Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Axiom Healthcare Of West Frankfort during CMS and state inspections, most recent first.
The facility failed to properly communicate and document the reasons for a resident’s transfer/discharge and then refused to readmit the resident after hospitalization. The resident had dementia, prior strokes, dysphagia, and escalating aggression, but the record showed conflicting accounts between the DON/ADM, hospital CM, and POA about whether the transfer was temporary, whether the resident could return, and whether the family was notified. The hospital documented that the facility later said the room was unavailable and would not coordinate the resident’s return, despite earlier planning for the resident to go back after medical clearance.
Insufficient nursing staff led to delayed resident care, missed snacks and showers, and slow call light response. Residents reported rude or rushed interactions, long waits for assistance, and episodes of being left wet or soiled when staff did not arrive in time. CNAs and housekeeping staff described shifts with too few workers to complete showers, pass snacks and ice, maintain bathrooms, or finish laundry duties, and staffing records showed only two CNAs on several evening shifts for 49 residents.
Kitchen Used for Food Preparation During Sewage Backup: The facility continued preparing and serving meals in the kitchen while sewage water was backing up through floor drains and standing in the food prep area. The Dietary Manager stated lunch and dinner were prepared during the sewage event and that he was not told the proper procedure until afterward. A plumber confirmed the kitchen area was backing up, and the issue was documented in a plumbing invoice.
Failure to maintain resident dignity and respectful communication: residents reported CNAs were rude, snippy, impatient, and sometimes told them to shut up or leave the dining room, while one resident stated call lights were sometimes unanswered for up to an hour and he soiled his bed waiting for help. Surveyors also observed a resident sitting in the dining room with urine under his chair on multiple occasions, with wet clothing and wet footprints, while staff walked by.
A facility failed to maintain working showers, functioning toilets, and a sanitary environment. Residents and CNAs reported that only one shower worked while the other shower rooms on the 200 and 300 halls had been out of service for months, and one resident said he refused showers because feces remained in the shower room. Surveyors also observed urine and feces odors in bathrooms and hallways, a clogged toilet that would not flush solids, and fecal matter remaining in the bowl after flushing. Staff further reported sewage backing up through floor drains into bathrooms and a shower room, with brown water and particulates present.
Exit doors on the 200 and 300 halls were blocked by carts and a plant cart, with residents reporting staff placed them there to prevent a resident from hitting the door alarm or going outside. Observations confirmed the plant cart remained in front of an exit door for several hours, and the ADM stated nothing should be placed in front of exit doors.
Cold food was served to multiple residents, with breakfast and lunch items observed below the facility’s hot-food standard. A resident reported breakfast items were cold, including sausage at 86 degrees F and milk at 51 degrees F, while other residents said food was frequently cold or barely warm and one resident sent cold food back. Refused lunch trays were also measured below acceptable temperatures, and resident council and food committee minutes documented ongoing complaints that food arrives cold.
Failure to provide transfer and bed hold notice. The facility did not give a resident and the resident's POA written discharge or bed hold information before or upon transfer, and the Ombudsman office also did not receive the required paperwork. The Administrator stated no paperwork was sent to the Ombudsman and was unsure whether any was sent to the family representative.
The facility failed to consistently implement care-planned fall-prevention interventions for two residents with significant mobility and cognitive impairments and a history of multiple falls. One resident with Parkinson’s disease and dementia had numerous documented falls from bed and wheelchair, including events where he fell while reaching for items, exercising, or trying to find staff, ultimately sustaining facial fractures confirmed in the ED. Despite care-plan directives for 15‑minute checks, call light within reach with yellow tape, proximity to the nurses’ station, and assisted transfers, surveyors repeatedly observed his call light out of reach without yellow tape, his door closed with no staff present, and him independently propelling and exiting his wheelchair while tangled in catheter tubing. A second resident with severe cognitive impairment and prior falls had a care plan calling for 15‑minute checks, yellow‑taped call light within reach, monitoring of wheelchair position, and offers to lie down after meals, yet was observed in bed with the door closed and no call light in reach, and sitting on the edge of his wheelchair attempting to get out while staff passed by without intervening. Staff interviews revealed inconsistent awareness and implementation of 15‑minute checks and other care-planned safety measures.
Insufficient CNA Staffing and Delayed Response to Resident Call Lights: Residents with significant care needs, including dependence for toileting, transfers, and personal care, reported long waits for call lights to be answered during the night. Observations showed staff passing by an activated call light without responding, and a CNA stated the facility did not have enough help to meet resident needs in a timely manner. The schedule showed only two CNAs on most night shifts, while the Administrator said she did not know whether that staffing level was enough to provide adequate care or evacuate residents in an emergency.
Missing RN Coverage and DON: The facility failed to maintain a full-time DON and did not provide an RN on duty for at least 8 consecutive hours a day, 7 days a week. The Administrator confirmed that some days had no required RN coverage, and reviewed schedules showed multiple dates with no RN coverage. The facility also had no DON in place, with Regional Nurses monitoring from afar while the facility remained responsible for 46 residents.
Pest Control Program Failed to Control Gnats: Residents reported gnats throughout the building, including in bedrooms and the dining room, and gnats were observed flying over a resident's bed and on another resident's food tray. Alert and oriented residents stated the gnats were interfering with food and belongings, and one resident said they had to swat gnats away while eating. The facility's pest control policy required regular and as-needed pest control and conditions to prevent insects or rodents.
Delayed call light response affected multiple residents who needed help with toileting, personal care, transfers, and oxygen equipment. Residents with intact cognition and mobility impairments reported waits ranging from about 15 minutes to 3 hours, and one observation showed staff walking past an activated call light before responding. A CNA said staffing was not enough and call lights were hard to answer timely, while the Administrator reviewed a night CNA schedule showing only two CNAs on most nights and one CNA on one night.
Missing Accessible Call Lights in Restrooms and Shower Areas: The facility failed to provide call lights accessible from the floor in multiple restrooms and a shower stall, affecting 36 of 36 residents reviewed for accommodations of needs. Surveyors observed that several bathrooms on the north and south halls lacked floor-accessible call lights near the toilet, and the shower stall on the north hall had no call light in the stall. The ADM stated that all restrooms, shower rooms, and toilets should have call lights that can be activated from the floor if a resident falls.
A facility failed to maintain a clean, safe, and homelike environment for multiple residents. Surveyors observed strong urine odors in several rooms, urine on floors and under a bed, a soiled wheelchair cushion, an old catheter bag with urine stored on a nightstand, dirty bathrooms with buildup around toilets, cracked tiles, missing baseboards, a broken window with taped glass and cardboard covering, exposed radiator metal, and ceiling tiles pushed up with insulation hanging and later found on a nightstand and floor.
Ordered nutritional supplements not provided. Multiple residents with documented malnutrition or underweight status had active diet orders for fortified foods or supplements, but during observed meal services they did not receive items such as fortified pudding, nutritional ice cream, fortified mashed potatoes, whole milk, or super cereal. RD notes and care plans documented nutritional problems and weight loss or underweight BMI, while the dietary manager and administrator acknowledged that residents with supplement orders should receive them.
Mechanical soft diet portions were not followed for several residents during lunch service. A dietary staff member served 2 oz of ground pork loin with gravy using a 2-oz scoop, while the diet spreadsheet and recipe called for a larger portion, and broccoli was served in pieces over 1 inch in size instead of the smaller chopped pieces expected by the RD and listed on the menu.
Mechanical soft diet trays were served with broccoli pieces larger than directed for 6 residents on the diet. A dietary staff member provided soft chopped broccoli with pieces over 1 inch in size, despite the recipe calling for bite-sized pieces of 1/2 inch or less and the RD stating the food should match the diet spreadsheet.
Infection control practices were not followed for residents with indwelling catheters and for portable glucometer sanitation. Multiple residents with Foley catheters were observed with drainage bags on the floor, in wheelchairs, or otherwise not secured as required, and CNAs performing catheter care changed gloves without hand hygiene between glove changes. An LPN also failed to disinfect the glucometer per policy, using an alcohol wipe instead of the required bleach-based process, while also missing hand hygiene steps during resident care.
Delayed Response to Resident Grievance: A resident with multiple diagnoses, including dementia and mood disorders, reported that the facility had not responded to a grievance she submitted several weeks earlier. The grievance form for the complaint against another resident was left without documentation of the grievance official’s findings, corrective actions, or follow-up, even though it was signed by the Administrator and SS Director. Resident council minutes also showed concerns about how complaints were being handled, and the facility policy states residents have the right to voice grievances and receive a response.
A resident with documented major depressive disorder, unspecified psychosis, anxiety, insomnia, and severely impaired cognition did not have a completed PASRR Level II despite the initial screen indicating a need for it. The PASRR record lacked clinical documentation from the facility, and staff later stated the original screen did not include diagnosis information. A later Level I screen triggered a Level II, and a Level II was scheduled.
Failure to honor documented dietary preferences for two residents. One resident with BIMS 13 and another with moderate cognitive impairment both had charted dislikes that included broccoli, and one also disliked pineapple. Despite this, they were served those items with meals, and each stated he did not like the food when asked. The Dietary Manager stated staff should follow dietary cards and avoid serving items listed as dislikes, using nutritionally equivalent substitutions instead.
Failure to administer consented flu and pneumococcal vaccines affected two residents. One resident had COPD, CKD, dementia, and other chronic conditions, and another had Parkinson’s disease, severe malnutrition, dementia, and schizoaffective disorder. Both had signed consents indicating unknown prior PCV13 history and agreement to receive the vaccine if not previously given, yet the ADON stated one resident did not receive flu or pneumococcal vaccines and the other did not receive the pneumococcal vaccine, despite facility policy requiring annual flu immunization and pneumococcal vaccination per CDC guidance.
Multiple residents with intact or moderately impaired cognition, many with complex medical conditions such as fractures, severe protein-calorie malnutrition, COPD, diabetes with neuropathy, dementia, and chronic pain, reported that CNAs and dietary staff frequently displayed exasperated, snappy, or dismissive attitudes when they requested assistance or information. Residents described inadequate perineal cleaning after incontinence, delayed or unfulfilled responses to call lights, refusal or reluctance to provide drinks or ice, and visible irritation when residents asked about menus or meal substitutes, particularly on evening and night shifts. Some residents stated they had raised concerns about staff attitudes, roughness, and rushing of more fragile residents among themselves and at resident council, but recent council minutes did not reflect these complaints, and leadership reported being unaware of poor CNA attitudes, despite an existing Employee Standards of Conduct requiring professional and respectful treatment of residents.
