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 Arcadia Care Morton during CMS and state inspections, most recent first.
Insufficient staffing led to delayed call light response and missed incontinence care on the night shift. Residents reported waiting over 30 minutes to more than an hour for help, being changed only once or not at all overnight, and not receiving timely assistance with toileting or hygiene. Staff described unstable staffing, frequent agency use, and a night shift with only one CNA covering part of the building while residents on the other side did not receive needed care.
Ice water was not consistently passed to residents three times daily as required by the facility policy. Residents reported that fresh ice water was often missed on second and third shifts, sometimes only passed once a day or delayed when requested, and observations found one resident with warm water and another with an empty cup. Staff, including LPNs, a CNA, and an agency LPN, described staffing shortages and lack of ice access after the kitchen closed as reasons ice water was not routinely provided, while the DON stated it should be passed every shift.
Resident-to-resident abuse occurred in separate incidents involving two residents in the dining room and two roommates in a room. In one event, a resident slapped another resident after coffee was thrown, and witnesses reported yelling and derogatory language during the altercation; in another, a resident hit her roommate multiple times over belongings and then struck an LPN who intervened. Records noted cognitive impairment and behavior histories for the residents involved.
The facility did not maintain a full-time DON who was a Registered Nurse (RN), as required by its own job description and regulatory standards. The facility assessment identified a DON role responsible for providing resources and support for all residents, and the census showed 78 residents in care. After the prior DON’s employment ended, the Administrator acknowledged that there had been no full-time RN DON in place, and the Assistant DON, who had been acting as DON, held only an LPN license according to state license verification.
A resident with an indwelling suprapubic catheter had a care plan requiring Enhanced Barrier Precautions, including gown and glove use during high-contact care, but an LPN performed catheter care without wearing a gown or mask, despite facility policy requiring adherence to infection control practices and the administrator’s expectation that staff use full PPE for catheter care. In a separate issue, two residents’ shared room was found with a wet incontinence brief, a towel with brown matter, and soiled clothing and socks left on the bathroom floor for hours, and later the soiled clothing was observed in a clear bag on the floor by the sink, contrary to housekeeping and administrative responsibilities to keep resident areas clean and waste discarded properly.
Multiple residents reported not receiving weekly showers and being left in urine and feces for prolonged periods despite facility policies requiring regular incontinence checks and hygiene care. Cognitively intact residents described waiting from 35 minutes to over 90 minutes after activating call lights for toileting assistance, sometimes putting wet briefs back on or remaining soiled when staff did not respond, and one resident reported linens not being changed after a bowel movement. Another resident dependent on toileting and with an ostomy stated that a family member routinely had to provide showers and incontinence care because staff relied on that person, and when the family member was absent, staff attempted bed baths instead of scheduled showers. One resident was later found by a CNA to be saturated with urine from neck to feet with reddened skin after reporting having asked all day to be changed. CNAs reported staffing shortages, delayed agency staff, and competing dietary duties that limited their ability to answer call lights and complete resident care, while the Administrator acknowledged staff were overworked and the Ombudsman confirmed frequent complaints about unanswered call lights.
A deficiency was identified in which residents’ rights to dignity, self-determination, and timely care were compromised by chronic food shortages and delayed call light responses. Facility policies required that call lights be answered promptly and that meals be prepared and served according to planned menus, yet residents reported that the kitchen frequently ran out of main menu items and desserts, resulting in substitutions such as toast or peanut butter and jelly instead of the listed foods. Several residents with intact cognition described not receiving the posted menu items, receiving smaller portions, and having to keep personal food supplies in their rooms to avoid hunger. Staff, including CNAs and dietary personnel, confirmed that there was often not enough food for all residents, particularly for those eating in their rooms, and that residents sometimes received whatever could be found rather than the planned meal. At the same time, multiple residents and family members reported long call light wait times ranging from many minutes to hours, with some residents remaining in soiled briefs or relying on family to provide showers, toileting, and ostomy care because staff said they were short-staffed. Resident council minutes, grievance forms, and statements from the ombudsman documented ongoing complaints about untimely call light responses and dissatisfaction with dietary services.
The facility failed to ensure daily room cleaning and trash removal for multiple residents, despite policies requiring adherence to cleaning schedules and proper waste disposal. Resident council minutes documented grievances about soiled items and rooms not being cleaned when housekeepers were off. Cognitively intact residents reported that their rooms were not cleaned for several days, trash was only removed on request, and one resident resorted to using a t‑shirt to mop bathroom water; surveyors observed strong urine odors, full wastebaskets with soiled briefs, dried spills on the floor, and unswept, unmopped floors. Staff interviews and staffing schedules showed inadequate housekeeping coverage on certain days and shifts, and staff confirmed that when the primary housekeeper was absent, rooms on one side of the building were not cleaned, even though leadership acknowledged rooms and trash should be addressed daily.
The deficiency centers on chronic understaffing and inaccurate staffing records that resulted in delayed call light response, missed or delayed showers, inadequate incontinence care, and inconsistent room cleaning for more than 80 residents. The facility’s own assessment and staffing calculator showed CNA hours below calculated needs on multiple days, while therapy and activity hours were overstated on daily reports. Staff and residents reported that on some shifts only two CNAs were present when many more were scheduled, that agency staff frequently filled in but did not consistently provide care or answer call lights, and that residents sometimes waited up to several hours for assistance, including one resident who remained soiled after a laxative and another who relied on family for showers and toileting. Resident Council minutes and grievances repeatedly documented concerns about call lights, showers, soiled items in rooms, and lack of housekeeping coverage, and one resident experienced multiple unwitnessed falls in common areas during this period.
A resident with severe cognitive impairment and total dependence for ADLs experienced multiple falls in a short period, including in the nurses’ station and an assisted dining room. Despite facility policies requiring incident reports, assessments, physician and family notification, and care plan updates after each fall, staff did not complete an incident report, nursing note, or notifications for at least one fall in the dining room, and no new interventions were implemented after that fall or a later fall. Witnesses reported the resident fell in the dining room when no staff were present and that other residents had to yell for help. The incident/accident log omitted this fall, and the resident’s representative reported being told of only some of the falls, demonstrating failures in supervision, documentation, investigation, and communication.
A resident with dementia, urinary retention, obstructive/reflux uropathy, and a history of UTI had physician orders and a care plan for Enhanced Barrier Precautions (EBP) related to an indwelling urinary catheter. During observed catheter care, a CNA entered the room, put on gloves without performing hand hygiene, and did not wear a gown, while another CNA assisted with repositioning the resident without gloves or a gown. The CNA used multiple washcloths from a single basin to clean the resident’s genital area, catheter tubing, and catheter bag, then changed gloves once without hand hygiene and adjusted the resident’s clothing. The CNA later stated that a gown was not required for catheter care, contrary to facility policy requiring gown and gloves for high-contact care and medical device care under EBP, and hand hygiene before and after contact with the catheter system.
