Au Well Care Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Illinois.
- Location
- 152 Wilma Drive, Maryville, Illinois 62062
- CMS Provider Number
- 145858
- Inspections on file
- 34
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Au Well Care Home, Inc during CMS and state inspections, most recent first.
During a facility closure, multiple residents experienced mental anguish and neglect due to abrupt discharge processes, lack of communication, insufficient notice, and inadequate support with transfers. Several residents did not receive all prescribed medications or personal belongings, and some were separated from friends or placed in inappropriate settings. Environmental issues such as lack of hot water and unsanitary conditions further contributed to residents' distress.
The facility did not follow its closure plan or regulatory requirements, resulting in the rapid discharge of all residents within about 30 hours instead of the planned 30 days. Residents and families were notified of the closure and given options, but the process was expedited due to the owner's financial and safety concerns. Required documentation for involuntary transfer or discharge was incomplete, and no closure policy was provided to surveyors.
Multiple residents were subjected to abuse and neglect, including a resident who sustained facial injuries and a human bite from a CNA, and was later verbally threatened with death by an LPN. Facility leadership failed to remove abusive staff, initiate required investigations, or report incidents to authorities. Additional resident-to-resident altercations occurred without proper assessment, documentation, or protective interventions, and the facility lacked an effective abuse prevention program.
A facility failed to investigate and report multiple allegations of physical, verbal, and sexual abuse involving staff and residents. One resident with significant mental health needs sustained serious injuries after an altercation with a CNA, but the administrator did not initiate an investigation, suspend the staff member, or report the incident as required. Another staff member verbally threatened and was accused of sexual abuse by the same resident, yet continued to work without suspension or investigation. Additional resident-to-resident altercations were also not investigated, and staff lacked training on abuse prevention and managing aggressive behaviors.
The facility failed to provide necessary behavioral health care and services to residents with mental illness, including those with schizophrenia and bipolar disorder. Residents exhibiting self-injurious and aggressive behaviors did not receive appropriate psychiatric follow-up, behavioral interventions, or psychosocial programs. Staff lacked training in managing behavioral health needs, and there were no structured programs or activities for this population. As a result, residents were left without support, and law enforcement and emergency services were frequently called to manage behavioral crises.
Systemic administrative failures led to widespread deficiencies, including lack of key leadership staff, uninvestigated abuse allegations, inadequate behavioral health and clinical care, and unsafe water temperatures. Multiple residents experienced harm due to lack of assessment, monitoring, and intervention, while staff accused of abuse or threats were not removed from duty. The facility also failed to provide required programs for residents with serious mental illness and did not maintain an effective QAPI program.
A resident with complex medical needs experienced a significant change in condition that went unaddressed for two days, leading to emergency hospitalization, ICU stay, and intubation due to staff failure to assess, intervene, and follow physician orders. Another resident with diabetes and vascular disease suffered an untreated foot wound for months, resulting in severe infection and above-the-knee amputation after the facility failed to perform required skin assessments and respond to complaints of pain. In both cases, lapses in assessment, documentation, and communication among staff led to serious harm.
The facility did not maintain comfortable water temperatures, with multiple areas showing water well below recommended levels. Several residents expressed discomfort and frustration, with some unable to bathe properly and one needing to leave the facility to shower elsewhere. Staff and maintenance confirmed ongoing issues with the hot water system, and documentation showed the problem persisted for months, affecting all residents.
The facility failed to ensure physician supervision and documentation for several residents, resulting in multiple individuals not being seen by a physician during their stays despite experiencing falls, injuries, pain, and hospitalizations. Staff confirmed the absence of required physician visits and documentation, in violation of facility policy and regulatory requirements.
A resident with multiple comorbidities and a history of pressure ulcers developed new wounds after the facility failed to update care plan interventions, consistently monitor and document wound status, complete weekly skin assessments, and implement dietitian-recommended nutritional support. Despite repeated recommendations and clear care protocols, staff did not follow through with necessary interventions, and documentation was incomplete or missing.
Surveyors found that the facility did not maintain safe hot water temperatures in resident-accessible areas, with multiple readings above recommended limits. Staff and maintenance confirmed ongoing issues with water temperature regulation. Additionally, the facility failed to provide adequate supervision to prevent falls, did not consistently complete incident reports, root cause analyses, or update care plans after falls, and did not always conduct fall risk assessments. These deficiencies affected multiple residents, some of whom experienced repeated falls and injuries.
Three residents experienced significant unplanned weight loss due to the facility's failure to follow dietitian recommendations, incomplete documentation of meal intake and weights, and lack of appropriate feeding assistance. One resident with severe cognitive impairment was not provided with recommended supplements or double portions, another resident did not receive prescribed snacks and had to retrieve them independently, and a third resident dependent on enteral feeding had no care plan for nutrition and was left without feeding assistance despite physical limitations.
A resident with a feeding tube, who required assistance with eating due to hand contractures, was not provided with the recommended support to restore oral intake. Despite being cleared for a mechanical soft diet and expressing a preference for eating by mouth, the resident's trays were left out of reach and staff did not assist with meals. Dietitian recommendations to decrease tube feeding and provide oral supplements were not followed, resulting in continued reliance on enteral feeding and significant weight loss.
Several residents with chronic pain and complex medical conditions did not receive their prescribed pain medications as ordered, with delays, missed doses, and incomplete documentation. Staff admitted to being late with medication passes due to understaffing and lack of leadership, and in some cases, pain relief was withheld based on resident behavior. These failures resulted in unnecessary pain and suffering for multiple residents.
Multiple residents did not receive their prescribed medications on time or at all due to nurse shortages, late administration, and medication unavailability. This led to residents experiencing pain, anxiety, emotional distress, and, in one case, a seizure requiring emergency intervention. Documentation errors and lack of physician notification further contributed to the deficiency.
The facility failed to ensure timely and ordered laboratory testing for four residents, including missed or delayed blood level monitoring for seizure and anticoagulant medications, and lack of routine diabetes labs. This resulted in a resident experiencing a seizure and fall without evidence of required medication level monitoring, and other residents not receiving necessary lab tests as ordered by their physicians. Staff interviews and record reviews revealed a lack of oversight, incomplete documentation, and breakdowns in the process for ordering, tracking, and reporting lab results.
Multiple incidents of abuse, neglect, and theft were not reported or investigated in a timely manner, including staff-to-resident and resident-to-resident altercations resulting in injuries. The facility failed to suspend accused staff, did not complete or submit required investigations, and lacked documentation of interventions or staff training. Care plans did not address known risks, and there was no evidence of abuse prevention education or psychosocial support for residents with mental illness.
The facility did not ensure that required physician visits were conducted and documented for several residents, including those with complex medical and psychiatric needs. Some residents were not seen by their primary physician during their entire stay, while others had only one documented visit over several months, despite regulatory and hospital discharge requirements. Staff interviews confirmed the absence of required physician visits and documentation.
The facility did not ensure an RN was on duty for at least 8 hours daily and lacked a full-time DON. Only one RN was employed, working sporadically, and staff reported no DON for an extended period. LPNs were left overwhelmed, and there was no policy or Facility Assessment addressing RN or DON coverage, affecting all residents.
The facility did not ensure that kitchen staff had appropriate food safety training or certification, resulting in unqualified staff, including the Activity Director and housekeeping, preparing and serving meals without proper hygiene practices. Residents received meals that did not meet their dietary needs, and the facility lacked documentation of staff credentials and relevant policies.
Surveyors identified multiple failures in food storage and preparation, including staff not performing hand hygiene, improper glove use, uncovered and unlabeled food items, and improper storage of food and supplies directly on the floor or in standing water. Additional issues included raw meat stored above ready-to-eat items, water leaks in the freezer, and staff lacking food safety certification, all in violation of facility policy.
The facility did not complete or document a required facility-wide assessment to determine necessary resources for competent care during daily operations and emergencies. The Administrator acknowledged the absence of this assessment and related policies, citing workload and lack of a DON, with 73 residents present at the time.
The facility did not ensure a qualified ICP was working at least part-time onsite, as required. The ICP primarily worked remotely, was onsite only a few times in the past month, and was unable to provide current information about COVID testing. Timecard reviews confirmed minimal onsite hours, and a requested COVID testing line list was not provided.
The facility did not maintain plumbing and equipment in safe, working condition, resulting in ongoing issues with water temperatures that were either too cold or too hot in resident areas. Staff and residents reported persistent problems over several months, and temperature checks showed readings outside the facility's policy range. Maintenance logs and invoices documented repeated service calls and unresolved boiler repairs, affecting all residents.
Multiple residents, including those requiring substantial assistance and those with cognitive impairment, reported that call lights were not answered promptly, often resulting in extended wait times for help. The issue was confirmed by the Ombudsman and discussed in Resident Council meetings, with staff acknowledging the absence of a call light policy. These delays compromised residents' rights to dignity and a comfortable environment.
Four medication cards, including antipsychotic, muscle relaxant, antidepressant, and statin drugs, were left unsupervised on top of a medication cart in a hallway, accessible to multiple residents with cognitive and psychiatric conditions. An LPN admitted to leaving the medications out after becoming sidetracked, and the ADON confirmed that medications should always be locked up according to facility policy.
The facility did not ensure that residents received required dental assessments or assistance with dental visits, resulting in multiple residents with unaddressed dental issues, no documentation of oral health needs in care plans, and no dental services provided, despite requests and facility policy.
A facility failed to provide required immunizations, did not implement infection control procedures during outbreaks of gastrointestinal illness and COVID-19, and did not properly assess or treat residents with new fractures or pneumonia. Multiple residents experienced symptoms without appropriate isolation or documentation, and staff were not tracking infections or following outbreak protocols. Vaccines were not administered despite signed consents, and staff and residents exposed to COVID-19 were not offered testing. The facility also failed to provide hot water for hygiene, and no acceptable abatement plan was submitted for these deficiencies.