Multiple residents reported that meals were frequently cold or barely warm, with butter or margarine not melting on vegetables or pancakes and visible solidified grease on entrees. Surveyors confirmed these concerns by measuring low food temperatures on resident trays and a test tray, including vegetables at 83°F and main dishes under typical hot-holding levels, despite a facility policy requiring proper holding temperatures and attractive presentation. Residents with conditions such as protein-calorie malnutrition, diabetes, anemia, GERD, and intellectual disabilities described the food as not good when cold and stated that this problem occurred often, whether they ate in their rooms or in the dining area, while facility leadership acknowledged that food should be hot when served but lacked clear implementation and documentation of food council activities.
A resident with a history of falls and diabetic neuropathy sustained significant arm lacerations after being bumped by another resident with impulsive behavior during a supervised smoking break. Multiple witnesses confirmed that the second resident frequently rushed and collided with others during smoke breaks. The supervising CNA was distracted while distributing cigarettes and did not ensure all residents were safely in the smoking area, leading to inadequate supervision and the resulting accident.
Staff were observed and reported discussing residents' health issues and care in common areas, such as the dining room and outside smoking areas, where other residents, families, and staff could overhear. These breaches of confidentiality included using resident names and making inappropriate comments, despite facility policies prohibiting such disclosures.
Residents reported ongoing issues with rude and dismissive behavior from some CNAs, which were discussed in resident council meetings but not formally documented or resolved. Multiple cognitively intact residents described staff responding with aggressive tones or reluctance to assist, and some staff acknowledged the problem. Despite the facility's grievance policy requiring prompt action, key staff and administration were unaware of the complaints, and no investigation or corrective measures were taken.
A nurse worked without a valid license for an extended period, administering medications and providing care to multiple residents with complex medical needs. The lapse was not identified by the DON until after the nurse had already performed nursing duties, after which she was reassigned as a CNA. This failure in licensure verification potentially affected all residents in the facility.
Multiple residents, including those with severe medical conditions and cognitive impairments, did not consistently receive water or other beverages as needed, despite being at risk for dehydration. Family members and staff reported that drinks were not regularly distributed, and some residents were left without access to water in their rooms. Staff acknowledged inconsistent drink distribution, and repeated complaints were documented in resident council minutes and concern forms.
Staff members repeatedly engaged in loud arguments, yelling, and use of inappropriate language in front of residents, creating a chaotic and undignified environment. A resident with mental health diagnoses reported increased agitation due to these incidents, and multiple staff confirmed ongoing conflicts and harassment among CNAs, which were audible throughout the facility. These actions violated the expectation of a respectful and professional environment as outlined in facility policy.
Multiple residents with significant medical and cognitive needs were found with their call lights out of reach, sometimes on the floor or placed intentionally by staff where they could not access them. Observations and interviews confirmed that this was a recurring issue, with some residents unable to summon help and staff not always responding to verbal requests. The facility's policy requires call lights to be accessible, but this was not consistently followed.
Several residents and staff reported witnessing staff members vaping inside the building, including hallways, resident rooms, and the break room. Despite facility policies and prior in-service training prohibiting vaping, staff continued to vape during various shifts, compromising the smoke- and vape-free environment expected for residents.
Multiple residents with nutritional risks and special dietary needs did not consistently receive meals as prescribed due to the facility running out of food, serving smaller portions, and providing inappropriate meal substitutions. Staff and residents reported frequent shortages, with some staff consuming resident food and leftovers being discarded, resulting in residents being unable to receive seconds or alternative options. These actions led to unmet nutritional needs for several residents.
Several residents reported not receiving adequate evening snacks, with options often limited to minimal items like saltine crackers and insufficient quantities for all. Staff, including CNAs and LPNs, confirmed frequent shortages and inconsistent distribution, sometimes leaving residents without snacks, especially those on special diets. Facility records and resident council minutes documented ongoing complaints about the lack of snacks and long periods without food between dinner and breakfast.
A resident with a history of depression and anxiety was subjected to mental abuse when a CNA compared the resident to a TV character in a derogatory manner, showing the character's image to other staff and laughing in the resident's presence. The incident was witnessed by multiple staff, and the resident reported feeling humiliated and mocked.
A resident with severe cognitive impairment and multiple health issues made allegations of staff abuse, including verbal threats and mistreatment during personal care. Staff failed to report these allegations to the state agency and the administrator as required by facility policy, and the incidents were not properly investigated or documented at the time they occurred.
A resident with severe cognitive impairment and multiple medical conditions alleged that staff made threatening and inappropriate comments during a breakfast incident. The facility did not thoroughly or promptly investigate the allegation, failed to obtain a statement from the resident at the time, and did not report the incident to the Department of Public Health as required by policy. The investigation was limited to staff interviews, and the required abuse protocol was not followed.
The facility did not ensure RN coverage for at least 8 hours per day, 7 days a week, as required. Facility schedules and staff confirmation showed that there were multiple days without an RN present, potentially affecting all 50 residents.
A resident with multiple diagnoses, including macular degeneration, was ordered Preservision AREDS 2 daily, but staff substituted Ocuvite without physician approval due to pharmacy and insurance issues. Staff continued to document that Preservision was administered, despite giving a different supplement, and the care plan did not address the resident's eye condition. The substitution persisted until the resident reported the issue to the state.
A resident with multiple psychiatric and medical diagnoses was not provided with the prescribed Preservision AREDS 2 supplement for an extended period, instead receiving Ocuvite without a physician's order to change the medication. Staff and pharmacy communication led to the substitution, and MARs inaccurately reflected administration of the ordered medication until the issue was brought to the attention of surveyors.
A resident with end stage renal disease and a physician order for regular dialysis missed multiple dialysis treatments because the facility's transportation van was out of service and no alternative transportation could be arranged. This led to missed appointments, hospital admissions, and documented complications, despite the facility's policy requiring assistance with transportation for essential medical services.
The facility failed to ensure RN coverage for 8 consecutive hours daily, 7 days a week, as required. Interviews and record reviews revealed no RN on shift for specific dates in November and December 2024. The absence of RN coverage was confirmed by an LPN, the DON, and the Regional Director of Operations. The facility lacked a specific policy on RN coverage, relying on general staffing regulations, potentially affecting all 40 residents.
The facility failed to maintain the required water temperature for dishwashing, with the dish machine's water at 80°F instead of the recommended 120°F. Additionally, improper food handling was observed, as a cook used the same gloves for multiple tasks, risking cross-contamination. These issues could affect all 40 residents.
The facility failed to document quarterly QAPI meetings, as required by their policy, potentially affecting the quality of care for all 40 residents. The Regional Director of Operations confirmed the meetings occurred but could not provide records after February 2024.
The facility failed to provide dietary supplements as ordered to four residents, impacting their nutritional status. Due to a late delivery, the dietary manager reported that mighty shakes were not provided at breakfast or lunch, affecting residents with specific dietary orders for weight management and nutritional needs.
A facility failed to notify law enforcement in an abuse investigation involving a resident who reported verbal abuse and theft by night shift CNAs. Despite the facility's policy requiring notification of authorities in such cases, the Regional Director of Operations confirmed that the police were not informed. The incident highlights a deficiency in the facility's adherence to its abuse prevention and reporting procedures.
A resident with multiple mental health diagnoses expressed suicidal ideations, but the LTC facility failed to provide timely interventions and documentation. The staff did not notify the physician immediately or conduct a suicide assessment promptly, contrary to the facility's policy. The resident's care plan included monitoring for depression and suicidal thoughts, but these were not effectively implemented, leading to a deficiency in care.
The facility failed to safeguard medical records for three residents due to water damage in the records room, resulting in missing documentation prior to the transition to electronic records. Staff confirmed the loss of paper records and the lack of a backup system to retrieve the missing information.
A resident was administered Chlorpromazine twice without consent or a physician's order, leading to an emergency room visit for possible allergic reaction. The LPN did not verify medication orders or document the administration, and the medication had been discontinued months prior.
Improper transfer/discharge communication and refusal to readmit after hospitalization
Penalty
Summary
The facility failed to ensure that notifications and required reasons for transfer/discharge were adequately communicated and documented in the medical record, and it failed to permit a resident to return to the facility after hospitalization. The resident had a history of cerebral infarctions, dysphagia, major depressive disorder, adjustment disorder with depressed mood, vascular dementia with anxiety and agitation, and was documented as rarely/never understood, moderately impaired in decision-making, and having fluctuating inattention. The care plan included multiple behavior-related focus areas, but it did not include a discharge planning focus area tied to the later transfer for behavioral evaluation. Facility and hospital records and interviews showed the resident had escalating behaviors, including hitting, kicking, biting, throwing objects, and agitation related to meals and care. The facility obtained psychiatric medication orders and documented episodes of aggression, but the record also showed conflicting accounts about the purpose of the transfer and whether the resident was expected to return. The administrator stated the resident was sent for evaluation and was supposed to return, while the hospital case manager documented that the facility said it would not accept the resident back and later requested alternative placement. The resident’s family/POA stated she was not informed in advance of the transfer, did not receive paperwork about the transfer or bed hold, and never said the resident could not return. After the resident was hospitalized, the hospital documented discharge planning that initially anticipated return to the original facility upon medical clearance. However, the facility later stated the resident’s room was being used as an isolation room and that no bed was available, and the hospital documented that the facility would not coordinate transportation for the resident’s return. The hospital case manager documented that the facility said the resident could not return due to behavioral concerns and that alternative placement would be pursued. The record contains no reproducible evidence that the facility participated in the scheduled phone meeting with the hospital, and the documentation reflects inconsistent communication between the facility, hospital, and POA regarding the resident’s return.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Interviewed residents and staff described delays in care, missed tasks, and staff being unable to complete duties because of low staffing. Residents reported rude or snippy interactions from staff, especially on weekends, and several stated that staff told them they did not have time to do requested care. One resident stated call lights sometimes took a long time to be answered, and another stated that after turning on the call light to use the bathroom, staff did not arrive in time and the resident soiled the bed. Staff interviews described how the shortage affected daily care. A CNA stated showers usually started after breakfast, took about 20 minutes each, and were difficult to complete along with other CNA duties, especially with only one shower room. Another CNA stated there had been shifts when there was not enough time to pass snacks, ice, or complete all showers. A CNA also stated expected duties were not always completed because there was not enough staff. Housekeeping staff stated the men's bathroom on the 300 hall had odors and that urine had to be mopped several times a day, but on weekends housekeeping left at 2:00 PM and CNAs had to mop when they saw it and had time. The housekeeping supervisor stated the facility lacked laundry staff on Saturday and Sunday evenings, and CNAs were expected to help when no housekeeping or laundry staff were scheduled. Resident interviews and council minutes also reflected unmet needs and inconsistent care. Residents reported not always receiving snacks, water, or ice because staff were too low or too busy, and some stated they were left wet for long periods, beds were left unmade, and some residents were laying on bare mattresses. The administrator stated her expectation for a reasonable call light response time was within 20 minutes and said that with approximately 49 residents the facility would need about 4 to 4.5 CNAs at times. Facility staffing records showed that on several dates only two CNAs worked the 2:00 PM to 10:00 PM shift, while the room roster documented 49 residents in the facility.
