Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accolade Healthcare Of Savoy during CMS and state inspections, most recent first.
Failure to follow the planned menu and provide substitutions when food service was disrupted. Residents reported not receiving coffee, hot food, or requested alternatives, and one resident with multiple diagnoses including dysphagia and cognitive issues was observed with a tray of items the resident said would not be eaten. The DON and dietary staff stated the kitchen was closed after the health permit was suspended, leaving only cold items and limited drinks available.
Meals Not Served in an Appealing or Appetizing Manner: Residents were observed receiving breakfast items such as boiled eggs, cottage cheese, and yogurt served in disposable bowls and plastic cups rather than dishes, and one resident stated the food did not look good and could not be eaten. A resident with dx including dysphagia, cognitive impairment, and weight loss, another resident with dx including dementia and dysphagia, and a third resident with anxiety, depression, and dysphagia were all affected by meals that staff described as not presentable or appealing; the DON provided a roster showing 182 residents in the facility.
Failure to provide adequate drinks with meals. Surveyors observed multiple residents with dx including dysphagia, dementia, CVA, and cognitive impairment eating meals with little or no beverage available; one resident stated staff were not very good at giving a drink and the resident had to ask most of the time, and another stated the tray did not come with any drinks. Staff interviews indicated residents should receive at least two drinks with meals, but observations showed only a single carton of milk or no drink at all for some residents.
Kitchen equipment malfunction led to the kitchen being closed after a failed health inspection, and staff reported they were unable to cook in-house meals or serve hot food and drinks. The DM said the hot box was not working, so only cold items such as prepacked eggs, yogurt, and cottage cheese were served, while lunch and dinner were catered. Residents reported the kitchen was shut down, hot beverages were unavailable, and food quality had declined.
Failure to Maintain a Clean and Homelike Environment: A cognitively intact resident with multiple diagnoses, including CP and malnutrition, was observed in bed with deep wall scratches by the head of the bed covered with white plaster. A white patch was also observed on a common-area wall near the lobby. The MDS, Maintenance Director, maintenance staff, and Administrator all described delayed or undocumented repairs, with no work order completed for the resident room plastering.
Failure to assist a resident with meal setup and eating support. The resident had multiple diagnoses including dysphagia, aphasia, cognitive impairment, dehydration risk, nutritional problems, and an ADL deficit, and the MDS documented severe cognitive impairment. During lunch, the resident had an unopened fruit cup, wrapped silverware, an unpeeled banana, and a condiment packet the resident could not open, while stating help was needed. A CNA said staff were expected to unwrap silverware, open cups, and cut food, and the DON said CNAs were expected to assist residents before walking away from meal trays.
Mechanical soft diets were not prepared in the expected moist form for three residents with dysphagia and other significant medical conditions. A resident with cognitive impairment and dysphagia, another resident with cerebral infarction and dysphagia, and a third resident with dementia and dysphagia were observed receiving dry ground chicken/meat without gravy or sauce, along with other items such as fries and garlic bread. Staff stated mechanical soft foods should be moist and mixed with gravy or another moistening agent.
Two residents with moderate cognitive impairment and significant ADL needs were observed in soiled clothing for extended periods, indicating a failure to provide dignified, hygienic care. One resident, who required staff assistance for dressing, hygiene, and toileting, remained in pants and a shirt with copious dried food despite having requested a clothing change after a meal and being taken to the bathroom by a CNA before being brought to therapy still soiled. A second resident, who needed partial assistance with dressing and personal hygiene, reported being put to bed after supper in soiled day clothes and was found the next morning still wearing the same soiled shirt, later confirmed by a CNA. These events occurred despite facility policy requiring all staff to ensure resident privacy and dignity.
The facility failed to maintain safe bed heights, ensure call lights and bed controls were within reach, and properly manage low air loss mattresses for several residents at high risk for falls. One resident with metastatic cancer, moderate cognitive impairment, and dependence for mobility fell from an elevated bed with a slick LAL mattress while attempting to reach a wheelchair that was routinely kept across the room, sustaining a displaced humeral fracture; the same resident was later found again in an elevated bed with both the call light and bed control out of reach. Another resident with diabetes, neuropathy, muscle wasting, moderate cognitive impairment, and multiple recent unwitnessed falls was observed in a similarly elevated bed with the bed control behind the head of the bed and the call light coiled on the floor, leaving no way to summon help. A third resident with osteoporosis, repeated falls, and moderate cognitive impairment had a documented fall after rising from a recliner and was later seen in a wheelchair with the call light attached to the bed and out of reach. A fourth resident with repeated falls and a physician order for a LAL mattress experienced repeated mattress deflations while in bed due to a plug that repeatedly popped open, leaving the surface partially or nearly flat.
A resident with multiple comorbidities, moderate cognitive impairment, and documented MASD to the buttocks, who required substantial/maximal assistance with ADLs and was frequently incontinent of bladder and always incontinent of bowel, was found in bed with a strong feces odor, the bed elevated, and the call light on the floor out of reach. Staff reported that incontinence care had last been provided several hours earlier, and the assigned CNA had not yet changed the resident during the current shift. When incontinence care was finally provided, staff found dried feces on both buttocks and visible MASD with shearing, and the wound RN confirmed the MASD was likely related to delayed incontinence care. This was inconsistent with the resident’s care plan and the facility’s policy requiring incontinence care after each incontinent episode and maintenance of clean, dry skin.
The facility failed to reasonably accommodate residents’ needs by not keeping call lights within reach for multiple residents and not maintaining a functional electric bed for a resident’s toileting independence. Several residents with conditions such as dementia, weakness, deconditioning, incontinence, hemiplegia, and impaired mobility were observed in bed or in wheelchairs without accessible call lights, with call cords found on the floor, under beds, or draped out of reach while they requested help for needs such as toileting, warmth, and fluids. Another resident with paraplegia and significant mobility impairments relied on an electric bed and bedside commode for independent bowel and bladder toileting but reported that the bed remote had malfunctioned intermittently for months, leaving the bed at a height mismatch with the commode and requiring the resident to manipulate exposed wires to adjust the bed. Maintenance records documented repeated problems with the bed remote, and an LPN confirmed the resident is reliable in reporting care concerns.
The facility failed to prevent accidents by not providing adequate supervision and not controlling environmental hazards for three residents. A resident with dysphagia and documented choking risk, whose care plan required supervised meals, was observed eating lunch alone in bed on multiple occasions after reporting a choking episode, and speech therapy was not promptly engaged despite prior recommendations for supervised dining. Another cognitively impaired, fully dependent resident ingested shampoo/body wash that had been left within reach, later developing vomiting, diarrhea, and low oxygen saturation, necessitating ER transfer, even though the product was labeled for external use only. A third resident with dementia, severe cognitive impairment, a history of falls, and high fall risk experienced an unwitnessed fall after staff propped open a keypad-locked central bathroom door that was supposed to remain locked and only used with staff supervision.
A resident with CHF had daily weight orders and a care plan requiring notification for weight fluctuations, but staff did not timely report a 39.6-lb weight gain to the NP. The resident later became lethargic with edema and was transferred to the hospital for acute on chronic respiratory and heart failure, where the resident required CPAP/BiPAP and IV diuretics. The DON stated the only documentation found was an unconfirmed fax, and the NP stated staff should have notified her sooner and followed the CHF protocol.
A resident with severe cognitive impairment had multiple elevated blood glucose readings documented, but staff did not notify the physician as required by both physician orders and facility policy. The DON and NP confirmed that these elevated results should have been reported, and the facility's policy mandated notification for readings above 200 mg/dl.
A resident with glaucoma did not receive prescribed Latanoprost eye drops for the first ten days of admission because the medication was not available. The resident reported the missed doses to staff, who confirmed the medication was on order. The DON verified the delay in administration, which was documented in the MAR, despite facility policy requiring timely medication administration.
A resident who was severely cognitively impaired and dependent on staff received water flushes, nutritional feeding, and medications through a G-tube without the LPN first checking tube placement, as required by physician orders and facility policy. The DON confirmed that the necessary verification was not performed before administration.
A resident with a G-Tube and severe cognitive impairment, who was on Enhanced Barrier Precautions (EBP) due to MDRO risk, received medication, water flushes, and nutritional feeding from an LPN who did not wear a gown as required by facility policy. The LPN was aware of the EBP protocol, and PPE was available and signage posted, but the protocol was not followed during high-contact care activities.
Two residents with complex medical histories did not receive appropriate monitoring and reporting of blood pressures, daily weights, and urination as ordered, leading to delayed recognition and response to significant changes in their conditions. Staff failed to notify providers of abnormal findings and unsuccessful attempts to collect urine samples, and did not consistently document or resume required monitoring after hospital readmissions, resulting in delayed treatment and adverse outcomes.
Two residents were transported in wheelchairs without foot pedals, leading to one sustaining ankle fractures after her leg dropped while being pushed by a staff member. Another resident with cognitive impairment exited the memory care unit unnoticed and was found in a nearby parking lot, with staff failing to follow the facility's missing resident policy or update the care plan after the incident.
The facility did not ensure that provider progress notes and incident reports were consistently uploaded into residents' EMRs, resulting in incomplete records for several residents. In one case, a resident's injury and the related provider note were not documented in the EMR, and in another, a resident's elopement was not recorded, nor were required notifications and procedures followed by the LPN and administrator.
A resident eloped from the memory care unit and was found by a family member in a nearby church parking lot. The LPN on duty did not assess the resident, notify the physician or power of attorney, or follow the facility's missing resident policy, including required notifications and documentation. The administrator and nurse practitioner were not informed of the incident, and the DON was only notified after the resident was found.
A resident with severe osteopenia and recent right ankle fractures was evaluated by a podiatrist, who ordered Vitamin D3 2000 units daily. The order was documented in a progress note but was not transcribed or implemented, resulting in the resident continuing to receive less than the prescribed amount of Vitamin D3. The DON confirmed that new orders from specialty appointments were not communicated to the facility, leading to the deficiency.
