West Suburban Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomingdale, Illinois.
- Location
- 311 Edgewater Drive, Bloomingdale, Illinois 60108
- CMS Provider Number
- 145333
- Inspections on file
- 50
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at West Suburban Nursing & Rehab Center during CMS and state inspections, most recent first.
The deficiency involves unsafe transfer practices and malfunctioning or ineffective shower chair brakes that allowed chairs to move despite being locked, contributing to a serious fall with head injury for a resident and unsafe transfers for two other residents. One resident with multiple comorbidities and a fall‑risk care plan was transferred from a shower chair to a wheelchair by a CNA; the resident reported confirming that both chairs were locked, then standing using the shower chair armrests when the chair moved backward, causing her to fall and strike her head. Hospital records documented a mechanical fall from a shower chair with a possible small subarachnoid hemorrhage and head hematoma. Staff interviews and incident documentation gave differing accounts of whether the resident held the shower chair or wheelchair, but consistently indicated that the shower chair moved and that a wheel was reported to have come off. Subsequent observations showed that plastic‑caster shower chairs could roll on tile floors even with brakes engaged, that staff were aware of this and sometimes relied on their own strength rather than brakes to stabilize chairs, and that in other transfers a resident’s shower chair rolled when he stood and another resident was able to pull a locked‑brake shower chair toward himself and slide it while sitting, with transport occurring while the chair’s brakes were still locked but wheels rolling. These practices did not align with the facility’s transfer policy requiring stabilization or locking of all surfaces and prohibiting residents from pulling up on assistive devices to stand.
Two residents who were transferred to a hospital did not receive required written bed-hold notifications. One resident was involuntarily transferred after aggressive behavior toward a peer, and the RN who arranged the transfer did not provide the bed-hold notice due to attending multiple emergencies. Another resident, who called 911 after feeling unwell, was only verbally informed by the DON that a return to the facility was possible, with no written bed-hold policy documented in the record. These actions did not follow the facility’s guideline requiring written presentation of the state and facility bed-hold policy at or shortly after transfer, with documented attempts if direct provision is not possible.
The facility failed to ensure shower chairs functioned safely, as multiple plastic-framed chairs with plastic casters could slide and roll on tile floors even when wheel brakes were fully engaged. A cognitively intact resident who required partial to moderate assistance for transfers fell when a shower chair moved backward and a wheel came out during a transfer to a wheelchair, despite staff reporting that the brakes were locked. CNAs, an LPN, the DON, and maintenance staff observed and demonstrated that several shower chairs could be easily moved or rolled with brakes applied, and one bariatric chair had locks on only two rear wheels, allowing the front to swing side to side. Staff reported they did not rely on the brakes and instead physically held the chairs during use, and the facility could not provide manufacturer instructions for the shower chairs.
Two residents who were cognitively intact but dependent on staff for toileting and incontinence care did not receive timely assistance consistent with their care plans and facility policy. One resident with hemiplegia and multiple chronic conditions reported that staff typically changed her brief only twice daily and that she was told if she requested a change after early afternoon, she would be placed in bed and left there until the next shift, a practice confirmed by a CNA during observation. Another resident with neurologic and psychiatric diagnoses, bowel and bladder incontinence, and care-planned two-hour checks and regular toileting reported activating the call light for bathroom assistance but waiting about three hours without help, resulting in a wet bed.
Three residents were enrolled in a new Medicare Advantage plan without being fully informed in a language or terminology they understood, leading to emotional distress, confusion about medication coverage, and changes in healthcare providers. One resident with moderate cognitive impairment was unable to access cancer medication, another with limited English proficiency was not provided information in his primary language and his Power of Attorney was not contacted, and a third resident felt pressured to enroll and became emotionally upset. The facility lacked a policy for obtaining consent for such changes.
A resident experienced severe dental pain and required a tooth extraction after the facility failed to provide timely dental services, despite repeated requests and documented assessments indicating dental issues. The resident's dental concerns were not addressed for several months, and no dental visits were documented during this period, contrary to facility policy.
The facility failed to verify and document that individuals signing Medicare Advantage enrollment forms on behalf of residents with cognitive impairment had the legal authority to do so. Multiple residents with moderate to severe cognitive impairment were enrolled in a new Medicare Advantage I-SNP plan by family members or significant others without proper POA or surrogate documentation in the medical record, and the facility lacked a policy to ensure compliance with CMS requirements.
The facility allowed an outside insurance vendor to change the Medicare Advantage plans of three cognitively impaired residents without proper consent or notification of their legal representatives. The Social Service Director provided a list of residents to the insurance agent, but did not ensure that only those capable of informed consent were approached. Enrollment forms were signed with typed signatures, and there was no documentation that family members or POAs were notified or involved, despite facility policy requiring protection against exploitation.
A resident with multiple complex medical conditions did not have a neurology consult scheduled as ordered by a physician for a second opinion, due to the facility's failure to track and arrange the appointment. The staff member responsible for scheduling was unable to provide evidence of an appointment, and the resident remained without the required specialist evaluation.
A resident with multiple health conditions and moderate cognitive impairment repeatedly requested help to see an audiologist due to hearing difficulties. Despite a formal grievance and internal communications among staff, there was no documentation that the facility assisted the resident in making an appointment or ensured access to audiology services.