Failure to Document Resident Council Complaints: A resident reported concerns that she was not receiving the correct meds and said she had raised the issue in Resident Council multiple times. Other residents and the Ombudsman confirmed that medication complaints were commonly voiced in council meetings, including reports of meds being late or not given. The AD stated these concerns should be treated as grievances, but no grievance forms were completed and the DON and Administrator were not informed.
The facility did not ensure adequate nursing staff coverage, leading to prolonged wait times for residents needing assistance with call lights and toileting. Multiple staff members, including LPNs and CNAs, reported frequent understaffing, and residents described waiting for hours in soiled briefs due to delayed responses. Facility records confirmed consistent nursing hour shortages, and concerns about delayed care were raised but not formally documented in resident council minutes.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility failed to serve visually appealing and palatable food, affecting 78 residents. Observations showed that meals were served with improperly drained zucchini, resulting in a watery appearance. Several residents expressed dissatisfaction with the food's temperature, taste, and saltiness. The Ombudsman noted that food palatability is a recurring issue not addressed by staff.
The facility failed to secure two large trash dumpsters from pests and rodents, as observed during a follow-up tour with the Regional Dietary Manager. The dumpsters had open lids, with one being overfilled with trash, contrary to the facility's policy requiring closed lids to prevent infection spread and deter pests. The Regional Dietary Manager confirmed the lids should have been closed.
The facility failed to conduct required PASARR screenings for three residents diagnosed with mental illnesses, including Schizoaffective and Schizophreniform Disorders. The absence of these screenings was confirmed by the Business Office Manager and Administrator, indicating non-compliance with the facility's policy and regulatory requirements.
The facility failed to notify state authorities of significant changes in mental health conditions for two residents diagnosed with Schizoaffective Disorder. The Business Office Manager confirmed that no PASARR screenings or notifications were made, despite the facility's policy requiring such actions.
A resident with wounds on the right inner thigh and left inner ankle did not receive timely wound care as per facility policy and physician's orders. The resident's right thigh wound was left exposed without a dressing, and the left ankle dressing was improperly adhered. Despite notifying staff, the resident experienced delays in receiving appropriate wound care, which was eventually addressed by an LPN after multiple reminders.
A resident with dementia was prescribed Fluphenazine for psychosis without appropriate indication, as required by the facility's policy. Despite no observed behaviors justifying the medication, the facility did not adjust the prescription. Staff noted the resident was calm and had no aggressive behaviors, and the DON acknowledged the diagnosis was inappropriate for the medication use.
A resident experienced a medication administration deficiency with a 23.53% error rate due to late administration of morning medications, including insulin, which was refused as it was too close to lunchtime. The LPN acknowledged the delay, and the DON confirmed the medications were not administered as per the physician's orders.
The facility failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies, leading to infection control deficiencies. Staff did not perform hand hygiene after glove changes during care for a resident with a catheter and feeding tube. Additionally, a resident with an indwelling catheter did not have appropriate EBP signage or PPE available, and another resident received catheter care without the staff wearing a protective gown.
The facility failed to notify in writing, and maintain a copy in the medical record, notification to the Ombudsman and resident/resident representatives of residents before transfers. The Director of Nursing could not provide documentation of such notifications, and the Social Services Director admitted to not notifying the Ombudsman or resident/resident representative in writing of hospital transfers, unaware of the requirement. This affects all 70 residents in the facility.
The facility failed to notify residents or their representatives in writing about the bed-hold policy during transfers and did not maintain a copy of this notification in the medical records. The DON and an RN confirmed that the required documentation was not completed, affecting all 70 residents.
The facility failed to implement enhanced barrier precautions (EBP) as required, affecting all 70 residents. Despite a policy mandating gown and glove use for residents with wounds, indwelling medical devices, or infections, staff were observed using only gloves. Interviews revealed a lack of awareness and delayed implementation of EBP, as acknowledged by the Director of Nursing.
The facility failed to ensure residents knew the Grievance Officer, did not provide a private area for Resident Council meetings, and did not respond to Resident Council concerns. Residents reported loud noise during meetings and lack of responses to their grievances. Observations confirmed inadequate postings and lack of follow-up on complaints.
The facility failed to accurately code a resident's visual status in their MDS assessments. Despite signs and verbal confirmation of the resident's legal blindness, the MDS documentation was inconsistent, listing the resident's vision as both highly impaired and adequate. Staff verified the resident's visual impairment but did not ensure accurate MDS documentation.
The facility failed to document a vision care plan for a legally blind resident, despite staff actions and signs indicating the resident's impairment. Both an LPN and the Social Services Director confirmed the oversight.
The facility failed to revise the Comprehensive Care Plans for two residents, resulting in discrepancies between documented care and actual care provided. One resident's care plan incorrectly indicated continuous oxygen use, and another's inaccurately documented a tracheostomy despite decannulation months prior.
The facility failed to provide necessary shower and nail care for a resident, as required by their policies. The resident had overgrown fingernails and reported not receiving a shower since admission. Documentation was inconsistent, and staff interviews confirmed that care was not provided as needed.
The facility failed to have orders for indwelling catheter care and to record catheter output for two residents. Observations showed catheters draining urine, but there were no orders or documentation for catheter care or output. An RN confirmed the lack of orders and documentation, and CNA charting for catheter care was missing.
The facility failed to post required State and Federal postings for resident use, with only the Ombudsman office information displayed. The Administrator confirmed the absence of other required postings, and the Activity Director noted that the postings were removed during remodeling and could not be found. New postings were eventually printed and displayed.
An incident of physical abuse occurred when one resident with Paranoid Schizophrenia and Major Depressive Disorder, exhibiting severe cognitive impairment (BIMS score 4/15), assaulted another resident diagnosed with Dementia. The aggressor physically hit the victim multiple times, causing an orbital fracture and injuries to the face and hands. The victim, who primarily speaks Vietnamese and has communication barriers, was unable to defend herself. The facility's Abuse Prevention and Reporting policy, which emphasizes residents' right to be free from abuse, was not effectively implemented, leading to an Immediate Jeopardy situation. The incident was captured on video and witnessed by staff members.
Insufficient Night Shift Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet resident needs and to have a licensed nurse in charge on each shift. The facility assessment called for assistance with activities of daily living, toileting programs, incontinence care, prompt response to requests for bathroom assistance, and fresh drinking water provided three times daily. The resident council minutes also documented ongoing concerns about showering, call light response times, staffing, and customer service. Multiple resident concern forms described delayed or absent care during the night shift, including residents reporting that they were changed only once overnight, not changed at all, or waited more than 30 minutes to over an hour for call lights to be answered. One resident reported that staff did not return to provide incontinence care after entering the room, and another reported prolonged delays in call light response. Residents also reported that staffing was unstable and that agency staff were used often. Staff interviews reflected that third shift was challenging because of staffing inconsistencies, that call light wait times were longer, and that incontinence care and fresh ice water were not always provided as scheduled. On 3/27/26, the facility’s staffing records showed one agency CNA, one agency nurse, and one facility LPN on the 10 p.m. to 6 a.m. shift. Staff and residents described that this shift was short-staffed, with one CNA covering only one side of the building and unable to complete incontinence care on the other side. A nurse reported that many residents were upset the next morning because they had not received incontinent care all night. The administrator later verified that the night shift had been understaffed with only two nurses and one CNA, and stated that this was not enough staff to care for all residents, ensure rounds were completed, and answer call lights timely.