A resident did not receive prescribed doses of Metoprolol, Midodrine, and Novolog insulin after a hospital discharge because an ADON mistakenly discontinued the medications, believing the resident was still hospitalized. The medications were not properly resumed, and there was no documentation explaining the missed doses or physician notification, resulting in significant medication errors.
A CNA took an unauthorized video of a resident with severe cognitive impairment and multiple diagnoses, using a personal cell phone and storing the video in personal cloud storage accessible to others. This action violated facility policy prohibiting the recording of residents and compromised the resident's right to privacy.
A resident experienced a fall that was not reported by a CNA to the licensed nurse, resulting in a lack of notification to the resident's physician and family. The incident was not documented in the medical record, and the family member only learned of the fall through informal means. Facility policy requiring prompt reporting of accidents and incidents was not followed.
A resident experienced a fall that was not reported to a licensed nurse, resulting in the resident being moved from the floor by CNAs without a nursing or neurological assessment. The incident was only discovered after a family member raised concerns, despite facility policy requiring nurse notification and assessment before moving a resident after a fall.
A resident with severe cognitive impairment and a history of potential for abuse was verbally abused with a racial slur and then physically struck on the head by another resident, despite care plan interventions and staff presence. The incident was witnessed by an LPN and occurred in the presence of the physically intact resident’s daughter. No injuries were noted after assessment.
A resident with severe cognitive impairment and a history of bruising was found with a large, unexplained bruise on the right upper extremity. Nursing staff documented and reported the injury internally, but the facility did not report the incident to the state agency as required, assuming it was related to the resident's medical history and anticoagulant use. This action was not in accordance with facility policy, which mandates reporting injuries of unknown origin to the state within 24 hours.
A resident with pressure ulcers did not receive proper Enhanced Barrier Precautions (EBP) during wound care, as two nurses performed the procedure without donning gowns, despite facility policy and orders requiring gown and glove use for high-contact care. The staff mistakenly believed EBP supplies were for the roommate, and the DON confirmed EBP should have been followed.
A resident who experienced a fall was initially assessed with no pain, but later developed significant left hip pain that was reported by therapy staff to nursing. There was a delay in notifying the provider and in obtaining a STAT x-ray, resulting in a delayed diagnosis and treatment of a hip fracture. Staff interviews and documentation revealed lapses in communication and failure to follow acute change protocols.
The facility failed to provide adequate care for residents dependent on staff for activities of daily living. A resident was admitted to the hospital with poor oral hygiene and had not been bathed or received oral care since returning. Another resident lacked oral care supplies and assistance, while a third was found saturated in urine and with old feces, indicating neglect in toileting care. The DON confirmed these deficiencies, stating the care provided was unacceptable.
A facility failed to identify and manage pressure ulcers for a resident returning from the hospital. The resident had stage two pressure wounds and a deep tissue injury, which were not assessed or treated by staff. The LPN did not perform a full skin check, and the wound nurse was not informed. The facility did not notify the treatment nurse, physician, or family, and there were no treatment orders or interventions in place.
The facility failed to accurately encode MDS for three residents, leading to incorrect documentation of falls and injury severity. One resident had multiple falls, including a major injury, but the MDS recorded only minor injuries. Another resident had a major injury from a fall, but the MDS documented only one fall with injury. A third resident's fall with a skin tear was recorded as a fall with no injury. The DON and RN Manager confirmed these inaccuracies.
The facility failed to obtain weights per physician orders for two residents and did not adequately monitor an at-risk resident for weight loss. One resident experienced severe weight loss without a proper care plan or notification to their representative. Another resident with congestive heart failure was not weighed daily as required, missing 53 daily weights. A third resident, nutritionally at risk due to renal dialysis, was also not weighed according to orders, with several weights missed. The facility acknowledged these deficiencies.
A resident with End Stage Renal Disease was hospitalized due to a central venous catheter infection after the facility failed to monitor the dialysis access site and maintain communication with the dialysis center. The facility's protocol required nursing staff to assess the site and communicate any changes, but these actions were not documented, leading to the resident's infection and hospitalization.
The facility failed to implement fall interventions for three residents, including ensuring a resident wore a required back brace, completing quarterly fall risk assessments, and maintaining functional call light systems. These deficiencies were confirmed by staff and observed during a survey.
A resident with severe cognitive impairment tested positive for COVID-19, but the facility failed to notify the family representative and healthcare providers of this diagnosis and subsequent changes in the resident's condition, including lethargy and abnormal lung sounds. The facility's policies require such notifications, but documentation was lacking.
A facility failed to document the application of a physician-ordered TLSO back brace for a resident with dementia and vertebral fractures. The Electronic Medication/Treatment Administration Records lacked nurse initials to confirm the brace was applied, due to an error by the admissions nurse in setting up the administration record option.
A resident admitted after joint replacement surgery did not receive prescribed Oxycodone for pain due to unavailability at the facility. The nurse on duty failed to contact medical staff for an alternative, resulting in the resident experiencing severe pain until the next day when the Nurse Practitioner intervened.
A facility failed to manage a resident's PICC line, which was necessary for administering IV antibiotics for osteomyelitis. The facility's policy required regular dressing changes to prevent infections, but no changes were documented until after the PICC line fell out, necessitating a peripheral IV. The oversight was confirmed by the ADON, who acknowledged that no dressing changes were performed since the resident's admission.
The facility failed to maintain residents' dignity by not responding to call lights in a timely manner, affecting several residents. Reports indicated wait times of up to 45 minutes, with staff sometimes turning off call lights without returning. Resident Council Meeting Minutes documented ongoing concerns, and a printout showed over 650 instances of delayed responses. Staffing levels appeared inadequate, contributing to prolonged response times.
The facility failed to maintain clean and safe bathroom flooring, affecting 15 residents. Observations revealed ground-in dirt, stains, and trip hazards due to cracks and loose edges in the vinyl floors. The Maintenance Director and Administrator acknowledged the issues, with the former expressing a desire to replace the vinyl with epoxy floors.
A resident's family member reported that a CNA startled the resident awake and was rude during care. The facility failed to report this allegation of mental abuse to the state agency within the required 2-hour timeframe, as mandated by their policy. The incident was only reported after a surveyor's intervention.
Two residents were affected by misappropriation of property by facility staff, with one resident experiencing unauthorized transactions totaling $1,515.96. The facility's investigation revealed that a CNA took photographs of residents' personal information, violating facility policy. The implicated CNA was suspended following the discovery.
A CNA at a facility was found to have taken unauthorized photographs of two residents' personal items, including debit cards and a Social Security card, and shared them with another individual. This breach of the facility's Abuse Prevention Program led to fraudulent transactions on one resident's account, causing financial distress. The CNA denied the allegations and was terminated.
The facility failed to ensure fall interventions and safety measures were in place, affecting three residents. One resident fell from a low air loss mattress due to improper positioning, another fell while trying to reach for a drink with no fall mat or call light within reach, and a third fell attempting to sit in a rolling chair left unattended in a dementia unit.
A resident with no cognitive impairment and frequent incontinence reported feeling humiliated by a CNA who questioned her about wearing a diaper and needing to use the bathroom. The facility's policy on resident dignity was not followed, leading to a dignity issue for the resident.
The facility failed to protect a resident from verbal and mental abuse by another resident with severe cognitive impairment. The abusive resident accused the other of theft, used racial slurs, and caused fear and distress. Despite staff intervention, the abusive behavior continued, highlighting a deficiency in the facility's abuse prevention measures.
The facility failed to ensure an allegation of physical and verbal abuse by one resident towards another was reported to the Administrator/Abuse Prevention Coordinator. This resulted in both residents continuing to reside in the same bedroom, potentially subjecting one resident to further abuse. The incident was documented by an LPN but not properly escalated, leading to a delay in addressing the abuse allegations.
A resident with multiple medical conditions fell during a mechanical lift transfer when a CNA attempted the transfer alone, contrary to the facility's policy requiring two staff members. The resident fell out of the sling, hitting her buttocks and head, and was sent to the Emergency Department but returned with no injuries.
Failure to Follow Menu and Provide Food Substitutions
Penalty
Summary
The facility failed to provide all items listed on the daily menu and failed to ensure substitutions were available for residents when the kitchen was closed after the Local Public Health Department suspended the food service permit on 4/30/2026. The inspection report stated that all food handling, preparation, and service had to cease at 11:15 a.m. because of an inadequate food safety management system, and the facility’s planned menus for 4/30/2026 through 5/4/2026 could not be followed. The Dietary Manager stated the facility could not serve hot food or hot beverages, including coffee or hot water for tea, and that only cold items, water, milk, and small cups of juice were available until a contracted food source would begin on 5/4/2026. Two residents described receiving meals that did not match their preferences or needs. One resident with diagnoses including generalized anxiety, osteoporosis, Barrett’s esophagus, major depressive disorder, mild cognitive disorder, dysphagia, communication deficit, and hearing loss stated breakfast was not going well, that coffee was not being served, and that hot water and hot food had not been available for the last couple of days. Another resident with diagnoses including iron deficiency anemia, ESRD on dialysis, type 2 diabetes, GERD, electrolyte and fluid balance disorder, dysphagia, and aphasia was observed with a tray containing boiled eggs, yogurt, and water, and stated the resident did not want the banana, would not eat the eggs or yogurt, had asked for bread and peanut butter, and had not received it. The resident’s family member stated the facility had been serving boiled eggs, cottage cheese, and yogurt for breakfast since the kitchen was closed and that the resident had not been getting the added bread and peanut butter.
