and required one-person assistance with ADLs, was incontinent of bowel and bladder, and had right-sided weakness. On the early morning in question, the resident reported that a CNA hit or bumped her head on the bed/headboard during incontinence care and also alleged being punched in the face. Following the allegation, the CNA immediately reported the incident to the RN and the RN supervisor. The RN assessed the resident’s head and reported no bruising, swelling, bleeding, obvious injuries, or pain on palpation. The RN documented that the resident stated her head was hit on the bed and the right side of her face and that she was punched in the face, and the RN completed a risk assessment report, a physical injury incident report, and a pain assessment report. The DON later assessed the resident’s head and reported no bumps or discoloration. Multiple internal incident and risk management forms were completed, including a Post Altercation/Alleged Abuse assessment, an Accident/Incident Report, and Risk Management documentation. Despite the resident’s report of her head being hit and the facility’s own expectations and policy, no neurological assessment or ongoing neurological checks were performed or documented. The RN acknowledged that neurological monitoring should be conducted anytime there is a report of a head injury or suspected head injury, and the DON stated that any witnessed or unwitnessed head injury requires neurological status monitoring with neuro checks for 72 hours. The facility’s Neurocheck policy states that the nurse will inform the physician of the incident and follow physician orders, including a neurocheck on the resident. Review of the Post Altercation/Alleged Abuse assessment, Accident/Incident Report, Risk Management form, and progress notes from the date of the incident through several days afterward showed no neurological checks documented or performed, demonstrating the failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Insufficient Nurse Staffing on Two LTC Facility Floors
Penalty
Summary
The facility failed to provide sufficient nursing staff, specifically Registered Nurses and Licensed Practical Nurses, to the third and fourth floors, which had the potential to affect 71 residents. On multiple occasions, only one nurse was assigned to each of these floors, with each nurse responsible for 35 to 38 residents per shift. Both nurses assigned to these floors reported feeling overwhelmed and unable to provide timely medication administration or adequate attention to all residents' needs. The nurses stated that while there were enough Certified Nursing Assistants (CNAs) present, the CNAs could not perform nursing duties, and the nurses were left to manage all clinical responsibilities alone. The staffing coordinator confirmed that the third and fourth floors were staffed with only one nurse per 12-hour shift, following instructions from the Director of Nursing (DON). The coordinator also reported that nurses had complained about the workload being too heavy for one nurse, but she was unable to make staffing changes herself. The DON acknowledged that the change to one nurse per floor was a recent decision and that nurses had previously expressed concerns about the workload, especially during the morning shift when medication passes and other activities were at their peak. The DON admitted to implementing the reduced nurse staffing schedule and recognized that the assignments were overwhelming for the nurses. She stated that she had previously tried the assignment herself and was able to complete the work, but acknowledged that the nurses' complaints indicated residents were not receiving the proper care. Review of staffing schedules and facility policy confirmed the reduction in nurse staffing and the facility's stated requirement to provide adequate staff to meet residents' needs.
Delayed Medication Administration Due to Staffing Changes
Penalty
Summary
The facility failed to administer prescribed medications to residents in a timely manner according to physician orders, affecting 29 out of 35 sampled residents. On the day of the survey, only one nurse was assigned to each of the third and fourth floors, whereas previously two nurses had been assigned per floor. Both nurses reported that the new staffing schedule made it difficult to complete the morning medication pass within the required time frame. The eMAR system showed multiple residents with overdue medications, indicated by a red color, and both nurses confirmed that some medications were late. Observations by the surveyor confirmed that numerous residents' eMARs were marked as late, and a medication audit report documented that scheduled medications for these residents were administered outside the facility's policy window of one hour before or after the scheduled time. Facility policies require medications to be administered according to prescriber orders and within the specified time window, but these requirements were not met due to the staffing changes and resulting delays.