Kitchen Used for Food Preparation During Sewage Backup
Penalty
Summary
The facility failed to discontinue using the kitchen for food preparation during a sewage backup that affected the kitchen area. Surveyor interviews and observations showed that sewage water started coming into the facility around 9:00 AM and was coming up through floor drains in the kitchen, with standing water extending about three feet around the drains. The kitchen floor drains were located near the dish machine, in front of the bathroom, and in the main kitchen area near the cooler, freezer, stove, oven, and steamtable, requiring staff to walk within approximately three feet of a floor drain to reach food preparation equipment. The Dietary Manager stated that lunch and dinner were prepared and served while sewage water was in the kitchen, and that he was not told the appropriate procedure until after that day. He stated that food should not have been prepared or served in the kitchen under those conditions and that cold sandwiches should have been served from a different room such as the breakroom. A plumber stated the kitchen area was backing up and other areas in the facility were affected, and a plumbing invoice documented camera and jet sewer pipes backing up. The facility roster showed 49 residents resided in the facility.
Failure to Maintain Resident Dignity and Respectful Response
Penalty
Summary
The facility failed to treat residents with dignity, respond to residents quickly, and speak to residents respectfully for 14 of 14 residents reviewed for dignity in a sample of 32. Multiple residents reported that staff were snipy, snappy, rude, impatient, or had attitudes, and several stated that staff sometimes told residents to shut up or chastised them. During a resident council meeting, residents stated CNA attitudes were bad and that some residents received more attention and care than others, with reports that some residents were left wet for long periods of time, beds were left unmade, and residents were laying on bare mattresses. Survey observations showed R26 sitting in the dining room with a puddle of urine under his chair on multiple occasions. On one occasion, the puddle was over 12 inches by 7 inches and later enlarged to approximately 14 inches by 9 inches, with R26's shorts visibly wet. A Social Services Director walked by the puddle while giving R26 hand sanitizer, and R26 remained in the dining room with the urine puddle under him while staff walked by bringing residents into the dining room and delivering food trays. On another day, R26 was again observed sitting in the dining room with a large puddle of urine under his chair while eating breakfast, and later left the dining room with wet footprints after standing up from the wet area. Additional findings included a CNA telling R23, "Well if you're going to cuss in here you are going to have to leave," while the surveyor did not hear R23 cuss at anyone. R28 stated that staff sometimes took up to an hour to answer his call light and that he had pooped his bed because staff did not get there in time after he turned on the call light to go to the bathroom. The Administrator stated her expectation was that visibly wet residents would be cleaned and changed, that residents who cussed but were not disruptive should be assessed for the cause of the behavior, and that call lights should be answered within 20 minutes.
Unsafe and Unsanitary Bathroom and Shower Conditions
Penalty
Summary
The facility failed to provide working showers for all residents reviewed for sanitary environment. Residents on the 100, 200, and 300 halls reported that only one shower was working, and multiple staff members confirmed that the showers on the 200 and 300 halls did not work and had not worked for months. On observation, the shower room on the 300 hall did not have a shower head. Residents stated this created delays in showering, and one resident reported refusing showers because staff had to do back-to-back showers and there was still feces in the shower room when he went in. The facility also failed to maintain toilets and bathrooms free of odors and visible waste. A resident reported ongoing urine and feces odors on both halls, and surveyors observed distinct and strong urine and feces odors in the men's bathroom on the 300 hall and a urine odor in the 100 hall hallway. One resident stated the toilet on the 300 hall did not flush all the way and was always clogged. During observation, fecal matter remained in the toilet bowl after flushing and the water rose to the inside rim of the bowl. Housekeeping staff stated the men often missed the toilet, odors were present, and urine could soak into the tiles if not mopped up frequently. The facility also experienced sewage backup through floor drains. Staff reported sewage coming up through floor drains on the halls, under a toilet in a bathroom, and in the shower room, with brown water and particulates present. A plumber stated the drain could not initially be unstopped and that the kitchen and other areas were backing up until the pipes were cleared from outside the building. Residents and staff described sewage on bathroom and shower room floors, and resident council minutes documented lingering bad smells in halls and bathrooms, especially where residents missed the toilets.
Exit Doors Blocked by Carts
Penalty
Summary
The facility failed to maintain free passage through exit doors in case of emergency procedures. Interview and observation showed that staff placed items in front of exit doors on the 200 hall and 300 hall, including a blue towel cart, a blue linen cart, a linen tower, and a plant cart. Residents reported seeing the carts placed at the doors, and several stated they believed the items were being used to keep R19 from hitting the door alarm or getting outside. The administrator stated there should not be anything in front of any of the exit doors. The observations documented that on the 300 hall, a plant cart was in front of the exit door at 9:30 AM and remained there at 11:20 AM, 2:07 PM, and 3:10 PM. The facility roster dated 4/27/26 showed 22 residents on the 200 hall and 9 residents on the 300 hall. The facility policy stated that the building and grounds must be maintained in compliance with federal, state, local, and NFPA codes and that the administrator must ensure safe and effective procedures are followed to maintain a safe environment for residents, visitors, and staff.
Cold Food Served Below Required Temperature
Penalty
Summary
The facility failed to provide food at a palatable temperature for 5 of 5 residents reviewed for cold food in a sample of 32. During interviews, multiple residents stated the food was frequently cold or barely warm. R10 reported that breakfast food was often cold and, during observation, received a breakfast tray with sausage measured at 86.0 degrees Fahrenheit and milk at 51 degrees Fahrenheit; R10 stated the sausage was cold and she would not use the warm milk for cereal. R30 stated sometimes the food is barely warm, R14 stated the food is cold frequently, and R31 stated he sends food back when it is cold. Survey observations also showed hot food items served below the facility’s stated hot-food temperature standard. A refused lunch tray contained a hamburger at 105 degrees Fahrenheit, mashed potatoes at 107 degrees Fahrenheit, and mixed vegetables at 111 degrees Fahrenheit; the food tasted cold. Another refused lunch tray for R13 contained broccoli at 97.2 degrees Fahrenheit, rice at 113.5 degrees Fahrenheit, and pork at 109.1 degrees Fahrenheit, and the food tasted cold. Staff acknowledged menu substitutions and stated residents had complained to CNAs about cold food. Resident council and food committee minutes also documented complaints that food arrives cold, particularly on the hall, and the facility policy stated hot foods are to be served at 135 degrees or higher.
Failure to Provide Transfer and Bed Hold Notice
Penalty
Summary
The facility failed to provide the bed hold policy before or upon transfer from the facility for one resident reviewed for discharge process in a sample of 32. During interview, the Ombudsman stated that the office had not received any bed hold or transfer/discharge paperwork for the resident or another resident from the facility. The resident's family power of attorney stated she had never received any documents concerning the resident's discharge or bed hold information. The Administrator stated the facility did not send any paperwork to the Office of the Ombudsman and was unaware whether any paperwork was sent to the family representative. The facility policy titled Notice of Transfer and Discharge, dated 08/14/17, states that prior to discharge or transfer the facility will notify the resident and the resident's representative in writing of the transfer or discharge and the reasons for the move, and send a copy of the notice to a representative of the State Long-Term Care Ombudsman.
Failure to Implement Care-Planned Fall-Prevention Interventions Leading to Repeated Falls and Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and consistently follow care-planned fall-prevention interventions for multiple residents at risk for accidents, resulting in repeated falls and injury. One resident with Parkinson’s disease, dementia, muscle wasting, lack of coordination, and a history of multiple falls had a care plan that included numerous specific fall interventions such as keeping the call light within reach, wrapping the call light with yellow tape as a visual cue, frequent and 15‑minute safety checks, moving the resident closer to the nurse’s station, ensuring proper footwear, and assisting with transfers per therapy recommendations. Despite these planned measures, the resident experienced numerous falls from bed and wheelchair, often while leaning forward to pick up items, attempting to exercise, or trying to reach staff without using the call light. Several fall investigations documented the resident being found on the floor, frequently on hands and knees or on the side of the bed, with staff noting that he attempted to get up or reach objects independently. Across multiple documented falls, the resident was observed or reported to have fallen forward out of his wheelchair or bed, sometimes while trying to pick up dropped items, reach snacks, or exercise, and at times while attempting to find staff. Incident descriptions repeatedly noted that the resident either forgot to use the call light or was trying to get to staff, and staff responses often consisted of one‑to‑one reminders to use the call light. The record shows that the resident had falls both in his room and in hallways, including near the nurse’s station and near an exit, and that he was sometimes able to get himself off the floor and back into his wheelchair without staff assistance. One fall resulted in facial trauma with swelling and bruising to the left cheek and orbital area, and hospital records confirmed a closed fracture of the left orbit and left maxilla. A subsequent hospital visit identified an old thoracic vertebra fracture of undetermined timing. Staff interviews indicated that 15‑minute checks for this resident were not always completed during busy night shifts, and the Assistant DON stated she was not aware of any residents currently on 15‑minute checks, despite the care plan specifying this intervention. Surveyor observations further showed that the resident’s care‑planned interventions were not consistently in place. On multiple occasions, the resident’s door was closed with no staff present, and the call light was out of reach on the nightstand, sometimes several feet away, and without the yellow tape that was care‑planned as a visual reminder. The resident was also observed independently propelling his wheelchair down the hallway, getting stuck in his doorway, standing up without staff assistance, becoming tangled in catheter tubing, and then walking with an unsteady gait while pushing the wheelchair and dragging the tubing, with no staff present until alerted by a housekeeper. Staff interviews acknowledged frequent falls, difficulty keeping up with 15‑minute checks, and uncertainty about whether certain monitoring interventions were actually in place. A second resident with severe cognitive impairment, cerebrovascular disease, muscle wasting, lack of coordination, and a history of multiple falls also had a care plan that included fall‑prevention interventions such as 15‑minute safety checks, yellow tape on the call light, ensuring the call light was within reach, offering to lay the resident down after meals, monitoring position in the wheelchair, using a nonskid mat on the wheelchair, and increasing visual checks when out of bed. A fall investigation documented this resident being found lying on the floor in the dining room. Surveyor observations later found the resident in bed with the door closed, no staff present, and the call light not in reach and without yellow tape. The resident was also observed sitting on the edge of his wheelchair, attempting to propel himself and trying to get out of the wheelchair, while staff walked past without intervening. On another occasion, the resident sat in his wheelchair in the foyer for over 16 minutes without staff checking or monitoring him. Certified nurse assistants interviewed stated that the resident was not on 15‑minute checks, while the MDS coordinator stated that the resident was on 15‑minute checks and should have the call light in reach with yellow tape and be offered to lie down after meals. These findings show that for both residents, the facility did not consistently carry out the fall‑prevention measures identified in their care plans, including environmental setup (call light placement and marking), frequent and 15‑minute checks, supervision when out of bed or in wheelchairs, and assistance with transfers and positioning. The repeated falls, including those resulting in significant injury for one resident, occurred in the context of these planned interventions not being reliably implemented or monitored by staff, as evidenced by staff statements, fall investigations, and direct surveyor observations.
