Wheaton Village Nrsg & Rhb Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheaton, Illinois.
- Location
- 1325 Manchester Road, Wheaton, Illinois 60187
- CMS Provider Number
- 145715
- Inspections on file
- 24
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wheaton Village Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
The facility failed to implement its grievance process for concerns about delayed call light response and missing or misdirected laundry and personal items. A resident and a representative reported call light response delays of 15–20 minutes or longer, sometimes up to an hour with no response, and the DON acknowledged receiving weekly concerns and Ombudsman complaints about call lights without corresponding grievance documentation or follow-up. Multiple residents and staff reported ongoing problems with missing clothing, items returned to the wrong rooms, and laundry staff turnover, while records lacked complete admission inventories or documentation of refusals. Resident council minutes and an Ombudsman grievance reflected repeated laundry concerns, yet there was no evidence that these grievances were consistently documented, investigated, or resolved in accordance with the facility’s grievance and resident rights policies.
Two cognitively intact residents with multiple chronic conditions, including diabetic polyneuropathy, osteoarthritis, hemiplegia, COPD, and respiratory failure, did not receive ordered doses of Gabapentin and Combivent Respimat as scheduled, even though an agency LPN had documented afternoon medications as administered. Video review showed the LPN at the nurses’ station, bathroom, medication room, and medication cart, but not moving the cart to resident rooms or preparing and giving medications in accordance with physician orders and facility policy.
The facility failed to maintain proper food safety and sanitation standards, affecting all residents receiving oral nutrition. Issues included using a dishwasher with a broken detergent line and low chlorine levels, improper food storage and labeling, and inadequate garbage disposal and sanitation practices. These deficiencies were observed during a kitchen tour, with expired and improperly stored food items, uncovered garbage cans, and low sanitizer levels noted.
The facility failed to ensure accessible call lights for five residents, impacting their ability to request assistance. Observations showed call lights were either missing, unreachable, or improperly placed, despite residents' ability to use them and needing assistance for ADLs. This was confirmed by staff and contradicted the facility's policy on call light accessibility.
The facility failed to properly store medications for five residents who were not assessed or had orders to self-medicate or store medications at the bedside. Medications were found unsecured in residents' rooms, and staff interviews confirmed that medications should be locked and residents supervised during administration. The facility's policy required a written order and assessment for self-administration, which was not followed.
The facility failed to provide written notification to two residents and their representatives about the reasons for discharge, and did not inform the Ombudsman. One resident with Alzheimer's and chronic kidney disease was transferred to a hospital for dehydration and a UTI without proper notification. Another resident with end-stage renal failure experienced multiple hospitalizations without receiving written notices. The facility's policy did not address these notification requirements.
The facility failed to provide written notification of its bed hold policy to two residents or their representatives upon hospital transfer, as required by its policy. One resident was transferred due to a sudden change in mental status, while another had multiple hospitalizations. The facility's leadership admitted to not following the practice of providing written notice, despite the policy requirements.
Two residents in the facility did not receive necessary nail care despite being dependent on staff for assistance due to conditions like arthritis. Their nails were excessively long, and staff interviews revealed that nail care was not provided as per facility guidelines, which emphasize regular trimming to prevent infections and maintain hygiene.
The facility failed to ensure proper respiratory care and infection control for three residents. One resident used a nasal cannula that had fallen on a dirty floor, while another had CPAP tubing on the floor, and a third stored her CPAP mask unbagged among clothing. The facility's policy lacked infection control guidelines.
The facility failed to provide the required square footage per resident in 12 rooms, affecting 35 residents. Rooms designed for three residents provide only 74 square feet each, while those for four residents offer 78 square feet. The administrator noted this issue is cited annually.
The facility was found to have resident rooms below ground level, affecting all residents reviewed. The administrator confirmed that the facility's structure has not changed since its inception, and this deficiency is cited annually.
Two residents experienced significant delays in receiving trust fund cash withdrawals due to procedural issues and missing signatures, with one resident waiting weeks for a requested amount. The facility's policy did not specify timely disbursement for larger withdrawals, contributing to the delay.
A CNA reported an allegation of abuse involving another CNA hitting a resident, but the facility failed to report this to the IDPH or police as required by their policy. The DON did not investigate the new allegation, as the initial investigation attributed the injury to the resident's combativeness. The facility's records show no investigation into the new allegation, despite policy requirements for immediate reporting.
