F0835

L

Systemic Administrative and Clinical Failures Leading to Missed Care, Worsening Wounds, and Medication Errors

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure of facility administration and nursing leadership to provide adequate oversight of wound care, medication administration, treatment administration, quality assurance, and basic activities of daily living. The Administrator-in-Training did not hold a temporary license and had been functioning in the role since July 2025 under a regional VP of Operations who was not present in the building daily. The DON role was filled on an interim basis, and staff reported that management kept office doors closed, was not consistently present in the building, and did not effectively address staffing or care problems. The facility did not have a full-time Activity Director, and activities were not provided daily, with no activity calendar posted and no planned activities after 4:00 PM or on weekends.

Multiple residents experienced missed or delayed wound care, skin assessments, and gastrostomy tube (g-tube) care. One resident was admitted without pressure ulcers and later developed a stage 3 coccyx ulcer for which treatment was delayed 24 hours and then missed 16 times, ultimately progressing to a stage IV sacral ulcer with concern for osteomyelitis and hospitalization for severe sepsis. Another resident with a pre-existing stage IV sacral ulcer was hospitalized for sepsis related to the wound and osteomyelitis, returned to the facility, and then had multiple missed wound treatments. This same resident’s rectal tube was accidentally removed and not replaced due to lack of supplies, leaving the sacral wound exposed to fecal matter for extended periods, and g-tube site care and residual checks were repeatedly not completed, with subsequent hospitalization for sepsis with suspected sources including g-tube site infection and the stage IV sacral wound.

Medication administration was not reliably carried out as ordered. One resident missed 18 scheduled doses of significant medications, including anticoagulants, anticonvulsants, antihypertensives, nutritional supplements, and stimulants, with documentation indicating medications were on order or not available. Another resident did not receive any scheduled doses of ordered Norco over several days, and additional residents missed multiple doses of anticonvulsants, antihypertensives, and anticoagulant injections. The facility nurse practitioner reported awareness of problems with medication availability. Documentation and oversight of showers and basic hygiene were also deficient, as several residents had no evidence of receiving showers over a two-month period, and the interim DON confirmed that no one was overseeing whether showers were completed and documented.

Staff interviews and observations further demonstrated systemic failures in supervision and quality assurance. CNAs and nurses reported chronic short staffing, heavy reliance on agency staff, delayed call light response, missed pain medications, and wound treatments not being done daily. Staff stated that management told them not to disclose issues to surveyors and that concerns about staffing and care were not addressed. The wound nurse/infection preventionist reported not being educated on the wound process, not having wound logs when starting in December 2025, and not being delegated responsibility for monitoring MARs and TARs until early February 2026. The medical director stated that continuity of care was affected by staff and management changes and that he had not been informed of widespread missing treatments, medications, and care concerns. The facility lacked documentation of annual QAPI training for staff, required CNA in-service hours, and quarterly QAA meetings, with leadership confirming that QAA meetings had not been held since July 2025.