Failure to Provide Timely Access to Medical Records for Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records as required by policy. The resident in question had a history of multiple medical conditions, including cerebral infarction, congestive heart failure, type 2 diabetes, and atherosclerotic heart disease. After the resident was discharged, the resident's daughter, acting as a surrogate decision maker, requested access to the medical records. She provided a surrogate decision form, which the facility accepts as valid documentation for releasing records. However, the Medical Records Director did not release the records, citing the absence of a power of attorney (POA) document, and referred the matter to the corporate office for review. Despite the surrogate decision form being provided and accepted by facility policy, the records were not released in a timely manner. The Medical Records Director assumed the corporate office had reviewed the attached surrogate form, but it appears only the first page was reviewed, and the form was overlooked. The legal representative did not receive the requested records until months later, after further review during the survey process. The delay was due to miscommunication and failure to properly review and act on the provided surrogate documentation.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure ulcers in a resident, identified as R2, who was admitted with intact skin. R2 had multiple medical diagnoses, including neuromuscular dysfunction of the bladder and impaired mobility, which increased the risk for skin breakdown. Despite being non-ambulatory and requiring assistance for repositioning, the facility did not consistently implement a turning and repositioning schedule as outlined in R2's care plan. This lack of regular repositioning and skin checks contributed to the development of two pressure ulcers on R2's right buttock and left heel. R2's care plan indicated a high risk for skin integrity impairment, necessitating skin checks every shift and repositioning every two hours. However, interviews with R2 and staff revealed that R2 was not regularly repositioned or checked on by the nursing staff, even after the development of the wounds. R2 expressed that he was unable to reposition himself and relied on staff assistance, which was not consistently provided. The wounds worsened, leading to hospitalization for infection and surgical intervention. The facility's wound care guidelines emphasized the importance of individualized care plans and regular skin inspections to prevent pressure injuries. Despite these guidelines, the facility did not promptly implement interventions such as an air mattress and heel protectors until after the wounds had worsened. The delay in appropriate interventions and failure to adhere to the care plan contributed to the deterioration of R2's condition, highlighting a significant deficiency in the facility's care practices.
Failure to Serve Adequate Food Portions as Specified on Menu
Penalty
Summary
The facility failed to serve adequate food portions as specified on the menu and meal tickets, affecting all residents receiving food from the kitchen. During a survey, it was observed that a 4-ounce ladle was used to portion grits and oatmeal for all diet types, and a number 12-scoop was used for pureed toast, which did not match the portion sizes indicated on the meal tickets and menu guides. The cook responsible for setting up the tray line confirmed that the meal tickets only listed portion measurements and not the specific utensils to use, and admitted to using incorrect utensils due to the absence of a previously posted diagram that matched utensils to portion sizes. Further review with the Dietary Director revealed that staff are expected to reference a Diet Manual Spreadsheet, which details the correct serving utensils, but this was not followed. The facility's own policy and menu documentation require that menus be served as written and that portion sizes be adhered to, with specific utensils designated for each food item and consistency. The incorrect use of serving utensils resulted in residents not receiving the full portions as planned and approved by the Registered Dietitian, as confirmed by both the cook and the Dietary Director.
Failure to Notify and Engage Residents in Meaningful Activities
Penalty
Summary
The facility failed to ensure that residents were properly notified, invited, and engaged in meaningful activities that matched their interests, as required by facility policy. Two residents, both cognitively intact and able to verbalize their needs, reported not being informed about daily activities. One resident, who is blind and dependent on staff for mobility, expressed a desire to participate in activities such as bingo and gospel hour but stated that staff had not provided information or invitations regarding these events. The resident also noted that activity sheets, previously distributed, had not been received for some time. The other resident, present in the facility for three months, similarly reported never being told about available activities and expressed interest in participating if informed. Observations confirmed that activity sessions were being conducted, but neither of the two residents attended, and staff interviews revealed that they had not been personally invited that day. The Activity Aide and Activity Director both acknowledged that they had not notified or invited these residents to the day's activities, despite the facility's policy and the residents' care plans indicating the need for daily engagement and encouragement. Documentation showed that one resident had a care plan goal to participate in at least one activity per week to address depression and isolation, yet there was no evidence of consistent efforts to inform or involve the resident in activities.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed during a survey. In the walk-in cooler, several food items were found without proper labeling, including beverage dispensers and pitchers filled with juice, a container of margarine spreads past its use-by date, an opened box of chocolate chips, and a package of hard-boiled eggs. In the walk-in freezer, items such as a box of fish fillets, a box of bread, and plates covered with aluminum foil were also found without appropriate labeling. Additionally, a 25-pound bag of instant nonfat dry milk was improperly stored in the dry storage area. The facility's dishwasher was found to be malfunctioning, as it did not reach the required temperature of 160 degrees Fahrenheit during the wash/rinse cycle, as evidenced by testing strips that failed to change color. This issue persisted despite attempts to repair the dishwasher, indicating that dishware was not being sanitized properly. The facility's only dishwasher was unable to sanitize dishware effectively, posing a risk of foodborne illness to residents. Furthermore, improper sanitization practices were observed in the kitchen's three-compartment sink. A cook was seen submerging a pan in the sanitizing solution for only 8 seconds, contrary to the required 30 seconds or manufacturer recommendations. This inadequate sanitization process further contributed to the facility's failure to maintain proper hygiene standards in food preparation and storage areas.