Failure to Address Resident Grievances on Call Light Response and Laundry/Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without reprisal and to establish and implement an effective grievance process, specifically regarding call light response times and laundry/personal belongings. A resident representative reported that one resident’s call light responses often took 15–20 minutes, leading the resident to attempt to toilet independently to avoid accidents; the resident confirmed this account. Another resident reported that staff sometimes took an hour to respond to his call light, with occasions of no response, and stated he used his call light or cell phone to request assistance and wore pullups due to bed sores. The DON acknowledged receiving call light concerns approximately once per week, including complaints from the Ombudsman, and stated such concerns should be documented on grievance forms and followed up on, but could not provide evidence of follow-up or documentation. Review of grievances from December 2025 through March 2026 showed no reports, findings, or resolutions related to poor call light response times. The facility also failed to address and document grievances related to laundry and missing personal items. A resident representative stated that one resident’s family had been doing her laundry due to missing items, including comforters in winter, and both the representative and resident reported that clothing sometimes went missing; the resident’s clothes at bedside were not labeled, and no inventory beyond admission was found in the record. The same representative reported that other residents’ clothes were routinely returned to another resident’s room, that something of that resident’s was missing every week, and that this was a common issue; the resident confirmed missing items from laundry, and the facility had only attempted to inventory her belongings about six months after admission with no subsequent updates. Another resident reported missing clothes, seeing other residents wearing his shirts, and missing about five pairs of shoes; his record contained no admission inventory or documentation that he declined an inventory. A fourth resident reported issues with clothes being returned from laundry and stated he had reported this to nurses. Staff interviews and facility documents further demonstrated unaddressed grievances and inadequate protection of personal property. A CNA reported recent issues with missing items from laundry related to laundry staff turnover, and another CNA stated she had received resident complaints about not receiving their clothes, noting that the former permanent laundry aide had left and new staff were unfamiliar with residents’ clothing, although she stated that residents’ clothes were labeled. Resident council minutes from December 2025 documented concerns about clothes not being returned correctly due to laundry staff not reading labels, and minutes from January and February 2026 documented concerns about clothes going to the wrong rooms and missing from laundry. A grievance form dated 02/21/2026 included Ombudsman-reported concerns about a resident’s missing items. The DON and ADON stated that the facility had an inventory form to be completed on admission and uploaded to the chart, that refusals should be documented, and that families were educated to label belongings or the facility would do so, and the DON acknowledged prior staffing issues in laundry and ongoing clothing return problems over several months. The facility’s Resident Rights Policy required reasonable care to protect personal property from loss, and the Grievance Policy required investigation and written findings to the administrator within five working days of receiving a written grievance, but the surveyors found no documentation showing that reported concerns about call lights or laundry were consistently documented, investigated, or resolved.
Failure to Administer and Accurately Document Scheduled Medications
Penalty
Summary
Surveyors identified a failure to ensure residents were free from significant medication errors when an agency LPN did not administer ordered medications as scheduled, despite documenting them as given. On the survey date around midday, the LPN reported she had already completed afternoon medications, and the manual medication administration record showed medications signed off. However, review of video footage between 10:45 AM and 11:40 AM showed the LPN at the nursing station, bathroom, medication room, and medication cart, but did not show her moving the cart to resident rooms, preparing medications, or entering resident rooms to administer medications, contrary to the facility’s medication administration policy requiring the cart to be moved close to residents before preparing and administering medications. One resident with diagnoses including diabetic polyneuropathy, osteoarthritis, and hemiplegia, and with intact cognition per MDS, reported in the afternoon that she had not received her scheduled dose of Gabapentin 800 mg ordered three times daily at 8:00 AM, 1:00 PM, and 5:00 PM. Another resident with diagnoses of COPD and acute and chronic respiratory failure, also cognitively intact per MDS, had an order for Combivent Respimat 20-100 mcg, one puff every six hours at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. The evidence from resident report, EMR review, and video review showed that ordered medications for these residents were not administered as prescribed, despite being documented as given.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, impacting all residents receiving oral nutrition from the facility kitchen. During a kitchen tour, it was observed that the low-temperature dishwasher was used despite having a broken detergent line and low chlorine levels, which are essential for proper dish sanitation. The Dietary Manager acknowledged that the dishwasher should not have been used under these conditions, yet the Dietary Aide continued to use it until instructed otherwise. Additionally, the facility did not maintain appropriate storage and labeling practices for food items. The milk cooler was found to be operating at temperatures above the recommended 40 degrees Fahrenheit, with milk cartons inside also measuring above this threshold. Several food items, including thawed frozen egg products, tomatoes, cottage cheese, raisins, and sweetened coconut, were either not dated, expired, or improperly stored, violating the facility's policy on labeling and dating foods. The facility's failure to use the first-in, first-out method for food storage further contributed to the risk of serving expired or spoiled food to residents. The facility also neglected proper garbage disposal and sanitation practices. Uncovered garbage cans with visible food debris were observed near the dishwasher, and small black flies were seen in the hallway outside the kitchen. Clean plates were improperly stored near a handwashing sink, risking contamination. The sanitizer bucket used by the cook showed low quaternary levels, indicating inadequate sanitization. These observations highlight the facility's failure to maintain a clean and safe kitchen environment, as outlined in their policies.