Meals Not Served in an Appealing or Appetizing Manner
Penalty
Summary
The facility failed to ensure meals were palatable, attractive, and appetizing. On 5/2/2026, R1, who had diagnoses including displaced fracture of the left humerus, metabolic encephalopathy, mild cognitive impairment, dysphagia, cognitive communication impairment, and aphasia, was observed eating breakfast with two untouched boiled eggs served in a small disposable bowl, untouched cottage cheese served in a five-ounce plastic cup, yogurt in a nine-ounce plastic cup, and a half pint carton of milk. R1 stated, "I cannot eat that," pointing to the cottage cheese, and said, "I don't even know what this is, it does not look good." R1's care plan documented nutritional problems, dehydration or potential fluid deficit, and a five percent weight loss in one month. R4, who had diagnoses including generalized anxiety, osteoporosis, Barrett's esophagus, major depressive disorder, mild cognitive disorder, dysphagia, and communication deficit, was observed in bed with breakfast consisting of two boiled eggs in a small disposable bowl, cottage cheese in a nine-ounce plastic cup, and yogurt in a five-ounce plastic cup, with no drinks observed on the tray. R4 stated the food did not look good and said food had not been well for a couple of days. R6, whose care plan documented dysphagia following cerebrovascular disease, chronic kidney disease stage 3, iron deficiency anemia, alcohol abuse, dementia, epilepsy, psychotic disturbances, mood disturbance, Alzheimer's disease, specified disorder of brain, cerebral infarction, dysphagia, and cognitive communication deficit, was observed eating breakfast in the smaller second-floor dining room with two boiled eggs in a small disposable bowl, cottage cheese in a five-ounce plastic cup, and yogurt in a nine-ounce plastic cup. The dietary manager, assistant dietary manager, dietary aides, and regional dietician all stated that meals should be appealing and presentable, served in dishes rather than disposable plates, bowls, or plastic cups, and that appetizing food should have variety of color and texture. The director of nursing provided a resident roster showing 182 residents in the facility on the date of observation.
Failure to Provide Adequate Drinks With Meals
Penalty
Summary
The facility failed to provide adequate beverages to residents during meals, despite care plans documenting dehydration or potential fluid deficit and interventions to encourage fluids of choice to maintain hydration. The report states this failure had the potential to affect all 182 residents residing at the facility. The facility’s Hydration and Prevention of Dehydration Policy dated January 2026 states nurse’s aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care. For one resident with diagnoses including displaced fracture of the left humerus, metabolic encephalopathy, mild cognitive impairment, dysphagia, cognitive communication impairment, and aphasia, surveyors observed the resident eating lunch with dry ground chicken strips, garlic bread, banana, french fries, and fruit, but no drink on the tray. An empty disposable cup was on the table, and the resident stated the cup had been empty for awhile and that staff were not very good at giving a drink, so the resident had to ask most of the time. The resident’s care plan documented dehydration or potential fluid deficit, and the nutrition/dietary note documented five percent weight loss in one month. For another resident with diagnoses including cerebral infarction due to stenosis of a small artery, weakness, constipation, dysphagia, and muscle atrophy, surveyors observed the resident eating lunch with dry ground chicken strips, french fries, and garlic bread, with only a half-pint carton of milk on the table and no other drinks observed. The resident stated the tray did not come with any drinks and that the resident had to ask for the milk. For a third resident with diagnoses including dysphagia following cerebrovascular disease, anxiety, dementia, Alzheimer’s disease, cerebral infarction, and cognitive communication deficit, surveyors observed breakfast with two boiled eggs, cottage cheese, yogurt, and one half-pint carton of milk, with no other drinks observed or offered during the meal. Staff interviews indicated residents should have at least two drinks with meals, and the dietary manager stated there should not be any resident without a drink at all.
Kitchen Closed After Equipment Malfunction Prevented Hot Food Service
Penalty
Summary
The facility failed to keep kitchen equipment functioning properly, resulting in the kitchen being closed after a Local Health Department inspection on 4/30/2026. On 5/2/2026, the Dietary Manager stated the kitchen had been closed since the inspection and that the facility was not able to serve hot food or hot drinks, including coffee or hot water for tea. Staff reported that only cold items were being served, with breakfast limited to prepacked cold foods such as boiled eggs, yogurt, and cottage cheese, while lunch and dinner were being catered from outside the facility. During observations, kitchen staff were not cooking or preparing in-house meals and were portioning yogurt and cottage cheese into disposable cups. The Dietary Manager stated the inspection failure was due to a malfunction of one piece of kitchen equipment, identified as the hot box, which was off and not being used. The Dietary Manager also stated the thermostat was located at the bottom of the equipment and was not easily visible. Residents interviewed stated the kitchen was shut down, only cold food was being served, and hot beverages were unavailable; one resident reported not having had good food for a couple of days and said a spouse had been bringing food from outside.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for one of three residents reviewed for environment. The resident had diagnoses including rhabdomyolysis, hypertension, cerebral palsy, muscle wasting and atrophy, lack of coordination, hypnosis, and unspecified protein-calorie malnutrition, and the care plan documented that the resident needed assistance during transfers. The resident’s MDS documented that the resident was cognitively intact. During observation, the resident was sitting in bed eating breakfast while scattered deep scratches were seen on the wall by the head of the bed, measuring approximately 2.5 feet by 2 feet, and the scratches were covered by white plaster. The resident stated that someone knew about the scratches and that the plaster had been applied about a month earlier, adding that the wall did not look good. Additional observations showed a white patch on the wall by the entrance door in the common area near the lobby, measuring approximately 2.5 feet by 1 foot. The Maintenance Director stated the patch was from drywall mud applied about two weeks earlier and needed time to dry before sanding and painting, and also stated that the maintenance department had only two staff and often got behind on work orders, prioritizing resident room repairs over common areas. The Maintenance Director further stated the plaster in the resident’s room should have been repaired the same day with a wall protection sheet and did not know about the plaster being applied or have a work order for it. Maintenance staff later stated they applied the plaster about a month earlier and did not make a work order, while the Administrator stated maintenance staff had been fixing what they saw as they went and did not need to complete a work order.
Failure to Assist Resident With Meal Setup and Feeding Support
Penalty
Summary
The facility failed to provide assistance with meals to a resident who was unable to perform the task independently. The resident’s care plan documented diagnoses including displaced fracture of the left humerus, metabolic encephalopathy, mild cognitive impairment, dysphagia, aphasia, cognitive communication impairment, dehydration or potential fluid deficit, nutritional problems, and an ADL self-care performance deficit. The MDS documented severe cognitive impairment. During lunch observation, the resident was seated in the room with a meal tray that included ground chicken strips, garlic bread, a banana that was unpeeled, French fries, and an unopened cup of fruit. The resident’s silverware was still wrapped, and the resident was holding a condiment packet that could not be opened independently. The resident stated not having the strength to open it, said the banana could not be peeled, and stated the fruit cup was likely not going to be eaten because it was hard to get someone to help open it. A CNA stated it was expected that CNAs assist residents by unwrapping silverware, opening cups, and cutting up foods when serving meal trays, and the DON stated CNAs were expected to provide assistance to residents before walking away after serving meal trays.
Mechanical Soft Diets Served Dry and Not Moist
Penalty
Summary
The facility failed to provide mechanical soft diet consistency that was prepared in a moist form for three residents reviewed for mechanical soft diets. Resident 1 had diagnoses including dysphagia, cognitive impairment, aphasia, and metabolic encephalopathy, and the care plan documented nutritional problems, ADL deficits, and dehydration or potential fluid deficit. On observation, Resident 1 was eating lunch with ground chicken strips that appeared dry with no moisture or gravy or sauce on the side, along with garlic bread, french fries, and an unpeeled banana. The resident stated there was no drink available and said the food did not look good and would not be eaten. Resident 3 had diagnoses including cerebral infarction, dysphagia, and muscle atrophy, with care plan documentation of nutritional problems related to dysphagia and dehydration or potential fluid deficit. Resident 3’s lunch tray also contained ground meat that appeared dry and not moist, along with French fries and garlic bread. Resident 6 had diagnoses including dysphagia following cerebrovascular disease, dementia, Alzheimer’s disease, and cognitive communication deficit, and was ordered a no added salt mechanical soft texture diet. Resident 6 was observed eating lunch in the dining room with ground chicken strips that had no sauce or gravy and appeared dry and not moist. Staff interviews confirmed that mechanical soft diets were expected to be moist, with meat mixed with gravy or another moistening agent, and that the lunch chicken strips were not prepared that way.
Failure to Provide Dignified, Hygienic Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide dignified care and maintain hygiene for dependent residents, affecting two residents reviewed for hygiene and dignity. One resident (R8) had multiple medical diagnoses including essential hypertension, acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, repeated falls, gait and mobility abnormalities, muscle wasting and atrophy, and osteoporosis. An MDS documented moderate cognitive impairment and a need for partial to substantial assistance with ADLs, and the care plan specified staff assistance for dressing, personal hygiene/oral care, and toileting, as well as prompt response to call lights due to fall risk. On observation, R8 was seated in a wheelchair with copious dried food on the upper legs of the pants and on the abdomen area of the shirt; the resident stated that breakfast had been at 7:30 a.m., that they had asked nurses to change their pants after breakfast, and that they needed assistance to use the bathroom. When R8 activated the call light, a CNA (V35) responded immediately and assisted the resident to the bathroom. Approximately 20 minutes later, the resident was no longer in the bathroom and was found in the therapy room receiving therapy, still wearing the same soiled pants and shirt with copious dried food. The resident’s family member expressed concern about nursing care and reported having previously waited 15 minutes for staff to respond to the call light, stating that the resident could not wait that long to use the bathroom. The family member also stated that a home care provider did the resident’s laundry and that there should be plenty of clean clothes available. The CNA later confirmed noticing the food on the resident’s clothes when taking the resident to the bathroom before therapy, acknowledged that the clothes should have been changed at that time, and stated that the resident probably was embarrassed going to therapy in soiled clothing, but the CNA went to help another resident instead and did not return to change the clothes. A second resident (R1) had an MDS documenting moderate cognitive impairment, a primary medical condition of a progressive neurological condition, and a need for partial/moderate assistance with dressing, toileting, transfers, and personal hygiene. On observation in the morning before breakfast trays were delivered, R1 was in bed with the lower body covered by a sheet and blanket, wearing a long-sleeve red shirt soiled with light-colored food-like particles on the chest and dried streaks of a liquid-like substance down the front. R1 reported not having had breakfast yet and stated that they had been put to bed in their soiled day clothes the previous night after supper, and that they would have preferred to sleep in clean pajamas for comfort. Later that morning, when a CNA (V56) entered to complete morning care, the CNA confirmed that R1 was in soiled day clothes and had slept in them overnight. The facility’s policy on Resident Privacy and Dignity stated that all residents are to be provided with dignity and privacy in a home-like environment, and that all staff are responsible for ensuring residents’ privacy and dignity.