A group of residents with complex medical needs did not receive their scheduled medications for most of a day due to the absence of a nurse in one wing. The DON was aware but unable to access the EMR, and paper MARs were not utilized to ensure timely medication administration. Residents experienced missed doses for conditions such as diabetes, hypertension, pain, and mental health, resulting in anxiety, elevated blood glucose, tachycardia, and distress. Required documentation, physician notification, and monitoring were not completed as per facility policy.
A facility failed to maintain adequate hot water for bathing and hygiene, resulting in all reviewed residents experiencing cold or insufficient water for extended periods. Multiple residents reported emotional distress, inability to shower, and resorted to unsatisfactory alternatives such as sponge baths with cold water or wipes. Staff confirmed the ongoing plumbing issues and inability to provide proper care, while maintenance and administration were unable to resolve the problem promptly.
The facility did not thoroughly investigate or implement interventions after repeated altercations between two residents, resulting in injuries such as a black eye and nosebleed. Additionally, an LPN failed to address a resident's distress and did not provide required paperwork to EMS during a hospital transfer, with the facility's investigation lacking key evidence and interviews. The facility did not follow its own abuse prevention policies in these cases.
Two residents experienced significant changes in condition that were not promptly assessed, monitored, or communicated to the physician. One resident had ongoing respiratory symptoms and chest pain without timely review of diagnostic results or intervention, leading to a hospital diagnosis of pneumonia and COVID-19. Another resident suffered pain and decreased mobility after an altercation, with delayed emergency evaluation and discovery of a hip fracture, and staff were unaware of the injury while continuing unsafe transfers.
Six residents were not offered or provided influenza and pneumococcal vaccines as required, despite having signed consents and physician orders. Two residents contracted pneumonia, with one requiring hospitalization and subsequently passing away. Documentation was missing or incomplete in the EMR, and staff were uncertain about vaccine administration, despite facility policies mandating timely vaccination and proper recordkeeping.
The facility did not provide enough nursing staff, leading to residents missing medications, delayed assistance with toileting and showers, and cold meals due to late tray delivery. Multiple residents and staff reported that CNA staffing was inadequate, with only one or two CNAs assigned to care for up to 35 residents per wing, resulting in unmet care needs and prolonged response times to call lights.
The facility did not maintain an effective infection prevention and control program, failing to track and isolate residents with gastrointestinal and COVID-19 illnesses, update care plans, provide adequate PPE, or ensure sanitary laundry practices. Staff did not consistently monitor symptoms, perform required testing, or notify public health authorities, and infection control documentation and procedures were lacking throughout the facility.
The facility did not maintain a functional plumbing system, resulting in inadequate hot water and water pressure in resident-use areas, the kitchen, and laundry. Multiple residents reported the inability to take warm showers or use sinks, and staff confirmed ongoing leaks, low water temperatures, and unresolved plumbing issues. The deficiency affected all residents, with water temperatures in several areas consistently below acceptable levels.
The facility did not maintain an effective pest control program, as evidenced by reports from staff and residents of mice and insects, lack of a current pest control contract or policy, and observations of unsanitary conditions such as doors propped open with boxes on the floor. These deficiencies had the potential to affect all 71 residents.
The facility did not provide required infection control training to staff, lacked an Infection Preventionist, and failed to track or isolate residents during a gastrointestinal illness outbreak. Multiple staff members were observed without source control, and there was no documentation of infection control education for employees.
Four dependent residents did not receive regular showers or bed baths as required, with some receiving only one or two baths in a month. Observations included greasy hair, body odor, and dirty feet or fingernails. Staff cited cold water as a reason for increased refusals, and documentation of bathing offers and refusals was inconsistent. The issue was also raised in a resident council meeting, and the facility could not provide a showering policy when asked.
The facility did not offer or document COVID-19 vaccinations for several eligible, cognitively alert residents, despite some expressing willingness to receive the vaccine and experiencing COVID-19 infections. Medical records lacked evidence of vaccine offers or education, and the facility's policy did not address vaccination procedures.
Two residents were involved in an altercation resulting in one sustaining a nosebleed and later a hip fracture. Staff did not promptly notify the Administrator or the state health department about the injury of unknown origin, and the required investigation and reporting were delayed. Facility policy for immediate internal and external reporting was not followed.
The facility did not complete or submit final abuse investigation reports for three residents with complex medical conditions following allegations of abuse and neglect. Only initial reports were filed, and the administrator confirmed that no final documentation or investigation findings were available, contrary to facility policy and regulatory requirements.
The facility did not conduct or document thorough investigations into multiple abuse allegations involving three residents with complex medical and psychiatric conditions. In each case, essential steps such as identifying accused staff, conducting interviews, and maintaining investigation records were missing, despite initial reports being filed and administrative acknowledgment of the incidents.
The facility did not employ a certified Dietary Manager with appropriate training or experience, resulting in food being prepared and served without adherence to the prescribed menu or required food safety practices. The dietician was unaware of the situation, and the Administrator confirmed the lack of oversight and menu compliance, potentially affecting all residents.
The facility did not follow planned menus or physician-ordered diets, serving unapproved substitute foods, failing to provide required diet textures, and not controlling food portions. The dietician was not notified of menu changes, and dietary policies were unavailable when requested. These failures had the potential to impact all residents.
The facility did not have a DON, ICP, certified Dietary Manager, or maintenance staff, and lacked essential policies and a Facility Assessment. The Administrator reported taking on multiple roles due to the absence of support staff, and no one was overseeing dietary operations or following menus, potentially affecting all residents.
Surveyors found that the facility did not maintain its plumbing and equipment in safe, working condition, as evidenced by ongoing water leaks in the basement, water flowing into storage areas, and repeated plumbing failures. Multiple residents reported frequent water shut-offs, persistent plumbing problems, and even sewer water in a room. The facility could not provide a maintenance policy when requested.
The facility did not provide or document required annual abuse training for its staff, as confirmed by the administrator's inability to produce any records of such training. This failure is contrary to the facility's policy, which mandates annual education on abuse, neglect, and exploitation for all employees. Seventy-two residents were potentially affected by this deficiency.
The facility did not maintain or provide documentation of a training program for CNAs, including annual in-services and policies, affecting all 72 residents. The administrator was unable to produce any records of required nurse aide education, such as dementia care and abuse prevention.
The facility did not ensure that prescribed diets were properly prepared and served, as staff failed to follow dietary guidelines for several residents with complex medical needs. There was confusion among dietary staff about diet orders, lack of proper menu substitutions, and missing documentation of dietary intake. One resident with dysphagia was not evaluated by ST and was on an inappropriate diet, while another with significant weight loss received a diet inconsistent with physician orders. The dietician was not informed of menu changes, and no dietary policy was provided when requested.
Failure to Prevent Mental Anguish and Neglect During Facility Closure and Resident Transfers
Penalty
Summary
The facility failed to protect multiple residents from mental anguish and neglect during a facility closure and transfer process. Several residents reported being given insufficient notice about the closure, with some stating they were told they had to leave immediately and were not provided with choices regarding their new placement. Residents described the process as rushed and traumatic, with some not receiving assistance in packing their belongings, and others being separated from friends or loved ones. One resident reported being transferred to a facility far from their family, and another was placed in a facility without appropriate security measures for their cognitive condition, causing distress to their power of attorney. Medication management during the transfer was inadequate. Multiple residents did not receive all of their prescribed medications upon discharge or arrival at the new facility. One resident with HIV missed several days of critical medication due to the facility not sending it with them, and the receiving facility was unable to obtain a timely refill. Another resident did not receive a glucometer or a complete supply of insulin, and was missing other essential medications. The receiving facilities had to use emergency supplies or work to refill missing medications, and communication with the original facility was reported as poor or unresponsive. Environmental conditions prior to transfer were also cited as contributing to residents' distress, with reports of lack of hot water, unsanitary conditions, and infestations. Residents expressed feelings of helplessness, anxiety, sadness, and trauma as a result of the abrupt closure, lack of communication, and insufficient support during the transition. The facility's actions and inactions resulted in psychosocial harm and failed to meet the standard of care required to prevent neglect and mental anguish.
Failure to Implement Safe and Orderly Facility Closure Plan
Penalty
Summary
The facility failed to implement an adequate closure plan to ensure the safe and orderly discharge and transfer of all 78 residents prior to closure. Although residents and their families were notified of the facility’s loss of Medicaid participation and impending closure, the facility’s closure plan documentation indicated that residents were given 30 days’ notice and a list of four local nursing homes, along with the option to choose any facility. However, the facility also allowed local nursing home staff to come and screen residents, and the stated goal was to close the facility within 30 days. Despite the written plan, interviews and observations revealed that the facility’s administrator and owner prioritized rapid discharge, with the owner expressing a desire to move residents out as quickly as possible, citing both safety concerns and financial motivations. The administrator stated that residents would begin transferring the day after the closure notice, and the owner later confirmed that all residents were moved within approximately 30 hours, rather than the 30 days referenced in the closure plan. The last resident was observed being transferred to a local hotel, and all residents were discharged within two days of the closure notice. Additionally, the facility failed to provide a policy regarding closure to the survey team, and review of the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing forms for all residents revealed that they were incomplete. The facility’s actions did not align with the stated closure plan or regulatory requirements for orderly and safe resident transitions, and the lack of complete documentation and policy further contributed to the deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by several incidents involving both staff-to-resident and resident-to-resident altercations. One resident with a history of bipolar disorder and cognitive impairment was involved in a physical altercation with a CNA, resulting in facial lacerations, a black eye, and a human bite to the finger that required emergency medical treatment and antibiotics. Despite being aware of the incident, the Administrator did not initiate an abuse investigation, failed to remove the involved CNA from the facility, and allowed the CNA to continue working the remainder of the shift. Additionally, the Administrator questioned whether an investigation or suspension was necessary, citing self-defense, and did not document or complete the required investigation or reporting procedures. Further, the same resident was subjected to verbal abuse and a death threat by an LPN in the presence of the Administrator and a regional consultant. The LPN was not immediately suspended and continued to work the night shift following the incident. The Administrator and other facility leadership failed to report the threat to authorities, did not implement protective interventions, and did not document or investigate the abuse allegations, including a subsequent sexual abuse allegation made by the resident. The facility also lacked documentation of staff education on caring for residents with mental illness, and there were no records of abuse investigations or terminations in the involved staff members' files. Multiple resident-to-resident abuse incidents were also documented, including physical altercations resulting in injuries such as bruising and unassessed injuries. The facility failed to implement an abuse prevention program or interventions to safeguard residents with cognitive impairments and wandering tendencies. Incident reports, follow-up assessments, and investigations were consistently missing or incomplete for these events. The facility leadership, including the Administrator and regional executives, acknowledged the absence of required documentation and investigations for these incidents, and the immediate jeopardy remained at the time of survey exit.