Ice Water Not Passed Consistently
Penalty
Summary
The facility failed to ensure fresh ice water was passed to residents three times per day in accordance with its Water Pass-Hydration Policy, which states that fresh cold ice water will be provided to each resident a minimum of three times each day unless contraindicated. The Census Report documented 77 residents in the facility, and the deficiency was identified through observation, interview, and record review. A resident concern form documented that one resident had asked for ice water after 4:00 AM and was told by two unknown CNAs that they could not do that between 4:00 AM and 6:00 AM. During observations, one resident had a cup of warm water on the bedside table, another had an empty water cup, and both residents stated that fresh ice water was not consistently passed three times a day. One resident reported that staff occasionally passed fresh ice water on second shift and rarely on third shift, while another stated the facility was lucky if ice water was passed one time a day. Staff interviews supported these concerns: an LPN stated that ice water often did not get passed on third shift, an agency LPN reported staffing shortages that made it impossible to complete tasks including providing ice water, another LPN stated third shift could not always access ice after the kitchen closed, a CNA reported fresh ice water was often not passed on second shift due to staffing and agency use, and the DON stated ice water should be passed every shift.
Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical and verbal abuse involving resident-to-resident altercations for three of four residents reviewed for abuse. The report states the facility’s Abuse Prevention and Reporting-Illinois Policy prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services, and mistreatment of residents. Despite this policy, survey findings documented multiple incidents in which residents physically struck one another and, in one case, used derogatory language during the altercation. One incident involved two residents in the dining room when yelling was heard and coffee was spilled on one resident and the table. One resident reported being slapped in the face by the other, while witnesses stated the resident had thrown coffee on the other resident first and that the resident then slapped the other in response. The abused resident reported being slapped several times, and another witness observed visible finger marks on the left side of the resident’s face consistent with the report. The resident who struck the other admitted to slapping the resident because the resident made him mad. Records showed one resident had moderate cognitive impairment, required supervision with most ADLs, and had physical and verbal behaviors directed at others, while the other resident also had moderate cognitive impairment and a care plan noting potential verbal and physical aggression. A second incident involved two roommates in their room when yelling was heard and one resident was seen tussling with the other over belongings. The resident reported trying to find clean socks when the roommate started throwing things and hitting her, and the LPN who intervened stated the roommate physically hit the resident in the arm multiple times and then began hitting the LPN as well. The resident later reported being hit in the face, arms, and upper body after being falsely accused of stealing socks. The resident’s MDS documented short-term and long-term memory problems. The report also documents that the facility identified the resident-to-resident altercations as physical abuse.
Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) who is a Registered Nurse (RN), as required by regulation and the facility’s own job description. The facility assessment tool dated 1/6/26 identified an individual (V9) as the DON and stated that a DON would provide resources needed to support competent care for the resident population every day and during emergencies, and that the Administrator’s team members included the DON. The resident census roster dated 3/6/26 showed 78 residents residing in the facility. Review of V9’s employee file showed a start date of 12/22/25 and a termination date of 1/26/26, and the facility’s DON job description dated 7/2023 required that the DON be an RN with a current, unencumbered state license and direct the overall operation of the nursing department in accordance with state and federal standards. On 3/8/26, during surveyor review, the Administrator (V1) was unable to provide a DON license and stated that the facility required a full-time DON but had not had one since V9’s termination on 1/26/26. V1 further stated that there was no RN serving as DON and that the Assistant Director of Nursing (V2), who was functioning as the acting DON, was only an LPN. Verification of V2’s professional license on 3/8/26 confirmed that V2 held an active LPN license, not an RN license. As a result, the facility did not have a full-time RN serving as DON for the period following 1/26/26, despite having 78 residents in care.
Failure to Use Enhanced Barrier Precautions and Maintain Sanitary Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), during indwelling urinary catheter care for one resident and to maintain a sanitary, homelike environment for two residents. The facility’s Infection Surveillance, Tracking and QA policy dated 12/2025 requires monitoring adherence to infection control practices, including proper use of PPE and ensuring proper precautions are initiated. The resident census roster shows multiple residents residing on the A Wing hallway. One resident (R7) had diagnoses including urogenital implants, benign prostatic hyperplasia with lower urinary tract symptom impairments, and urinary retention, and the care plan specified EBP related to an indwelling urinary catheter, including gown and glove use during high-contact care such as hygiene and device care. On 3/9/26 at 9:48 a.m., an LPN (V12) performed suprapubic catheter care for R7 without wearing a gown or mask, despite being assigned to the entire A Wing hallway and acknowledging not using this PPE. The Administrator (V1) later stated that nurses should always wear a gown, gloves, and mask when providing catheter care and that EBP is required. The deficiency also includes failure to maintain a clean and safe environment in a resident room shared by two residents (R11 and R12). The Administrator job description requires ensuring the facility is maintained in a clean and safe manner, and the housekeeper job description requires following cleaning schedules, coordinating with nursing, cleaning resident living areas and floors, and discarding waste in proper containers. On 3/7/26 at 10:32 a.m., surveyors observed a soiled wet incontinence brief, a white bath towel with an approximately eight-inch area of brown matter, wet maroon sweatpants, a wet brown sweatshirt, and yellow non-skid socks on the floor in front of the commode in R11 and R12’s room. At 1:09 p.m. the same day, the same soiled items remained on the floor in front of the commode. On 3/8/26 at 8:15 a.m., a clear bag containing the soiled maroon sweatpants, brown sweatshirt, and yellow non-skid socks was observed on the floor in front of the sink in the same room. The Administrator stated that it was unacceptable for the soiled clothing, towel, and dirty incontinence brief to remain on the bathroom floor for that length of time.