A resident who is cognitively intact requested transfer to a facility closer to family and provided a list of preferred locations. Despite repeated requests and involvement from the Ombudsman, the facility's Social Services staff made minimal documented efforts, with only one referral sent and no evidence of follow-up or communication with the suggested facilities. The resident's chart lacked documentation of referrals or follow-up, and emails from the Ombudsman requesting updates went unanswered.
Two residents with dementia were left unsupervised in the dining area when the only staff present left to answer a phone call. During this time, one resident attempted to move into a spot at the table, resulting in physical contact and a fall that caused bruising and required hospital evaluation.
The facility failed to protect residents from abuse, as evidenced by two incidents involving physical altercations. In the first incident, a resident with intact cognition confronted another resident with dementia, resulting in a physical altercation and injuries. In the second incident, a resident with severe cognitive impairment physically confronted another resident over a misunderstanding, leading to minor injuries. Both incidents highlight the facility's failure to prevent abuse and ensure resident safety.
The facility failed to provide timely assistance with transfers to bed and showers for residents requiring staff assistance, affecting three residents. One resident, dependent on staff for bathing, reported not receiving scheduled showers due to insufficient staffing, with records showing only nine showers offered over ten weeks. Another resident experienced a four-hour delay in being transferred to bed due to staff shortages, highlighting the facility's failure to meet scheduled care needs.
The facility failed to provide adequate staffing, resulting in missed showers and delayed transfers for residents requiring assistance. A resident with multiple sclerosis and another with paraplegia did not receive scheduled showers due to insufficient CNAs. Another resident experienced a four-hour delay in being transferred to bed, causing dizziness. Staffing records showed frequent understaffing, with only four CNAs for 86 residents, impacting care delivery.
The facility failed to prevent cross-contamination in food service by not ensuring proper handling of pans, trays, and utensils. A dietary aide used the same gloves for cleaning and handling clean items, while another aide did not wash hands between handling dirty and clean dishes. These actions violated the facility's policies on handwashing and dishwashing, potentially affecting 183 residents receiving food from the kitchen.
The facility failed to dispose of expired medications and did not maintain the correct refrigeration temperature for medications, affecting nine residents. Expired medications were found on a medication cart, and the medication refrigerator was at 50°F, above the recommended range for certain medications. This indicates lapses in medication management and storage practices.
The facility failed to provide pureed broccoli and ham at the required smooth consistency for residents on a pureed diet. Observations revealed that the food contained small chunks, requiring chewing, which is inappropriate for such diets. The cook did not test the consistency before service, affecting four residents. Facility guidelines specify that pureed food should be the consistency of pudding or mashed potatoes.
A resident with Alzheimer's and dementia was injured after being pushed out of bed by her confused and aggressive roommate, resulting in a large hematoma. The facility failed to ensure the safety of the resident, who required extensive assistance and was non-ambulatory, despite the roommate's known history of agitation and aggression.
A resident with rheumatoid arthritis experienced a lapse in treatment due to the facility's failure to clarify medication orders after a missed appointment. The resident, who missed her September appointment due to transportation issues, did not have her steroid medication orders updated, resulting in continued pain and inadequate treatment. The oversight was partly due to a float nurse being unaware of the missed appointment and the lack of follow-up by the nursing staff.
A resident did not receive prescribed eyeglasses despite being alert and oriented to express her needs. She reported seeing an eye doctor and receiving a prescription, but the facility did not follow up to ensure she received the glasses. The Social Services representative acknowledged the prescription but noted the glasses might not have arrived, and no option to order them was provided to the resident.
A resident with multiple health conditions, including a right leg amputation and stage 3 sacral pressure ulcer, was found without a protective dressing on the ulcer. Despite physician orders for daily dressing changes, the wound nurse was not informed of the missing dressing, leading to non-compliance with the facility's guidelines for pressure injury prevention and treatment.
The facility failed to implement adequate smoking precautions for a resident who was observed smoking without the necessary safety measures, such as a smoking apron, despite her care plan requirements. Additionally, another resident at risk for falls was left without a functioning call light, preventing him from alerting staff for assistance. These deficiencies highlight lapses in safety protocols and supervision.
Two residents in the facility had improperly positioned urinary catheter collection bags and tubing, leading to potential infection risks. One resident's catheter bag was hung at bladder level, causing urine stagnation, while another resident's tubing was dragging on the floor. Both residents have medical conditions that increase their risk for urinary tract infections.