Failure to Maintain Safe Bed Heights, Call Light Access, and Mattress Function for Multiple Residents at Fall Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for multiple residents at risk for falls, particularly in relation to bed height, use of low air loss (LAL) mattresses, and access to call lights and bed controls. One resident with metastatic cancer, moderate cognitive impairment (BIMS 11), inattention, incontinence, and dependence or substantial assistance needs for bed mobility and transfers was care planned as at risk for falls. Prior to a major fall, staff documented that this resident adjusted the bed independently and that the bed was observed in the air with the remote in the resident’s hand. On the day of the fall, CNAs reported finding the resident in bed with the call light in reach and the bed at a reasonable height, then later sitting on the side of an elevated bed with the bed control beside the resident. Shortly afterward, the resident was found on the floor lateral to the bed, without non-skid socks, and stated he had been trying to get to his wheelchair. Facility investigation and interviews with the DON, hospice nurse, and family indicated that the resident’s LAL mattress was slick and that the mattress and elevated bed height contributed to the resident being “nudged” or “lifted” off the bed when attempting to sit or stand, while the wheelchair was routinely positioned across the room rather than next to the bed. After this fall with a right humerus, moderately displaced spiral fracture of the mid-humeral diaphysis requiring hospitalization, the same resident experienced a second safety event. On a later observation, the resident was found lying in an elevated bed with the mattress surface approximately three and a half feet above the floor. The wheelchair remained across the room near a recliner, about eight feet from the bed. A sign on the bathroom door directed the resident to use the call light for help, but at the time of observation the call light cord was dangling off the bed frame out of reach, and the bed remote control was also out of reach near the foot of the bed. The resident, described as pleasantly confused and with ongoing moderate cognitive impairment, stated he did not understand why the bed was elevated, did not know how it got that way, and reported difficulty seeing and using the call light when it was not positioned where he could see it. Another resident with diabetes, polyneuropathy, muscle wasting, difficulty walking, moderate cognitive impairment (BIMS 12), and a history of multiple recent unwitnessed falls (from a wheelchair while leaning for shoes, from bed while reaching for a bag, and from in front of the toilet) was care planned as at risk for falls and dependent on staff for substantial/maximal assistance with ADLs. This resident was later observed lying in an elevated bed with the mattress about three and a half feet off the floor, the head of bed at about 45 degrees, the bed control device positioned behind the elevated head of the bed and out of reach, and the call light cord coiled on the floor under the head of the bed. The resident stated having no way to ask staff for help when the call light was not on the bed, could not reach the bed control, and did not like the bed being so far off the floor, and believed the bed had been left that way after night shift incontinence care. A third resident with repeated falls, osteoporosis/osteopenia, gait and mobility abnormalities, muscle wasting, and moderate cognitive impairment (BIMS 11) had a care plan identifying fall risk and the need for the call light to be within reach. Nursing documentation showed a recent fall when the resident stood from a recliner and fell, striking the head on a bedside table and sustaining a large skin tear to the right elbow. During surveyor observation, this resident was seated in a wheelchair about three feet from the bed while the call light was attached to the pillowcase on the bed, out of the resident’s reach despite the care plan requirement that the call light be accessible. A fourth resident with repeated falls, encephalopathy, gait and coordination problems, cognitive communication deficit, high fall risk, and an order for a LAL mattress was found to have an air mattress that repeatedly deflated while the resident was in bed. The physician order required the LAL mattress dial to be set at the resident’s weight and specified use of a loose sheet or bed pad only. A COTA reported finding the mattress almost flat with the resident lying on it and identified that the beach-ball-type plug had come out, causing the mattress to deflate. The COTA stated this had happened previously, including over a weekend, and that the plug had to be forced back in. A CNA also reported that about a week earlier the night RN supervisor had shown her that the same resident’s air mattress had gone flat because the plug had popped open, and staff remained with the resident while the mattress refilled. These repeated episodes show that the LAL mattress was not consistently maintained in a safe, inflated condition while the resident was in bed.
Failure to Provide Timely Incontinence Care and Maintain Call-Light Access
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and maintain access to a call light for a resident who is frequently incontinent of bladder and always incontinent of bowel. The resident had multiple diagnoses including Type II diabetes with complications, chronic kidney disease on dialysis, muscle wasting, difficulty walking, and depression, and was care planned as needing substantial/maximal assistance with all ADLs except eating, with use of a sit-to-stand lift and instructions to use the call bell for assistance. The care plan also documented existing MASD to the scrotum and bilateral buttocks, present on admission, with directions to keep the skin clean and dry and follow facility protocols for treatment of skin injury. The facility’s toileting and incontinence care policy required incontinence care after each incontinent episode and stated that CNAs are responsible for providing this care and charge nurses are responsible for ensuring it is provided. On the morning in question, the resident was observed in bed with the mattress elevated approximately three and a half feet above the floor, a strong feces odor in the room, and the call light on the floor out of reach. The resident reported having no way to call staff, believed night-shift CNAs had left the bed elevated and the call light out of reach after changing him in the middle of the night, and expressed uncertainty about being wet and needing to be checked. A CNA entered the room, adjusted the bed, and returned the call light, stating she would inform the assigned CNA that the resident needed incontinence care. The assigned CNA later stated she had not yet changed the resident since starting at 6:00 a.m. and that night shift had reported providing care around 5:00 a.m. At approximately 9:30 a.m., about four and a half hours after the last reported incontinence care, staff provided incontinence care and found dried feces on the resident’s bilateral buttocks and visible MASD with shearing areas on both buttocks. The wound nurse confirmed the MASD was likely caused by delays in incontinence care, demonstrating that incontinence care was not provided in a timely manner after an incontinent episode as required by facility policy and the resident’s care plan.
Failure to Maintain Accessible Call Lights and Functional Electric Bed for Toileting Independence
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not maintaining call lights within reach for multiple residents and not ensuring a consistently functional electric bed for toileting independence. The facility’s own Call Lights policy required staff to keep call lights within easy reach when a resident is in bed or in a chair. Surveyors observed five residents in their rooms without accessible call lights: one resident in a wheelchair in a room smelling of bowel movement, who stated she was soiled and waiting for staff but had her call light coiled on the floor out of reach; another resident in a wheelchair who wanted fresh ice water but could not reach a call light hanging over a folded fall mat; a resident sitting on the side of a bed that was soiled with urine, with the call light coiled on the floor by the wall; a resident sitting on her bed asking for help who did not know where her call light was, later found on the floor under the bed; and another resident sitting on her bed, asking for help because she was cold and needed a blanket, whose call light was coiled on the floor out of reach. Care plans for these residents documented risks such as falls, dementia, weakness, deconditioning, incontinence, vision and hearing problems, hemiplegia, confusion, and the need for staff assistance with ADLs, and directed staff to keep call lights within reach and encourage their use. The deficiency also includes the facility’s failure to ensure an electric bed remained consistently functional for a resident who relied on it to maintain toileting independence. This resident, with diagnoses including paraplegia, muscle wasting and atrophy, abnormality of gait and mobility, and lack of coordination, was unable to walk and used a wheelchair. The resident reported independent use of a bedside commode for bowel and bladder toileting, facilitated by raising and lowering the electric bed with a remote to match the commode height for transfers. The resident stated the bed remote had been intermittently malfunctioning for months, causing the bed to become stuck at a higher position than the commode and making transfers back into bed difficult, with the commode sliding on the floor during attempts to transfer. The resident reported informing staff numerous times about the malfunctioning remote without timely resolution and described having to manipulate the wires to operate the bed. When the surveyor observed the resident attempting to use the remote, the buttons did not work, and the facility maintenance log documented issues with wires hanging from the remote and the remote not working on multiple prior dates. An LPN familiar with the resident reported that the resident does not make false statements about staff and nursing care.
Failure to Prevent Accidents Through Adequate Supervision and Hazard Control
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement interventions to prevent accidents for multiple residents. One resident with dysphagia, hemiplegia, vascular dementia, and a care plan identifying a swallowing problem and risk for choking and aspiration was ordered a mechanical soft diet and required supervision while eating. The resident’s MDS documented that she coughed or choked during meals and had complaints of difficulty or pain with swallowing. A nurse’s progress note recorded that the resident reported a choking episode during a noon meal, with a short instance of labored breathing, and that her diet was downgraded and a referral to speech therapy was entered. Despite this, surveyors observed the resident eating lunch in bed in her room on two separate dates without staff supervision. The Director of Therapy confirmed that therapy had not been promptly notified of the choking episode and that prior speech therapy discharge recommendations included supervised dining and upright posture. Another deficiency involved a resident with cognitive impairment, dependence for all ADLs, inattention, disorganized thinking, and bowel and bladder incontinence who ingested an unknown amount of shampoo and body wash. An incident report documented that a CNA entered the room and observed the resident holding the bottle with the lid off, stating it tasted good and offering a drink. The CNA removed and discarded the bottle and notified an LPN. The incident report and staff interviews indicated that the resident subsequently vomited, developed diarrhea, and had decreased oxygen saturation with abnormal lung sounds, leading to transfer to the ER. The manufacturer’s safety data sheet for the product specified it was for external use only and to consult a physician if ingested. The DON acknowledged that the shampoo/body wash should not have been left where the resident could reach and drink it. A third deficiency concerned a resident with dementia, osteoporosis, osteoarthritis, severely impaired cognition, a history of falls, and a high fall risk score who resided on the memory care unit. A fall investigation documented that the resident had an unwitnessed fall and was found on the ground at the doorway to a central bathroom. The investigation and subsequent interview with the Dementia Unit Director indicated that staff had propped the central bathroom door open, allowing the resident to access the bathroom independently. The central bathroom was observed with a keypad lock, and the Dementia Unit Director stated the door was supposed to remain shut and locked at all times, with residents only accessing the bathroom under staff supervision. This sequence of events showed that the door was not maintained in the required locked state, contributing to the resident’s unwitnessed fall.