Failure to Provide Timely Showers and Incontinence Care, Leaving Residents Soiled for Extended Periods
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for hygiene and incontinence care, resulting in residents going without weekly showers and remaining in urine and feces for extended periods. Facility policies state that residents have rights to exercise autonomy and choice in daily life and care, and that CNAs are responsible for bathing, grooming, answering call lights promptly, and washing and drying incontinent residents. The Incontinent Care policy requires incontinent residents to be checked approximately every two hours and provided perineal and genital care after each episode. Despite these policies, Resident Council minutes and concern/compliment forms over several months document repeated complaints that showers were a persistent concern on all shifts, that residents had to ask multiple times to receive showers, and that some residents received bed baths instead of preferred showers. One cognitively intact resident who required partial/moderate assistance with toileting reported going to the bathroom, removing a wet disposable brief, and activating the bathroom call light for a replacement. After waiting 35 minutes without staff response, the resident put the wet brief back on and returned to the room to activate the room call light. The resident estimated wearing the wet brief from about 8:45 a.m. until 10:30 a.m., describing discomfort, burning, and feelings of helplessness and anger due to not being properly cared for. Another cognitively intact resident, dependent for toileting and rolling, reported that after receiving a laxative and having a bowel movement, staff did not respond promptly to the call light, resulting in remaining soiled for more than 90 minutes, and that bed linens were not changed afterward. This resident stated feeling degraded and that dignity was compromised, and also reported being given a quick bed bath instead of a requested shower because use of a mechanical lift required two staff. The same resident described waiting two and a half hours to be changed when an agency CNA said she had a hernia and could not lift, requiring the resident to wait for the next shift. Another resident with moderate cognitive impairment and partial/moderate assistance needs for toileting and transfers was reported by a roommate to have been left wet in urine for over 40 minutes after a call light was activated at 6:14 a.m. and not answered until 6:56 a.m. A cognitively intact resident who was always incontinent of urine and had an ostomy, and who was dependent for toileting and showers, stated that a family member typically visited daily to assist with showers, disposable brief changes, and ostomy care, and that staff relied on this family member to perform these tasks. When the family member did not visit, staff attempted to provide bed baths instead of showers, and the resident had to repeatedly request the scheduled shower. Another cognitively intact resident, dependent on toileting care and requiring substantial/maximal assistance for rolling, reported waiting all morning and afternoon for help changing a soiled and wet disposable brief. A staff member began to assist but left, stating there were no clean sheets and did not return, leaving the resident with soiled brief and linens. The resident became visibly upset, tearful, and angry, questioning whether life would continue with such mistreatment. A CNA who worked on the day the last resident described the incident stated that it was after 3:00 p.m. when the resident reported having asked all day to be changed, and that the resident was covered in urine from back to neck and down to the feet, with a saturated brief, strong urine odor, and reddened skin everywhere urine had touched. Another CNA stated that all staff were having to choose which resident cares to complete and that agency staff often arrived hours late, slowing resident care. A different CNA reported that staffing was becoming an issue, that the facility had not evaluated resident load compared to staff, and that CNAs were required to perform dietary tasks such as serving and picking up room trays, serving in the dining room, and feeding residents while also trying to chart and provide resident care, resulting in residents suffering because CNAs could not care for them properly. The Administrator acknowledged being unaware that residents were sitting in urine and feces for long periods, confirmed CNAs were required to help with dietary tasks, and agreed staff were overworked. The Ombudsman reported receiving a call from a very upset resident who said she had sat in feces for 90 minutes with the call light on and no staff response, and also noted numerous complaints from residents about call lights not being answered or being turned off by staff who said they would return but did not.
Insufficient Food Supply and Delayed Call Light Response Compromise Resident Rights
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to a dignified existence, self-determination, and timely communication by not providing sufficient food to follow the posted menu and not answering call lights in a timely manner. Facility policies required that resident rights be promoted, that call lights be answered promptly by all staff, and that dietary staff prepare and serve meals according to planned menus and standardized recipes. Despite these policies, surveyors observed that on a day when the lunch menu listed beef and bean chili, cornbread, and Snickerdoodle Blonde Bars, residents were served chocolate pudding instead of the listed dessert because the facility was out of eggs. Multiple CNAs and a prior dietary manager reported that running out of food, including main menu items and desserts, had been an ongoing issue, with residents sometimes receiving only toast when eggs or sausage were unavailable, or peanut butter and jelly sandwiches when portions were small. Staff also reported that residents who ate in their rooms, particularly those in certain room ranges, often did not receive the menu items because there was not enough food for all residents. Several residents with intact or mildly impaired cognition described not receiving the food listed on the menu and having to supplement with personal food supplies. One resident with a BIMS score indicating intact cognition stated that the kitchen runs out of food and that she does not get served what other residents are having, regardless of what the menu says. Another cognitively intact resident reported that the facility does not serve enough food during meals and kept a basket of various food items at the bedside to avoid going hungry. A different resident with intact cognition stated that she never receives a menu and that even when menus were posted, they were not followed; she kept a three-shelf storage unit in her room stocked with items such as beef stew, tamales, and soda. CNAs corroborated that several residents purchased their own cereal and other food because the facility frequently ran out of items like juice, eggs, and sausage, and that residents in specific rooms often did not receive the planned menu items. The deficiency also includes repeated failures to answer call lights in a timely manner, affecting multiple residents. One cognitively intact resident reported turning on the bathroom call light after removing a wet disposable brief and waiting 35 minutes without response, ultimately putting the wet brief back on and returning to bed, where she waited with the room call light on until staff eventually arrived and took her to the shower; she stated she is supposed to have help with toileting but often goes alone because there is not enough staff. Another resident with intact cognition stated that call light response times ranged from two minutes to two hours, especially on evening shifts. A resident with mild cognitive impairment had a roommate report that a call light activated at 6:14 a.m. for incontinence care was not answered until 6:56 a.m., during which time the resident remained soiled in urine. Additional residents with intact cognition reported long call light wait times and reliance on family members to assist with showers, changing disposable briefs, and ostomy care because staff said they were short-staffed. Family members and staff further described the impact of delayed call light responses. A family member of a severely cognitively impaired resident stated that staff were often short, that he routinely toileted the resident himself because staff did not answer call lights quickly, and that staff would delay responding because they knew he helped. CNAs reported that staffing was always short, that daily staffing sheets were inaccurate, and that they did not have time to complete all resident care because they were also required to assist dietary by delivering trays and serving meals and drinks. Resident council minutes and concern/compliment forms documented repeated complaints over several months about call lights not being answered timely and concerns about the dietary menu, including late trays, missing milk for cereal, and dissatisfaction with peanut butter and jelly or grilled cheese as meal alternatives. The ombudsman reported numerous complaints from residents that call lights were not answered or that staff would turn off the light and state they would return but did not. The administrator acknowledged that residents should not have to wait more than 10–15 minutes for call lights to be answered and that the kitchen should have the ingredients needed to follow the menu and provide the same meal to all residents, while the registered dietitian and regional dietary manager indicated they had not been fully informed of the extent of menu noncompliance and food shortages.