Removal Plan

• V2 (Interim DON) and V4 (ADON/Wound Nurse) in-serviced all licensed nurses on Physician Orders—Entering and Processing and Documentation in the Health Record, including the Physician Orders—Entering and Processing policy; orders are entered into the EMR by V2 and V4.
• V2 and V4 in-serviced all licensed nurses on Pressure Injury and Skin Condition Assessment and Documentation—Electronic Health Record policy (entries must be timely, accurate, relevant, and complete by V2 or V1).
• V2 and V4 in-serviced all staff on Change of Condition and Physician-Family Notification, including the Physician-Family Notification—Change in Condition policy.
• V2 and V4 in-serviced all staff on Comprehensive Care Plan/Baseline Care Plan, including the Baseline Care Plan.
• V2 and V4 in-serviced all staff on admission of residents, including the Admission of Resident Care Plan.
• V2 and V4 in-serviced all staff on the Resident/Admission–Readmission Checklist, including the admission checklist.
• V2 and V4 in-serviced the IDT on Comprehensive Care Plan, including the Comprehensive Care Plan.
• V2 and V4 in-serviced all staff on Infection Prevention and Control Program, including the Infection Prevention and Control Program policy.
• Initiated a facility audit to identify all residents with pressure ulcers, including completing wound assessments, contacting the physician and wound nurse, reassessing wounds in 24 hours, and obtaining consents to see the wound physician; 56 residents were assessed.
• V2 and V4 in-serviced staff on Pressure Injury and Skin Condition Assessment and implemented a process requiring the direct care nurse to review the TAR prior to providing wound care.
• V2 and V4 in-serviced staff on Pressure Ulcer Prevention and multiple related policies (Med Error/Adverse Drug Reaction, Physician Orders—Entering and Processing, Documentation—Health Record, Comprehensive Care Plan/Baseline Care Plan) and implemented a process to train staff on pressure ulcer prevention/worsening prevention interventions (review care plan before care; follow skin policy; weekly skin assessments; follow physician orders; identify residents dependent for repositioning; dietary/clinical follow meal ticket/orders for diet/supplements; review MAR/TAR prior to med pass and wound care; skin assessments on return from hospital; open risk management for skin breakdown and notify wound nurse/DON).
• V2 and V4 in-serviced all staff on Pressure Injury and Skin Condition Assessment and Skin Condition Assessment and Monitoring Pressure and Non-Pressure, including the Pressure Injury and Skin Condition Assessment policy.
• V2 and V4 in-serviced all nurses and CNAs on Pressure Ulcer Prevention, including the Pressure Ulcer Prevention policy.
• Began a facility-wide audit of all residents’ wound care plans and updated wound care plans.
• Completed a facility-wide review/audit of residents with wounds for needed changes and updated the physician; produced a wound report.
• Educated all licensed nurses on the complete Gastrostomy Tube—Feeding and Care policy (by V2, V3, and V4).
• Completed a facility-wide audit of all residents with gastrostomy tubes to ensure stoma site treatment orders, tube feeding orders in EHR, residual checks on MAR, monitoring/notification for GI symptoms, documentation of stoma abnormalities and physician notification, and care plan review/updates on TAR by the nurse (V2/designee).
• V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Management Policy.
• V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Assessment Policy.
• V3 and V4 in-serviced all licensed nurses on Medication Administration General Guidelines.
• V3 and V46 in-serviced all licensed nurses and CNAs on the Resident Rounds Policy and procedure.
• V3 and V46 in-serviced all clinical staff on the Bathing—Shower and Tub Policy.
• V3 and V4 in-serviced all staff on the Incontinence Care Policy and Procedures.
• V1 (AIT) in-serviced V25 (Housekeeping Supervisor) on the Activities Program Policy.
• V1 (AIT) in-serviced all staff on the Residents Rights and Dignity Policy.
• V14 (Corporate President of Operations) in-serviced facility leadership on the facility Quality Assurance Performance Improvement (QAPI) Program Procedure.
• V14 in-serviced facility leadership on the Program of Angel Round to ensure leadership availability to residents, families, and staff.
• V14 in-serviced facility leadership on ensuring oversight and implementing policies for wound care, medication administration, treatment administration, quality assurance measures, and basic ADL resident care, including review of job descriptions.
• V14 re-oriented V1 (AIT) on Administrator duties for the facility.
• Held an impromptu meeting with the medical director and interdisciplinary team to discuss the deficiency and facility action plan.
• Performed an audit on one resident per day to ensure residents with pressure injuries have wound prevention orders in EMR and that wound assessments are completed upon admission/re-admission or weekly per policy.
• Performed an audit on one resident per day to ensure treatments were performed and initialed/dated per policy.
• Performed an audit on one resident per day to ensure care plans are revised timely and interventions are linked to the Kardex; treatments are charted and signed off in PCC.
• Performed an audit on one resident per day to ensure wound physician progress notes are reviewed and the Physician Order Sheet is updated (treatments, labs, supplements, pressure-relieving devices) prior to the next scheduled wound care.
• Performed an audit on one resident per day to ensure weekly skin assessments are completed by the responsible nurse.
• Performed an audit on one resident per day (five days per week) to ensure nurses review the TAR prior to performing wound care procedures.
• Performed an audit on one resident per week to ensure the Dietary Department provides the correct diet/supplements.
• Performed an audit on one resident per day to ensure Infection Prevention Guidelines are followed when performing wound care.
• Performed an audit on one new admission per day to ensure all required equipment and supplies are obtained and in the facility.
• Completed the missed administration report and medication administration report daily to ensure MAR accuracy and completeness per policy/procedure.
• Completed a daily audit to ensure residents with gastrostomy tubes have stoma site treatment orders, TAR sign-off for completion, tube feeding orders in EHR, residual checks on MAR, physician notification/documentation for GI symptoms, and documentation/notification for stoma abnormalities.
• Planned to monitor all residents’ MARs daily to ensure residents are not going without medication (including visibility of medications documented as on hold).