Delayed reporting of CHF weight gain and symptoms
Penalty
Summary
The facility failed to timely report daily weight changes related to CHF to the physician for a cognitively intact resident who had an active care plan requiring daily weight monitoring and notification of the physician for weight fluctuations as ordered. The resident’s record showed a standing order for daily weights before breakfast and to report a gain of 3 pounds in 24 hours or 5 pounds in one week related to CHF. The resident’s weights remained at 355 pounds on 11/1, 11/2, and 11/8, then increased to 394.6 pounds and 393.5 pounds, reflecting a 39.6-pound gain. There was no documentation that a provider was notified of the weight gain until 11/11/25, and there was no documentation that the resident was assessed or monitored for CHF symptoms such as edema after 11/9/25, other than routine vital signs and pulse oximetry. On 11/11/25, the resident was documented as lethargic, pale, and sleeping on and off throughout the shift, with edema to both arms and the left leg and low hemoglobin contributing to lethargy. These findings were reported to the nurse practitioner, who gave orders for an additional one-time dose of Torsemide 40 mg, hourly vital signs for four hours, and CPAP while resting in bed. Later that day, the nurse practitioner was updated again and ordered transfer to the hospital. The resident’s ICU history and physical documented progressive shortness of breath and more than 35 pounds of weight gain over several days, hypoxia requiring bilevel PAP, pulmonary vascular congestion on chest x-ray, IV furosemide in the emergency room, and admission to the ICU for acute on chronic hypercapnic, hypoxemic respiratory failure and acute heart failure exacerbation. The DON stated the provider was thought to have been notified before 11/11/25 because of the significant weight gain, but the only documentation located was a fax letter dated 11/10/25 that did not show receipt or confirmation that it was reviewed by the nurse practitioner. The DON also stated the facility’s CHF symptom monitoring would be documented on the MAR/TAR and SpO2 monitoring, and confirmed this did not include monitoring for edema. The nurse practitioner stated no one notified her of the weight gain until 11/11/25 and that staff should have been following the daily weight CHF protocol and notifying her sooner; she also stated the resident was hospitalized for fluid retention and required IV diuretics, and that the hospitalization could have been prevented if staff had reported the weight gain sooner.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels, as required by both physician orders and facility policy. The resident in question was documented as severely cognitively impaired and had a physician order for blood glucose monitoring twice daily. Despite repeated blood glucose readings above 200 mg/dl, there was no evidence in the electronic medical record that the physician was notified of these elevated results. The medication administration record showed numerous instances where the resident's blood glucose exceeded the reporting threshold, with values ranging from 206 mg/dl to 350 mg/dl over several days. Interviews with facility staff, including the Director of Nursing and a Nurse Practitioner, confirmed that the facility's policy required staff to report any blood glucose readings above 200 mg/dl. Both staff members acknowledged that the elevated readings should have been reported to the physician, but this did not occur. The facility's policy on blood glucose monitoring, revised in June 2023, also specified that such results must be communicated to the physician or according to physician-ordered parameters.
Failure to Administer Prescribed Eye Drops Due to Medication Unavailability
Penalty
Summary
The facility failed to administer Latanoprost 0.005% ophthalmic solution as prescribed to one resident diagnosed with glaucoma. The resident's physician order and care plan both directed staff to administer the eye drops in each eye at bedtime, starting from the date of admission. However, the medication was not available and was not administered on multiple days during the resident's initial stay, as documented in the Medication Administration Record. The resident reported not receiving the medication for the first ten days and stated that nursing staff informed him it was on order. The Director of Nursing confirmed that the medication was not available for the first ten days of the resident's admission. Facility policy requires that medications be administered timely and in accordance with orders.
Failure to Verify G-Tube Placement Prior to Medication and Feeding Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to check the placement of a resident's gastrostomy tube (G-tube) prior to administering scheduled water flushes, a liquid nutritional bolus feeding, and morning medications. The resident was documented as severely cognitively impaired and fully dependent on staff for daily care. Physician orders and the resident's care plan required that the G-tube placement and gastric residual be checked and recorded before administering any feedings or medications. The LPN did not follow these orders or the facility's policy, which specifically instructed staff to verify G-tube placement before administering medications. Interviews with the LPN and the Director of Nursing (DON) confirmed that the required checks were not performed prior to the administration of substances through the G-tube. Both staff members acknowledged that there was no way to confirm whether the administered substances entered the resident's stomach as intended, since the placement was not verified. The facility's policy, revised in February 2024, also required checking G-tube placement before medication administration, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow the facility's Enhanced Barrier Precautions (EBP) protocol during medication administration for a resident with a gastrostomy tube (G-Tube) who was on EBP due to the presence of an indwelling medical device and risk for multi-drug resistant organisms (MDROs). The resident was documented as severely cognitively impaired and dependent on staff for all activities of daily living, including oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. The resident's care plan and physician orders required staff to use gown and gloves during high-contact care activities, such as G-Tube care, to prevent the transmission of MDROs. On the observed date, the LPN administered water flushes, medications, and nutritional bolus feeding through the resident's G-Tube without wearing a gown, despite signage and available personal protective equipment (PPE) outside the resident's room indicating EBP requirements. The LPN acknowledged awareness of the EBP protocol and the need to wear a gown during these activities. Additionally, the Director of Nursing (DON) confirmed that the LPN should have checked the placement of the G-Tube prior to administering any substances, as failure to do so could result in improper administration. The facility's policy, reviewed prior to the incident, clearly outlined the necessity of gown and glove use during high-contact care for residents on EBP.
Failure to Monitor and Report Changes in Condition for Two Residents
Penalty
Summary
The facility failed to monitor and report significant changes in condition for two residents, including not consistently tracking and reporting blood pressures, daily weights, and urination as required by physician orders and facility policy. For one resident, who had a history of heart failure, kidney disease, and recent hospitalization, there was a lack of routine documentation and provider notification regarding low urine output, low blood pressures, and weight gain. Despite orders to notify the provider for specific changes, such as no urinary output for eight hours or significant weight gain, these were not reported in a timely manner. Attempts to collect urine samples were unsuccessful over several days, and there was no documentation that the provider was notified of these failed attempts or of the resident's ongoing symptoms and abnormal findings until the resident's condition had significantly deteriorated. The resident subsequently experienced a series of acute medical events, including hyponatremia, acute kidney injury, renal failure, urinary tract infection, and required hospitalization and dialysis. Documentation shows that the resident and family had expressed concerns about urine output and fluids to staff, but these concerns were not adequately addressed or communicated to the provider. Staff interviews revealed confusion about when to escalate care, how to document and report changes, and how to follow up on orders, particularly over weekends when laboratory services were limited and there was no nurse manager present to ensure continuity of care. A second resident, also with a history of heart failure and recent hospitalizations, did not have daily weights or vital signs resumed or documented after readmission from the hospital, despite clear orders to do so. The lack of monitoring and documentation was confirmed by facility leadership, who cited issues with order entry and access to provider notes in the electronic medical record. These failures resulted in delays in recognizing and responding to changes in condition for both residents, as evidenced by the lack of timely provider notification and incomplete monitoring as required by policy and physician orders.
Failure to Prevent Accidents and Inadequate Supervision Resulting in Resident Injury and Elopement
Penalty
Summary
The facility failed to ensure the use of wheelchair foot pedals during transportation for two residents, resulting in one resident sustaining significant injury. One resident, who had recently undergone right knee replacement surgery and was admitted for rehabilitation, was transported by a physical therapy assistant in a wheelchair without foot pedals. The resident, unable to hold her leg up due to weakness and fatigue, dropped her right leg as the wheelchair crossed a threshold, causing her ankle to twist and resulting in acute nondisplaced fractures of the medial and lateral malleoli. The resident's medical records confirmed the absence of prior ankle pain or injury, and both the staff involved and the director of nursing acknowledged that the lack of foot pedals contributed to the injury. Another resident, who had a recent clavicle fracture and was receiving therapy, was also observed being transported in a wheelchair without foot pedals, requiring her to hold her feet up during transport. Staff confirmed that foot pedals were not in use and should have been applied. Additionally, the facility failed to provide adequate supervision for a cognitively impaired resident at risk for elopement. The resident, who had a documented history of dementia and was assessed as low risk for elopement, was able to exit the memory care unit through an alarmed door and was found in a nearby church parking lot by a visitor. The incident was not reported to the administrator or medical director, and the facility's missing resident policy was not followed. There was no immediate reassessment of the resident's elopement risk or update to the care plan following the incident, and required notifications and documentation were not completed as outlined in facility policy. These deficiencies were identified through observation, interviews, and record review, highlighting failures in both accident prevention during wheelchair transport and supervision of residents at risk for elopement. The lack of adherence to established safety protocols and failure to follow facility policy directly contributed to resident injury and unauthorized exit from the facility.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as required by its own policies and professional standards. For several residents, provider progress notes were not uploaded into the electronic medical record (EMR), making them inaccessible to floor nurses and not part of the official resident record. Specifically, provider notes for four residents were only available through a separate electronic health record system accessible by nurse managers, not by floor staff. Additionally, an incident involving a resident's right leg injury was documented in an incident report but not in the resident's EMR, and the related provider note was also missing from the EMR. In another case, a resident eloped from the facility, but the incident was not documented in the resident's medical record, and required notifications and procedures outlined in the facility's missing resident policy were not followed. The LPN involved did not document the elopement or the steps taken after the resident's return, and the administrator was unaware of the incident until after it occurred. The facility's policy requires thorough documentation and specific actions in the event of a missing resident, but these were not completed or recorded in the medical record.