Failure to Investigate and Report Abuse Allegations Involving Staff and Residents
Penalty
Summary
The facility failed to operationalize its abuse prevention and investigation policies, resulting in multiple uninvestigated and unreported incidents of alleged physical, verbal, and sexual abuse involving both staff and residents. In one incident, a resident with significant mental health diagnoses, including bipolar disorder and psychotic symptoms, was involved in a physical altercation with a CNA, resulting in the resident sustaining multiple facial lacerations, a black eye, and a human bite to the finger that required emergency medical treatment and antibiotics. Despite being aware of the incident, the administrator did not initiate an abuse investigation, did not suspend the staff member involved, and failed to report the incident to the state agency within the required timeframe. The administrator also failed to review video evidence, did not assess the resident's injuries, and did not complete required documentation or incident reports. Staff interviews revealed a lack of training on handling aggressive residents, and there was no evidence of staff education on abuse prevention since the facility changed ownership. Further deficiencies were identified when another staff member, an LPN, verbally threatened the same resident in the presence of management, stating he would "beat her to death" if she attacked another staff member. The resident subsequently made an allegation of sexual abuse against the LPN, which was reported to the administrator and the facility ombudsman. Despite these serious allegations, the LPN was not immediately suspended and continued to work the night shift. No initial or final abuse investigation was completed or submitted to the state agency, and there was no documentation of the incident or any disciplinary action in the staff member's file. The facility's regional leadership and medical director were aware of the allegations but failed to ensure proper investigation or documentation. Additional incidents included uninvestigated resident-to-resident altercations, with one resident reporting being attacked and scratched by another, and the facility failing to complete an abuse investigation or implement interventions to safeguard those involved. The facility also lacked documentation of psychiatric follow-up for residents with serious mental illness and did not implement required psychosocial programs. Throughout these events, the facility failed to maintain required records, conduct timely and thorough investigations, report allegations as required, and provide staff training on abuse prevention and management of residents with mental illness.
Failure to Provide Behavioral Health Services and Maintain Psychosocial Well-being
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents with mental illness, resulting in a deficiency that affected all 73 residents. Multiple residents with serious mental illness, including schizophrenia, bipolar disorder, and a history of self-harm, were not provided with appropriate psychiatric services, behavioral interventions, or psychosocial programs as required by their care plans and PASRR recommendations. The facility lacked a psychiatrist on staff, and residents had not received psychiatric assessments or follow-up for extended periods. Staff interviews confirmed that there were no behavioral health programs in place, and staff had not received training on managing residents with behavioral issues. One resident with schizophrenia and severe cognitive impairment exhibited daily behavioral symptoms such as hallucinations, delusions, verbal and physical aggression, self-injurious behavior, and environmental soiling. Her care plan was outdated and did not address her current behaviors, including isolation, room cleanliness, or feces-throwing. Staff routinely avoided intervening with her, and she was left to act out without redirection or support. Another resident with bipolar disorder and a history of suicidal ideation repeatedly engaged in self-harm behaviors, including banging her head and expressing suicidal thoughts, but was only intermittently redirected or sent to the hospital without consistent follow-up or structured behavioral support as recommended in her PASRR. Staff interviews revealed a lack of behavioral health training, with no specialized interventions or group activities for residents with mental illness. The Social Service Director and Activity Director both reported no behavioral programs or targeted activities, and the facility administrator acknowledged the absence of such programs. Law enforcement and emergency services were frequently called to manage behavioral crises, indicating that staff were not equipped to handle these situations. Documentation showed that behavioral tracking was incomplete and did not specify staff interventions for medication refusal or self-isolation, further demonstrating the facility's failure to maintain or improve residents' psychosocial well-being.
Systemic Administrative Failures Result in Widespread Deficiencies
Penalty
Summary
The facility failed to ensure effective administration and oversight, resulting in multiple systemic deficiencies affecting all residents. There was a lack of key leadership positions, including the absence of a licensed administrator, Director of Nursing (DON), and a Registered Nurse (RN) for required hours. The facility also did not have a qualified Infection Control Preventionist or Activity Director, and lacked a certified Dietary Manager. These staffing failures led to breakdowns in critical areas such as abuse prevention, behavioral health services, clinical care, and environmental safety. Abuse prevention systems were not in place or followed, as evidenced by multiple uninvestigated and unreported allegations of abuse involving both staff and residents. Staff members accused of abuse or making threats were not suspended or removed from duty pending investigation, and required reports to the state agency were not completed. The administrator failed to initiate or complete abuse investigations, did not maintain documentation, and did not implement safety measures for residents. Additionally, there was no annual staff education on abuse policies, and the facility lacked an effective Quality Assurance and Performance Improvement (QAPI) program to monitor and address these issues. Residents' clinical and psychosocial needs were not met, including failures to provide behavioral health interventions, monitor and treat weight loss, manage gastrostomy tubes, and ensure ongoing laboratory services. There were also significant lapses in environmental safety, with water temperatures in resident rooms and showers consistently below safe and comfortable levels for an extended period. The facility did not follow prescribed menus, and recommendations from the dietician were not implemented. In one case, a resident with a history of diabetes and vascular disease suffered an untreated wound that progressed to severe infection and amputation due to lack of assessment and intervention. Another resident experienced a significant change in condition that went unaddressed, resulting in a prolonged hospital stay. The facility assessment was not completed, and there were no programs in place for residents with serious mental illness.
Failure to Assess and Treat Change of Condition and Wounds Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to assess and treat a change of condition for a newly admitted resident with a complex medical history, including chronic liver disease, hepatic encephalopathy, diabetes, and recent psychiatric hospitalization. Upon admission, there was no interim care plan created, and staff were unfamiliar with the resident's baseline status. Over the course of two days, the resident exhibited significant changes in condition, including being hard to arouse, poor appetite, and declining oxygen saturation. Despite these symptoms, there was inconsistent documentation of physician notification, and the resident was not sent to the hospital until her oxygen levels dropped critically low. The lack of timely intervention resulted in the resident requiring emergency transfer, a prolonged hospital stay, ICU admission, and mechanical intubation. Additionally, hospital discharge orders for follow-up appointments and lab work were not completed, and physician orders for labs were not carried out during her stay at the facility. Another resident with multiple comorbidities, including diabetes, end-stage renal disease, and peripheral vascular disease, was admitted with a history of non-pressure ulcers. The facility failed to complete an initial skin assessment and did not consistently perform or document weekly skin assessments as required. The resident complained of excruciating left foot pain for two days, but no assessment was documented at the time of the complaint. The resident was eventually sent to the hospital, where she was diagnosed with severe infection, osteomyelitis, and septic arthritis, which had been present for 2-3 months without evaluation or treatment. The infection progressed, requiring surgical debridement and ultimately an above-the-knee amputation. In both cases, staff interviews revealed a lack of clarity regarding responsibility for assessments and follow-up, as well as inconsistent communication and documentation practices. Nurses reported relying on physician direction or assuming symptoms were baseline without adequate assessment or escalation. There was also a lack of oversight for wound care, with no designated staff to monitor ongoing skin integrity issues. These failures resulted in significant harm to both residents, including prolonged hospitalization, ICU stays, and major surgical interventions.
Failure to Maintain Adequate Hot Water Temperatures for Resident Comfort
Penalty
Summary
The facility failed to ensure that water temperatures were comfortable and appropriate for residents, resulting in multiple complaints and discomfort among the residents. Water temperature measurements taken throughout the building revealed that both shower and sink water temperatures were consistently below the recommended range, with many readings between 62.4°F and 89.9°F, and several shower rooms registering temperatures in the 70s°F. Residents reported that the water was cold, making it unpleasant or impossible to bathe, and some stated that the issue had persisted for months. One resident even reported having to leave the facility to bathe at a friend's house due to the ongoing problem. Staff interviews confirmed the ongoing nature of the water temperature issue, with CNAs and the Activity Director acknowledging that complaints had been received since at least December. Maintenance staff reported that only one of two boilers was operational and that the recirculatory system, which is responsible for distributing hot water throughout the building, was not functioning properly. The temperature gauge on the working boiler was significantly below the desired level, and maintenance logs and invoices documented repeated attempts to repair leaks and restore hot water, as well as the need for significant repairs to both boilers. Resident council meeting minutes and direct resident statements further corroborated the widespread dissatisfaction and discomfort caused by the lack of adequate hot water. The facility's own documentation indicated that water temperatures for resident use should be between 105°F and 120°F, but actual measurements fell well below this standard. The deficiency affected all 73 residents in the facility, as the water temperature issue was present throughout the building and impacted both personal hygiene and overall comfort.