Unsafe Shower Chair Transfers and Ineffective Brakes Leading to Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and prevent accidents during use of shower chairs and wheelchairs, resulting in a serious fall with head injury for one resident and unsafe transfer practices for others. One resident with diagnoses including atrial fibrillation, dementia, chronic kidney disease, obesity, sequelae of cerebral infarction, diabetes mellitus type 2, hypertension, and osteoarthritis was care planned as at risk for falls and required partial/moderate assistance for transfers. During a transfer from a shower chair to a wheelchair after a shower provided by a CNA, the resident reported asking if both the shower chair and wheelchair were locked and being told they were. The resident stated she placed her hands on the arms of the shower chair, began to stand, and the shower chair moved backward; she was unable to sit back down and fell to the floor, striking her head. She reported that the CNA was in front of her near the wheelchair rather than behind the shower chair securing it, and that in the past staff had held the back of the shower chair during transfers. Hospital documentation following this event described a mechanical fall while the resident was getting out of the shower chair when it slipped, causing her to strike her head, with imaging showing a possible 2–3 mm subarachnoid hemorrhage and a minimal parieto‑occipital hematoma. Facility staff interviews provided differing accounts of the transfer mechanics but consistently indicated that the resident was transferring from the shower chair to the wheelchair when the incident occurred. The CNA involved stated he locked both the shower chair and wheelchair, that the resident declined assistance and transferred independently, and that she became weak, sat on the edge of the shower chair seat, and the back of the chair raised and tipped forward. The facility’s incident note documented that the CNA reported holding the wheelchair while the resident transferred and that one of the shower chair wheels came out, causing her to lose balance and fall. Nursing leadership interviews reflected conflicting recollections of whether the resident was holding the shower chair armrests or the wheelchair armrests at the time of the fall, but confirmed that the shower chair moved and that a wheel was reported to have come off. Further observations and staff interviews revealed that the plastic‑caster shower chairs used in the facility did not remain stationary even when their brakes were applied, and that staff were aware they could slide or roll on tile floors. Direct testing of the shower chairs showed that with the brakes locked, the chairs could still be propelled or rolled on the tile floor. A maintenance director initially stated he had no concerns about the brakes and that CNAs knew they had to hold the shower chairs because they slide on tile regardless of brake use, later acknowledging that the wheels did turn despite the brake mechanism being applied. An LPN and CNA demonstrated that locked shower chair wheels could roll when pushed, and another CNA stated she did not rely on the brakes, instead using her own strength to hold the chair and at times moving a shower chair and positioning a wheelchair for a resident without locking the wheelchair brakes before seating the resident. In another observed transfer, a cognitively intact resident who required only setup or cleanup assistance was able to pull a locked‑brake shower chair toward himself and cause it to slide backward as he sat, and was then transported down the hall with the shower chair brakes still locked while the wheels continued to roll. These observations occurred in the context of a facility transfer policy that required stabilizing or locking all surfaces, including wheelchairs and beds, and prohibiting residents from pulling up on assistive devices to achieve standing, indicating that the transfer practices and equipment performance did not align with the written policy. The residents involved in these events had significant medical and functional conditions relevant to safe transfers. The resident who fell and sustained a head injury had intact cognition per MDS but multiple comorbidities including prior cerebral infarction, morbid obesity, and dependence on renal dialysis, and was care planned as at risk for falls. Another resident had dementia, unsteadiness on feet, abnormal gait and mobility, lack of coordination, and weakness, and required supervision/touching assistance for all transfers; during an observed shower transfer, his shower chair rolled slightly back when he stood because the CNA was holding his incontinence brief and not securing the chair, and the CNA acknowledged that most shower chair brakes were not solid and that she did not put faith in them. A third resident with Parkinson’s disease with dyskinesia, bipolar disorder, anxiety, congestive heart failure, cardiomegaly, osteoarthritis, and prior cerebrovascular events was cognitively intact and required only setup or cleanup assistance for transfers, yet was able to move a locked‑brake shower chair toward himself and cause it to slide during transfer. Across these cases, the combination of shower chairs whose wheels rolled despite engaged brakes, staff reliance on physical strength rather than reliable braking mechanisms, and failure to consistently secure both the shower chairs and wheelchairs during transfers contributed to unsafe transfer conditions and the cited deficiency. The facility’s own transfer policy specified that all surfaces, including wheelchairs and beds, must be stabilized or locked, and that residents should push up from wheelchair armrests and not pull up from assistive devices to achieve standing. However, the observed practices showed residents pulling on shower chair armrests and moving chairs with brakes applied, staff not always locking wheelchair brakes before seating residents, and staff acknowledging that they did not rely on shower chair brakes because they allowed movement on tile floors. The facility was unable to provide a manufacturer’s instruction manual for the shower chairs in use, and staff interviews indicated awareness that the chairs could slide even when brakes were engaged. These documented actions, inactions, and equipment conditions formed the basis of the deficiency for failing to ensure the environment was free from accident hazards and that adequate supervision and safe transfer practices were provided to prevent accidents.
Failure to Provide Required Written Bed-Hold Notifications at Hospital Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notifications to residents who were transferred to the hospital. For one resident, a Petition for Involuntary/Judicial Admission dated 2/26/26 documented that the resident was involuntarily transferred to the hospital after displaying aggressive behavior toward a peer. Review of this resident’s clinical record showed no evidence that a facility bed-hold notification was provided. A registered nurse reported that she transferred the resident to the hospital on that date and did not provide the bed-hold notification because she was attending to multiple emergencies at the time of transfer. For another resident, progress notes dated 3/30/26 documented that the resident complained of not feeling well and called 911 to be transferred to the hospital. The DON stated that this resident did not receive a written copy of the facility’s bed-hold policy, but that she verbally informed the resident at the hospital that the resident could return to the facility. Review of the clinical record showed no evidence that a written copy of the bed-hold policy was provided at the time of transfer. The facility’s own Guidelines for Resident Bed Holds and Readmissions, dated 2/20/25, require that the state’s and facility’s bed-hold policy be presented and discussed with the resident or responsible party at the time of transfer, or within 24 hours in writing for emergency transfers, with documentation of attempts if direct provision is not possible.