Failure to Notify Physician and Power of Attorney After Resident Elopement
Penalty
Summary
The facility failed to notify the physician and power of attorney following an incident in which a resident eloped from the memory care unit. The resident exited the facility through an alarmed door and was found by a family member in a nearby church parking lot, approximately a football field away from the facility. The LPN on duty did not complete an assessment, notify the resident's physician or family, or follow the facility's Missing Resident Policy, which requires immediate notifications and specific actions when a resident is discovered missing. The administrator was unaware of the incident until after it occurred, and the nurse practitioner confirmed that no communication was received regarding the elopement. The Director of Nursing was informed by the LPN after the resident was found but only instructed the LPN to document the resident's exit-seeking behavior. The facility's policy mandates prompt notification of the attending physician and legal representative, as well as thorough documentation and incident reporting, none of which were completed in this case.
Failure to Transcribe and Implement Physician's Order for Vitamin D3
Penalty
Summary
A deficiency occurred when the facility failed to transcribe and implement a physician's order for Vitamin D3 2000 units daily for a resident who had sustained right ankle fractures. The resident, who had severe osteopenia and was already receiving Os-Cal Calcium plus D3 and a multivitamin, was evaluated by a podiatrist who documented the new order in a progress note. However, this order was not transcribed or implemented as of several days after the evaluation. The failure was identified during a review of the resident's records, which showed that the resident continued to receive less than the prescribed amount of Vitamin D3. The DON confirmed that new orders or progress notes from orthopedic or podiatry appointments were not communicated to the facility and had to be obtained from the electronic health records system. This lack of communication led to the omission of the physician's order for increased Vitamin D3 supplementation.
Significant Medication Errors Due to Improper Discontinuation and Lack of Documentation
Penalty
Summary
A resident was discharged from the hospital with orders for Metoprolol Succinate, Midodrine, and Novolog insulin, which were to be administered according to specific schedules. The resident's Medication Administration Record showed that these medications were discontinued after the morning dose on 7/23/25 and were not given again prior to the resident's subsequent hospitalization on the evening of 7/24/25. There was no documentation in the medical record explaining why the medications were stopped or indicating that the physician was notified about the missed doses. The Assistant Director of Nursing stated that they mistakenly believed the resident was still hospitalized and used a batch order to discontinue the medications, later attempting to resume them, but not all orders were restored due to the timing of the batch process. This resulted in missed doses of significant medications, which were acknowledged as medication errors.
Unauthorized Video Recording of Resident by CNA
Penalty
Summary
A facility failed to protect a resident's right to privacy when a Certified Nurse Aide (CNA) took an unauthorized video of a resident using a personal cell phone. The resident involved had diagnoses including dementia, hemiplegia, cerebral infarction, and major depressive disorder, and was documented as having severe cognitive impairment, being immobile, and dependent on staff for all activities of daily living. The video, which was approximately 10-12 seconds long, showed the resident fully clothed and in bed, with bedding covering the lower extremities and torso, while the resident was speaking to the CNA. The audio in the video was indecipherable. The CNA stored the video in personal digital cloud storage, which was accessible to others, including the CNA's boyfriend and his mother. The facility's employee handbook explicitly prohibits photographing or recording residents due to privacy rights, and the CNA had previously acknowledged understanding and agreeing to these policies. The incident was discovered when the video was accessed and reported by a third party, leading to facility leadership being notified.
Failure to Report Resident Fall and Notify Physician and Family
Penalty
Summary
The facility failed to report a resident's fall to the licensed nurse, which resulted in the resident's physician and family member not being notified of the incident. A Certified Nursing Assistant (CNA) found the resident on the floor by the bed, but did not immediately report the fall to the nurse on duty, as the nurse was not readily available and the CNA became occupied with other duties. The fall was not documented in the resident's medical record, and the only reference to the incident was found in the risk management section, which was not accessible to survey staff. The resident's family member and legal Power of Attorney was not informed of the fall and only learned about it through a third party. The resident's medical record did not contain documentation of the actual fall event, though it did show a post-fall neurological check and subsequent monitoring. The nurse manager confirmed that the fall was not reported by staff at the time it occurred, and that the incident was only discovered after questioning staff members. Facility policy requires that all accidents and incidents be reported to the department manager and the charge nurse so that appropriate medical attention can be provided, but this protocol was not followed in this case.
Failure to Report and Assess Resident Fall
Penalty
Summary
Facility staff failed to report a resident fall to a licensed nurse, resulting in the absence of a nursing and neurological assessment before the resident was moved from the floor. A certified nursing assistant (CNA) discovered the resident on the floor by the bed while delivering a meal tray. Unable to locate the licensed nurse, the CNA, with the help of another CNA, picked up the resident and returned them to bed without notifying the nurse on duty. The incident was only discovered when a family member inquired about the fall during a care plan conference the following day. At the time of the incident, there were at least two licensed nurses and a nurse manager present on the unit. Facility policy requires that all accidents and incidents be reported to the charge nurse, and that residents not be moved until examined by a licensed nurse. The failure to follow this policy led to the resident not being assessed for injuries or neurological changes prior to being moved after the fall.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of potential for abuse and neglect was subjected to both verbal and physical abuse by another resident. The incident involved one resident, who is dependent on staff for activities of daily living and has multiple medical diagnoses including spastic quadriplegic cerebral palsy and schizophrenia, being verbally abused with a racial slur and then physically struck on the head by another resident. The care plan for the cognitively impaired resident included interventions such as monitoring whereabouts and behaviors, and staff were instructed to intervene in potential or actual acts of abuse or neglect. The event was witnessed by an LPN, who observed the physically intact resident wheel up to the cognitively impaired resident and strike them on the head with an open palm after the latter was heard yelling a racial slur. The incident occurred in the presence of the physically intact resident’s daughter, who confirmed the verbal abuse. Both residents were assessed after the altercation, with no injuries noted. The facility’s abuse prevention policy affirms the right of residents to be free from abuse by anyone, including other residents, and requires staff to monitor and intervene as necessary. Despite these policies and care plan interventions, the facility failed to prevent the verbal and physical abuse between residents.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency as required by its own policy and state regulations. A resident with severe cognitive impairment and multiple medical diagnoses, including atrial fibrillation and a history of bruising, was observed with significant discoloration (11 cm x 7 cm) on the right upper extremity. The injury was documented by nursing staff and reported internally to the Administrator and Director of Nursing, but no external report was made to the Illinois Department of Public Health. The facility's policy mandates that all accidents and incidents, including those of unknown origin, be reported to the department supervisor and that major injuries be reported to the state agency within 24 hours. Despite the resident's inability to explain the cause of the injury and the absence of any clear source, facility staff assumed the bruise was related to the resident's medical history and anticoagulant use. The Assistant Director of Nursing confirmed that the injury was not considered to be of unknown origin and therefore was not reported to the state agency. This omission occurred even though the facility's policy specifically requires reporting such incidents when the origin is unknown.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers, as required by facility policy and physician orders. The policy specifies that gloves and gowns must be worn during high-contact care activities for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms (MDROs). The resident in question had a stage three pressure injury on the left Achilles area and a stage four pressure injury on the left ischial area, and the care plan and physician orders both indicated that EBP should be maintained during high-contact care, including wound care and urinary catheter care. During an observation, a registered nurse and an LPN entered the resident's room and performed wound care without donning gowns, despite an EBP sign on the door instructing staff to wear gowns and gloves for such activities. Both staff members stated that they believed the EBP sign and supplies were intended for the resident's roommate, not for the resident receiving wound care. The Director of Nursing later confirmed that the resident was on EBP and that the staff should have worn gowns and gloves during the wound treatment.
Delay in Reporting and Treatment of Post-Fall Hip Fracture
Penalty
Summary
The facility failed to timely report and address post-fall pain and did not implement radiology orders promptly for a resident who experienced a fall. After the resident was found on the floor in the early morning hours, initial assessments documented bruising and abrasions but no pain, and the on-call physician was notified. However, later therapy notes indicated the resident began complaining of significant left hip pain, refused to participate in therapy, and requested an x-ray. Despite these complaints, there was a delay in notifying the physician about the pain and in obtaining the necessary diagnostic imaging. Therapy staff reported the resident's pain to nursing staff, but there was no immediate follow-up with the physician regarding the new onset of pain. An x-ray was eventually ordered as STAT, but the imaging was not performed until the following day. The nurse practitioner was not notified of the resident's pain until the day after the x-ray order was placed, at which point a STAT x-ray was again ordered and the resident was placed on nonweight bearing status. The x-ray ultimately revealed an acute nondisplaced left femoral intertrochanteric fracture, requiring surgical intervention. Interviews with staff confirmed that the resident's complaints of pain were communicated between therapy and nursing, but not escalated to the provider in a timely manner. The delay in reporting and acting on the resident's post-fall pain, as well as the delay in obtaining the ordered x-ray, resulted in a delay in diagnosis and treatment of the hip fracture. Documentation also showed that the provider was not aware of the fall or the pain until well after the incident, and the facility's protocol for acute condition changes was not followed.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate care for residents who were dependent on staff for activities of daily living, including bathing, oral care, and toileting. One resident, who was severely cognitively impaired and totally dependent on staff, was admitted to the hospital with poor oral hygiene, including thick hardened oral secretions. Observations revealed that this resident had not been bathed or had oral care since returning from the hospital, as evidenced by disheveled appearance, urine odor, and a white film on teeth and tongue. The Director of Nursing confirmed that the resident had not received a bath since readmission, and the hospital reported that it took 45 minutes to clean the resident's mouth upon arrival. Another resident, who was cognitively intact and required partial assistance with oral care, was observed with food in their teeth and reported not having a toothbrush or toothpaste. The medical record did not document any oral care assistance. Additionally, a third resident, dependent on staff for toileting, was found saturated in urine and with old feces, indicating they had not been changed for many hours. The CNAs confirmed the lack of care, and the Director of Nursing stated that the care provided was not acceptable, as residents should be checked and changed every two hours.