Insufficient CNA Staffing and Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide needed care in a timely manner, and the report states this had the potential to affect all 46 residents living at the facility. The facility’s CNA schedule for 10:00pm to 6:00am showed only two CNAs scheduled on most nights reviewed, and only one CNA scheduled on one night. The facility’s census list showed residents requiring varying levels of transfer assistance, including residents needing a full body lifting machine, two staff for transfers, and one staff for transfers. Several cognitively intact residents described long waits for call lights to be answered during the night. One resident with chronic pulmonary edema, mild intellectual disability, morbid obesity, and dependence for transfers and toileting said he waited about 3 hours after activating his call light because only two staff were working the night shift. Another resident with peripheral vascular disease, muscle wasting/atrophy, and chronic CHF said he waited about 2 hours for staff to answer his call light and stated only two CNAs were on duty. A third resident with pulmonary fibrosis, atrial fibrillation, muscle wasting/atrophy, and chronic CHF said it took 30 to 45 minutes for staff to answer the call light for bathroom assistance and said there were only two staff for all the residents at night. Direct observation also showed delayed response to call lights. One resident with emphysema, COPD, seizures, and dependence for personal care had a call light activated while two staff walked past without answering it, and staff responded several minutes later. Another resident with COPD, hypertension, dependence on supplemental oxygen, and need for personal care said his call light had been on for a while before staff responded and assisted with oxygen equipment. A CNA stated the facility did not have enough help, had difficulty meeting resident needs in a timely manner, and that residents sometimes waited 30 to 45 minutes for call lights to be answered. The Administrator said she handled scheduling because there was no DON and acknowledged she did not know whether two CNAs were enough to provide adequate care or evacuate residents in an emergency.
Missing RN Coverage and DON
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing and failed to have a Registered Nurse on duty for at least 8 consecutive hours a day, 7 days a week. On 4/14/2026, the Administrator stated the facility did not have the required 8 consecutive hours per day of RN coverage and that some days did not have the required RN coverage. Facility schedules reviewed for 4/13/2026, 3/24/2026, 3/25/2026, 3/18/2026, and 3/13/2026 documented no RN coverage on those dates. The Administrator also stated the facility had not employed a DON since the prior DON stepped down on November 2, 2025, and that Regional Nurses were monitoring the facility from afar rather than being physically present on a daily basis. The Assistant DON said the facility had not had a DON since mid-November 2025, and the Regional Nurse said the facility was actively seeking to hire a DON. The facility matrix dated 4/12/26 documented 46 residents, and the facility assessment listed a staffing plan calling for one full-time DON RN on days.
Pest Control Program Failed to Control Gnats
Penalty
Summary
The facility failed to maintain an effective pest control program to rid the building of gnats. During interview and observation, a resident who was alert and oriented stated that the facility had a problem with gnats and that they were all over the building, and two gnats were observed flying over that resident's bed in the room. Gnats were also observed on another resident's food tray sitting on the bedside table in the resident's room. Additional alert and oriented residents stated that gnats were present in the dining room and in the bedrooms, including one resident who reported a gnat had been in the room for a while and would not leave the resident's food or belongings alone, and another resident who said gnats were in the bedrooms and dining room and that residents had to swat them away while eating. The facility's pest control policy stated the program would be conducted on a regular and as needed basis and that the facility would be kept in a condition and cleaned to prevent harborage or feeding of insects or rodents. The CMS 671 documented 46 residents in the facility.
Delayed Call Light Response
Penalty
Summary
The facility failed to answer resident call lights in a timely manner to promote dignity for 5 of 5 residents reviewed for call light response times. Residents with intact cognition and significant physical assistance needs reported prolonged waits for help with toileting, personal care, and oxygen equipment. R23, who was wheelchair dependent and needed staff assistance for transfers and toileting, said he waited about 3 hours for his call light to be answered overnight because only two staff were working. R22, also cognitively intact and dependent on staff for toileting and personal hygiene, said he waited about 2 hours for his call light to be answered overnight. R32, who used a walker and needed supervision or touch assistance for toileting and personal hygiene, said it could take 30 to 45 minutes for staff to answer her call light for bathroom assistance. Direct observations also showed delayed response to activated call lights. R15, who was wheelchair dependent and needed staff assistance for toileting, turned on her call light and two staff were observed walking past it without answering before staff responded about 17 minutes later. R38, who used a wheelchair and needed partial moderate assistance with toileting and had supplemental oxygen dependence, said he had waited about 15 minutes for help with his oxygen concentrator and tubing before staff answered. A CNA stated the facility did not have enough help and that call lights were especially hard to answer in a timely manner, with waits as long as 30 to 45 minutes. The Administrator said she handled scheduling because there was no DON and reviewed a schedule showing only two CNAs on the night shift, with one CNA on one night, and stated she did not know if two CNAs were enough to provide adequate resident care in a timely manner.
Missing Accessible Call Lights in Restrooms and Shower Areas
Penalty
Summary
The facility failed to provide a method for residents to call for assistance from toilets and shower rooms for 36 of 36 residents reviewed for accommodations of needs in a sample of 46. During observation on 04/12/26, the shower room on the north hall had no call light in the shower stall. The first bathroom on the left side of the north hall had no call light accessible from the floor, and the first and second bathrooms on the right side of the north hall also had no call light accessible from the floor. On the south hall, the first and second bathrooms had no call light accessible from the floor near the toilet. On 04/16/26, the Administrator stated that all restrooms, shower rooms, and toilets should have call lights and should be able to be activated from the floor if a resident was to fall. The room roster dated 03/23/26 showed that R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46 resided on the north and south halls. The undated Physical Plant & Environmental Policy & Guidelines stated that the facility administrator must ensure safe and comfortable conditions and referenced nurse call light systems and door signaling systems/wander guard systems.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for 36 of 36 residents reviewed. Surveyors observed multiple rooms with urine odors, urine on floors, and soiled or damaged surfaces, including R5’s room where the resident reported that the contents of his incontinent brief had spilled onto the floor overnight and had not been cleaned up, with a white polymer substance observed on the floor next to the bed. R24’s room had a strong urine smell, urine under the bed covering an area of approximately four by three feet, missing floor tiles, and saturated flooring with brown marks around the tile edges; similar urine was later observed under the bed on additional visits. R5’s wheelchair cushion appeared to have liquid on it, and the resident stated his room sometimes smelled like urine. Strong urine odors were also observed in R29’s, R45’s, and R2’s rooms, with an old indwelling catheter bag containing urine found in a trash can on top of R2’s nightstand. Surveyors also found environmental maintenance and housekeeping issues in resident bathrooms and rooms. Several bathrooms on the north and south halls had buildup of dirt and debris or dark substances around toilet bases, cracked tiles, and missing baseboards. R22’s room had a broken window with a taped crack, offset glass pieces, cardboard covering the window, and apparent water damage at the bottom of the cardboard. In R9 and R36’s room, the baseboard radiator had no covering, exposing sharp metal pieces. In R28’s room, ceiling tiles were pushed up into the ceiling with insulation hanging from the tile track above the nightstand and head of bed area, and the insulation later was observed on the nightstand and floor. The administrator stated bathrooms should not have accumulation of dirt or debris and that the building should be maintained in good repair; the facility policy required routine room cleaning, shower room and restroom cleaning, and repairs to ceiling, wall, and floor damage.
Ordered nutritional supplements not provided
Penalty
Summary
The facility failed to provide ordered supplements and fortified foods to multiple underweight residents who had documented nutritional problems and active dietary orders. Based on interview, observation, and record review, R1, R2, R3, and R15 did not consistently receive the supplements or fortified items ordered for them during meal service. R15 had diagnoses including COPD, CKD, anemia, dementia, depression, and anorexia, and the care plan and RD notes documented a nutritional problem, underweight status, and a recommendation for additional calorie supplementation. Although R15 had orders for super cereal at breakfast, whole milk in place of menu milk, and fortified pudding at lunch and supper, R15 did not receive fortified pudding during observed lunch services on multiple days. The record also showed a March weight of 106.2 pounds with significant weight loss over 3 months and a BMI of 18.8, which was noted as underweight. R2 had diagnoses including Parkinson's disease, severe protein-calorie malnutrition, muscle wasting and atrophy, dementia, and schizoaffective disorder, with a care plan focused on nutritional problems and an active order for nutritional ice cream at lunch. Despite this order, R2 did not receive nutritional ice cream during observed lunch services on multiple days. R1 had diagnoses including severe protein-calorie malnutrition, COPD, Alzheimer's disease, hypothyroidism, depression, and cognitive communication deficit, with orders for nutritional shake at all meals, whole milk three times a day, fortified pudding at lunch and supper, and 2.0 calorie supplement three times a day. R1 did not receive fortified pudding or whole milk at observed lunches and did not receive super cereal at an observed breakfast. R3 had diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, dementia, anemia, and frontotemporal neurocognitive disorder, with an order for fortified mashed potatoes at lunch, but did not receive that item during observed lunch services and stated she was supposed to get it but did not receive it.
Mechanical Soft Diet Portions Not Followed
Penalty
Summary
The facility failed to follow the menu provided for residents receiving the mechanical soft diet for 6 of 6 residents reviewed. During lunch service, residents receiving the mechanical soft diet were served 2 ounces of ground marinated pork loin with gravy and 4 ounces of soft chopped broccoli, with pieces of broccoli observed to be over one inch in size. The diet spreadsheet for the meal specified a mechanical soft ground meat portion of ground marinated pork loin with gravy using an #8 scoop and soft chopped broccoli using a 4-ounce spoodle. Record review showed the recipe for ground marinated pork loin with gravy listed a portion size of an #8 scoop, and the facility’s dietary staff used a blue scoop that the Dietary Manager identified as 2 ounces. The Dietary Manager stated that two scoops of the 2-ounce scoop should have been served, meaning 4 ounces of pork loin should have been provided to residents on the mechanical soft diet. The Registered Dietician stated she would expect the broccoli to be cut into pieces smaller than one inch and expected residents to receive the portions directed by the diet spreadsheet. The facility policy stated menus are to be planned to provide nourishing meals that meet residents’ nutritional needs.