Failure to Provide Daily Room Cleaning and Trash Removal
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring that resident rooms were cleaned and trash removed on a daily basis. The facility’s own housekeeper job description requires adherence to cleaning schedules, including cleaning and sanitizing resident rooms and discarding trash into proper containers. Resident council minutes documented grievances about soiled items in rooms and reports that rooms were not cleaned when housekeepers were off work. Review of the housekeeping/laundry schedule showed limited staffing, including days with only one staff member on days and no staff scheduled for evening shifts, and other days with no housekeeper assigned to one side of the building. Multiple cognitively intact residents reported that their rooms were not cleaned daily and that trash was not removed unless they specifically requested it. One resident stated his room was not cleaned on specific days and that when a particular housekeeper was off, his room did not get cleaned, despite the housekeeping manager being expected to cover. Another resident reported her room had not been cleaned for several days, that she had to mash down garbage in an overfull wastebasket, and that she used a t‑shirt to mop water off the bathroom floor; surveyors observed a strong urine odor, full trash cans, and soiled disposable briefs in her room and bathroom. A roommate reported that no one had cleaned the shared room, where surveyors observed a large dried brown sticky stain on the floor and unswept, unmopped floors. A third resident stated she was “lucky” if housekeeping came to sweep and mop and that her room and trash were not addressed daily. Staff interviews confirmed that when the primary housekeeper was off, daily cleaning did not occur in all rooms, that rooms on one hall were not cleaned on a specific date, and that there was no housekeeper for one side of the building on another date. The administrator confirmed that resident rooms and floors should be cleaned daily and trash removed daily or when full.
Chronic Understaffing Leads to Delayed Care, Missed Showers, and Inadequate Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and accurately reported nursing and direct care staffing to meet residents’ needs for timely call light response, showers, incontinence care, room cleaning, and fall prevention. The facility’s own Facility Assessment Tool for 08/2025–08/2026 documented expected CNA staffing levels (seven CNAs on days and evenings for 87–92 residents and three CNAs on nights for a census under 86), but the Administrator later stated the assessment had not been updated and did not reflect the actual number of CNAs needed. Daily staffing calculator reports for multiple dates in December 2025 showed CNA hours worked were below the calculated hours needed on numerous days. Staff schedules and interviews confirmed that on some shifts there were significantly fewer CNAs present than planned, including reports that at 6:00 AM on at least one day there were only two CNAs in the building when there should have been seven or eight. The facility also failed to accurately document staffing on its Daily Staffing Calculator reports. On two randomly selected dates, the calculator overstated therapy and activity staff hours compared to the actual treatment and direct engagement hours documented by the Therapy Director and Activity Director. The Administrator acknowledged relying on reported numbers from these department heads and was unaware they were inaccurate. Additionally, daily assignment sheets showed that the Administrator, the MDS Coordinator (RN), and the previous DON were working the floor for portions of shifts to cover staffing gaps, while the Laundry and Housekeeping schedule showed limited housekeeping/laundry coverage on certain evenings, with no staff scheduled 4:00 PM–12:00 AM on some dates. Resident and family interviews, Resident Council minutes, and grievance/concern forms documented repeated complaints of long call light response times, missed or delayed showers, and inadequate room cleaning. Residents reported waiting from an hour to several hours for call lights to be answered, including one resident who stated she remained in feces for approximately 90 minutes after receiving a laxative and that her bed linens were not changed afterward. Another resident reported having only one shower since admission and needing to ask multiple times for showers, while others stated they were given bed baths instead of preferred showers and had to “nag” staff. A family member reported having to toilet a resident himself due to call lights not being answered. Residents and staff also reported that staff were too busy or too few to get residents up as ordered, to provide showers as scheduled, or to remain present in the assisted dining room as required. Staff interviews further described chronic understaffing, particularly on evening and night shifts, frequent reliance on agency CNAs and nurses, and agency staff not completing all required care or answering call lights consistently. CNAs reported that staffing on some mornings started with only two CNAs in the building, that they often had to cover large halls and also assist in the assisted dining room, and that daily staffing sheets did not match the actual staff present. The Ombudsman reported receiving multiple complaints about call lights not being answered or being turned off without staff returning, including a call from a resident who said she sat in feces for 90 minutes with her call light on. The incident/accident log and Regional Nurse Consultant interview documented multiple unwitnessed falls for one resident in the assisted dining room and at the nurses’ station, including a fall on one date that was not documented on the log, while a CNA stated she believed residents were having falls because there was not enough staff. Resident Council minutes over several months consistently recorded concerns about call lights, showers, soiled items in rooms, and lack of room cleaning when housekeepers were off work. Overall, the observations, records, and interviews show that the facility did not maintain sufficient numbers of CNAs and licensed nurses on each shift to meet residents’ needs for timely assistance, personal hygiene, toileting, and environmental cleanliness, and did not maintain accurate staffing records or an updated facility assessment reflecting actual staffing needs for its census of approximately 83–91 residents.
Failure to Investigate, Document, and Intervene After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention Program and Incident/Accident policies for a resident with severe cognitive impairment and total dependence for ADLs and transfers. The resident, who had athetoid cerebral palsy, anxiety, and a developmental speech and language disorder, was care planned as being at risk for falls related to immobilization and decreased cognition. Despite this, the resident experienced multiple falls in a short period, including falls at the nurses’ station and in the Assisted Dining Room (ADR), while dependent on staff for safety and supervision. On one occasion, therapy staff observed the resident lean forward in a wheelchair and fall, striking her head on a sharps container and nurses’ cart. On another documented fall at the nurses’ station, the resident was noted as alert but disoriented at baseline. The facility’s own policies required completion of incident/accident reports for all accidents, assessment and documentation of injuries and vital signs, physician and family/legal representative notification, and care plan updates with appropriate interventions after each fall. However, for a fall that occurred in the ADR on 12/3, staff statements show the resident was found on the floor tipped back in her wheelchair, but no incident report was completed, no nursing note was entered, no notifications were made to the physician or the resident’s representative, and no new interventions were implemented. Additional documentation and interviews show that the resident had further falls in the ADR on subsequent dates, and that at least one of these later falls also did not result in new interventions being put in place. The incident/accident log omitted the 12/3 ADR fall entirely, despite staff and a resident witness describing that the resident fell backwards in her wheelchair in the ADR while no staff were present, and that another resident had to yell repeatedly for help. The resident’s representative reported being informed of only three falls and stated she would have wanted to know about other falls. Overall, the facility failed to prevent falls, failed to investigate at least one fall, failed to notify the physician and resident representative of two falls, and failed to implement fall-related interventions after two of the resident’s falls, contrary to its written policies and fall prevention program.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of catheter care and adherence to Enhanced Barrier Precautions (EBP) and hand hygiene requirements for one resident with an indwelling urinary catheter. Facility policy on urinary catheter care required disposable one-time-use gloves when emptying urinary drainage bags and performing perineal care, and hand hygiene before and after touching any part of the urinary catheter drainage system. The EBP policy required gown and gloves for high-contact resident care activities, including medical device care and incontinent care, and specified that standard precautions must be followed with all care. The CNA job description required adherence to infection control and standard precaution practices when performing nursing procedures. The resident involved was an older adult with dementia, cognitive communication deficit, urinary retention, obstructive and reflux uropathy, and a history of UTI, with physician orders and a care plan in place for EBP related to an indwelling urinary catheter and for infection risk related to poor oral intake, dehydration, and weakened immune function. During an observation of catheter care, a CNA entered the resident’s room, applied gloves without performing hand hygiene, and did not don a gown despite the resident being on EBP for an indwelling catheter. Another CNA entered the room, assisted with repositioning the resident in bed, and did not wear gloves or a gown. The first CNA filled a washbasin with water and multiple washcloths, then used one washcloth to clean the resident’s penis, another to clean the scrotum, and another to clean the catheter tubing and catheter bag, all from the same basin. The CNA then changed gloves for the first time after completing this sequence of care but again did not perform hand hygiene, and proceeded to adjust the resident’s pants. When questioned, the CNA stated that a gown was not required for catheter care, which conflicted with the facility’s EBP policy and the resident’s orders and care plan for EBP and infection prevention measures.