Failure to Identify and Manage Pressure Ulcers
Penalty
Summary
The facility failed to properly identify, assess, and manage pressure wounds for a resident, leading to a deficiency in pressure ulcer care. Upon the resident's return from the hospital, where they were documented to have multiple pressure injuries, the facility did not conduct a complete skin assessment as required by their Skin and Wound Management Guidelines. The resident had stage two pressure wounds on the coccyx and buttocks, and a deep tissue injury on the right heel, which were not identified or treated by the facility staff. The Licensed Practical Nurse who readmitted the resident did not perform a full skin check, and the wound nurse was not informed of the existing wounds. The facility's failure to notify the treatment nurse, physician, or family about the resident's wounds, and the lack of treatment orders or interventions for the pressure injuries, further contributed to the deficiency. Observations revealed that the staff, including CNAs and the Nurse Manager, were unaware of the resident's pressure wounds, and the dressings on the wounds appeared old and undated. This lack of communication and adherence to protocol resulted in inadequate care for the resident's pressure ulcers.
Inaccurate MDS Encoding for Falls and Injuries
Penalty
Summary
The facility failed to accurately encode the Minimum Data Sets (MDS) to reflect the true status of residents regarding falls and the severity of injuries incurred. This deficiency affected three residents. One resident, who was observed wearing a padded helmet, had experienced multiple falls, including a significant fall resulting in a subdural hematoma, a scalp laceration, and a wrist fracture. However, the MDS inaccurately documented only two falls with no injuries since the prior assessment. Another resident had a fresh scar on the forehead and had previously sustained bilateral nasal fractures and a scalp laceration requiring sutures. The MDS inaccurately recorded only one fall with injury, omitting another fall with a major injury. A third resident, observed with a gauze dressing on the forearm, had a documented fall resulting in a skin tear, yet the MDS recorded this as a fall with no injury. The Minimum Data Set Manual 3.0 specifies that injuries such as skin tears, abrasions, lacerations, bruises, hematomas, or sprains are considered injuries, while fractures, joint dislocations, closed head injuries, and subdural hematomas are considered major injuries. The Director of Nursing and a Registered Nurse Manager confirmed the inaccuracies in the MDS coding for these residents, acknowledging that the number of falls and the severity of injuries were not correctly documented. This failure to accurately encode the MDS could lead to inadequate care planning and interventions for the residents involved.
Failure to Monitor Resident Weights and Address Severe Weight Loss
Penalty
Summary
The facility failed to obtain weights per physician orders for two residents and did not adequately monitor an at-risk resident for weight loss. Specifically, one resident experienced severe weight loss without a proper care plan or notification to the resident's representative. The facility's weight policy required weekly weights in cases of significant weight changes, but this was not followed for the resident who lost a significant amount of weight over several months. The resident's care plan did not address the severe weight loss, and there was no order for nutritional supplements or increased weight monitoring until after the issue was identified. Another resident with a history of congestive heart failure was not weighed daily as required by their care plan and physician orders. The resident's care plan specified daily weights and notification of the provider if there was a significant weight gain, but the facility missed 53 daily weights over a period of time. This oversight could have impacted the resident's health management related to their heart condition. A third resident, who was nutritionally at risk due to renal dialysis and other medical conditions, was also not weighed according to physician orders. The resident's care plan required weights to be taken on specific days, but several weights were missed. The facility acknowledged that residents were not being weighed per physician orders, which contributed to the deficiencies identified in the report.
Failure to Monitor Dialysis Access Site and Communicate with Dialysis Center
Penalty
Summary
The facility failed to provide adequate dialysis care and coordination for a resident, resulting in the resident's hospitalization due to a central venous catheter infection. The facility did not maintain regular communication with the dialysis center and failed to monitor the resident's dialysis access site for signs of infection. The facility's Dialysis Protocol required nursing staff to monitor the access site and communicate with the dialysis center regarding any changes in the resident's condition. However, the resident's medical records lacked orders to monitor the dialysis site for several months, and there was no documentation of routine communication with the dialysis center. The resident, who had diagnoses including End Stage Renal Disease and Chronic Kidney Disease, was hospitalized with a suspected central line-associated bloodstream infection. The resident reported increased drainage and itching at the dialysis site, which was confirmed by the emergency department to have erythema and purulent drainage. Despite the facility's protocol and transfer agreement with the dialysis center, the nursing staff did not document assessments of the catheter site or maintain communication with the dialysis center, contributing to the resident's infection and subsequent hospitalization.
Failure to Implement Fall Interventions and Assessments
Penalty
Summary
The facility failed to implement necessary fall interventions for three residents, R1, R2, and R3, which were identified during observations, interviews, and record reviews. R1, who has a history of repeated falls and multiple fractures, was observed without the required TLSO back brace while out of bed, despite physician orders and family instructions. The Director of Nursing confirmed the absence of the brace, and R1's family member expressed concerns about the staff's failure to ensure the brace was worn, which is critical for R1's spinal support. R2, diagnosed with dementia and a history of falls, did not have quarterly fall risk assessments documented for March and June 2024. The Director of Nursing acknowledged the missing assessments, indicating they were likely not completed. Additionally, R2's care plan interventions were not followed, as observed by the absence of non-skid material in R2's wheelchair, the wheelchair being unlocked and out of reach, and the lack of visual cues to remind R2 to use the call light for assistance. These oversights were confirmed by the Director of Nursing and a Licensed Practical Nurse. R3, who has a history of falls and requires assistance with daily activities, was found transferring herself unsteadily in a shared bathroom due to a malfunctioning call light system. R3 communicated that she had to use a different bathroom because the call light in her room did not alert staff for assistance. The Social Service Director confirmed the call light issue and acknowledged R3's tendency to transfer herself without waiting for staff, leading to previous falls. Staff members, including a CNA and an LPN, confirmed that R3 should not be transferring herself and noted the lack of staff intervention during a shift change.
Failure to Notify Family and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's family representative and healthcare providers of significant changes in the resident's condition, including a positive COVID-19 test result and a decline in consciousness, abnormal lung assessment, and a productive cough. The resident, who had severe cognitive impairment due to Alzheimer's Disease and Unspecified Dementia, tested positive for COVID-19, but there was no documentation that the family representative or the attending physician was informed of this diagnosis. Additionally, the resident exhibited symptoms such as lethargy, diminished lung sounds, and a productive cough, yet there was no record of these changes being communicated to the family or healthcare providers. The Director of Nursing acknowledged the lack of documentation regarding the notification of the resident's condition changes. The facility's policies require that both the attending physician and the resident's responsible party be notified of any significant changes in the resident's condition, including symptoms of an infectious process and changes in the level of consciousness. Despite these policies, the Licensed Practical Nurse involved did not notify the family or the nurse practitioner, assuming that the previous shift had already done so, which was not documented.
Incomplete Documentation of Physician-Ordered Back Brace
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident diagnosed with dementia and vertebral fractures. The deficiency involved the lack of documentation for the application of a physician-ordered TLSO back brace, which was to be worn by the resident when out of bed. The Physician Order Summary Report indicated that the brace was active and required, but the Electronic Medication/Treatment Administration Records did not have the necessary nurse initials to confirm the brace was applied over a period of 24 days. This oversight was attributed to an error by the admissions nurse, who failed to set up the administration record option for nurses to document the application of the brace.
Failure to Provide Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R1, upon their admission. R1, who had recently undergone joint replacement surgery and was diagnosed with Chronic Lymphocytic Leukemia, was admitted to the facility with a physician's order for Oxycodone 5 mg to be administered every six hours as needed for severe pain. However, upon admission, the facility did not have the prescribed pain medication available, resulting in R1 experiencing severe pain. On the night of R1's admission, the nurse on duty, V5, was informed by R1 that they would need pain medication to sleep. Despite this, V5 did not contact the Nurse Practitioner or R1's doctor to obtain an alternative pain medication order. The facility's emergency box did not contain the specific Oxycodone prescribed, only Oxycodone with Tylenol, which was not administered. Consequently, R1 did not receive any pain medication until the following day, leading to significant discomfort. The Nurse Practitioner, V7, discovered R1 in excruciating pain during a visit the next morning and took immediate action to address the situation. V7 ordered an emergency prescription for Percocet, which was available in the emergency box, and ensured R1 received the necessary medication. The facility's failure to have the correct medication available and the lack of communication with medical staff to obtain an alternative contributed to the deficiency in pain management for R1.
Failure to Maintain PICC Line Leads to Complications
Penalty
Summary
The facility failed to properly manage the peripherally inserted central catheter (PICC) line for a resident diagnosed with osteomyelitis, who required intravenous antibiotics. The facility's policy required PICC line dressings to be changed every seven days or as needed to prevent infections. However, upon review, it was found that the resident's August Medication Administration Report (MAR) did not document any dressing changes for the PICC line, and the order for dressing changes was only placed on September 9, 2024. The resident reported that the PICC line fell out on September 7, 2024, due to the lack of dressing changes, necessitating the use of a peripheral IV until a new PICC line was placed on September 9, 2024. Interviews with the Assistant Director of Nurses (ADON) confirmed that the resident was admitted with a PICC line for intravenous antibiotics and that no dressing change orders were placed or documented until after the PICC line fell out. The ADON acknowledged that the facility realized the oversight on September 7, 2024, and confirmed that no dressing changes had been performed since the resident's admission on August 29, 2024. This oversight led to the resident's PICC line falling out, requiring additional medical intervention to continue the necessary antibiotic treatment.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity by not responding to call lights and requests for assistance in a timely manner. This issue affected eight residents out of 17 reviewed in a sample of 35. Residents reported waiting times of up to 45 minutes for call lights to be answered, particularly during meal times and overnight shifts. Some residents mentioned that staff would turn off the call lights and promise to return but failed to do so unless the call light was pressed again. The facility's Resident Council Meeting Minutes from the past three months documented ongoing concerns about call light response times, especially during the night shift. The administrator provided a printout showing call light response times over the last 30 days, with over 650 instances exceeding 20 minutes. Despite this documentation, it did not address the residents' claims that staff would turn off call lights without returning. The report highlights that the facility's staffing levels may be inadequate, as residents noted that there were not enough CNAs to cover all halls effectively, leading to prolonged response times. This deficiency in timely response to call lights compromises the residents' dignity and their ability to exercise self-determination and communication rights.