Mechanical Soft Diet Served in Improper Texture
Penalty
Summary
The facility failed to provide the mechanical soft diet as directed for 6 residents (R9, R13, R16, R28, R31, and R37) who were documented to receive that diet. During lunch service, a dietary staff member served 4 ounces of broccoli with pieces over one inch in size to these residents, and they received soft chopped broccoli with pieces larger than one inch. The diet spreadsheet for the meal listed soft chopped broccoli as a 4 ounce spoodle, while the recipe for soft chopped broccoli directed that the broccoli be chopped into bite-sized pieces of 1/2 inch or less before being transferred to steam table pans. The registered dietician stated that the soft chopped broccoli should have been smaller than an inch in size and that residents should receive portions as directed by the diet spreadsheet. The facility policy defined the mechanical soft diet as a consistency-modified diet for individuals with limited or difficult chewing that provides food in nearly regular textures while eliminating very hard, sticky, crunchy, or hard-to-chew foods.
Infection Control Failures With Catheter Care and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain proper infection control practices for residents with indwelling urinary catheters and failed to properly sanitize a portable glucometer. The report identifies deficiencies involving six residents: R2, R5, R19, R29, R31, and R34. The findings were based on interviews, observations, and record review, including care plans, MDS data, progress notes, and facility policies related to hand hygiene, urinary catheter care, and glucometer cleaning. For residents with indwelling catheters, multiple observations showed catheter drainage bags lying on the floor under beds or otherwise not secured in a protective bag or holder. R2, R5, R19, R29, and R31 were each observed with catheter bags on the floor or otherwise improperly positioned, and in some cases the bags were observed in wheelchairs or in a way that allowed contact with the floor or wheelchair components. R19 was also observed with the catheter bag in his wheelchair while the wheelchair wheel struck the bag as he propelled himself. R2’s room also contained an old catheter bag with urine still in it placed in a regular trash can, and the room had no isolation bins for trash or linens while contact isolation signage remained posted. During catheter care for R2 and R5, CNAs changed gloves but did not perform hand hygiene between glove changes. One CNA acknowledged that hand hygiene should have been performed between glove changes but said he forgot. The report also documents improper sanitation of the facility’s portable glucometer. An LPN performed a blood sugar test, then later wiped the glucometer with an alcohol wipe instead of the facility’s bleach-based disinfecting process described in policy. The LPN also did not perform hand hygiene before donning clean gloves for resident care, did not perform hand hygiene between glove changes, and placed supplies on another resident’s bed during the procedure. The facility policy required the glucometer to be cleaned and disinfected between each resident test using a bleach solution and to be allowed to air dry before gloves were removed and hands washed.
Delayed Response to Resident Grievance
Penalty
Summary
The facility failed to respond to a resident grievance in a timely manner for one resident reviewed for grievance responses. The resident’s record documented multiple diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, anxiety disorder, PTSD, major depressive disorder, polyarthritis, dementia, acute duodenal ulcer with perforation, anemia, amnestic disorder, vitamin D deficiency, and frontotemporal neurocognitive disorder. The resident’s MDS documented a BIMS score of 15, indicating the resident was cognitively intact. During interview, the resident stated the facility had not responded to a grievance she submitted about three weeks earlier and that she wanted to know what they were doing about it. The resident’s concern/compliment form documented a complaint against another resident, but the grievance form did not include documentation in the section for the grievance official, such as steps taken, pertinent findings, corrective actions taken, or follow-up with the person filing the complaint. The form was signed by the Administrator and the Social Service Director. The Administrator stated the concern had been addressed and acknowledged that the form should have documented whether the grievance was substantiated, the corrective action, and when the resident was spoken to. Resident council minutes also documented that residents had concerns about how complaints were being handled and that grievances from the prior month would be reviewed at each meeting. The facility policy stated residents have the right to voice grievances and have the facility respond to those grievances.
PASRR Level II Not Completed for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a level II PASRR was completed for a resident with diagnosed mental health conditions. The resident’s admission record documented major depressive disorder, recurrent, unspecified psychosis, anxiety, and insomnia. The resident’s MDS also documented a BIMS score of 07, indicating severely impaired cognition. A PASRR summary of findings dated 05/03/24 stated that no clinical documentation was submitted by the facility and that a PASRR needed to be completed. The record also showed a Level II outcome document stating the resident was excluded from PASRR because there was no diagnosis and no LOC, which conflicted with the resident’s documented diagnoses. During interview, the Regional Administrator stated she did not know why the PASRR did not include any diagnosis or information on the original screen. The Administrator stated that a new PASRR would be submitted, and the Regional Financial Administrator later stated that a new Level I screen was completed and it triggered a Level II, with a Level II scheduled. The facility policy stated that all potential admissions are to be screened for mental disorder, intellectual disability, or related condition, and that individuals with a mental disorder or intellectual disability are not to be admitted until the Level II screening process is completed and recommendations allow for admission.
Failure to Honor Documented Dietary Preferences
Penalty
Summary
The facility failed to follow the dietary preferences for 2 of 12 residents reviewed for dietary preferences. R10’s record showed an admission date of 07/28/25, a BIMS score of 13 indicating cognitive intactness, and a dietary assessment listing dislikes that included fish, Brussel sprouts, broccoli, coleslaw, cottage cheese, crabmeat, oranges, pineapple, and cucumber. Despite these documented dislikes, the diet spreadsheet for week 3 day 13 listed roasted broccoli with lunch, and on 04/12/26 R10 was served Italian marinated pork loin, stuffing, roasted broccoli, apple pie, and a beverage. At 12:40 PM, R10 did not eat any of the broccoli and stated he did not like broccoli. On 04/15/26, R10 was served hamburger stroganoff, buttered peas, pineapple, and a beverage, and at 12:25 PM he did not eat any of the pineapple and stated he did not like pineapple. R40’s record showed an admission date of 06/24/21, a BIMS score of 09 indicating moderate cognitive impairment, and a dietary assessment listing dislikes that included mushrooms, cucumber, broccoli, carrots, cauliflower, coleslaw, spinach, and green pepper. The same diet spreadsheet for week 3 day 13 listed roasted broccoli with lunch, and on 04/12/26 R40 was served broccoli with lunch. At 12:38 PM, R40 did not eat any of the broccoli on his plate, and when asked, stated he did not like broccoli. On 04/16/26, the Dietary Manager stated dietary staff should follow dietary cards and residents should not receive items listed as dislikes, and should receive a nutritionally equivalent substitution. The facility policy titled Menu Planning and Requirements stated deviations from the planned menu allow for individualized nutrition based on nutritional or medical needs and/or resident requests and are indicated on a meal card or other communication tool for serving staff.
Failure to Administer Consented Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide influenza and pneumococcal vaccinations for 2 of 5 residents reviewed for immunization after consent forms had been signed. One resident had diagnoses including pan lobular emphysema, COPD, chronic kidney disease, anemia, dementia, GERD, depression, anorexia, and conversion disorder with seizures or convulsions. That resident’s undated consent indicated the resident had not previously received PCV13 or that the history was unknown, and consent was given to receive PCV13 if not previously given or if unknown. Another resident had diagnoses including Parkinson’s disease, severe protein-calorie malnutrition, vitamin D deficiency, anemia, hyperlipidemia, muscle wasting and atrophy, anxiety disorder, depression, dementia, and schizoaffective disorder. That resident’s undated pneumococcal vaccine authorization form also indicated unknown prior PCV13 history and consent to receive PCV13 if not previously given or if unknown. During interview, the ADON stated that one resident did not receive influenza or pneumococcal vaccinations and the other did not receive the pneumococcal vaccination, although they had been ordered. The facility policy required residents who signed consent to receive influenza vaccine annually and pneumococcal immunizations per CDC recommendations, with documentation of whether the vaccine was received or not received due to contraindication or refusal.
Failure to Ensure Resident Dignity and Respect in Daily Care and Staff Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect and that their input was valued, particularly in relation to staff attitudes, responsiveness, and thoroughness of care. Multiple residents with intact or moderately impaired cognition reported that CNAs, especially on the night shift, displayed “nasty” or exasperated attitudes when residents requested assistance. One resident with multiple medical conditions, including muscle wasting, lymphedema, venous insufficiency, and spinal stenosis, stated that a night CNA did not clean him adequately after incontinence episodes, wiping only the front and not further down despite his explanation that urine runs down due to gravity. Another resident with fractures, an artificial hip joint, and severe protein-calorie malnutrition reported that a male night CNA acted exasperated when she requested care, sometimes wiped her with a used brief, and did not adequately clean her when she had stool related to medication side effects. Several other residents with diagnoses such as anxiety, depression, COPD, diabetes with neuropathy, osteoporosis, epilepsy, dementia, and chronic pain described CNAs as snappy, short, rushed, or not always nice, with particular emphasis on evening and night shifts. Residents reported that call lights could take a long time to be answered, sometimes 45 minutes to an hour at night, and that staff would say they would return but often did not. One cognitively impaired resident, alert to situation at the time of interview, stated that some staff were not nice or gentle and that they did not return after saying they would, and that a recent request for ice was denied with the explanation that they were out. Another resident stated that staff were often too busy on their phones to pay attention and specifically identified a CNA who lacked patience with certain residents, noting that some residents “have nothing else” and need staff to be patient. Residents also reported issues with dietary and ancillary staff interactions that affected their sense of dignity and respect. One resident’s written concern described drinks not being made available until late in the afternoon despite repeated requests, leading residents to feel they were “making them mad” by knocking on the door. Another resident’s written complaint stated that the menu was posted late and too high to read, and that a kitchen worker became angry when asked for ice and told the resident to obtain it from a locked break room, causing the resident to stop asking for drinks due to staff reactions. Additional residents reported that kitchen staff were unhappy when residents knocked to request substitutes, that they sometimes had to knock multiple times because staff would not answer, and that night staff would not provide items such as milk. Multiple residents stated that concerns about staff attitudes, roughness, and rushing of more fragile residents had been discussed among residents and, at times, in resident council, although recent council minutes did not reflect these concerns. Facility leadership and some staff reported being unaware of poor staff attitudes, and resident council minutes documented few or no complaints about nursing, despite residents’ statements that they had raised these issues previously. The facility’s own Employee Standards of Conduct document, dated 07/2024, states that the company expects each employee’s conduct and performance to conform with the highest standards of professionalism in the treatment of residents, visitors, and families, and to comply with applicable laws and regulations. However, the resident interviews and written complaints describe repeated instances where staff behavior—such as exasperated responses, refusal or reluctance to provide requested care or beverages, inadequate cleaning after incontinence, delayed call light response, and visible irritation when residents requested information or substitutes—did not align with these standards. The DON stated she was not aware of poor CNA attitudes, and a CNA reported not having seen staff display attitudes with residents, which contrasts with the multiple resident accounts of disrespectful or dismissive interactions. These findings collectively demonstrate that the facility did not consistently maintain residents’ rights to dignity, respect, and self-determination in daily care and communication.