Failure to Document Resident Council Complaints
Penalty
Summary
The facility failed to document all complaints and concerns voiced during Resident Council meetings. The Resident Council policy dated 02/2025 states the council is intended to allow residents to express thoughts and ideas in a safe and confidential manner and to promote improvement and control concerning quality of life at the facility. The Grievances policy dated 09/2017 states grievances may be filed orally, in writing, or anonymously and are to be resolved in a timely manner, usually within 5 business days. During interview, a resident stated she had concerns that she was not receiving the correct medications and reported that she had counted her pills and believed the number was sometimes wrong. She stated she had raised the issue with staff and had brought it up in Resident Council multiple times. Other residents who frequently attended Resident Council confirmed they had heard residents complain about medications. The Ombudsman stated she had heard residents complain about not getting the right medications, getting them late, or not getting them at all, and said these concerns had been voiced multiple times over the prior three months. The Activity Director stated concerns voiced during Resident Council should be treated like a grievance with a written form for investigation and tracking, but she did not document any medication-related concerns on a grievance form or inform the DON or Administrator. The Administrator stated her expectation was that all concerns voiced during Resident Council have a grievance form so the appropriate manager can investigate and improve the situation. The facility census listed 82 residents.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple documented instances of delayed responses to call lights and toileting assistance. The facility's own Call Light policy requires timely responses, especially for bathroom lights, which are to be treated as emergencies. However, interviews with staff, including LPNs and CNAs, revealed that frequent staff call-ins and understaffing led to longer wait times for residents. Residents reported waiting extended periods, sometimes up to three hours, for assistance with toileting and call lights, resulting in residents remaining in soiled briefs for prolonged periods. The Activity Director confirmed that concerns about delayed call light responses were raised in resident council meetings but were not documented in the minutes as instructed by previous administration. Review of facility records, including Daily Assignment Sheets and the Facility Assessment, showed that the facility was consistently short of the required nursing hours on several days, with shortages ranging from 33 to 47.1 hours per day based on their own staffing calculations. The Regional Director of Operations confirmed these staffing shortages. Resident complaints documented in concern forms and interviews further corroborated the impact of insufficient staffing, with reports of residents being told to wait for assistance and experiencing significant delays in care.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Food Palatability and Presentation Deficiency
Penalty
Summary
The facility failed to serve food that was visually appealing and palatable to residents, potentially affecting 78 residents who are prescribed oral intake. During an observation, the lunch meal of beef stroganoff, steamed zucchini, and chilled pears was served with the zucchini not properly drained, resulting in a watery and unappetizing appearance. Several residents did not eat the served lunch and requested an alternative meal. Multiple residents expressed dissatisfaction with the food, citing issues such as it not being warm, not pleasing to taste, and being too salty. The Ombudsman confirmed that food palatability is a recurring issue raised at resident council meetings and is often not addressed by staff. The Director of Nursing verified that two residents do not eat and take nothing by mouth.
Improper Trash Disposal and Pest Control
Penalty
Summary
The facility failed to ensure that two large trash dumpsters were secured from pests and rodents, as the lids of the dumpsters were not closed. This deficiency was observed during a follow-up tour with the Regional Dietary Manager, where it was noted that one of the dumpsters was overfilled with facility trash. The facility's policy on trash disposal requires that the dietary department dispose of trash appropriately and maintain the dumpster area to prevent the spread of infection and deter pests and rodents. The policy specifically states that dumpster lids should be closed and no trash should be on the ground surrounding the dumpster. The Regional Dietary Manager confirmed that the lids should have been closed, indicating a lapse in adherence to the facility's trash disposal policy.
Failure to Conduct PASARR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to obtain Pre-Admission Screening and Resident Review (PASARR) and/or Level II Resident Reviews for three residents diagnosed with mental illness. Resident 17, diagnosed with Schizoaffective Disorder, did not have a PASARR screening in her electronic medical records, and there was no evidence that a PASARR was initiated at the time of her diagnosis. Similarly, Resident 60, diagnosed with Other Schizoaffective Disorder, lacked a PASARR screening in his records, and no evidence was found that a PASARR was initiated at the time of his diagnosis. The Business Office Manager confirmed that the necessary screenings were not conducted for these residents, despite the facility's procedure requiring psychiatric evaluations and agency notifications for significant changes or new diagnoses. Resident 32, who was admitted with a diagnosis of Schizophreniform Disorder, also did not have a PASARR Level II screening following the diagnosis. The Administrator confirmed the absence of a PASARR Level II for this resident. The facility's policy mandates annual PASARR Level I screenings and reporting of any changes to the state mental health or intellectual disability authority, which was not adhered to in these cases. The lack of PASARR screenings for these residents indicates a failure to comply with regulatory requirements for residents with mental health diagnoses.
Failure to Notify Authorities of Significant Changes in Mental Health Conditions
Penalty
Summary
The facility failed to notify the appropriate state mental health and intellectual disability authorities regarding significant changes in the mental health conditions of two residents. Resident 17 was diagnosed with Schizoaffective Disorder on February 4, 2023, and Resident 60 was diagnosed with Other Schizoaffective Disorder on October 2, 2023. Despite these new diagnoses, the facility did not initiate the required Preadmission Screening and Annual Resident Review (PASARR) screenings or notify the relevant authorities as mandated by their policy. The Business Office Manager, who was responsible for coordinating PASARR screenings with the Social Services Director, confirmed that no screenings or notifications were made for the new diagnoses of these residents. The manager, who began employment at the facility in October 2024, acknowledged that the procedure for handling significant changes in diagnoses was not followed, as no agency notifications were made for the residents' significant changes in condition.