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide access to the resident call system for five residents, which is essential for obtaining needed assistance. Observations revealed that one resident's call light was on the floor entangled among personal items, making it unreachable. Another resident was found without a call light on multiple occasions, confirmed by both a CNA and an RN. This resident was cognitively intact and required extensive assistance for activities of daily living (ADLs), yet was unable to communicate needs due to the absence of a call light. Additional observations showed a resident verbally calling for help without a call light, and another resident's call light was found behind a dresser, inaccessible. A fifth resident's call light was under the bed, out of reach, despite being able to communicate needs and use the call light for assistance. The facility's policy requires call lights to be accessible from various positions, yet this was not adhered to, as confirmed by the Director of Nursing.
Improper Medication Storage and Lack of Assessment for Self-Administration
Penalty
Summary
The facility failed to properly store medications for residents who were not assessed or had orders to self-medicate or store medications at the bedside. This deficiency was observed in five residents, each with different medications left unsecured in their rooms. For instance, one resident had a medication cup with a pill on her dresser without an order to keep medications at the bedside, and the facility could not provide an assessment form to show she was evaluated to self-administer medications. Another resident had three bottles of Flonase on her bedside table, and although she was cognitively intact, there was no assessment form to show she was evaluated to self-administer medications. The resident's care plan was updated during the survey to allow her to self-administer Flonase, but prior to this, there was no documentation supporting her ability to do so. Similarly, another resident had an inhaler on his bedside table without a physician's order to self-administer or store medications at the bedside, and his care plan did not indicate he could self-administer medications. Additional observations included a tube of prescription cream and Nystatin powder left on bedside tables without proper orders or assessments for self-administration. Staff interviews revealed that medications should be locked in the medication cart and that residents should be supervised when administering their medications. The facility's policy required a written order and an assessment for residents to self-administer medications and store them at the bedside, which was not followed in these cases.
Failure to Notify Residents and Ombudsman of Discharge
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding the reasons for discharge, as well as failing to notify the Ombudsman. This deficiency was identified in two residents, R73 and R51, who were reviewed for discharge. R73 was admitted to the facility with multiple diagnoses, including Alzheimer's Disease and chronic kidney disease. On a specific date, R73 experienced a sudden change in mental status and was transferred to a hospital for dehydration and a urinary tract infection. The facility administrator admitted that they do not notify residents or their representatives in writing about the reasons for hospital transfers, nor do they inform the Ombudsman. No documentation of such notifications was found in R73's medical records. Similarly, R51, who has diagnoses including end-stage renal failure and chronic anemia, reported multiple hospitalizations without receiving written notices of transfer. The facility's progress notes confirmed these hospitalizations, but there was no evidence of written notifications to R51 or the Ombudsman. The facility's existing policy on discharge did not address the requirement for written notification to residents, their representatives, or the Ombudsman, as confirmed by the facility's administrator and director of nursing.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital, as required by its own policy. This deficiency was identified in the cases of two residents. The first resident, admitted with multiple diagnoses including Alzheimer's Disease and chronic kidney disease, was transferred to a hospital due to a sudden change in mental status and was diagnosed with dehydration and a urinary tract infection. The Director of Nursing acknowledged that the facility forgot to provide the bed hold notice to the resident's representative at the time of transfer, and no documentation of such notice was found in the resident's medical records. The second resident, who had diagnoses including end-stage renal failure and chronic anemia, reported multiple hospitalizations without recalling receiving a bed hold notice. The clinical records for this resident also lacked documentation of providing the required notice to the resident and the Ombudsman. The facility's Administrator and Director of Nursing admitted that the practice of providing written notice to residents, families, and the Ombudsman was not followed, despite the facility's policy stating that such notification should be given at the time of transfer.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were dependent on staff for assistance with activities of daily living. Resident R71 had nails that were a quarter of an inch long and jagged, and despite repeatedly asking staff for help due to his arthritis, his nails had not been cut since his admission. His care plan indicated a need for substantial assistance with personal hygiene due to decreased mobility and endurance. Similarly, Resident R107 had fingernails that were one inch long and expressed a preference for shorter nails, but was unable to cut them herself due to arthritis. She could not recall the last time staff had assisted with her nail care. Interviews with facility staff, including CNAs and the Director of Nursing, revealed that nail care was typically performed on shower days or as needed. However, the CNAs responsible for these residents admitted they had not provided nail care. The facility's policies emphasized the importance of regular nail trimming to prevent infections and maintain hygiene, yet these guidelines were not followed for the residents in question. The lack of nail care was a clear deficiency in meeting the residents' needs for personal hygiene assistance.