Failure to Provide Physician Supervision and Documentation
Penalty
Summary
The facility failed to ensure that residents were under adequate medical supervision by a physician, as required. Four residents were identified as not having received timely or documented physician visits during their stays, despite experiencing significant medical events. For example, one resident with multiple complex diagnoses, including bipolar disorder and diabetes, experienced several falls, altercations, and injuries requiring emergency medical treatment, yet there was no documentation of any physician visits during her entire stay. Another resident with schizophrenia, dementia, and other comorbidities sustained multiple falls, altercations, and injuries, but only had one documented physician visit, which was a late entry. A third resident, who was cognitively intact and had a history of hidradenitis suppurativa and diabetes, reported not seeing his primary physician since admission, despite multiple hospitalizations for uncontrolled pain and infection. This resident also stated that his pain medication was reduced without a physician assessment. The medical record corroborated the lack of physician visits and incomplete documentation of hospitalizations and pain management events. A fourth resident with traumatic brain injury, epilepsy, and dementia had only one documented physician visit over several months, despite experiencing multiple falls, a grand mal seizure, and being transferred to the emergency room for further treatment. Laboratory monitoring for seizure medication was also not up to date. Interviews with facility staff and the regional MDS consultant confirmed the absence of required physician documentation and visits for these residents. The facility's own policy requires that each resident's medical care be supervised by a licensed physician, with participation in assessments, care planning, and routine visits, as well as proper documentation. The lack of physician oversight and documentation was acknowledged by facility staff, who confirmed that the primary physician had not seen or documented visits for the affected residents during the relevant periods.
Failure to Prevent and Monitor Pressure Ulcers and Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement new care plan interventions to prevent pressure ulcers, provide ongoing monitoring of a new pressure ulcer, complete weekly skin assessments as ordered, and implement dietitian recommendations for a resident with a history of pressure ulcers and multiple comorbidities. The resident, who had diagnoses including a history of TIA, hypertension, type II diabetes, hyperosmolality, hypernatremia, and chronic kidney disease, was admitted with a pressure ulcer to the coccyx and a left below knee amputation. The care plan included interventions such as notifying the physician and family of changes in skin status, weekly body assessments, and monitoring wound healing, but did not address the resident's nutritional status. Despite being seen by a wound specialist and having wounds resolved as of January, documentation showed that the resident refused several weekly skin assessments over multiple months. However, the resident was observed as alert and oriented during the survey period and denied refusing repositioning, instead attributing the recurrence of wounds to not being changed on time. New stage two pressure ulcers were identified on the buttocks in February, but there was a lack of ongoing documentation regarding the measurement and monitoring of these wounds. The facility did not maintain a wound care log, and staff were unable to provide comprehensive wound documentation when requested by surveyors. Additionally, the registered dietitian made repeated recommendations for nutritional interventions to support wound healing, including specific supplements and changes to enteral feeding, but these recommendations were not implemented or communicated effectively. The dietitian was not notified that her recommendations were not being followed, and the wound nurse practitioner indicated that timely intervention could have improved the resident's outcome. The facility's policy required regular assessment and monitoring of residents at risk for pressure ulcers, including attention to nutrition, but these protocols were not consistently followed for this resident.
Failure to Maintain Safe Water Temperatures and Inadequate Fall Prevention Practices
Penalty
Summary
The facility failed to ensure that hot water temperatures were maintained at safe levels in areas accessible to residents. Multiple observations over several days revealed that water temperatures in resident rooms and shower areas consistently exceeded the recommended maximum, with readings ranging from 115.5°F to 120.6°F. Staff interviews confirmed that residents used both shower rooms interchangeably, and maintenance staff acknowledged ongoing issues with water temperature regulation since January. Despite attempts to address the problem, such as replacing a mixing valve, water temperatures remained above the ideal range, potentially affecting all residents in the facility. Additionally, the facility failed to provide adequate supervision to prevent falls and did not consistently complete incident reports, conduct thorough assessments, analyze fall incidents for root causes, implement interventions, or update care plans after falls. Several residents with significant medical histories and cognitive impairments experienced multiple falls, some resulting in injuries and hospital transfers. Documentation repeatedly showed that event reports were left open, lacked root cause analyses, and did not include new interventions or care plan updates following each fall. In some cases, fall risk assessments were not completed at all during the residents' stays. Interviews with facility staff, including the Regional MDS Consultant and ADON, confirmed that required procedures for fall management were not followed. Staff acknowledged that incident reports were incomplete, root cause analyses were not performed, and interventions were not implemented or documented. The lack of proper fall risk assessments, failure to update care plans, and absence of follow-through on fall prevention measures contributed to ongoing deficiencies in resident safety and supervision.
Failure to Follow Dietitian Recommendations and Monitor Weights Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that dietitian recommendations were followed and that resident weights were properly monitored for three residents who experienced significant weight loss. For one resident with severe cognitive impairment and multiple medical diagnoses, there was no care plan documentation addressing weight loss, and physician orders did not reflect the dietitian's recommendations for increased caloric intake, dietary changes, or supplementation. Meal consumption records were incomplete, and direct observation showed that the resident was not provided with recommended supplements or double portions, and staff did not encourage or offer alternative food when intake was poor. Another resident, cognitively intact but with a history of diabetes and cardiac issues, had a care plan that included monitoring for weight loss and dietitian evaluation as needed. However, meal consumption records were frequently incomplete, and despite the dietitian recommending specific snacks and supplements to address significant weight loss, these were not provided. The resident reported that snacks were not delivered as ordered and that he had to retrieve them himself, with limited options available, particularly for diabetic residents. A third resident, also severely cognitively impaired and dependent on enteral feeding, had no care plan documentation regarding nutritional status or tube feeding. Physician orders did not include weight monitoring, and multiple months of weights were missing. The dietitian's recommendations for changes in tube feeding, oral supplements, and meal assistance were not implemented. Observations revealed that the resident's meal tray was left out of reach for extended periods without staff assistance, despite the resident's inability to feed himself due to hand contractures. Staff interviews confirmed a lack of clarity regarding dietary orders and a failure to provide necessary feeding assistance.
Failure to Follow Dietitian Recommendations and Provide Feeding Assistance
Penalty
Summary
The facility failed to follow dietitian recommendations and did not implement an individualized plan of care to restore oral nutritional intake for a resident with a feeding tube. The resident, who had a history of TIA, cerebral infarction, hypertension, diabetes, hypernatremia, and chronic kidney disease, was admitted with a feeding tube and required assistance with eating due to hand contractures. Despite a modified barium swallow evaluation showing no aspiration risk and physician orders allowing a mechanical soft diet with thin liquids, the resident continued to receive continuous enteral feedings without adequate support for oral intake. Observations revealed that the resident's meal trays were repeatedly left at the bedside, covered and out of reach, with no staff present to assist with eating. The resident reported being unable to eat independently due to hand contractures and expressed a preference for oral feeding over tube feeding. The resident also stated that he often felt too full to eat because of the ongoing tube feeding and indicated that he would eat in the dining room if provided assistance and encouragement. Interviews with staff and the registered dietitian confirmed that recommendations to decrease tube feeding, provide oral supplements, and assist the resident with meals in the main dining room were not implemented. The dietitian noted that her recommendations were not followed and that she was not informed of this. The facility's policy required prompt meal service and appropriate feeding assistance, but these were not provided, resulting in the resident's extended reliance on tube feeding and significant weight loss over six months.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for four residents, resulting in unnecessary pain and suffering. Multiple residents with complex medical histories, including chronic pain conditions such as polyneuropathy, diabetes, spondylosis, hidradenitis suppurativa, and osteoarthritis, did not receive their prescribed pain medications in a timely manner or as ordered. In several instances, residents' requests for pain relief were ignored, delayed, or contingent upon their behavior, and documentation of medication administration was incomplete or missing. One resident reported repeated delays in receiving pain and anti-diarrheal medications, with staff admitting to being over two hours late in medication administration due to understaffing and lack of leadership. The resident described escalating pain, ultimately calling 911 for assistance after being denied medication until an apology was given. Another resident with a history of hidradenitis suppurativa and stroke did not receive scheduled morphine, leading to uncontrolled pain and a hospital admission. This resident also reported not seeing their primary physician since admission and overheard staff intentionally delaying pain medication. Additional residents experienced similar issues, including the absence of a nurse on their unit, resulting in late administration of scheduled pain medications and unaddressed pain complaints. Staff interviews confirmed that medications were administered late and not documented properly. The facility's own policy requires prompt assessment and administration of pain medication, as well as thorough documentation, none of which were consistently followed. These failures affected all residents reviewed for pain management and had the potential to impact all residents in the facility.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances where medications were not administered as ordered, were given late, or were unavailable. On one unit, there was no nurse available to administer medications during a scheduled med pass, resulting in residents not receiving their medications on time. The only available LPN was required to cover both sides of the building, leading to delays in medication administration. This resulted in residents experiencing pain, anxiety, and emotional distress due to missed or late doses of critical medications, including pain medications, antipsychotics, anticonvulsants, and HIV medications. One resident with a history of epilepsy and severe cognitive impairment did not receive scheduled doses of pain medication and anticonvulsant (Keppra) on time, with documentation showing repeated late administrations. This resident subsequently experienced a grand mal seizure and required emergency medical intervention. Another resident with schizophrenia and anxiety reported increased anxiety and auditory hallucinations due to delayed administration of antipsychotic and anti-anxiety medications. A third resident with diabetes, pain, and a history of deep vein thrombosis did not receive scheduled pain medications, anticoagulants, and insulin as ordered, with documentation gaps for blood sugar checks and insulin administration. This resident reported severe pain and concern over missed medications. Additionally, a resident with HIV did not receive their antiretroviral medication on time, expressing concern about the importance of timely administration. Another resident did not receive several scheduled medications, including those for depression, gastroesophageal reflux disease, and prostatic hyperplasia, due to the medications being unavailable in the facility. There was no documentation of physician notification regarding the missing medications. The facility's own policy requires prompt identification and reporting of adverse consequences and medication errors, but these procedures were not followed, as evidenced by the lack of timely administration, documentation errors, and failure to notify physicians when medications were unavailable.