Deficiency in Bathroom Flooring Maintenance
Penalty
Summary
The facility failed to maintain the flooring in resident bathrooms in a clean, safe, and homelike manner, affecting 15 residents out of 23 reviewed for environmental concerns. During an environmental tour, it was observed that the bathroom vinyl floors in several rooms had ground-in dirt and stains that could be rubbed off with a dry piece of bathroom tissue. Some stains were embedded in the vinyl, and there were cracks and loose edges at the bathroom thresholds, presenting a trip hazard. Residents confirmed that the floors were cleaned recently, yet the dirt and stains persisted. The Maintenance Director acknowledged the issues with the vinyl floors, expressing a desire to replace them with poured epoxy floors, as the current flooring could not be adequately cleaned, especially in the cracks. The Administrator confirmed the presence of stained and dirty floors in the bathrooms. Additionally, some rooms had missing thresholds at the entry doors, which was noted as a common issue. The facility's Resident Roster documented the residents residing in the affected rooms.
Failure to Timely Report Allegation of Mental Abuse
Penalty
Summary
The facility failed to report an allegation of mental abuse to the state agency within the required 2-hour timeframe. This deficiency involved a resident who was reportedly startled awake by a CNA during the night. The resident's family member initially reported the incident to the facility, describing the staff member as rude. The facility's representative, V1, investigated by speaking with the resident, who confirmed that a CNA had startled her awake and had not properly cleaned her after using a bedpan. The resident also reported that the CNA was rude and yelled at her from the hallway. Despite these allegations, the facility did not report the incident to the Illinois Department of Public Health until prompted by a surveyor. The facility's policy mandates that any allegation of abuse be reported immediately, but not more than 2 hours after the allegation. V1 initially did not consider the family member's complaint as an allegation of abuse, which led to the delay in reporting. The facility's failure to adhere to its own abuse prevention policy resulted in a deficiency being cited by the surveyors.
Misappropriation of Resident Property by Facility Staff
Penalty
Summary
The facility failed to protect two residents from misappropriation of property by facility staff, resulting in financial exploitation. One resident, who is cognitively intact and requires total assistance with daily activities, reported her debit card missing. An investigation revealed that 11 fraudulent transactions totaling $1,515.96 were made from her account, involving mobile payment services and online sports betting. The names associated with the transactions were unknown to the resident. A CNA was implicated in taking photographs of the resident's personal information, including her debit card and Social Security card, and sharing them with an external individual. The facility's investigation, prompted by a tip-off from an external individual, led to the suspension of the implicated CNA. The investigation also uncovered that another resident's debit card information was compromised, although no unauthorized transactions were made. The facility's policy prohibits staff from photographing or recording residents or their private spaces for non-medical purposes, yet this policy was violated, leading to the misappropriation of the resident's property.
Misappropriation of Resident Property by CNA
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property, as outlined in their Abuse Prevention Program. The deficiency involved a Certified Nursing Assistant (CNA) who allegedly took photographs of personal items belonging to two residents, including debit cards and a Social Security card, and shared these images with another individual. This breach of policy was discovered when a third party, not associated with the facility, provided evidence of the CNA's actions to the facility administrator. The facility's policy explicitly prohibits staff from photographing or recording residents or their private spaces for non-medical or non-facility purposes. The incident resulted in one resident experiencing fraudulent transactions totaling $1,515.96 after their debit card information was compromised. The resident expressed distress over the situation, as the fraudulent activity affected their financial stability, with most of their Social Security check going towards room and board at the facility. The other resident's debit card was also photographed, but no unauthorized transactions were reported. The CNA involved denied the allegations, attributing the situation to personal conflicts, and was subsequently terminated from the facility.
Failure to Ensure Fall Interventions and Safety Measures
Penalty
Summary
The facility failed to ensure fall interventions were in place, safely position a resident on a low air loss mattress, keep necessary items within reach for a resident, and store a rolling chair away from resident areas. Specifically, the facility did not complete post-fall assessments, transfer a resident post-fall according to facility policy, and thoroughly investigate falls. These failures affected three residents reviewed for falls. One resident (R1) with severe cognitive impairment and multiple medical conditions, including Chronic Obstructive Pulmonary Disease (COPD) and Vascular Dementia, fell from a low air loss mattress. The resident was found face down on the floor with his right arm pinned under his body. The investigation revealed that the resident was positioned in a high Fowler's position on the air mattress, which likely caused the fall. Staff admitted that the resident should not have been left unattended in that position. Another resident (R4) with moderate cognitive impairment and multiple medical conditions, including Chronic Osteomyelitis and Alzheimer's Disease, fell while trying to reach for a drink. The resident's fall mat was not in place, and the call light was out of reach. The resident was assisted back to bed without using a mechanical lift, and no physical or neurological assessments were completed before moving the resident. Additionally, a third resident (R5) with severe cognitive impairment and Alzheimer's Disease fell while attempting to sit in a rolling chair left unattended in a dementia unit. The resident was known to wander and required supervision due to poor safety awareness.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure a resident's right to dignified care and treatment, affecting one of three residents reviewed for dignity/abuse. The resident (R3) has no cognitive impairment and is frequently incontinent of bowel and bladder. During an interview, an Auxiliary Assistant (V10) reported overhearing a Certified Nursing Assistant (V13) question R3 about wearing a diaper and needing to go to the bathroom, which R3 found humiliating. R3 confirmed the incident, stating that V13's behavior made her feel disrespected and humiliated, although she did not feel it was abuse. The facility's Grievance/Complaint Form and interviews with the Administrator (V1) corroborated R3's account, identifying the issue as a dignity concern. The facility's policy on resident privacy and dignity emphasizes the importance of treating residents with respect and addressing them by their preferred names. However, the incident with V13, CNA, demonstrated a failure to adhere to this policy, resulting in a dignity issue for R3.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by another resident. This deficiency involved two residents, one with severe cognitive impairment and another with moderate cognitive impairment. The incident began when the resident with severe cognitive impairment accused the other resident of stealing her belongings, leading to a verbal altercation. The resident with severe cognitive impairment used racial slurs and got physically close to the other resident, causing fear and distress. Despite staff intervention, the abusive behavior continued, and the resident with severe cognitive impairment was not immediately removed from the room, leading to further incidents of verbal abuse. The resident with moderate cognitive impairment, who is bedridden and uses a wheelchair for mobility, reported feeling scared and threatened by the other resident's actions. The staff documented multiple instances where the abusive resident accused the other of theft and used racial slurs. The staff attempted to redirect the abusive resident and reassure her about her belongings, but the abusive behavior persisted. The facility's initial report to the State Agency and subsequent interviews with staff and residents confirmed the ongoing verbal abuse and the failure to protect the resident from such mistreatment. The facility's abuse prevention program aims to create a resident-sensitive and secure environment, but in this case, it failed to prevent the verbal and mental abuse. The staff's actions to separate the residents and address the abusive behavior were insufficient, as the abusive resident continued to harass the other resident. The facility acknowledged the incident and stated that the investigation was ongoing, but the deficiency in protecting the resident from abuse was evident in the documented events and staff statements.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of physical and verbal abuse by one resident towards another was reported to the Administrator/Abuse Prevention Coordinator. This failure resulted in both residents continuing to reside in the same bedroom, potentially subjecting one resident to further abuse. The incident involved a resident becoming physically violent and verbally abusive towards her bedridden roommate, including pulling her hair and using racial slurs. The incident was initially reported by a housekeeper and documented by an LPN, but the report was not properly escalated to the on-call manager or the Administrator as required by the facility's policy. The LPN notified the Administrator via text message that a resident was combative but did not specify that the combative behavior involved physical and verbal abuse towards another resident. The Director of Nursing and the on-call RN Manager were not informed of the abuse allegations until the following day when a note was found in the resident's medical record. The LPN who initially documented the incident was terminated for failing to follow the protocol related to abuse prevention and reporting. The facility's policy on abuse prevention requires employees to report any incident, allegation, or suspicion of abuse immediately to the Administrator or an immediate supervisor. In this case, the failure to follow this policy resulted in a delay in addressing the abuse allegations and ensuring the safety of the residents involved. The facility's internal reporting requirements were not met, leading to a deficiency in handling the abuse incident appropriately.
Failure to Ensure Two Staff Members During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that two staff members were present during a mechanical lift transfer for a resident with Chronic Obstructive Pulmonary Disease, heart failure, and morbid obesity. The resident's care plan required two staff members for all transfers, including those using a mechanical lift. On April 20, 2024, a CNA attempted to transfer the resident from a wheelchair to a bed using a mechanical lift without the assistance of a second staff member. During the transfer, the resident fell out of the mechanical sling and hit the floor, resulting in a fall on her buttocks and head. The resident was sent to the Emergency Department and returned to the facility with no injuries. The incident report and interviews confirmed that the CNA proceeded with the transfer alone after the second staff member left the room due to an emergency phone call. The facility's policy on transfers, dated August 2017, clearly states that a minimum of two staff members is required for mechanical lift transfers. The administrator confirmed that the CNA did not follow this policy, leading to the resident's fall. The incident highlights a failure to adhere to established safety protocols, which are designed to prevent such accidents. The resident involved was independent in decision-making skills but required staff assistance for activities of daily living due to her medical conditions.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 94 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Savoy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clark-lindsey Village | 2.5 mi | ★★★★★ | 7 | 0 |
| Haven Of Champaign | 2.8 mi | ★★★★★ | 14 | 0 |
| Piatt County Nursing Home | 16.9 mi | ★★★★★ | 0 | 0 |
| The Haven Of Bement. | 19.8 mi | ★★★★★ | 20 | 0 |
| The Haven Of Tuscola | 20 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.