Unsafe Shower Chairs with Ineffective Brakes Used During Resident Transfers
Penalty
Summary
The facility failed to maintain safe shower chair equipment, resulting in unstable and malfunctioning shower chairs being used for resident care. One resident with intact cognition who required partial to moderate assistance for tub/shower and sit-to-stand transfers reported that during a transfer from a shower chair to her wheelchair, the shower chair moved backward and she fell, despite having asked the CNA to confirm that both the shower chair and wheelchair were locked. The facility’s incident note documented that during this transfer, one of the wheels from the shower chair came out, causing the resident to lose balance and fall to the floor. The DON stated that the resident reported pulling up on her wheelchair during the transfer and that the shower chair “popped out” even though the wheels were locked, and examination of the involved shower chair showed a plastic frame with plastic casters, only two of which had locks. Further observations and staff interviews showed that multiple shower chairs in the facility did not remain stationary even when all wheel locks were applied. The DON and other staff demonstrated that when sitting in or pushing the plastic shower chairs with the brakes locked, the chairs could still be propelled backward or rolled on the tile floor, and the locked wheels slid easily and then rolled despite the brakes being engaged. A CNA and an LPN reported that some shower chairs moved and slid on the tile even if all four wheels were locked, and that staff had to physically hold the chairs during resident use because the plastic wheels allowed the chairs to slide and roll even with brakes applied. The Maintenance Director initially stated he had no concerns about the brakes and believed CNAs knew they had to hold the chairs because they slid on tile regardless of the locks, but later acknowledged that on reexamination of the involved chair, the wheels did turn despite the brake mechanism being applied. Additional observations showed that residents were being transferred and transported in shower chairs whose brakes did not effectively prevent movement. In one instance, a CNA, while holding a resident’s incontinence brief, used one arm to easily move a shower chair away from the resident’s back even though she stated all brakes were engaged, and she demonstrated that the wheels rolled with the brakes locked, noting that most of the chairs were like that and that she did not rely on the brakes. In another instance, a CNA locked the wheels of a plastic-wheeled shower chair in a resident’s room, yet the resident was able to slide the chair back and forth by holding the armrest during transfer, and the chair slid backward when the resident sat down; the resident was then transported down the hall in the same chair with the brakes still locked. The DON and a corporate consultant also observed multiple plastic shower chairs, including a bariatric chair with only two rear wheel locks, whose wheels moved and rolled on the floor despite the brakes being locked. The facility was unable to provide a manufacturer’s instruction manual for the shower chairs in use.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting and incontinence care to residents who were dependent on staff for these activities of daily living. One resident with hemiplegia, anoxic brain damage, neuralgia, depression, anxiety, low back pain, weakness, cognitive communication deficit, and muscle wasting required a mechanical lift with two staff for transfers and was care planned to be toileted at regular intervals, including before and after meals, activities, naps, and at bedtime. The MDS documented that this resident was cognitively intact, dependent on staff for toileting, and frequently incontinent of bladder and bowel. The resident reported that staff typically changed her brief only when getting her up around late morning and again when putting her to bed in the evening, and that staff told her if she requested a change after early afternoon, she would be transferred to bed and have her brief changed but would have to remain in bed until the next shift began. During observation, when the resident requested a brief change early in the afternoon, a CNA confirmed she would transfer the resident to bed and change her but stated the resident would need to remain in bed until the next shift because the CNA had not yet had a break and needed to complete rounds before the end of her shift. This practice conflicted with the expectations stated by the DON and Administrator, as well as with the facility’s written incontinence care guidelines requiring assistance after incontinent episodes and at least every two hours based on care planning. Another resident, with diagnoses including cerebral infarction, cirrhosis, depression, anxiety, seizures, encephalopathy, schizoaffective disorder, dementia, hemiplegia, abnormal gait/mobility, weakness, and a history of falls, was care planned as incontinent of bowel and bladder, to be checked every two hours, toileted at regular intervals, and assisted with toileting as needed. The care plan also noted that this resident’s ADL needs, including transfers and toileting, could fluctuate with acute changes or exacerbations of chronic conditions. The MDS showed the resident had intact cognition, required substantial/maximal assistance for toileting, and supervision/touching assistance for transfers. The resident reported that on one evening she activated her call light because she needed to use the bathroom but was not assisted for approximately three hours, during which time she wet the bed. These findings demonstrate that staff did not provide toileting assistance and incontinence care in accordance with the residents’ assessed needs, care plans, and facility policy.