Deficiency in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents, as observed during a survey. One resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease and Schizoaffective Disorder, was seen using a nasal cannula that had fallen on the dirty floor, which was not in accordance with professional standards of practice. The resident's oxygen order was for 2-5 liters per minute as needed, but the resident was using it continuously. The RN acknowledged that the nasal cannula should have been bagged when not in use and replaced if it fell on the floor, but this was not done. Another resident with Dementia, Obstructive Sleep Apnea, and Diabetes Mellitus had a CPAP machine with tubing on the floor, and the room was noted to be dirty. A third resident, diagnosed with Asthma, Heart Failure, Depression, and Obstructive Sleep Apnea, stored her CPAP machine and mask unbagged among her clothing, which was also against infection control practices. The Director of Nursing confirmed that respiratory equipment should be bagged when not in use to prevent contamination, but the facility's policy on oxygen administration did not address infection control aspects.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to provide adequate square footage per resident in 12 of 48 rooms, as required by regulations. Specifically, rooms A22, A24, A26, A28, A30, A31, A33, and A34, which are designed to accommodate three residents each, only provide 74 square feet per resident. Additionally, rooms A18, A19, B7, and B8, intended for four residents each, offer only 78 square feet per resident. This deficiency affects 35 out of 110 residents, as indicated by the facility's daily roster. The administrator acknowledged that the facility has maintained the same room sizes since its inception and receives this deficiency annually during surveys.
Resident Rooms Below Ground Level
Penalty
Summary
The facility failed to ensure that resident rooms were at or above ground level, affecting all 36 residents reviewed for physical environment. Observations and interviews revealed that rooms B1 through B14 were located below the garden or ground level. The facility administrator acknowledged that the structure has remained unchanged since the facility's inception, and this deficiency has been cited annually during surveys.
Delayed Trust Fund Cash Disbursement
Penalty
Summary
The facility failed to provide resident trust fund cash to residents within three business days, affecting two of the three residents reviewed for trust funds. Resident R6 reported waiting weeks for her requested trust fund cash, with delays ongoing for several months. On June 6, 2024, R6 requested $450.00 from her trust fund, but the check was not issued until June 24, 2024, due to missing resident signatures. The check arrived at the facility on June 25, 2024, but was not cashed immediately, causing further delays. Staff interviews confirmed the delay in processing and disbursing the funds. Resident R7 also experienced significant delays in receiving trust fund cash withdrawals, stating that the checks were not arriving and that he had waited a month for a withdrawal when the facility changed banks. The facility's policy and procedures for resident personal trust funds did not specify that withdrawals of $100.00 or greater should be honored within three banking days, contributing to the delay. The facility's admission packet outlined residents' rights to manage their money and access their financial records, which were not upheld in these instances.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse according to its policy. A Certified Nursing Assistant (CNA) reported to the Administrator that another CNA allegedly hit a resident in the face, causing the resident to fall back and hit the bed. The reporting CNA attempted to contact the Illinois Department of Public Health (IDPH) using a number from a poster at the facility entrance but later realized it was a corporate number. The Administrator was unaware of any abuse allegations, and the Director of Nursing (DON) stated that the incident had been investigated and attributed the resident's facial injury to the resident becoming combative during care. Despite the new allegation of abuse, the DON did not report it to IDPH or the police, as the initial investigation concluded that the injury was due to the resident's combativeness. The facility's abuse prevention policy requires immediate reporting of any abuse allegations to the administrator and IDPH within two hours. However, the facility's records from April to July show no investigation into the new allegation. The policy also mandates contacting local law enforcement in cases of physical injury inflicted by staff, which was not done in this instance.
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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