Failure to Provide Timely and Ordered Laboratory Services
Penalty
Summary
The facility failed to provide laboratory services in accordance with physician orders for four residents, resulting in missed or delayed laboratory tests critical for monitoring and managing their medical conditions. For one resident with epilepsy and a history of traumatic subdural hemorrhage, the facility did not obtain a Keppra (levetiracetam) blood level as ordered, with the last documented test occurring in the previous year. This resident experienced a grand mal seizure and a fall, with no evidence of routine monitoring of antiseizure medication levels as required by the physician's orders. Additionally, medication administration records showed multiple instances of late or delayed administration of Keppra, and the facility was unable to provide timely lab results or ensure that the lab orders were completed as scheduled. Another resident on warfarin therapy for a history of cerebral infarction and cardiac arrest had an order for regular PT/INR monitoring, but the last documented test was several months prior, and there was no documentation that the physician was notified of the results. Staff interviews revealed uncertainty about the frequency of required testing and a lack of follow-up on abnormal results. The resident reported that PT/INR checks had stopped after the initial period following admission, and facility staff could not provide evidence of ongoing monitoring or physician notification. Additional deficiencies included a resident prescribed divalproex for schizophrenia who did not have required valproic acid levels drawn as ordered, and a resident with diabetes who did not have quarterly hemoglobin A1C and fasting blood sugar labs completed as per physician orders. The facility's own laboratory services policy outlined procedures for timely testing, reporting, and follow-up, but staff interviews and record reviews indicated a breakdown in the process for ordering, tracking, and documenting laboratory tests and results. There was no evidence of management oversight to ensure compliance with physician orders or integration of lab results into the electronic medical record.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting and investigation of multiple allegations of abuse, neglect, and theft, as well as failed to report the results of investigations to the State Survey Agency within the required timeframes. Several incidents involving both staff-to-resident and resident-to-resident abuse were not reported within two hours of the allegation, and in many cases, no investigation was completed or submitted. For example, after a physical altercation between a resident and a CNA, which resulted in the resident sustaining multiple injuries including scratches, a bite, and a bruised eye, the administrator did not report the incident promptly, did not suspend the staff member involved, and did not initiate or complete an investigation. The administrator also failed to review video evidence and did not document the incident or the injuries in the resident's records. The staff member continued to work after the incident, and the administrator expressed uncertainty about the need to report or investigate the event, citing self-defense as a reason for inaction. In another instance, a resident reported feeling threatened by an LPN, including allegations of sexual abuse and verbal threats to cause harm. Despite being made aware of these allegations by both the resident and the ombudsman, the administrator did not suspend the accused staff member immediately, did not report the incident to the State Agency, and did not complete or submit an investigation. The LPN continued to work after the allegations were made, and there was no documentation of the investigation or any disciplinary action in the employee's file. Witnesses, including other staff and the regional CEO, confirmed that the required reporting and investigation procedures were not followed. Additionally, the facility failed to investigate and report incidents of resident-to-resident abuse, such as altercations resulting in physical harm or threats. In several cases, there was no documentation of interventions to protect residents from further abuse, and care plans did not address known risks or histories of aggression. Staff reported a lack of training on handling aggressive residents, and there was no evidence of psychosocial programs or safety plans for residents with serious mental illness. The facility also lacked documentation of staff education on abuse prevention policies since a change in ownership, and multiple abuse investigations requested by surveyors were missing or incomplete.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that physician visits were conducted according to regulatory requirements for four residents reviewed, with the potential to affect all residents in the facility. Specifically, residents were not seen by their primary physician every 30 days for the first 90 days after admission, at least once every 60 days thereafter, or as directed by hospital discharge instructions. Documentation in the electronic medical record (EMR) confirmed the absence of required physician visits for these residents during their stays. One resident with multiple diagnoses, including bipolar disorder, diabetes, and a recent fall with head injury, was not seen by her primary physician during her entire stay, despite discharge instructions from a local hospital emergency room requiring a follow-up visit within 3-5 days. Another resident with schizophrenia, depression, and other complex medical conditions was seen only once by his primary physician during a stay of several months. A third resident, who was cognitively intact and had a history of pain and diabetes, reported not seeing his primary physician since admission and expressed concerns about medication management. The fourth resident, with severe cognitive impairment and multiple diagnoses, was seen only once by the primary physician over several months, with no nurse practitioner visits documented. Interviews with facility staff and the regional MDS consultant confirmed the lack of physician visits and documentation for these residents. The primary physician stated that he aimed to see each resident every 60 days, but the EMR did not reflect the required frequency of visits. Facility policy requires physician supervision and documentation in accordance with OBRA regulations, but these requirements were not met for the residents reviewed.
Failure to Provide Required RN and DON Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 hours each day and did not have a full-time Director of Nursing (DON) in place. Interviews with the administrator and staff confirmed that there was only one RN employed, who worked sporadically and was not present every day. Timecard reviews showed that the RN worked only one day during the reviewed period, and there was no evidence of any RN providing the required daily coverage. Additionally, staff reported the absence of a DON for an extended period, and no policy was in place regarding RN or DON coverage. Further observations and interviews revealed that staff, including LPNs, were overwhelmed due to the lack of RN and DON support, leading to delays in medication administration and increased workload. The facility also lacked a Facility Assessment and could not provide documentation to show compliance with RN and DON staffing requirements. The facility's application indicated 73 residents, all of whom were potentially affected by these staffing deficiencies.
Failure to Employ Sufficient Qualified Dietary Staff and Ensure Food Safety Practices
Penalty
Summary
The facility failed to ensure that staff working in the kitchen had the appropriate training and skills to carry out food and nutrition services for all 73 residents. Observations revealed that only one cook was present to prepare breakfast for over 70 residents, and this individual did not possess food safety certification. The cook was assisted by the Activity Director, who also lacked food safety certification and was not a regular kitchen staff member. During meal service, neither staff member was observed practicing proper hand hygiene, and both wore the same pair of gloves throughout the entire breakfast service. Meals were served on Styrofoam plates without being covered during transport, and there was confusion regarding resident meal tickets and dietary requirements. Interviews with staff and residents confirmed that the kitchen was understaffed over the weekend, with housekeeping staff stepping in to help despite lacking food safety certification. Residents reported dissatisfaction with the meals provided, including being served items not appropriate for their diets. The facility was unable to provide food safety certifications for any kitchen staff except the Dietary Manager, who was absent due to illness. Additionally, the facility did not have a policy on kitchen staffing credentials and requirements available for review.
Food Storage and Preparation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in food storage and preparation practices that could lead to potential contamination affecting all 73 residents in the facility. During breakfast service, two staff members, including the Activity Director, did not perform hand hygiene and wore the same pair of gloves throughout the meal service, regardless of the items handled. All food was served on Styrofoam plates without any covering during transport. In the dry storage area, cases of canned goods and napkins were found stored directly on the floor, with some napkins loose and in contact with the floor. Inside the walk-in refrigerator, tubs of milk were stored in standing water directly on the floor, and other tubs of milk were stored in water on crates. There were also uncovered, unlabeled, and undated food items, including a pan with a brown substance, opened deli meats, and a block of cheese. Raw hamburger meat was thawing above ready-to-eat items, and the refrigerator ceiling had black spots with a musty odor present. Further inspection of the walk-in freezer revealed a large block of ice on the floor, water dripping from the ceiling, and boxes of food covered in ice crystals and wet from the leak. Opened boxes of breadsticks and French fries were also found exposed and wet. The facility's food storage policy requires food to be stored off the floor, covered, labeled, and separated by type, but these procedures were not followed. A staff member admitted to lacking food safety certification and was unaware of the contents of some food items due to missing labels. These observations demonstrate a failure to store and prepare food in accordance with professional standards and facility policy.
Failure to Complete Facility-Wide Assessment
Penalty
Summary
The facility failed to complete and document a facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. During an interview, the Administrator acknowledged awareness of the requirement for a Facility Assessment but admitted that one had not been completed due to being occupied with other responsibilities and the absence of a DON. Record review confirmed that no Facility Assessment or related policy was available for review, and the Administrator stated there was nothing in place to evaluate current resources or needs for day-to-day operations. The facility's application indicated there were 73 residents at the time of the survey.
Failure to Ensure Onsite Infection Control Preventionist
Penalty
Summary
The facility failed to ensure that a qualified Infection Control Preventionist (ICP) was working at least part-time onsite, as required for the infection prevention and control program. During the survey period, no ICP was observed working onsite. The ICP, who had started working for the facility about a month prior, reported via phone interview that she worked at another facility as well and primarily performed her duties from home, only being onsite three times in the past month. She was not able to provide up-to-date information regarding recent COVID testing in the facility and was unsure of the current testing status. Review of timecards confirmed that the ICP worked minimal hours onsite at the facility, with 3.5 hours, 1.5 hours, and 5 hours recorded over three consecutive weeks, and no documented hours onsite during the week of the survey. Additionally, when a line list of COVID testing was requested, it was not provided by the facility. At the time of the survey, there were 73 residents living in the facility.
Failure to Maintain Safe and Consistent Water Temperatures
Penalty
Summary
The facility failed to ensure that plumbing and equipment were maintained in safe, working condition, resulting in inconsistent and inappropriate water temperatures throughout resident areas. Observations during a basement tour revealed that only one of two large boilers was operational, with the working boiler's temperature gauge reading 78.0°F, which is significantly below the expected level. Staff interviews confirmed ongoing issues with hot water availability and temperature fluctuations since at least December, with both residents and staff reporting periods of cold water and, at times, excessively hot water. Water temperature measurements taken in various resident rooms and shower areas over several days showed that temperatures frequently exceeded the facility's policy range of 105°F to 120°F, with some readings as high as 120.6°F. Maintenance logs did not consistently document hot water temperatures, and plumbing invoices detailed repeated service calls for broken hot water lines, leaks, and the need for significant boiler repairs. Despite attempts to address these issues, such as replacing a mixing valve and isolating leaks, the facility continued to experience problems with water temperature regulation. Multiple staff members, including the administrator, maintenance personnel, and the assistant DON, acknowledged the persistent nature of the water temperature issues. Residents also reported ongoing dissatisfaction with water temperatures, indicating that the problem had not been resolved over several months. The facility's failure to maintain proper water temperatures and ensure the safe operation of plumbing equipment had the potential to affect all 73 residents living in the facility.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for five out of seven residents reviewed for this issue. Multiple residents, including those who were cognitively intact and those with moderate cognitive impairment, reported that call lights were not being answered promptly, with some stating they waited for hours to receive assistance. Residents who required substantial or maximal assistance with activities of daily living, such as those using wheelchairs, were particularly affected. The issue was corroborated by the Ombudsman, who noted numerous complaints about delayed responses to call lights and residents waiting extended periods to be changed. Resident Council meeting minutes and interviews with residents and staff further confirmed ongoing concerns about delayed call light responses. The President of the Resident Council and other residents reported frequent complaints about the issue, and it was discussed during council meetings. Additionally, the Regional MDS Coordinator stated that there was no facility policy on call lights. The facility's Resident Rights Policy emphasized the right to dignity, respect, and a comfortable living environment, but the lack of timely call light response and absence of a specific policy contributed to the deficiency.