Failure to Ensure Residents Understood Health Insurance Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood changes to their health insurance coverage, specifically regarding enrollment in a new Medicare Advantage plan by a third-party vendor. Several residents reported not understanding the implications of signing up for the new plan, with some indicating they were pressured or inadequately informed by facility staff and the insurance agent. One resident, who has moderate cognitive impairment and multiple complex medical diagnoses including cancer, dementia, and anxiety, stated he did not understand the new insurance would affect his medication coverage and experienced significant distress when he was unable to access his cancer medication. The Director of Nursing confirmed there was a period during which the resident's medication access was uncertain due to the insurance change. Another resident, whose primary language is Polish and who is cognitively intact but has a significant medical history including heart disease and depression, reported not understanding the insurance documents he signed and felt misled about the services he would receive. His son, who holds Power of Attorney, was not contacted about the insurance change, and the facility lacked documentation of the Power of Attorney or any communication with the son regarding the change. The enrollment form for this resident was completed with a typed signature and indicated assistance from an insurance agent, but there was no evidence the information was provided in a language the resident could understand. A third resident, also cognitively intact and with a history of Parkinson's disease and depression, described being approached by the Social Service Director to hear a presentation about the new insurance. Despite initially declining, the resident felt pressured to enroll and later became emotionally distressed upon learning the change meant a new doctor and nurse practitioner. The facility administrator acknowledged there was no policy regarding obtaining consents for such changes, and the only documentation provided to residents was a brochure outlining general rights, including the right to information in a language they understand.
Failure to Provide Timely Dental Services Resulting in Resident Pain and Tooth Extraction
Penalty
Summary
The facility failed to follow its policy to ensure a resident received timely routine and emergency dental services. Despite multiple requests from the resident, staff, and the Ombudsman beginning in May, there was no documented follow-up or dental evaluation until late August. The resident had lost a dental filling in May and repeatedly reported severe pain to various staff members, including the Social Service Director and the Ombudsman, who submitted a grievance on the resident's behalf. Nursing documentation indicated that a request for a dental referral was made in June, and a nursing assessment in July noted broken or carious teeth, but there was no evidence that these concerns were addressed or that the resident was seen by a dentist during this period. The resident's medical record showed a history of multiple chronic conditions, including COPD, dementia, anxiety, hypertension, anemia, and other significant diagnoses. The Minimum Data Set assessment indicated moderate cognitive impairment and a need for assistance with activities of daily living. Despite these vulnerabilities, the facility did not document any dental visits for the resident from April of the previous year until late August, even though a dental exam in April had already recommended urgent extractions of two teeth. There was also no documentation that the resident refused the recommended extractions at that time. When the dentist finally saw the resident in late August, the resident was found to have significant pain, swelling, and infection due to the lost filling. The dentist was unable to perform an extraction immediately because of the infection and prescribed antibiotics, returning a few days later to extract the affected tooth. The dentist confirmed that if the resident had received prompt dental care when the initial concerns were raised, the pain and infection could have been prevented. The facility's own policy required prompt assessment and coordination of dental care, but there was no evidence that these procedures were followed.
Failure to Verify Legal Authority for Medicare Advantage Enrollment
Penalty
Summary
The facility failed to ensure that there was proper documentation verifying that residents' representatives had the legal authority to make decisions regarding enrollment in a Medicare Advantage plan. This deficiency was identified for eight residents who were enrolled in a new Medicare Advantage Institutional Special Needs Plan (I-SNP) through an outside insurance vendor. The process involved the Social Service Director (SSD) introducing the insurance agent to residents and contacting representatives for those deemed non-decisional based on their Brief Interview for Mental Status (BIMS) scores. However, the SSD was not present during the enrollment discussions or when consent forms were signed, and the facility did not verify or maintain documentation confirming the legal authority of those signing on behalf of cognitively impaired residents. For several residents with moderate to severe cognitive impairment, as indicated by low BIMS scores, enrollment forms were signed by family members or significant others whose legal authority to act as Power of Attorney (POA) or health care surrogate was not established in the residents' medical records. In some cases, POA paperwork was either missing, incomplete, or executed after the enrollment forms were signed. For example, one resident's enrollment form was signed by a significant other, but the POA paperwork did not include the resident's name, and another resident's daughter signed the enrollment form before POA documentation was completed. Other cases involved siblings or children signing without any supporting legal documentation in the records. The facility did not have a policy regarding the obtaining of consents for such enrollments, and staff relied on the insurance vendor's process without ensuring compliance with CMS requirements. CMS guidance specifies that an authorized representative must have legal authority under state law and that documentation of this authority must be available upon request. The lack of verification and documentation of legal authority for those enrolling residents with cognitive impairment in the Medicare Advantage plan constituted the deficiency identified during the survey.
Failure to Protect Residents from Exploitation During Medicare Advantage Plan Changes
Penalty
Summary
The facility failed to protect residents from exploitation by allowing an outside insurance vendor to make unauthorized changes to the Medicare Advantage plans of cognitively impaired residents. The process involved the facility's Social Service Director (SSD) introducing the insurance agent to residents and providing a list of residents deemed 'conversational' or cognitively intact, based on BIMS scores. However, the SSD was not present during the insurance presentations or when enrollment forms were signed, and could not explain why residents with BIMS scores below 12 were included. The insurance agent relied solely on the facility's assessment of residents' decisional capacity and did not verify cognitive status or legal authority to consent. Three residents were specifically identified as having their Medicare Advantage plans changed without proper consent. One resident, with severe cognitive impairment and no documented POA or family notification, was unable to recall or understand the insurance change and had a history of mental illness and behavioral symptoms. Another resident, also with moderate cognitive impairment and no POA or family notification, did not understand the insurance discussion or why they signed the paperwork. The third resident, with severe cognitive impairment and a documented POA, was not able to understand or recall the insurance change, and the POA was not contacted or present for the consent process. In all cases, the enrollment forms were signed with a typed signature, and there was no evidence that the residents or their legal representatives were properly informed or consented to the changes. The facility's own policies require the prevention of exploitation and the identification of residents at increased risk for abuse or neglect, including those with cognitive impairment. Despite this, the facility did not ensure that only residents capable of informed consent were approached by the insurance agent, nor did they notify or involve family members or legal representatives as required. The process lacked oversight, documentation, and verification, resulting in unauthorized changes to vulnerable residents' insurance coverage.