Failure to Provide Palatable, Hot Meals to Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were provided in a palatable, attractive manner and at safe and appetizing temperatures for 14 of 15 residents reviewed. Multiple residents with intact or moderately impaired cognition reported that their meals were frequently cold or barely warm, with specific complaints that butter or margarine would not melt on hot items and that food appeared unappetizing. One resident with diagnoses including muscle wasting, anemia, and vitamin deficiencies stated that food quality, temperature, and insufficient meat portions had been raised several times with staff and in Resident Council, and that his food arrived cold and “gross,” which he attributed to his room being far from the kitchen. Surveyors directly observed and measured food temperatures that corroborated resident complaints. One resident received a lunch tray with peas that she refused to eat because they were cold; the peas were measured at 83°F using a calibrated thermometer, and the resident pointed out visible solidified grease on the beef stew. Another resident demonstrated that margarine placed on peas did not melt at all, and surveyors observed solid margarine spread over the peas with no signs of melting. A test tray obtained from the kitchen on another day showed tuna noodle casserole at 98°F and carrots at 103°F, temperatures that the acting dietary manager acknowledged should have been hotter and sufficient to melt margarine at least somewhat. Additional residents with diagnoses such as protein-calorie malnutrition, diabetes, GERD, anemia, and intellectual disabilities consistently reported that food was often cold, barely warm, or not good when cold, whether eaten in their rooms or in the dining room. One resident stated that food is one of the only things residents have to look forward to and expressed disappointment that it was generally not warm. Another resident reported being told that food would be hotter if she ate in the dining room, but she believed she should receive hot food in her room as well. Resident Council minutes over several months documented dietary complaints about specific menu items and service issues, though they did not specifically record temperature concerns. The acting dietary manager, who was also the Activities Director, stated she was unaware of any food council minutes and acknowledged that food should be hot regardless of where residents eat, while the Administrator stated he expected food to be hot when residents receive it, even though he was unsure of exact temperature standards. The facility’s policy on handling, serving, and transporting foods required proper holding temperatures and attractive presentation according to the menu, but the observed practices and resident reports showed that food was not consistently served hot or palatable. The facility’s failure to maintain appropriate food temperatures and palatability affected residents across multiple units and with varying cognitive and medical conditions. Residents repeatedly raised concerns in interviews and in Resident Council about cold food and poor quality, and surveyor observations of solid margarine on hot items and substandard temperatures on both resident trays and a test tray supported these complaints. Despite a written policy requiring proper holding temperatures and attractive presentation, the facility did not ensure that meals were consistently served hot and appetizing to residents in their rooms or in the dining area.
Failure to Provide Adequate Supervision During Smoking Breaks Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision during a designated smoking break, resulting in a resident with a history of falls and diabetic neuropathy sustaining significant injuries. The resident, who was cognitively intact and required supervision and touching assistance for ambulation, was attempting to navigate a ramp to the smoking area using a rolling walker. During this time, another resident with moderately impaired cognition and a history of impulsive behavior during smoke breaks was also present. The second resident, known for being impatient and having previously bumped into others with his walker, collided with the first resident, causing her to fall and sustain large skin tears and lacerations to both forearms, necessitating emergency medical care and wound specialist intervention. Multiple interviews with residents and staff confirmed that the second resident frequently rushed during smoke breaks, often bumping into others with his walker. Witnesses described the incident as the injured resident trying to move out of the way to avoid being run over, ultimately losing her balance and falling. Several other residents reported similar experiences of being bumped by the same individual during smoking breaks, with at least one other resident sustaining a skin tear as a result. Staff statements indicated that supervision during the incident was insufficient, as the supervising CNA was occupied distributing cigarettes and did not ensure all residents were safely in the smoking area before doing so. The facility's policies required supervision during smoking and interventions to address individual fall risks, but these were not effectively implemented. The care plan for the resident who fell included interventions for fall prevention, but did not address the specific risk posed by the other resident's impulsive behavior during smoke breaks. Additionally, the care plan for the resident with impulsive behavior had previously removed a focus area on his rushing during smoke breaks, despite ongoing incidents. The lack of adequate supervision and failure to implement appropriate interventions directly contributed to the accident and resulting injuries.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
Staff at the facility failed to maintain the privacy and confidentiality of residents' personal and medical information. Multiple residents, both cognitively intact and moderately impaired, reported overhearing staff discussing other residents' health issues, care, and personal backgrounds in common areas such as the dining room, outside smoking areas, and even in residents' rooms. Some residents also stated that staff would make fun of other residents during these conversations. These discussions were reportedly held in the presence of other residents, families, and staff, with specific instances of staff using residents' names while talking about their care. Interviews with staff members, including CNAs and the Activities Director, confirmed that conversations about resident care occurred in common areas where they could be overheard by others. The facility's confidentiality agreement explicitly prohibits the sharing of resident information except as required for care or by authorized personnel. Despite this policy, the practice of discussing resident information in public areas was observed and reported, affecting the privacy rights of all 52 residents in the facility.
Failure to Address and Resolve Resident Grievances Regarding Staff Attitudes
Penalty
Summary
The facility failed to address and resolve concerns raised by residents regarding the rude and disrespectful attitudes of some Certified Nurse Assistants (CNAs), as documented in resident council meeting minutes. Despite the issue being discussed and recorded in the resident council, there was no evidence that a grievance or concern form was completed, nor was there any documentation of investigation or resolution. Multiple residents, all cognitively intact as indicated by their BIMS scores, reported ongoing issues with staff rudeness, including dismissive or aggressive responses when requesting assistance. Staff interviews confirmed awareness of the problem, with some CNAs and the Activities Director acknowledging that certain staff members had been rude to residents. However, key personnel such as the Social Service Director, Administrator, and Director of Nursing were unaware of the complaints, and no in-service training or corrective action was documented. The facility's grievance policy requires prompt documentation, investigation, and resolution of all grievances, including those discussed in resident council meetings. However, the policy was not followed in this instance, as the concern about staff attitudes was neither formally documented nor addressed. The lack of communication and follow-through among staff and administration resulted in the residents' grievances remaining unresolved, affecting all 52 residents in the facility.
Unlicensed Nurse Provided Care and Administered Medications
Penalty
Summary
The facility failed to ensure that all nursing staff maintained appropriate and current licensure while working, resulting in an unlicensed individual performing duties as a nurse. Specifically, an LPN's license expired, and she continued to work as a nurse for a period of time without a valid license. The Director of Nursing (DON) and other staff confirmed that the lapse in licensure was not identified until after the LPN had already worked several shifts in the nursing role. The DON admitted that the LPN was a transfer from another facility and her license status was not checked upon transfer. Once the expired license was discovered, the LPN was removed from nursing duties and reassigned as a CNA while she worked to renew her license. During the period when the LPN's license was expired, she administered medications and provided nursing care to multiple residents with complex medical conditions, including Alzheimer's disease, bipolar disorder, chronic kidney disease, and various mental health disorders. Medication administration records confirmed that the unlicensed LPN dispensed a range of medications to several residents during this time. The facility census indicated that 52 residents could have been affected by this lapse in licensure oversight.
Failure to Consistently Provide Beverages to Residents
Penalty
Summary
The facility failed to consistently provide beverages to residents in accordance with their needs and preferences, resulting in multiple instances where residents did not have access to water or other drinks. Several residents, including those with significant medical conditions such as acute kidney failure, urinary tract infections, epilepsy, and cirrhosis of the liver, were identified as being at risk for dehydration and required assistance with personal care. Despite care plans indicating a risk for dehydration, residents and their family members reported that water and ice were not regularly passed out, and at times, residents were left without any drinks in their rooms. Observations confirmed that some residents did not have water or cups within reach, and staff interviews corroborated that the distribution of drinks was inconsistent. Multiple staff members, including CNAs and an agency LPN, acknowledged that water and ice were not always provided, citing staffing issues as a contributing factor. Resident council minutes and concern forms documented repeated complaints about the lack of drink distribution, with some residents stating they had to request water from night staff or that staff became upset when asked for drinks other than water. The facility had previously conducted an in-service on passing water and snacks, but there was no evidence of follow-up to ensure compliance. The deficiency had the potential to affect all 52 residents residing in the facility.
Staff Conflicts and Disruptive Behavior Compromise Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to maintain an environment that promotes the maintenance and enhancement of residents' quality of life, as evidenced by multiple incidents of staff members engaging in loud arguments, yelling, and using inappropriate language in the presence of residents. Interviews and record reviews revealed that staff conflicts, particularly among CNAs on the evening shift, were frequent and disruptive, with staff members yelling and cursing at each other in hallways and near the nurses' station. These altercations were witnessed by residents and other staff, and were described as ongoing and creating a chaotic atmosphere within the facility. One resident, who was cognitively intact and had a history of mental health diagnoses including bipolar disorder, schizophrenia, and anxiety, reported that staff frequently got loud and fought in front of residents, which contributed to agitation and restlessness. Staff interviews corroborated these accounts, with one CNA describing being harassed and verbally abused by coworkers to the point of feeling unsafe and needing to leave work early. Other staff, including an activity director and agency LPNs, confirmed that yelling and drama among staff were common occurrences, and that these behaviors were audible throughout the north and south halls where a large number of residents resided. Documentation showed that the facility's own policy required staff to treat residents, family members, coworkers, and visitors with respect, kindness, and professionalism at all times. Despite this, the environment described by both residents and staff was one of frequent conflict and lack of professionalism, directly impacting the residents' right to a dignified existence and a quality living environment.