Unsecured Medications Left on Unattended Medication Cart
Penalty
Summary
Surveyors observed four medication cards, including Seroquel, tizanidine HCL, Remeron, and atorvastatin, left unsupervised on top of a medication cart in the hallway outside the unit nurse's station. These medications, labeled for a specific resident, were accessible to all residents from 8:44 AM to 9:05 AM, with several residents, some with cognitive and psychiatric diagnoses such as developmental disorder, bipolar disorder, intellectual disability, dementia, and schizophrenia, seen near the unsecured medications during this period. The cart was unattended, and the medications were not secured in accordance with facility policy and professional standards. A Licensed Practical Nurse later confirmed that she had left the medication packs out on the cart, stating she became sidetracked and forgot to secure them. The Assistant Director of Nursing acknowledged that medications should never be left out where residents can access them and should always be locked up. The facility's policy requires all medications to be stored in locked compartments when not in use, and this procedure was not followed at the time of the incident.
Failure to Provide Dental Assessments and Services
Penalty
Summary
The facility failed to ensure that residents were assessed and assisted with dental visits, as required, for four residents reviewed for dental services. Multiple residents had significant dental issues that were not addressed through assessment or care planning. For example, one resident had only one remaining upper tooth, with the rest missing, and broken, crowded, and deformed lower teeth. Despite a history of dental pain and the need for dental care, there was no documentation of a dental assessment or care plan addressing oral health. Another resident had a discolored front tooth, inflamed gums, and halitosis, and reported requesting dental care without receiving assistance or an appointment. Additional residents were also not provided with dental assessments despite documented cognitive impairments and the need for assistance with oral hygiene. Care plans for these residents did not address oral health or dental issues, and Minimum Data Set (MDS) assessments either left oral/dental sections blank or failed to document oral care needs. Requests for dental assessments were made, but no assessments were completed or documented for the residents in question. Interviews with facility staff, including the administrator and chief executive, confirmed that there were no dental assessments on file for any residents and that no dental professionals were providing exams or oral care services in the facility. The facility's own policy required dental assessments within ninety days of admission and the offering of dental services as needed, but this was not being followed for the residents reviewed.
Immediate Jeopardy Due to Failure in Infection Control, Immunization, and Resident Care
Penalty
Summary
The facility failed to protect residents from neglect by not offering or administering required immunizations for influenza, pneumonia, and COVID-19, and by failing to implement infection control procedures during outbreaks of gastrointestinal illness and COVID-19. Multiple residents experienced symptoms such as vomiting, diarrhea, and fever, but there was no documentation of isolation orders, severity or duration of symptoms, or infection tracking. Staff did not track or trend infections, and residents with symptoms were not isolated or instructed to stay in their rooms. The facility lacked an Infection Preventionist, and the Administrator was unaware of the extent of the outbreak. Housekeeping staff were not instructed to perform enhanced cleaning, and there was no line list of affected residents. The facility also failed to ensure that residents received vaccinations as ordered. Many residents had signed consents for influenza and pneumococcal vaccines, but there was no documentation that these vaccines were administered. Some residents reported requesting vaccines but not receiving them, and the facility had influenza vaccines in stock that had not been given. COVID-19 testing and isolation procedures were inconsistently applied, with staff and residents who had been exposed not being offered testing, and outbreak protocols not being followed. The local health department was not notified of the COVID-19 outbreak, and staff were unclear on current guidelines for testing and isolation. Additionally, the facility failed to assess, monitor, and treat significant changes in condition for residents with new fractures, pneumonia, and COVID-19. One resident with a hip fracture was not properly assessed or had precautions implemented, resulting in staff attempting unsafe transfers. Another resident with pneumonia and COVID-19 had delayed follow-up on chest X-ray results, and staff were unaware of the resident's condition or test results. The facility also failed to provide a functioning plumbing system to supply hot water for resident hygiene. These failures resulted in an Immediate Jeopardy situation affecting all residents in the facility, and no acceptable abatement plan was provided at the time of the survey exit.
Failure to Administer Medications as Ordered Due to Lack of Nursing Coverage
Penalty
Summary
On the date in question, the facility failed to ensure that medications were administered as ordered to approximately 40 residents in one wing, including four residents with significant medical needs. The deficiency occurred when there was no nurse assigned to the 200-hall wing, resulting in residents not receiving their scheduled medications from approximately 7 AM to 4 PM. The Director of Nursing (DON) was aware of the situation but did not have access to the electronic medical record (EMR) to administer medications, and the administrator confirmed that no medications had been passed that morning. The facility owner and Medical Director did not allow the use of agency nurses, and the DON had only recently started and lacked EMR access. Paper MARs were available, but medications were still not administered in a timely manner. The affected residents had complex medical histories, including diagnoses such as anxiety disorder, schizophrenia, depression, chronic pain syndrome, diabetes, hypertension, heart failure, tachycardia, and a history of suicidal ideation. These residents did not receive critical medications for conditions such as anxiety, depression, neuropathy, seizures, hypertension, diabetes, and pain management. For example, one resident with a recent psychiatric hospitalization for suicidal ideation did not receive any of her prescribed medications, including anti-anxiety and anti-seizure drugs, and reported increased anxiety as a result. Another resident with diabetes and hypertension did not receive her blood pressure or psych medications and expressed significant distress and anxiety. Documentation in the EMR and MARs confirmed that medications were not administered as ordered, and there was no evidence of physician notification or orders to hold or delay medications. Vital signs and blood glucose monitoring were not completed as required, and residents reported symptoms such as elevated blood glucose, tachycardia, pain, and emotional distress. The facility's own policies required timely administration of medications, prompt reporting of medication errors, and close monitoring of residents affected by such errors, but these procedures were not followed during the incident.
Failure to Provide Adequate Hot Water for Resident Hygiene and Comfort
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring that water temperatures were adequate for bathing and hygiene for all residents reviewed. Multiple instances were documented where water temperatures in shower rooms and bathroom sinks were significantly below comfortable or acceptable levels, with readings consistently ranging from 58°F to 86°F after running the water for over a minute. This issue persisted over several days, and in some cases, there was no water flow at all in the showers or only a trickle from faucets, making it impossible for residents to bathe properly. Residents reported being unable to take showers for extended periods, with some expressing emotional distress and feelings of neglect or borderline abuse due to the lack of hot water. Several residents described resorting to sponge baths with cold water or using wipes, which they found unsatisfactory. One resident, who is a type 1 diabetic, became emotional and cried when discussing the inability to shower. Staff interviews confirmed the ongoing problem, with CNAs stating that they had to use cold water or wipes for perineal care and that residents were increasingly upset by the situation. Maintenance staff and the administrator acknowledged the issue, citing ongoing plumbing problems, leaks, and the need for major repairs, but were unable to provide a timeline for resolution. The deficiency affected all residents reviewed for homelike environment, regardless of their cognitive or physical status. Residents who were cognitively intact, as well as those with moderate cognitive impairment, were impacted. The lack of hot water not only prevented proper bathing and hygiene but also led to residents feeling undignified and concerned about infection control. The facility's failure to address the water temperature and plumbing issues in a timely manner resulted in significant discomfort and distress among residents and staff.
Failure to Investigate and Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to conduct thorough investigations and implement corrective actions following multiple incidents of resident-to-resident altercations and alleged neglect. In one case, two residents with histories of behavioral issues and cognitive impairment were involved in repeated physical altercations. Despite documented incidents where one resident sustained a black eye and nosebleed after being struck by another, the facility did not update care plans or implement interventions to prevent further incidents. Both residents continued to reside in close proximity, and no immediate steps were taken to separate them or address the risk of further altercations. Additionally, the facility did not complete a comprehensive investigation into an allegation of neglect involving a nurse and a resident who exhibited self-harming behavior and suicidal ideation. The nurse allegedly failed to address the resident's distress and refused to provide necessary paperwork to EMS during a hospital transfer. The administrator did not obtain written statements from EMS personnel, failed to review available surveillance footage, and did not conduct resident interviews as part of the investigation. The investigation was deemed unsubstantiated despite the lack of critical evidence collection and review. The facility's own Abuse Prevention Program policy outlines requirements for thorough investigation, documentation, and protection of residents during investigations, including immediate separation of involved parties and comprehensive fact-finding. However, these procedures were not followed in the cases reviewed, as evidenced by incomplete investigations, lack of timely intervention, and failure to update care plans or implement protective measures for residents at risk.
Failure to Assess, Monitor, and Notify Physician for Significant Changes in Condition
Penalty
Summary
The facility failed to assess, monitor, notify the physician, and implement timely treatment for two residents who experienced significant changes in condition. For one resident with a history of heart disease, diabetes, and hypertension, there was a documented onset of a non-productive cough and raspy lung sounds, prompting a physician order for a chest X-ray. Although the X-ray was performed and results were faxed to the facility, there was no documentation of symptom monitoring or physician notification for several days. The resident continued to experience severe coughing and difficulty breathing, repeatedly expressing distress to staff, but the chest X-ray results were not reviewed or acted upon until the resident developed chest pain and was ultimately sent to the hospital, where diagnoses of pneumonia and COVID-19 were made. Another resident, with diagnoses including dementia and mood disorders, was involved in a resident-to-resident altercation resulting in a nosebleed and visible bruising. Despite ongoing signs of pain, wincing, and decreased mobility over the following days, there was no timely notification to the physician or emergency medical evaluation until the resident became unable to stand or ambulate and exhibited altered mental status. Only then was emergency medical transport arranged, and the resident was diagnosed with a right hip fracture at the hospital. There was no evidence that staff were aware of the fracture prior to hospital notification, and staff continued to attempt transfers without appropriate precautions. The report documents that in both cases, there was a lack of timely assessment, monitoring, and communication with the physician regarding significant changes in the residents' conditions. There was also a failure to implement appropriate interventions and follow-up, including reviewing diagnostic results and ensuring safe handling of a resident with a new injury. These deficiencies resulted in delayed treatment and ongoing symptoms for both residents.