Failure to Complete and Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a resident's assessment data to the CMS system within the required timeframe. Specifically, the discharge assessment for a resident, identified as R151, was not completed within 14 days after the resident was discharged from the facility. During an interview, the MDS/Clinical Coordinator, V34, acknowledged familiarity with the resident and explained the process for completing assessments when residents are admitted or sent to the hospital. However, upon review, it was found that R151's discharge assessment was overdue by 122 days. The facility's documentation indicated that the discharge assessment should have been completed within 14 calendar days, but this was not adhered to in the case of R151.
Failure to Conduct PASARR Level II Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to refer a resident with serious mental disorders for a Preadmission Screening and Resident Review (PASARR) Level II assessment. The resident, identified as R143, is a [AGE] year-old individual with medical diagnoses including schizoaffective disorder, anxiety disorder, and depression. Despite these diagnoses, the resident's PASRR Level I Screening incorrectly documented that there was no suspected or known mental diagnosis. This oversight was discovered during a survey, revealing that the resident's mental health needs might not be properly addressed due to the lack of a PASARR Level II assessment. The Director of Nursing acknowledged that the resident should have been evaluated for PASARR Level II to monitor behavior and medications related to behavioral health. The facility's administrator stated that they rely on hospitals to provide accurate information regarding PASARR assessments, and in this case, the hospital failed to document the resident's mental health diagnoses. Additionally, the facility's admission office staff, who is not a nurse, did not review the resident's diagnoses to determine the need for a PASARR Level II screening. This lack of proper assessment and coordination led to the deficiency identified by the surveyors.
Improper Use of Low Air Loss Mattresses for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer preventative measures for three residents using low air loss mattresses. Observations revealed that the mattress settings for two residents were not adjusted according to their weights, with one resident's mattress set at 310-318 pounds despite their weight being 227 pounds, and another resident's mattress set at 90 pounds despite their weight being 148.4 pounds. Additionally, the facility staff, including a Registered Nurse and a Certified Nursing Assistant, confirmed that there were multiple layers between the residents and the mattresses, which could impede the effectiveness of the mattresses in preventing pressure ulcers. The facility's staff provided conflicting information regarding the appropriate number of layers allowed on the low air loss mattresses. While some staff members stated that only one layer should be used, others mentioned that up to three layers, including a brief, chuck, and sheet, were permissible. The facility's Director of Nursing and Wound Care Coordinator acknowledged the importance of setting the mattress according to the resident's weight and the role of the mattress in preventing and aiding in the healing of pressure ulcers. However, the discrepancies in mattress settings and layering practices indicate a failure to adhere to the intended use of the low air loss mattresses, potentially compromising the residents' care.
Controlled Substance Recordkeeping Deficiency
Penalty
Summary
The facility failed to maintain accurate records of controlled substances, specifically Hydromorphone, Hydrocodone, Pregabalin, and Clonazepam, leading to discrepancies in medication counts. An agency nurse discovered a Hydromorphone tablet in a medication cart without a resident name or controlled substance record form. The nurse was informed by a colleague that it was an extra medication, but acknowledged that it should not have been unaccounted for in the cart. Additionally, another agency nurse admitted to not signing the narcotic book after medication pass, which contributed to the discrepancies in narcotic counts for three residents. The discrepancies included missing tablets for Hydrocodone, Pregabalin, and Clonazepam, with the actual count being less than the recorded count. The Director of Nursing later stated that the unaccounted Hydromorphone was used for a resident whose supply had not yet arrived, but confirmed that all narcotics should be documented on a controlled substance sheet. The facility's policy requires an accurate count of Schedule II controlled medications, with nurses signing off on the controlled medication sheet after removing medication from its packaging.
Medication Administration Errors Lead to 6.67% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.67% error rate during a survey of 35 residents. Two residents were directly affected by this deficiency. One resident, identified as R427, received Vancomycin at an incorrect infusion rate. The Registered Nurse (RN) set the IV pump to 166ml/hr instead of the prescribed 120ml/hr, causing the medication to be administered over 55 minutes instead of the ordered 75 minutes. The RN was unsure if the rate could be adjusted manually on the pump and stated that the usual procedure was to input the dose, allowing the pump to determine the rate. The Medical Director confirmed that the medication was administered faster than prescribed but noted no adverse reactions at the IV site. Another resident, identified as R89, received an incorrect dosage of Vitamin D. The Licensed Practical Nurse (LPN) administered one tablet of 1000 IU instead of the prescribed two tablets. The facility's policy, dated 8/16/2024, mandates adherence to all Federal and State regulations regarding medication pass procedures, which was not followed in these instances. These errors contributed to the facility's failure to maintain the required medication error rate.