Failure to Ensure Call Lights Are Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were consistently within reach for multiple residents who required assistance, as observed through direct observation, interviews, and record review. Several residents with significant medical conditions and varying levels of cognitive impairment were found with their call lights placed out of reach, sometimes on the floor, on bedside tables several feet away, or wrapped around bed lights. In some cases, residents were unable to summon help due to the inaccessibility of their call lights, and staff did not always respond to verbal requests for assistance. Specific examples include a resident with chronic respiratory failure and moderate cognitive impairment whose call light was repeatedly found three feet away while she was in bed, and another resident with vascular dementia and a history of falls whose call light was similarly out of reach. One resident, dependent for transfers and at risk for falls, was observed with her call light on the floor, and the cord was not long enough to reach her recliner. Residents and staff reported that call lights were sometimes intentionally placed out of reach, with one resident stating that staff would hide her call light or put it where she could not access it, and a CNA confirming that it was common practice to take away call lights from certain residents. The facility's own policy requires that call lights be available and easily accessible to all residents capable of using them, and that maintenance be notified if the call light cord is not long enough. Despite this, multiple observations and interviews confirmed that call lights were not consistently kept within reach, and some residents had to rely on others to turn on their call lights or resorted to yelling for help when they could not access them. Family members and staff corroborated that this was a recurring issue affecting several residents.
Staff Vaping Inside Facility Violates Smoke-Free Environment Policy
Penalty
Summary
Multiple residents who were alert and oriented reported observing staff members vaping inside the facility, including in hallways, resident rooms, and the break room. These observations were corroborated by several staff members, including CNAs and the Activities Director, who stated they had witnessed staff vaping in various areas of the building. One resident specifically identified a CNA vaping while pushing a resident in a wheelchair. The reports indicated that vaping occurred on both day and evening shifts and involved several staff members, some of whom were not named. Facility documentation, including an in-service form and the Employee Standards of Conduct, clearly stated that vaping is not permitted within the building and that violations of the non-smoking policy could result in corrective action or termination. Despite these policies and prior in-service training on vaping, staff continued to vape inside the facility, compromising the expectation of a smoke- and vape-free environment for residents.
Failure to Follow Menus and Provide Adequate Portions Leads to Food Shortages
Penalty
Summary
The facility failed to follow the prescribed menus and provide adequate portion sizes as directed, resulting in multiple instances where residents did not receive meals that met their nutritional needs. Several residents, including those with diagnoses such as protein-calorie malnutrition, diabetes, and vitamin deficiencies, reported that the facility frequently ran out of food or essential meal components. In some cases, residents received smaller portions or were given inappropriate food items, such as a diabetic resident being served two cinnamon rolls and a bowl of cereal due to a lack of suitable alternatives. Staff interviews corroborated these accounts, with multiple CNAs and dietary staff acknowledging that food shortages led to reduced portion sizes and an inability to provide seconds or alternative options when requested. Residents described situations where staff and sometimes other employees consumed food intended for residents, further contributing to shortages. There were also reports of the kitchen discarding leftover food after serving the main meal, leaving nothing available for residents who requested additional servings. The issue was not isolated to a single meal or day, as both residents and staff recounted repeated occurrences of running out of food, including breakfast meats and eggs, and lacking basic supplies like sugar and condiments. These deficiencies were documented through resident interviews, staff statements, and concern forms submitted by residents requesting larger portions and more snacks, especially during long intervals between dinner and breakfast. Care plans and medical records reviewed for affected residents indicated that many were at risk for malnutrition or had specific dietary needs that were not consistently met due to these failures. The facility's inability to ensure that menus were followed, meals were prepared in advance, and adequate food was available for all residents directly led to the deficiency. The administrator and dietary staff acknowledged awareness of the problem, with the administrator stating efforts were being made to address menu compliance, but the deficiency persisted at the time of the survey.
Failure to Provide Adequate Evening Snacks to All Residents
Penalty
Summary
The facility failed to provide sufficient evening snacks to ensure that every resident had access to a snack, as required by their needs and preferences. Multiple residents, including those with diagnoses such as protein-calorie malnutrition and those at risk for malnutrition, reported that evening snacks were inadequate, often limited to only two saltine crackers or other minimal options. Residents also noted that snacks were sometimes only available to certain groups, such as smokers, and that there was a lack of variety and quantity, with some residents suggesting that additions like peanut butter would make the snacks more suitable, especially for those with diabetes. Staff interviews consistently confirmed that the facility frequently ran out of snacks in the evening, with CNAs and LPNs stating that there were not enough snacks to serve all residents. Staff described situations where ambulatory residents would take preferred snacks, leaving little or nothing for others, and noted that mechanically altered diets were not always accommodated. Dietary staff reported assembling snack baskets with a limited number of items, estimating that the total number of snacks was often insufficient for the resident population, and that they did not count or track the distribution to ensure all residents received a snack. Documentation and resident council minutes further supported these findings, with written complaints about the lack of snacks and long intervals between dinner and breakfast without adequate nourishment. The facility's own policy required snacks to be provided as requested and at bedtime, but observations and interviews indicated that this was not consistently implemented. The deficiency was substantiated by direct resident statements, staff admissions, and review of facility records and snack basket contents.
Mental Abuse of Resident by Staff Through Derogatory Comparison
Penalty
Summary
A resident with multiple diagnoses, including COPD, depression, and anxiety disorder, was admitted with a care plan identifying a risk for abuse or neglect. The care plan included interventions such as assessing for abuse risk, educating the resident to report uncomfortable situations, and observing the resident during care and in the company of peers. Despite these measures, an incident occurred in which a Certified Nursing Assistant (CNA) showed other staff members a picture of a TV character on her cell phone, making a comparison to the resident's appearance and intelligence. The resident witnessed the CNA pointing at him and laughing, which caused him to feel humiliated. Multiple staff members confirmed that the CNA showed the image and made the comparison in the dining room, and some acknowledged that the comparison could be perceived as offensive. The resident reported feeling mocked and mortified by the incident, and a family member stated that the resident was upset and did not want to return to the facility. Written statements from staff corroborated the resident's account, with one CNA confirming that the comparison was made and the image was shown to others. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the actions of the CNA constituted mental abuse, as determined by the facility's investigation.
Failure to Report Allegations of Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to the state agency and the facility administrator as required by policy. One resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder and a need for assistance with personal care, made allegations that a staff member threatened her and that another staff member allowed shampoo to run into her eyes during a shower, causing her distress. The resident's care plan included interventions for behavior management and abuse risk, with instructions to investigate allegations per facility protocol and notify the abuse care coordinator immediately. Despite these protocols, the incident where the resident accused a staff member of threatening her was not reported to the Illinois Department of Public Health (IDPH), and the administrator did not obtain a statement from the resident at the time of the allegation. Staff interviews revealed that the resident had reported being mistreated during a shower, with one CNA witnessing the resident in distress and reporting it to a nurse. However, the nurse did not escalate the report to the administrator, and the administrator was not made aware of the incident until it was brought to her attention by IDPH. The facility's policy required immediate reporting of any incident, allegation, or suspicion of abuse, neglect, or exploitation to the administrator and, in cases of abuse, to the Department of Public Health within specified timeframes. In these cases, the required notifications and investigations were not completed as outlined in the policy, resulting in a failure to follow internal and regulatory reporting requirements for suspected abuse.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder, overactive bladder, and a history of cancer. The resident, who was dependent on staff for toileting, alleged that staff made threatening and inappropriate comments during a breakfast incident. The care plan for the resident included interventions for behavior management and a specific protocol for investigating abuse allegations, including checking for physical marks, interviewing assigned staff, and notifying the abuse care coordinator immediately. On the date of the incident, the resident accused staff of making a threatening statement, which was reported to the nurse by the Activity Director. The nurse notified the Administrator and DON, and statements were taken from several staff members present. However, the Administrator did not obtain a statement from the resident at the time of the incident and did not report the allegation to the Department of Public Health as required. The investigation was limited to staff interviews, and the staff members involved were not suspended during the investigation. The Director of Nursing was not aware of the allegation until much later, and there was confusion among staff regarding the resident's toileting schedule and care plan interventions. Documentation shows that the facility's abuse prevention and reporting policy required a thorough investigation of all allegations, including interviews with the person reporting the incident, the resident if interviewable, and review of all relevant documentation. Despite this, the facility did not follow its own protocol, as the investigation was incomplete and not timely, and the required notifications were not made. The failure to properly investigate and report the abuse allegation constituted a deficiency in the facility's response to alleged violations.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 hours per day, 7 days a week, as required. Record review and staff interviews confirmed that there was no RN coverage on several specific dates, and the Director of Nurses acknowledged the absence of RN staff on those days. Facility schedules for July and August documented the lack of RN coverage on multiple occasions, and the Director of Nurses confirmed via email that no RN was present during those times. This deficiency had the potential to affect all 50 residents currently residing in the facility. No information was provided regarding the specific medical history or condition of any individual resident at the time of the deficiency.
Failure to Administer Medications as Ordered Due to Unapproved Substitution
Penalty
Summary
The facility failed to administer medications as ordered for a resident with diagnoses including bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. The resident had a physician's order for Preservision AREDS 2 Soft gel to be given once daily, which was documented on the Medication Administration Records (MAR) as being administered. However, interviews and observations revealed that the facility was actually administering Ocuvite instead of Preservision for an extended period. Staff, including LPNs and the DON, acknowledged that due to pharmacy and insurance issues, they substituted Ocuvite for Preservision without a physician's order to do so, and continued to document that Preservision was given. The pharmacist confirmed that Preservision and Ocuvite have different formulas and that no refills for Preservision had been provided since late April. The resident reported the issue to multiple staff members and administration, but the substitution continued until the resident contacted the State Survey Agency. The care plan did not address the resident's diagnosis of macular degeneration, and staff were unclear about how long the incorrect medication had been administered. The facility's policy requires medications to be administered as ordered by the physician, but this was not followed in this case, as staff substituted a different supplement and documented administration of the original ordered medication.
Failure to Administer Ordered Medication Due to Unapproved Substitution
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident with diagnoses including bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. The resident had a physician's order for Preservision AREDS 2 Softgel to be given once daily, which was documented on the Medication Administration Records (MAR) as being administered. However, the resident reported that she was receiving Ocuvite instead of Preservision for her macular degeneration, despite informing nursing staff, administration, the DON, and the ADON. Upon inspection, it was confirmed that Preservision was only obtained after the resident contacted the State Survey Agency, and the medication bottle was dated the same day as the surveyor's visit. Interviews with staff revealed that the pharmacy stopped sending Preservision, and staff substituted Ocuvite based on information from the pharmacy and direction from the DON, without a physician's order to change the medication. The pharmacist confirmed that Preservision and Ocuvite have different formulas and that Preservision had not been refilled since the initial supply. Staff were unsure how long the resident had been receiving the incorrect medication, and the MARs continued to indicate that Preservision was administered, despite the substitution. The facility's policy requires medications to be administered according to physician orders and regulations, which was not followed in this case.