Failure to Provide and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and provide influenza and pneumococcal vaccinations to six residents, as required by policy and physician orders. Despite having signed consents and physician orders for vaccination, there was no documentation in the electronic medical records (EMR) for several residents indicating that the vaccines were administered. In some cases, residents expressed a desire to receive the vaccines but reported not having received them. The facility had influenza vaccines available since November, but they were not administered during the current flu season, and no pneumonia vaccines were given that year. Two residents, both with significant comorbidities such as chronic obstructive pulmonary disease, heart disease, and diabetes, contracted pneumonia. One of these residents was hospitalized and subsequently passed away, with pneumonia and related complications contributing to the death. Documentation showed that these residents had signed consents and physician orders for the vaccines, but there was no record of administration or immunization history in the EMR. Staff interviews confirmed uncertainty about when vaccines were last offered or administered, and the medical director was unaware that vaccines had not been given. Other residents had incomplete or undated consent forms, lacked documentation of vaccine information statements, or had discrepancies between the EMR and hard copy records regarding vaccine administration. The facility's policies required timely assessment and administration of vaccines, as well as proper documentation, but these procedures were not followed. The failure to provide and document vaccinations resulted in preventable illness and hospitalization for some residents.
Insufficient Nursing Staff Resulting in Missed Care and Delayed Medications
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the needs of all residents, as evidenced by multiple instances where residents did not receive timely care, medications, or assistance with activities of daily living. On one occasion, the assigned nurse for a wing called off, leaving approximately 40 residents, many of whom were diabetic, without their morning medications from 7 AM to 4 PM. The Director of Nursing, who was newly hired and did not have access to the electronic medical record, was unable to administer medications, and the administrator confirmed the lack of nursing coverage for that wing. Residents reported not receiving essential medications, including nerve and blood pressure medications, and expressed distress over the situation. Residents also reported inadequate CNA staffing, resulting in missed showers, delayed toileting assistance, and prolonged periods in bed due to insufficient help to transfer to wheelchairs. Several residents, including those who are cognitively intact, stated that call lights were not answered promptly, sometimes taking up to 15 minutes, and that meal trays were often delivered late, causing food to be cold. Resident council minutes and interviews corroborated these concerns, noting that residents sometimes had to assist each other with showers due to staff shortages and that CNA rounds were not consistently completed. Review of staffing schedules over multiple days showed that the facility routinely assigned only one or two CNAs per wing to care for up to 35 residents, which staff and residents alike described as inadequate to meet resident needs. The facility did not provide a staffing policy when requested. The daily census confirmed 71 residents in the facility, and both staff and residents consistently reported that the number of CNAs on duty was insufficient to provide necessary care and services.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of infection tracking, surveillance, and appropriate isolation procedures for residents experiencing gastrointestinal and COVID-19 illnesses. The administrator acknowledged that there was no Infection Preventionist on staff, no line list of affected residents, and no tracking or trending of infections. Multiple residents reported symptoms of gastrointestinal illness, such as vomiting and diarrhea, but there was no documentation of symptom monitoring, duration, or physician orders for isolation. Staff did not instruct residents to remain in their rooms, and there was no evidence of enhanced cleaning or isolation measures during the outbreak. In addition, the facility did not follow proper procedures for COVID-19 positive residents. Several residents returned from the hospital with confirmed COVID-19 diagnoses, but care plans were not updated promptly, and vital signs or oxygen saturation checks were not consistently documented. Isolation carts outside affected residents' rooms were often missing essential personal protective equipment (PPE) such as gloves, gowns, and masks. Staff were observed entering and exiting rooms without appropriate PPE or hand hygiene, and isolation signage was inconsistently posted. There was also a lack of routine COVID-19 testing for staff and residents, and the local health department was not notified of positive cases as required. Laundry practices were also found to be unsanitary, with soiled linens piled high, inadequate handwashing facilities, and staff handling both dirty and clean laundry without proper hand hygiene or PPE. The facility lacked a written laundry policy, and the laundry room environment was not maintained in a sanitary manner. These failures in infection control practices had the potential to affect all residents in the facility.
Failure to Maintain Functional Plumbing and Hot Water Supply
Penalty
Summary
The facility failed to maintain a functional plumbing system, resulting in inadequate hot water supply and water pressure in resident-use areas, the kitchen, and laundry. Multiple staff, including the Administrator and Maintenance Director, confirmed ongoing plumbing issues, including a massive water leak, leaking pipes in the basement, and the need for extensive plumbing repairs. Observations and interviews revealed that hot water temperatures in resident bathrooms, shower rooms, the kitchen, and laundry were consistently below acceptable levels, with some areas having no water or only a trickle. Residents reported the inability to take warm showers for extended periods, resorting to sink baths, and noted a lack of communication regarding water shut-offs. The facility's records indicated that the plumbing problems had persisted for at least a week, with water temperatures ranging from 58 to 87.9 degrees Fahrenheit in various locations. Residents who were cognitively intact expressed concerns about the lack of hot water and the facility's deteriorating condition. The Maintenance Director, who had recently started, was unsure of the timeline for repairs, and the Administrator was awaiting approval for plumbing repairs. The facility did not have a policy regarding the maintenance of functional equipment. Resident council meeting minutes also documented prior concerns about frozen pipes. The deficiency affected all 71 residents in the facility, as documented in the daily census report.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program to prevent and address pest and rodent infestations, as evidenced by multiple staff and resident reports of mice and insects within the building. The Maintenance Supervisor, who had recently started working at the facility, acknowledged the presence of insects. An LPN reported that a resident had a mouse in his room a few days prior, and the resident himself confirmed this, stating it was not the first time he had seen mice in the facility. Another resident reported seeing mice on a specific hall for one and a half to two weeks. These accounts were corroborated by direct observation of a mouse trap in a resident's room and by the residents' statements. Further review revealed that the facility's pest control contract may not have been renewed after a change in ownership, and the administrator was unsure if regular monthly pest control services were being provided. The last available pest control invoices were from several months prior, and the administrator confirmed there was no current pest control policy in place. Additionally, the administrator described the facility as not clean, and surveyors observed double doors propped open with boxes placed directly on the floor, which could contribute to pest issues. The facility census indicated 71 residents were potentially affected by these deficiencies.
Failure to Provide Mandatory Infection Control Training and Oversight
Penalty
Summary
The facility failed to provide mandatory infection control training to its employees, as required by its infection prevention and control program. The Administrator confirmed that there was a recent outbreak of a stomach bug in the facility, but no tracking of the illness occurred due to the absence of an Infection Preventionist. Residents who experienced the stomach bug were not placed on isolation, nor were they instructed to remain in their rooms. The Housekeeping Supervisor was aware of the gastrointestinal illness but was not given any special instructions beyond normal duties. During the survey period, several residents were present in the facility with COVID-19, and the Administrator stated she was not properly notified of these infections or the positive test of an employee. The facility was not conducting any testing, citing state and CDC guidelines. Multiple staff members, including CNAs, the Maintenance Supervisor, and a Resident Assistant, were observed not wearing source control in various areas of the facility. A CNA reported not having received any infection control training, and the Administrator confirmed that no in-service training or documentation of infection control education for staff existed. The facility had not had an Infection Preventionist since the Administrator's tenure began.
Failure to Provide Adequate Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate bathing and personal hygiene assistance to four dependent residents who required substantial or total help with activities of daily living. Documentation and observations revealed that these residents received infrequent showers or bed baths, with some receiving only one or two baths over the course of a month. Observations included residents with greasy, unkempt hair, noticeable body odor, dirty feet, and visible dirt under fingernails. In one case, a resident reported being unable to get out of bed to shower and stated she had only received one or two bed baths during her stay. Another resident's shower documentation was not provided upon request. Staff interviews indicated that cold water in the facility led to increased refusals of bed baths by residents, and there was a lack of consistent documentation regarding bathing offers and refusals. The facility's own expectations were for showers to be given twice weekly and for resident preferences to be honored, but this was not consistently documented or achieved. Additionally, the issue of inadequate showers was raised in the Resident Council Meeting Minutes, and the facility was unable to provide a showering policy when requested.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to all eligible residents reviewed, as evidenced by the lack of documentation and resident interviews. Seven residents, all cognitively alert and oriented, were not offered the COVID-19 vaccine, and their electronic medical records (EMRs) either lacked entries regarding COVID-19 vaccination or showed outdated vaccination records. Several residents expressed willingness to receive the vaccine if offered, and some had signed consents on file, but there was no evidence that the vaccine was offered or administered during their stay. Multiple residents experienced symptoms or tested positive for COVID-19 during their time at the facility. For example, one resident was admitted to the hospital with pneumonia and COVID-19, while others returned from the hospital with positive COVID-19 diagnoses and were placed on isolation. Despite these events, there was no documentation in the residents' records indicating that the COVID-19 vaccine was offered, nor was there evidence of education provided regarding the vaccine. The facility's policy on COVID-19 did not include procedures for offering vaccinations to residents, and the medical director confirmed that no one in the facility had received the COVID-19 vaccine. The CDC guidance recommends vaccination for all eligible individuals in LTC settings, but the facility did not follow this guidance, as shown by the lack of vaccine offers and documentation for the residents reviewed.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of injury of unknown origin to the Administrator, did not notify the Illinois Department of Public Health (IDPH) within two hours of the incident, and did not submit the final investigation report within five days as required. Specifically, two residents were involved in a resident-to-resident altercation, resulting in one resident sustaining a nosebleed and later being diagnosed with a hip fracture. Documentation shows that staff were aware of the altercation and the resulting injuries, but the Administrator and other key personnel were not promptly informed of the full extent of the injuries, particularly the hip fracture. One resident, who was confused and had a history of wandering, entered another resident's room and was struck, resulting in a nosebleed and later a black eye. The resident was initially treated for the nosebleed, and 911 was called, but the resident's emergency contact declined hospital transport after the bleeding stopped. Two days later, the same resident exhibited significant changes in mobility and mental status, prompting another call to 911. At the hospital, the resident was diagnosed with a right greater trochanter fracture. The facility's records indicate that the Administrator was not aware of the fracture until informed by the surveyor, and there was no timely investigation or reporting of the injury of unknown origin. Interviews with facility staff and review of records revealed that there was confusion and lack of communication regarding the resident's injuries and the required reporting procedures. The Administrator admitted to not being notified of the hip fracture in a timely manner and had not completed the investigation or submitted the required reports to IDPH within the mandated timeframes. The facility's own policy requires immediate internal reporting and timely external reporting to authorities, which was not followed in these cases.