Failure to Schedule Neurology Consult per Physician Order
Penalty
Summary
The facility failed to follow physician orders to obtain a neurology consult for a resident who required a second opinion for spine consultation at a tertiary care center. Despite a physician's order dated June 18, 2025, there was no evidence that an appointment had been scheduled for the resident. The resident, who was admitted with multiple diagnoses including mononeuropathy of the left lower limb, PVD, hypertension, heart disease, and other significant conditions, reported ongoing leg weakness and expressed frustration about the delay, stating that staff indicated it could be several more months before an appointment could be arranged. The resident was cognitively intact and dependent on staff for most activities of daily living. During the investigation, the staff member responsible for scheduling appointments was unable to locate any documentation or confirmation of a scheduled neurology appointment for the resident, either in the facility's appointment calendar or among her personal and office papers. The facility's policy requires that upon receiving a physician's order for an outside appointment, the nurse must notify the staff member coordinating transport and ensure the appointment is scheduled and tracked. However, there was no system in place to reliably track or confirm appointments, resulting in the resident's continued wait for necessary medical evaluation.
Failure to Assist Resident in Accessing Audiology Services
Penalty
Summary
A resident with multiple medical diagnoses, including COPD, dementia, generalized anxiety disorder, and hearing difficulties, repeatedly requested assistance from facility staff to see an audiologist. Despite these requests, and a formal grievance submitted by the ombudsman in May, there was no documentation that the facility assisted the resident in making an appointment with an audiologist or that the resident had seen one as of early September. The resident's electronic medical record and Minimum Data Set indicated moderate cognitive impairment and a need for supervision with most activities of daily living. Facility records show that the ombudsman submitted the resident's grievance to the administrator, and a registered nurse communicated the need for an audiology referral to the social services director in June. The nurse also contacted the insurance case manager to obtain a list of providers, including an audiologist. However, there was no evidence that staff followed up on the provider list or facilitated an appointment. The lack of follow-through resulted in the resident not receiving the requested audiology services over several months.
Failure to Assist Resident with Discharge Planning and Transfer Requests
Penalty
Summary
The facility failed to adequately assist a resident in discharge planning, specifically in facilitating a transfer to another facility closer to the resident's family. The resident, who is cognitively intact, expressed a clear desire to move and provided a list of preferred facilities. Despite repeated requests and involvement from the Ombudsman, there was minimal documented action by the facility's Social Services staff. Only one referral was documented as sent, with no evidence of follow-up or confirmation of receipt, and no further documented efforts or communication with the suggested facilities. The resident's chart lacked documentation of referrals or follow-up actions from December 2024 to the present. Interviews with facility staff and the Ombudsman confirmed that the resident's requests were not actively pursued, and the administrator of a local facility reported never receiving a referral. Email correspondence showed ongoing requests from the Ombudsman for updates and additional facility options, but these were not responded to by the facility. The facility's own discharge planning policy emphasizes preparation and coordination, but these steps were not followed in this case, resulting in a lack of progress toward meeting the resident's expressed needs and preferences for transfer.
Inadequate Supervision in Dining Area Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision in the dining area, resulting in a resident-to-resident incident that led to a fall. Two residents with dementia and cognitive deficits, both residing in the memory care unit, were involved. During a noon meal, one resident attempted to move into a spot at the table occupied by another resident. In the process, there was physical contact, and the first resident lost her balance and fell to the floor. There were no staff witnesses to the incident, and another resident present could not recall staff being in the area at the time. On the day of the incident, only one staff member was monitoring the dining room, as other staff were either on break or passing meal trays. The sole staff member left the area to answer a phone call, leaving the dining room unsupervised. This absence of supervision allowed the incident to occur without immediate intervention. Following the fall, the resident was found to have bruising on her buttock and was sent to the emergency room for evaluation, as per facility protocol for unwitnessed falls.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving residents R6, R7, R4, and R5. In the first incident, R6 entered R7's room and initiated a physical altercation. R7, who has a history of dementia and other mental health issues, was accused by R6 of rummaging through other residents' belongings. R6, whose cognition was intact, confronted R7 and used a jiu-jitsu move to throw R7 to the ground, resulting in R7 sustaining a head injury and other minor injuries. The police were involved, and video surveillance contradicted R6's claims, showing that R7 had not left his room prior to the altercation. In the second incident, R4, who has a history of misinterpreting situations and responding with aggression, physically confronted R5 in the dining room over a box of pizza. R4, whose cognition was severely impaired, believed R5 was taking someone else's pizza and attempted to pull R5 away by his sweatshirt, resulting in a scratch on R5's cheek. Witnesses, including a psychologist and an LPN, observed the altercation and intervened to separate the residents. The police were notified, and R4 was sent to the hospital following the incident. Both incidents highlight the facility's failure to prevent resident-to-resident abuse and ensure a safe environment. The facility's abuse prevention policy was not effectively implemented, as evidenced by the lack of staff intervention before the altercations escalated. The facility's inability to protect residents from physical harm and intimidation resulted in injuries and distress among the involved residents.