Failure to Provide Timely Dialysis Due to Transportation Breakdown
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a resident dependent on dialysis received scheduled dialysis treatments. The resident, who had diagnoses including end stage renal disease, chronic diastolic heart failure, and dependence on renal dialysis, was admitted with a care plan specifying the need for regular dialysis to avoid complications. Despite this, the resident missed multiple dialysis appointments due to the facility's transportation van being out of service and the inability to secure alternative transportation. Documentation and interviews revealed that the resident missed dialysis sessions on several occasions, resulting in at least one hospital admission for dialysis and pulmonary venous congestion. The facility's progress notes and staff interviews confirmed that the transportation van was broken for approximately one and a half weeks, during which time the resident was unable to attend scheduled dialysis treatments. Attempts to arrange alternative transportation were unsuccessful, as local companies either did not operate early enough or did not service the area. The resident was sent to the hospital twice; on one occasion, dialysis was not provided, and on another, the resident was admitted overnight to receive dialysis. The dialysis center and hospital staff confirmed that the resident had not received dialysis for an extended period due to transportation issues. The facility's own policy required assistance in obtaining transportation for necessary medical services, but this was not achieved, resulting in missed life-sustaining treatments. The resident expressed awareness of the missed treatments and the importance of dialysis, and laboratory findings indicated a need for ongoing dialysis.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, which is a requirement for long-term care facilities. This deficiency was identified through interviews and record reviews, revealing that there was no RN on shift for specific dates in November and December 2024. The facility's agency nursing time reports documented the absence of RN coverage on 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. Interviews with a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Regional Director of Operations confirmed the lack of RN coverage on these dates. The facility did not have a specific policy on RN coverage, instead relying on general staffing regulations. This failure had the potential to affect all 40 residents living in the facility.
Deficiencies in Dishwashing Temperature and Food Handling Practices
Penalty
Summary
The facility failed to maintain the hot water source at the required minimum temperature for dishwashing, which could potentially affect all 40 residents. During an observation, the dish machine's water temperature was recorded at 80 degrees Fahrenheit, below the manufacturer's recommended minimum of 120 degrees Fahrenheit for proper dish cleansing and sanitization. The Dietary Manager acknowledged the issue, noting that the facility's two 40-gallon water heaters were insufficient when both the three-compartment sink and the dish machine were in use simultaneously. The Maintenance staff suggested a temporary procedure to avoid simultaneous use until a long-term solution is found. Additionally, improper food handling practices were observed in the kitchen. A cook was seen using the same pair of gloves to handle various tasks, including taking food temperatures and touching food directly, which could lead to cross-contamination. The Dietary Manager recognized the need to address this behavior, as it violated the facility's policy on proper hand washing and glove use, which requires changing gloves whenever hand washing is necessary or when gloves become contaminated.
Lack of Documentation for QAPI Meetings
Penalty
Summary
The facility failed to maintain documentation of quarterly Quality Assurance and Performance Improvement (QAPI) meetings, which is a requirement for ensuring ongoing quality assessment and improvement processes. During the investigation, no evidence of meeting attendance or information was found for any QAPI meetings held after February 16, 2024. This lack of documentation was confirmed by the Regional Director of Operations, who acknowledged that while the facility has been conducting these meetings, they were unable to produce any records to substantiate this claim. The facility's policy, last revised on October 24, 2022, outlines the purpose and guidelines for the QAPI program, emphasizing the need for an organized and systematic approach to quality improvement. The policy specifies that the QAPI Committee should identify issues, assess quality assurance activities, and develop action plans to address performance variations. However, the absence of documented evidence of these meetings suggests a failure to adhere to the policy, potentially affecting the quality of care for all 40 residents residing in the facility.
Failure to Provide Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide dietary supplements as ordered to four residents, leading to a deficiency in maintaining their nutritional status. Resident 4, diagnosed with dementia and vitamin deficiencies, was ordered a regular diet with mighty shakes twice a day due to a low BMI. Resident 13, with bipolar disorder and muscle wasting, was ordered mighty shakes with meals for significant weight loss. Resident 19, with dementia and Alzheimer's, was ordered mighty shakes with three meals to address weight loss. Resident 20, diagnosed with Alzheimer's and muscle wasting, was ordered mighty shakes at meals to encourage increased intake due to weight loss. Each resident's care plan included interventions to provide the diet as ordered to maintain adequate nutritional status. On the day of the survey, the dietary manager, V5, reported that the delivery truck arrived late, and the mighty shakes were frozen upon delivery. As a result, the residents did not receive their supplements for breakfast or lunch. V5 confirmed that residents who were supposed to receive supplements twice a day did not receive them at breakfast and lunch, and those ordered supplements three times a day did not receive them with each meal. This failure to provide the dietary supplements as ordered contributed to the deficiency in maintaining the residents' nutritional status.
Failure to Notify Law Enforcement in Abuse Investigation
Penalty
Summary
The facility failed to notify the proper authorities in an abuse investigation involving a resident, identified as R14, who was admitted with multiple diagnoses including peripheral vascular disease, heart failure, Type 2 Diabetes Mellitus, and chronic pressure ulcers. R14, who was cognitively intact with a BIMS score of 15, reported to a dayshift CNA that night shift CNAs were rude and took his laptop away. The facility's initial report to the IDPH Regional Office documented the allegation of verbal abuse and noted that the CNAs in question were suspended, and the physician and Power of Attorney were notified. However, there was no documentation indicating that the local police were notified, which was confirmed by the Regional Director of Operations. The facility's policy on Abuse Prevention and Reporting requires informing local law enforcement in certain situations, including when there is a reasonable suspicion that a crime has been committed. Despite this policy, the facility did not contact law enforcement regarding the incident involving R14. The final report submitted to the IDPH also lacked information on whether law enforcement was notified, highlighting a deficiency in the facility's adherence to its own abuse prevention and reporting procedures.
Failure to Implement Suicide Prevention Protocols
Penalty
Summary
The facility failed to provide necessary behavioral interventions and procedures for suicide observation and prevention for a resident with suicidal ideations. The resident, identified as R23, was admitted with multiple diagnoses including major depressive disorder, schizophrenia, and borderline personality disorder. Despite these conditions, the facility did not adequately monitor or document the resident's suicidal ideations as required by their policy. On a specific date, R23 expressed suicidal thoughts multiple times during a shift, but the staff did not document any follow-up actions or notify the physician immediately. The resident's care plan included interventions for monitoring signs of depression and suicidal thoughts, but these were not effectively implemented. The staff failed to complete a suicide checklist or assessment promptly, and there was no evidence of continuous monitoring or physician notification until days later. The facility's policy on suicide observation and prevention requires prompt notification of the physician and continuous monitoring of residents exhibiting suicidal tendencies. However, the staff did not adhere to these procedures, resulting in a lack of timely intervention and documentation. The Director of Nursing and Social Services Assistant were not informed of the situation until after the fact, and the necessary assessments and notifications were delayed, compromising the resident's safety and care.
Failure to Safeguard Medical Records Due to Water Damage
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. This deficiency was identified for three residents whose electronic health records (EHR) were missing critical documentation dated prior to the facility's transition to electronic records on January 29, 2025. The missing records included progress notes, behavior tracking, physician orders, and discharge summaries. The absence of these records was attributed to water damage in the medical records room caused by a burst pipe in the facility's sprinkler system, which rendered the paper records illegible. During interviews, facility staff confirmed the loss of paper records due to flooding and acknowledged the lack of a backup system to retrieve the missing information. The Regional Director of Operations and the Financial Coordinator both stated that the facility's electronic medical records system went live on January 29, 2025, and that the paper records prior to this date were destroyed and unreadable. This incident highlights the facility's failure to ensure the security and accessibility of medical records, resulting in a significant gap in the documentation of residents' medical histories.
Unauthorized Administration of Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as staff administered an injectable anti-psychotic medication, Chlorpromazine, twice within an 8-hour period without the resident's consent and without a physician's order. The resident, who had a history of Parkinsonism, Paranoid Schizophrenia, and other mental health disorders, was given the medication by an LPN without verifying the current medication orders. The medication had been discontinued in September 2023, and there was no valid order for its administration at the time of the incident. The LPN administered the first injection at 10:30 PM after the resident exhibited behaviors such as spitting and verbal aggression. The LPN did not inform the resident about the injection, and the resident expressed that the action was sneaky. A second injection was reportedly given at 5:30 AM, although this was not witnessed by the CNA who was monitoring the resident. The LPN admitted to not checking the medication orders or documenting the administration of the medication in the Medication Administration Record (MAR). As a result of the unauthorized administration of Chlorpromazine, the resident was sent to the emergency room with symptoms of lethargy, facial swelling, and a possible allergic reaction. The emergency room physician was not initially aware of the Chlorpromazine injections, which could have posed additional risks to the resident's health. The facility's failure to follow proper medication administration protocols and to attempt less restrictive alternatives before resorting to chemical restraints led to this deficiency.
Removal Plan
- Facility Restraint Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator initiated in-servicing, for all staff, on the use of non-pharmacological interventions for resident behaviors all other staff will be in-serviced before the beginning of the next shift.
- The Administrator will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand using non-pharmacological interventions for resident behaviors.
- Director of Nursing in-serviced all nurses to obtain orders for the administration of an injectable anti-psychotic to be completed by the beginning of the next scheduled shift.
- Director of Nursing in-serviced all nurses on documenting all medication administration in the MAR to be completed by the beginning of the next scheduled shift.
- Social Service Director will interview 3 residents, 3 times weekly x4 weeks to ensure that residents are getting their medication as prescribed.
- IDT has assessed R1 and care plan updated to reflect non-pharmacological interventions for behaviors.
- IDT team reviewed all residents for the potential to not be free of abuse and care plans updated to reflect interventions to protect residents from abuse.
- IDT in-serviced by Regional Director of Operations to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff.
- Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevent situations that may cause abuse to a resident.
- The nurses in question were suspended pending investigation of the med error and ultimately terminated.
- ADON completed an audit of the medication carts and medication room to ensure there were no medications present that did not have orders from the physician.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Nursing & Rehab | 6.1 mi | ★★★★★ | 8 | 0 |
| Helia Healthcare Of Benton | 6.9 mi | ★★★★★ | 2 | 0 |
| Shawnee Senior Living | 7.3 mi | ★★★★★ | 5 | 0 |
| Integrity Hc Of Herrin | 7.4 mi | ★★★★★ | 0 | 0 |
| Benton Rehabilitation And Health Care Center | 7.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.