Failure to Maintain Proper Wound Care for Resident
Penalty
Summary
The facility failed to maintain proper wound care for a resident, identified as R12, who had wounds on the right inner thigh and left inner ankle. The facility's policy requires that wound dressings be checked daily for placement, cleanliness, and signs of infection, and that a licensed nurse observe the condition of the wound daily or with dressing changes as ordered. However, observations revealed that R12's right inner thigh wound was exposed without a dressing, and the left inner ankle dressing was not properly adhered and lacked a date and signature. R12 reported notifying staff about the issue, but the dressings were not promptly changed, leaving the wounds exposed to potential contamination. The facility's records indicated that R12's right thigh wound was due to trauma, while the left ankle wound was diabetic in nature. Despite having a physician's treatment order for specific wound care procedures, the facility did not adhere to these orders. R12 expressed frustration over the delay in receiving wound care, stating that the nurse eventually changed the dressings after multiple reminders. The Licensed Practical Agency Nurse, identified as V5, acknowledged the delay in changing the dressings, indicating a lapse in timely wound care management.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medication for a resident diagnosed with dementia. The resident, admitted to the facility with a diagnosis of dementia and other related conditions, was prescribed Fluphenazine, an antipsychotic medication, for psychosis. However, the facility's policy requires that psychotropic drugs are only given when necessary to treat a specific or suspected condition, and at the lowest therapeutic dose. Despite this, the resident's behavior monitoring records from January 22 to February 20 documented no observed behaviors that would justify the continued use of the antipsychotic medication. Observations and interviews conducted during the survey revealed that the resident appeared calm and well-kempt, with no aggressive or other concerning behaviors noted by staff. The Director of Nursing acknowledged that the behaviors associated with dementia are not an appropriate diagnosis for the use of Fluphenazine. Despite this understanding, the facility had not received orders to change the diagnosis or adjust the medication, indicating a lack of appropriate action to ensure compliance with the facility's policy on psychotropic medication use.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 23.53%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in the case of one resident, R12, during a medication pass. The facility's Medication Administration Policy requires that medications be administered in accordance with a physician's order and documented on the Medication Administration Record. However, R12's medications, which were scheduled for 8:00 am, were administered late, between 10:38 am and 11:02 am. This delay in administration led to R12 refusing their insulin dose, as it was too close to lunchtime, potentially affecting their diabetic management. R12, a diabetic resident, expressed concern about the timing of their medication administration, stating that they had already eaten breakfast and had not received their morning medications, which include insulin and other diabetic medications. The Licensed Practical Agency Nurse, V5, acknowledged the delay in medication administration, admitting to being late in passing the morning medications. The Director of Nursing, V2, confirmed that the medications were administered later than the scheduled time, which was not in accordance with the physician's orders. This failure to adhere to the prescribed medication schedule highlights a significant lapse in the facility's medication administration process.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its hand hygiene and Enhanced Barrier Precautions (EBP) policies, resulting in deficiencies in infection control practices. During an observation, the Director of Nursing (DON) and a Wound Nurse were seen performing care for a resident with an indwelling urinary suprapubic catheter and a feeding tube. The DON dropped a glove on the floor, picked it up, disposed of it, and then donned a new glove without performing hand hygiene. Similarly, the Wound Nurse changed gloves without performing hand hygiene after completing catheter care and before proceeding with feeding tube care. This lack of hand hygiene was verified by the facility's Administrator. Additionally, the facility did not follow its EBP policy for residents with indwelling medical devices. A Licensed Practical Nurse (LPN) provided catheter care to a resident with an indwelling urinary catheter without wearing a protective gown, contrary to the facility's expectations. Another resident, who had an indwelling catheter, was found to have no EBP sign or personal protective equipment (PPE) available in their room after being moved. The LPN acknowledged the absence of the EBP sign and PPE, indicating a lapse in maintaining infection control measures for residents with medical devices.
Failure to Notify Ombudsman and Resident Representatives of Transfers
Penalty
Summary
The facility failed to notify in writing, and maintain a copy in the medical record, notification to the Ombudsman and resident/resident representatives of residents that were reviewed for notices before transfers. This deficiency was identified based on interviews and record reviews. The facility's Bed Hold and Return to Facility policy, revised on 9/17/17, requires that residents and/or their representatives be notified of a transfer from the facility. However, on 4/11/24, the Director of Nursing was unable to provide any documentation that the Ombudsman or resident/resident representative was notified of resident transfers. Additionally, on 4/12/24, the Social Services Director admitted to not notifying the Ombudsman or resident/resident representative in writing of transfers to the hospital, stating they were unaware of the requirement. The facility has 70 residents, all of whom could potentially be affected by this failure.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed-hold policy during transfers to a hospital or therapeutic leave, and did not maintain a copy of this notification in the medical records. This deficiency was identified through interviews and record reviews. The facility's policy, revised on 9/17/17, mandates that residents and/or their representatives be informed of the bed-hold policy upon admission and at the time of transfer. However, on 4/11/24, the Director of Nursing (DON) was unable to provide documentation that such notifications were given. Additionally, on 4/12/24, the DON admitted that although staff were instructed to send the bed-hold policy with residents at discharge and to make a copy for the resident's record, this procedure had not been followed. An RN also confirmed that they had not documented the bed-hold policy in the resident's chart during transfers. The facility houses 70 residents, all of whom could potentially be affected by this oversight.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required, which has the potential to affect all 70 residents. The facility's EBP policy, revised on 4/8/24, mandates the use of gowns and gloves during high-contact resident care activities for residents with wounds, indwelling medical devices, or infections. Despite this, observations during the survey from 4/9/24 to 4/12/24 revealed that no EBP signs were posted throughout the facility, and staff were not adhering to the required precautions. For instance, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) were observed performing treatments on residents with only gloves, and Certified Nurse Aides (CNAs) confirmed they were unaware of the need to wear gowns in addition to gloves for certain care activities. Interviews with staff further highlighted the lack of implementation and awareness of the EBP. A CNA stated she only learned about the gown requirement the day before the survey, and another CNA, responsible for showering residents, admitted to using only gloves. The Director of Nursing (DON) acknowledged that an email was sent on 4/8/24 to start EBP on 4/9/24, but the implementation was delayed due to the survey. The DON mentioned that signs had just arrived, and staff education was ongoing. The facility's failure to implement EBP as required by their policy and corporate directive resulted in a deficiency that could impact the health and safety of all residents.
Failure to Address Resident Council Concerns and Provide Privacy
Penalty
Summary
The facility failed to ensure residents were aware of the Grievance Officer, did not provide a private area for Resident Council meetings, and did not respond to Resident Council concerns. During a Resident Council meeting, residents reported that the meetings were always loud due to the lack of doors in the dining room where the meetings were held. The residents also stated they did not know who the Grievance Coordinator was, were unaware of the location of required postings, and did not receive responses to their concerns. The monthly Resident Council Minutes did not include follow-up on resident complaints or concerns from the prior month. Observations confirmed that the only required posting in the facility was for the Ombudsman office information. The Administrator acknowledged that resident grievances were completed with the individual who reported the grievance and not shared with all Resident Council members. The Administrator also confirmed the lack of a private area for Resident Council meetings and stated that the required postings and the name of the Grievance Officer would be made available to residents.