Failure to Provide Timely Assistance with Transfers and Showers
Penalty
Summary
The facility failed to provide timely assistance with transfers to bed and showers for residents who require staff assistance, affecting three residents in the sample. Resident R2, diagnosed with multiple sclerosis and other conditions, was dependent on staff for bathing. Despite being scheduled for two showers a week, R2 reported not receiving showers due to insufficient staffing, with records showing only nine showers offered over ten weeks. Similarly, R3, also dependent on staff for bathing, reported not receiving scheduled showers due to a lack of CNAs, with records indicating only nine showers offered in the same period. Resident R8, who required substantial assistance for transfers and bathing, experienced a significant delay in being transferred to bed, waiting four hours due to staff shortages. R8 reported feeling dizzy from sitting too long and had to call a nurse to be transferred. The Resident Council Meeting minutes also highlighted concerns about call lights not being answered promptly, especially during the second shift. R8's shower records showed only seven showers offered over ten weeks, further indicating the facility's failure to meet scheduled care needs.
Inadequate Staffing Leads to Missed Showers and Delayed Transfers
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of residents requiring assistance with transfers and bathing. Three residents, identified as R2, R3, and R8, were affected by this deficiency. R2, diagnosed with multiple sclerosis and other conditions, expressed dissatisfaction with not receiving scheduled showers due to insufficient staff. Records indicated R2 was only offered nine showers over a ten-week period, despite the facility's policy of offering two showers per week. Similarly, R3, who also required staff assistance for bathing, reported not receiving scheduled showers due to a lack of CNAs. Records showed R3 was offered only nine showers in the same period. R8, who required substantial assistance for transfers, experienced a significant delay in being transferred to bed, waiting four hours due to staff shortages. This delay caused R8 to experience dizziness from sitting too long. The facility's staffing records revealed that the first floor was often understaffed, with only four CNAs available for approximately 86 residents, leading to inadequate care. The Director of Nursing acknowledged the staffing issues, citing restrictions on using agency staff and increased call-offs due to illnesses as contributing factors.
Improper Handling of Food Service Items Leads to Cross-Contamination Risk
Penalty
Summary
The facility failed to ensure proper handling of food service pans, trays, and utensils, leading to potential cross-contamination affecting all 183 residents receiving food from the kitchen. Observations revealed that a dietary aide, V4, wore the same gloves while performing multiple tasks, including cleaning food debris from a three-compartment sink and handling clean, sanitized pans. V4 did not change gloves between these tasks, which included stacking wet pans on top of clean, dry ones, contrary to the facility's policy that prohibits stacking until items are completely dry. Another dietary aide, V6, was observed handling both dirty and clean dishes without washing hands in between tasks. V6 moved between the dirty and clean sides of the dish machine without adhering to handwashing protocols, as outlined by the facility's handwashing policy. The facility's dietitian, V8, confirmed the standard practice of washing hands before serving food, after touching garbage, and between handling dirty and clean dishes. The facility's policies on handwashing and machine dishwashing, both dated 4/2017, emphasize the importance of preventing cross-contamination through proper handwashing and ensuring that pots and pans are dried before stacking.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to properly dispose of expired medications and did not maintain the correct refrigeration temperature for medications, affecting nine residents. During an inspection, a Licensed Practical Nurse found expired medications, including a glucagon injection and various eye drops, on a medication cart. The nurse confirmed that eye drops are marked with the date they are opened and are considered usable for 30 days thereafter. However, several medications were found to be past their expiration dates, indicating a lapse in the facility's medication management practices. Additionally, the medication refrigerator on the second floor was found to be at 50 degrees Fahrenheit, which is above the recommended storage temperature for certain medications. This refrigerator contained insulin, eye drops, and a multidose vial of Tuberculin, all of which require refrigeration at temperatures between 36 and 46 degrees Fahrenheit. The facility's policy and the pharmacy guidelines specify these temperature requirements, but the facility failed to adhere to them, compromising the proper storage of medications.
Inadequate Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed broccoli and pureed ham were prepared to a smooth consistency, as required for residents on a pureed diet. This deficiency was observed during a survey where the cook, identified as V7, was seen preparing pureed broccoli that contained small chunks, which were not tested for consistency before being placed in a steam table pan for service. Similarly, the pureed ham also contained small chunks, requiring chewing, which is inappropriate for a pureed diet. This issue affected four residents who were on a pureed diet. The facility's guidelines for pureed food preparation, dated 10/25/23, specify that pureed food should be the consistency of pudding or mashed potatoes, which was not adhered to in this instance.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident, identified as R146, from abuse, resulting in a traumatic incident. R146, who was admitted with Alzheimer's disease, dementia, and other conditions, was found with a large bump on her forehead and bruising on her face. The incident occurred when R146's roommate, R72, who has a history of aggressive behavior and confusion, pushed R146 out of bed, believing it was her own. This resulted in R146 falling to the floor and sustaining a significant hematoma. The facility's records indicate that R146 required extensive assistance for bed mobility and was non-ambulatory, highlighting her vulnerability. R72, who was admitted with alcohol-induced dementia and other psychiatric conditions, had a documented history of agitation and aggression. Despite this, R72 was placed in a shared room with R146. The facility's Memory Care policy emphasizes providing a safe environment, yet the incident suggests a failure in ensuring the safety and proper placement of residents with known behavioral issues. The report details the observations and statements from staff members who witnessed the aftermath of the incident, confirming the aggressive behavior of R72 and the resulting injury to R146.