Failure to Ensure Functioning Call Lights for Residents
Penalty
Summary
The facility failed to ensure that residents had access to functioning call lights, which is crucial for their ability to request assistance. In the case of one resident, the call light was not within reach as it was wrapped around the bed frame. Although the resident was cognitively intact and able to use the call light, the CNA on duty acknowledged that she should have ensured the call light was accessible during her rounds. The resident's care plan emphasized the importance of having the call light within reach due to her dependency on assistance for activities of daily living. Another resident experienced a non-functional call light, which prevented her from calling for help. This resident, who had severe cognitive impairment and required assistance with various activities, was observed trying to use the call light without success. The CNA confirmed the call light was not working and highlighted the risk of the resident attempting to reach for items without assistance, potentially leading to injury. The facility's policy mandates regular checks of call lights to ensure they are operational, but this was not adhered to in this instance. A third resident's call light was found on the floor, out of reach, which prevented her from calling for assistance. The LPN and CNA responsible for her care acknowledged the oversight, with the CNA noting she had not yet conducted her rounds. The resident was alert and oriented, capable of using the call light, and required significant assistance. The facility's policy clearly states that call lights should be within reach at all times, but this was not followed, leading to the deficiency.
Failure to Address Resident's Dental Care Needs
Penalty
Summary
The facility failed to provide adequate planning of care related to oral and dental care for a resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident, who is cognitively intact, reported tooth pain that began in early September, which was initially noted by a medical doctor on 9/11/2024. Despite being seen by a dentist on 9/12/2024, who recommended a tooth extraction, the resident's care plan did not include any interventions for the dental issue until 10/16/2024. The delay in addressing the dental problem resulted in the resident experiencing significant pain and anxiety, affecting her ability to eat and contributing to her depression. The resident's care plan was not updated to include the dental issue until over a month after the problem was first identified. The Director of Nursing acknowledged that the care plan was not comprehensive enough to address all issues related to the resident's tooth problem, including pain management and dietary changes. The facility's policy requires that care plans be developed and implemented within seven days of a comprehensive assessment, but this was not adhered to in this case. The deficiency was identified during a review of the resident's care plan and interviews with facility staff, highlighting a failure to meet federal regulations for comprehensive, person-centered care planning.
Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall precaution interventions for two residents identified as a fall risk. The first resident, R2, was observed lying in bed with a bed alarm pad hanging on the rails at the top of the bed instead of being placed underneath the resident's body. The registered nurse, V5, acknowledged that the bed alarm pad was incorrectly placed and that R2 required 1:1 care with a CNA present at all times. However, the assigned CNA, V6, was on a break and had instructed another CNA to monitor R2, but the bed alarm pad was still not correctly positioned. R2's care plan indicated a risk for falls with interventions including a mobility alarm, and a nursing progress note documented a previous incident where R2 was stuck between the bed and side rail. The second resident, R4, was found with a bed alarm pad in place but not plugged in, rendering it ineffective. The CNA, V7, who started her shift late, was unaware of the bed alarm requirement and only plugged it in after being prompted. The LPN, V8, confirmed that R4's fall precaution interventions included a bed alarm, and acknowledged that an unplugged alarm would not alert staff if R4 fell. R4's care plan and fall risk assessment indicated a high risk for falls, with a history of falls in the facility. The facility's policy required that residents at high risk for falls be provided with interventions, which were not properly implemented in these cases.
Failure to Administer Medication Per Physician Parameters Before Hemodialysis
Penalty
Summary
The facility failed to administer medication per physician parameters prior to hemodialysis for one resident (R2). R2, who has a diagnosis of end-stage renal disease and other significant health conditions, reported that they are supposed to receive Midodrine before leaving for dialysis sessions on Tuesdays, Thursdays, and Saturdays. Despite reminding the nurses, R2 did not receive the medication as prescribed. The resident's records confirmed the physician's order to administer Midodrine if the systolic blood pressure (SBP) was less than 100 before dialysis. However, the medication was not administered on at least one occasion when R2's blood pressure was recorded as 93/54 before dialysis, and there was no documentation of the medication being given in the Medication Administration Record (MAR) for that date. Interviews with the nursing staff revealed that the nurse responsible for R2's care during the night shift did not administer the Midodrine, citing that R2's blood pressure was usually too high before dialysis. The nurse admitted to not administering the medication and not documenting it in the MAR. The Director of Nursing (DON) confirmed that nurses are expected to follow physician orders and document medication administration immediately in the electronic medication administration record (EMAR). The facility's policies on medication pass and hemodialysis care were not adhered to, as the nurse failed to administer the medication as ordered and did not document the administration or the reason for not administering it. The facility's failure to follow physician orders and document medication administration properly resulted in R2 not receiving the prescribed Midodrine before dialysis. This deficiency highlights a lapse in the facility's adherence to its medication pass procedures and hemodialysis care policies, as well as a failure to ensure that nursing staff follow physician orders and document care accurately. The DON emphasized the importance of checking order summary reports and following medication parameters, which were not met in this case.
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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