Failure to Accurately Code Visual Status in MDS
Penalty
Summary
The facility failed to accurately code the visual status of a resident (R12) in their Minimum Data Set (MDS) assessments. On 4/9/24, it was observed that a sign above R12's bed indicated the resident was legally blind, and R12 confirmed he could only see shadows but not details. However, R12's MDS dated [DATE] documented his vision as highly impaired, while a subsequent MDS dated [DATE] documented his vision as adequate. On 4/10/24, an LPN verified that R12 was visually impaired and required visitors to introduce themselves. On 4/12/24, the LPN Careplan Coordinator confirmed that R12's visual impairment should have been accurately documented in the MDS.
Failure to Develop Vision Care Plan for Legally Blind Resident
Penalty
Summary
The facility failed to develop a vision care plan for one resident (R12) who was legally blind. Despite the presence of a sign above R12's bed indicating the resident's visual impairment and staff actions such as introducing themselves and placing the call light in the resident's hand, R12's current care plan did not document this impairment. Observations included a tape player with headphones for books on tape in R12's room, and staff were seen identifying themselves and explaining the location of items to R12. Both a Licensed Practical Nurse (LPN) and the Social Services Director confirmed R12's visual impairment and acknowledged that it should have been included in the care plan.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise the Comprehensive Care Plan for two residents, leading to discrepancies between the documented care plans and the actual care being provided. For one resident, the care plan indicated continuous oxygen dependency, but there was no physician order for continuous oxygen, and the resident was observed multiple times without using oxygen. The MDS Coordinator confirmed that the resident had not been on oxygen since being taken off hospice care in April 2023, yet the care plan was only updated on the day of the surveyor's visit. For another resident, the care plan inaccurately documented the presence of a tracheostomy, despite the resident having been decannulated several months prior. Observations and staff interviews confirmed that the resident no longer had a tracheostomy, and the care plan should have reflected a history of tracheostomy instead. The Director of Nursing and the MDS Coordinator acknowledged that the care plan should have included information about the resident's open airway post-decannulation.
Failure to Provide Shower and Nail Care
Penalty
Summary
The facility failed to ensure that shower and nail care were performed for a resident (R125) who was unable to perform these activities of daily living independently. The facility's policies and procedures require CNAs to assist residents with personal hygiene, including showers and nail care, and to document these actions. However, observations and interviews revealed that R125 had overgrown and jagged fingernails, and the resident reported not having received a shower since admission. The EHR and Shower Sheets for R125 showed inconsistencies and lack of documentation regarding the provision of showers and nail care, with no reasons provided for the missed care. Interviews with the DON and CNAs confirmed that nail care should be done on shower days or as needed, but this was not consistently documented or performed for R125. The DON acknowledged the deficiency and personally attended to R125's nail care after the issue was identified. The lack of proper documentation and adherence to the facility's policies resulted in the failure to provide necessary hygiene care for R125, compromising the resident's health and dignity.
Failure to Document Catheter Care and Output
Penalty
Summary
The facility failed to have orders for indwelling catheter care and to record catheter output for two residents. One resident was observed multiple times with a catheter draining clear amber urine, but there were no orders for catheter care or documentation of catheter output in the resident's records. Similarly, another resident was observed with a catheter draining cloudy yellow urine, but there were no orders for catheter care or documentation of catheter output in the resident's records. The facility's Urinary Catheter Care policy requires routine hygiene and catheter drainage bag emptying each shift, but these were not documented for the residents in question. A Registered Nurse (RN) confirmed the lack of orders and documentation for catheter care and output for the two residents. The RN also mentioned difficulty in finding where Certified Nurse Aides (CNAs) chart catheter output, emphasizing the importance of knowing the output for residents with catheters. The CNA charting for catheter care was reviewed and found to be missing, further highlighting the deficiency in adhering to the facility's catheter care policy.
Failure to Post Required State and Federal Postings
Penalty
Summary
The facility failed to post required State and Federal postings for Long-Term Care Facility Resident use, which has the potential to affect all 70 residents residing in the facility. The only posting observed was for the Ombudsman office, with no other required postings noted. The facility's Resident and Family Handbook and Residents' Rights policy document the residents' rights to contact outside organizations and advocates, but these postings were not displayed. The Administrator confirmed the absence of required postings and mentioned that she had never put up the required postings in any of her facilities, only the Ombudsman's poster. The Activity Director stated that the postings were removed by the previous Housekeeping Supervisor before the start of remodeling in November of the previous year and could not be found. The Resident Council Minutes indicated that residents were reminded about the ongoing remodeling. The Activity Director eventually printed new postings and hung them on the glass window at the front of the facility. The Long-Term Care Facility Application for Medicare and Medicaid form documented that there are 70 residents currently residing in the facility.
Resident-to-Resident Physical Abuse Incident Resulting in Injury
Penalty
Summary
The report details a case of physical abuse involving a resident (R2) in a long-term care facility. The incident occurred when another resident (R1) physically assaulted R2, resulting in R2 sustaining an orbital fracture. R1 exhibited aggressive behavior towards R2, hitting her multiple times with a closed fist, causing injuries to R2's face and hands. R2, who primarily speaks Vietnamese and has communication barriers, was unable to effectively communicate or defend herself during the assault. The report highlights that R1 displayed a lack of remorse for his actions, stating that R2 deserved the assault. R1, the aggressor in this incident, has a documented history of Paranoid Schizophrenia and Major Depressive Disorder. R1's medical records indicate severe cognitive impairment, with a BIMS score of 4/15, suggesting significant mental health challenges. On the other hand, R2, the victim, has a diagnosis of Dementia and other medical conditions, including an orbital fracture that put her at risk of experiencing pain and discomfort. R2's language barrier and memory problems further compounded the challenges she faced in this abusive situation, as she was unable to effectively communicate or understand the events unfolding. The facility's Abuse Prevention and Reporting policy emphasizes the residents' right to be free from abuse and outlines various forms of abuse, including physical harm, pain, and mental anguish. The report underscores the failure of the facility to prevent abuse, resulting in an Immediate Jeopardy situation. The incident involving R1 and R2 was captured on video, providing clear evidence of the physical assault. The report details eyewitness accounts from staff members who witnessed the assault, highlighting the severity of the incident and the immediate actions taken to address R2's injuries and ensure her safety.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 120 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — 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.
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Nursing homes near Morton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apostolic Christian Restmor | 1 mi | ★★★★★ | 1 | 0 |
| Fondulac Rehabilitation And Health Care Center | 7 mi | ★★★★★ | 4 | 1 |
| Hallmark Healthcare Of Pekin | 7.7 mi | ★★★★★ | 1 | 0 |
| Timbercreek Rehab And Health Care Center | 8 mi | ★★★★★ | 10 | 1 |
| Loft Rehab Of East Peoria, The | 8.3 mi | ★★★★★ | 0 | 0 |
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