Failure to Clarify Medication Orders After Missed Appointment
Penalty
Summary
The facility failed to clarify medication orders for a resident with rheumatoid arthritis after a missed medical appointment. The resident, who suffers from rheumatoid arthritis, COPD, anxiety, major depressive disorder, and low back pain, was observed experiencing pain in her hands, shoulder, and arms. She reported not receiving treatment for her rheumatoid arthritis, despite being on a regimen of injections and steroids. The resident missed a scheduled appointment in September due to transportation issues, and her follow-up appointment was set for November. However, her steroid medication orders were not clarified after the missed appointment, leading to a gap in her treatment. The resident's nurse on the day of the new orders, a float nurse, was unaware of the missed appointment and did not follow up on the steroid medication orders. The Director of Nursing confirmed that the resident's appointment was missed and rescheduled, but the necessary follow-up to clarify the prednisone order was not conducted. The resident's physician orders for October did not include prednisone until the end of the month, indicating a lapse in the continuity of care for her rheumatoid arthritis treatment.
Failure to Provide Prescribed Eyeglasses
Penalty
Summary
The facility failed to ensure that a resident received a pair of corrective eyeglasses as prescribed. The resident, identified as R118, reported on multiple occasions that she had seen an eye doctor and was prescribed glasses, but had not received them. On 10/28/24, R118 stated she needed glasses but had not gotten them. On 10/29/24, the Social Services representative, V20, confirmed that R118 had a prescription from an eye exam conducted on 6/17/24 but had not received the glasses, suggesting they might not have arrived yet. On 10/30/24, R118 reiterated her need for glasses and expressed that she was not given the option to order them, nor was there any follow-up from the facility. The resident's care plan indicated she was alert, oriented, and able to express her needs, yet the facility did not ensure she received her prescribed eyeglasses.
Failure to Maintain Protective Dressing for Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to ensure a protective dressing was in place for a resident with a stage 3 sacral pressure ulcer. The resident, a male with multiple diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes, peripheral vascular disease, end-stage renal disease, and hypertensive heart disease, was observed without a dressing on his sacral pressure ulcer. This observation was made when a Certified Nursing Assistant (CNA) was providing assistance, revealing an open area on the resident's sacrum without the required dressing. The resident's physician had documented a stage 3 sacral pressure ulcer with specific treatment orders to cleanse with normal saline, apply triad cream, oil emulsion, and foam dressing daily. However, the wound nurse was not informed that the dressing was missing, and thus it was not re-applied as per the facility's guidelines. The facility's guidelines emphasize the importance of evidence-based recommendations for the prevention and treatment of pressure injuries, which were not adhered to in this instance.
Failure to Implement Smoking and Fall Prevention Precautions
Penalty
Summary
The facility failed to implement adequate smoking precautions for a resident, identified as R30, who was observed smoking without the necessary safety measures in place. R30, who uses an electric wheelchair and has limited use of her left arm, was seen smoking with cigarette ashes on her lap and clothing, and without the required smoking apron on multiple occasions. Despite the facility's policy and care plan indicating that R30 requires a smoking apron due to her inability to independently handle smoking products and dispose of ashes safely, staff did not consistently ensure she wore the apron. The activity aid acknowledged the oversight, noting that there is a list of residents who need aprons for safety, but it was not always followed. Additionally, the facility failed to ensure proper fall prevention interventions for another resident, R152, who is at risk for falls due to general weakness and is dependent on staff for assistance. R152's call light was not functioning, preventing him from alerting staff when needed. Despite pressing the call light multiple times, it did not alarm, and the issue was not recorded in the maintenance book for repair. This oversight left R152 without a reliable means to request assistance, as confirmed by the Director of Nursing, who found no record of the malfunction in the maintenance log.
Improper Positioning of Urinary Catheter Collection Bags
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter collection bags and tubing for two residents, leading to potential infection risks. One resident, who was observed in an electric wheelchair, had a urinary catheter collection bag hung at the same level as the bladder, causing urine to remain stagnant in the tubing. This resident has a history of a perpetual urinary tract infection and a care plan that requires monitoring the position of the drainage bag to ensure it is below the waist for proper drainage. Another resident was seen propelling himself in a wheelchair with urinary catheter tubing dragging on the floor, which was observed multiple times. The tubing contained bloody urine and was not properly positioned, posing a risk for bacterial contamination. This resident has a diagnosis of neuromuscular dysfunction of the bladder and is at risk for urinary tract infections due to catheter use. The facility's guidelines emphasize the importance of keeping the drainage bag below the bladder level to prevent catheter-associated urinary tract infections.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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