Failure to Submit Final Abuse Investigation Reports
Penalty
Summary
The facility failed to submit final abuse investigation reports for three residents who were reviewed for abuse allegations. In each case, only initial reports were completed and submitted, with no documentation of the final investigation findings or conclusions. The administrator confirmed that no final reports were available for any of the cases, and that only initial reports and some interviews were conducted, but the final documentation was either not completed or could not be located. This lack of final reporting was also confirmed by a state public service administrator, who noted that no final reports had been submitted for any abuse allegations during the relevant period. The residents involved had complex medical histories, including diagnoses such as Parkinson's disease, schizophrenia, diabetes, encephalopathy, and polyneuropathy. One resident was described as cognitively intact, while another was not interviewable but capable of communication. Allegations included verbal abuse, physical abuse (being pulled by the feet), and neglect (being left on the floor for extended periods). In each instance, the facility's initial response included suspending the accused staff member and initiating an investigation, but the process was not completed as required by facility policy and state regulations. The facility's own abuse policy requires that all incidents of alleged abuse be documented and that a final investigation report, including facts, conclusions, and relevant resident information, be submitted to the Department of Public Health within five working days of the occurrence. Despite this policy, the facility did not provide any final investigation reports for the reviewed cases, and no supporting documentation such as interview records or investigation folders was available for review.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for three residents, each with complex medical histories and varying cognitive statuses. For one resident with diagnoses including Parkinson's disease, schizophrenia, and morbid obesity, an initial report of verbal abuse was filed, but the investigation lacked essential documentation such as the name of the accused staff member, verification of staff suspension, and interviews with other staff or residents. The administrator confirmed that no further investigative materials were available. In the case of a second resident with multiple neurological and psychiatric diagnoses, an allegation was made that a staff member physically pulled the resident by the feet into his room. Although the incident was reported and the investigation was said to have been initiated, there was no documentation of interviews, no final report, and no evidence that the accused staff member was identified or suspended. The resident's progress notes did not mention the abuse allegation, and the administrator could not provide any supporting documentation for the investigation. A third resident, who was cognitively intact, reported involvement in an alleged physical incident with a staff member. The initial report indicated that the accused staff member was suspended pending investigation, but no final investigation report, interviews, or documentation of the process were provided. Across all three cases, the facility's records lacked critical elements required for a thorough abuse investigation, including staff and resident interviews, identification of accused staff, and evidence of appropriate administrative actions.
Unqualified Dietary Manager and Failure to Follow Menu Requirements
Penalty
Summary
The facility failed to employ a Dietary Manager with the appropriate training, certification, and skills to oversee the food and nutrition service. Observations revealed that food was being prepared and served without following the prescribed menu, and no food temperatures were taken prior to service. The individual acting as Dietary Manager had only been in the position for three weeks, lacked certification, had no associate degree, and had no prior experience in long-term care. The menu was not being followed, and recipes were not used as required. Additionally, there was no mechanical soft diet or pureed egg roll available on the steam table, and the Dietary Manager stated that the availability of mechanical soft diets varied depending on admissions and discharges. The facility's dietician was new and had only conducted a remote consult, being unaware that the Dietary Manager was uncertified and had not been informed of any dietary issues. The Administrator confirmed that the Dietary Manager was not certified and that no one was overseeing the kitchen operations. The facility was unable to provide a menu, as it was not being followed. These deficiencies had the potential to affect all 72 residents living in the facility, as documented in the facility's CMS 671 application.
Failure to Follow Menus and Physician-Ordered Diets
Penalty
Summary
The facility failed to ensure that menus and physician-ordered diets were followed, as evidenced by multiple discrepancies between the planned menu and the food actually served to residents. On two separate days, the lunch menu items listed were not provided; instead, residents received substitute foods such as fried egg rolls, chicken Alfredo, and fried chicken strips, none of which matched the planned entrees or met the nutritional guidelines outlined by the dietician. Additionally, required food temperatures were not taken before service, and there was no evidence of portion control, as dietary staff used gloved hands to serve food without measuring or weighing portions. No mechanical soft diets were available on the steam table, and residents who were documented to require mechanical soft diets were instead served pureed diets. The dietician was not informed of menu substitutions and was unaware that key components, such as vegetables, were omitted from meals. The dietician also noted concerns about the nutritional adequacy of the substitutions and the use of fried foods. Furthermore, when dietary policies were requested, the facility was unable to provide them. These failures had the potential to affect all 72 residents in the facility, as documented in the facility's CMS 671 application.
Failure to Employ Key Personnel and Maintain Required Policies
Penalty
Summary
The facility failed to employ key personnel and adequately trained staff necessary to meet resident needs, as evidenced by the absence of a Director of Nursing (DON), Infection Control Specialist (ICP), and a certified Dietary Manager. The Administrator confirmed that there was no DON, no full-time ICP, and no maintenance staff, with the previous maintenance worker terminated and a contractor deemed ineligible due to background check issues. The Dietary Manager lacked required certification and oversight, and the Administrator admitted to not having a menu or anyone ensuring kitchen operations, resulting in her taking on additional responsibilities. Additionally, the Administrator stated that the facility did not have a Facility Assessment and lacked policies on administration, dietary/food and nutrition, care plans, equipment and physical environment, and training requirements. The absence of these key staff members and policies affected the facility's ability to use its resources effectively and efficiently, potentially impacting all 72 residents. No specific resident medical histories or conditions were mentioned in the report.
Failure to Maintain Safe and Functional Plumbing Systems
Penalty
Summary
The facility failed to ensure that plumbing and equipment were maintained in a safe and functional condition, as evidenced by ongoing water leaks and plumbing issues affecting multiple areas of the building. During a tour of the basement, surveyors observed water covering the floor, originating from a crawl space/tunnel above the main structure, with a sump pump running nearby. The water, which was hot or warm and clear, was found flowing into adjacent rooms containing storage boxes and supplies, with two fans running in an attempt to address the situation. The source of the leak was not immediately visible, and the plumber indicated that the extent of the problem could not be determined without further access and investigation, noting the building's old and thin pipes as a contributing factor. Interviews with several residents revealed that plumbing issues had been ongoing for months, with frequent water shut-offs and repeated pipe breaks. One resident reported experiencing sewer water in their room, describing the situation as both disgusting and persistent. Resident council meeting minutes from previous months also documented complaints about leaking bathrooms and broken pipes. Despite a request, the facility was unable to provide an equipment and maintenance policy, further indicating a lack of adequate procedures to address these recurring issues.
Lack of Required Annual Abuse Training for Staff
Penalty
Summary
The facility failed to ensure that all staff completed the required annual abuse training, as evidenced by the absence of any documentation of such training for current employees. During the survey, the administrator reported being unable to locate any records of abuse training, attributing this to the practices of the prior administration, which reportedly did not document or report abuse. The facility's own Abuse Prevention Program Policy requires that all staff receive training on abuse, neglect, and misappropriation of resident property during orientation and annually thereafter. At the time of the survey, there were 72 residents living in the facility, all of whom could potentially be affected by this deficiency.
Lack of CNA Training Program and Documentation
Penalty
Summary
The facility failed to maintain a training program for Certified Nurses Assistants (CNAs), as evidenced by the lack of documentation for annual nurse aide in-services and the absence of a policy regarding such training. During the survey, the administrator was unable to provide any records or policies related to annual nurse aide in-services when requested by the survey team. This deficiency was identified through interviews and record reviews, and it was noted that the facility had 72 residents at the time of the survey. No documentation of nurse aide training or in-service education, including topics such as dementia care and abuse prevention, was available for review, indicating that the required training program was not maintained for the CNAs.
Failure to Follow Dietary Guidelines and Provide Prescribed Diets
Penalty
Summary
The facility failed to ensure that kitchen management and nutritional guidelines were followed for five residents reviewed for dietary needs. The Dietary Manager and Cook both demonstrated a lack of understanding regarding the proper preparation of mechanical soft and pureed diets, specifically regarding the use of gravy to aid swallowing. The Dietary Manager was unaware of residents' weight issues and did not consistently provide gravy for mechanical or pureed diets. The Cook reported that gravy was not being added to these diets until recently, and there was confusion about who was responsible for entering and updating diet orders. Additionally, the Dietician was not informed of menu substitutions or omissions, such as the absence of vegetables or the use of fried foods as protein replacements, and was not consulted about changes to the menu or dietary needs. Specific resident records revealed further deficiencies. One resident with a diagnosis of dysphagia and other complex medical conditions was on a regular diet without evidence of a speech therapy evaluation to determine appropriate dietary texture. Another resident with diabetes and significant unplanned weight loss was served a pureed diet without gravy, which did not match physician orders for a mechanical soft diet with double portions and health shakes. Dietary intake records were not maintained or provided as requested, and the last intake documentation was several months old. The facility also failed to provide a dietary policy for kitchen coordination when requested. These actions and omissions resulted in residents not receiving diets that met their prescribed nutritional and special dietary needs.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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