Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cisne Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, incontinence, and a pressure ulcer present on admission had worsening wound measurements, drainage, odor, and later tunneling, while the chart lacked timely skin-integrity interventions and orders to pack the tunneling. Staff documented delayed follow-up on a wound culture that later grew ESBL E. coli and Enterococcus faecalis, and surveyors observed the resident without EBP signage or PPE use, with stool and urine contamination and periods when no dressing was in place.
A resident with a coccyx pressure wound and cognitive impairment had repeated reports of severe pain, especially during wound and incontinence care, but the facility did not complete routine pain assessments and the care plan did not include a pain management focus area. The resident stated the medication did not help and that she felt helpless and miserable, while staff observed crying out, moaning, and flinching during care. Although PRN analgesics were ordered and given, the resident continued to have documented pain scores up to 8, and the DON stated the facility did not do routine pain assessments on everyone.
A resident with severe cognitive impairment, incontinence, and a stage 2 pressure ulcer had an active order for EBP related to a wound, but the care plan did not reflect EBP until later and the room lacked isolation signage and a PPE station. Staff were observed providing care without PPE, and during perineal care a CNA reused gloves while cleaning stool-soiled areas and changed gloves without hand hygiene. Interviews showed staff confusion about whether the resident was on EBP, and the DON stated the resident should have been on EBP for the wound.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
A resident with extensive traumatic injuries and chronic pain was admitted on scheduled and PRN Percocet and PRN ibuprofen, but only ibuprofen was administered, and it was documented as ineffective. The hospital did not send written narcotic prescriptions, and the DON focused on obtaining those scripts and gave ibuprofen while the resident continued to complain of pain and inability to sleep. Although the pharmacy and facility policy allowed access to Percocet from the electronic stat kit with a provider order and access code, no timely provider order was obtained to use the emergency kit, and no Percocet was given before the resident called 911 and went to the ED for pain management and opioid withdrawal symptoms.
A resident with multiple comorbidities and moderately impaired cognition sustained a right forearm skin tear when his arm became caught between bathroom rails. An RN cleansed the wound with normal saline, applied steri-strips, and notified the NP, who agreed the treatment was appropriate, but no provider order for the dressing or for daily monitoring until healed was entered into the EHR. Review of physician orders and the TAR showed no treatment or monitoring orders and no documentation of ongoing wound care, despite facility policy and the DON’s expectations that new wounds prompt provider orders and documented monitoring.
The facility did not have a licensed administrator in compliance with state law, as the acting administrator's temporary license had expired and there was no documentation of a valid extension or recent exam attempt. The AIT present did not hold a temporary license, and no other active administrator license was identified, affecting all 19 residents.
A resident experienced a fall in the bathroom, resulting in a head scratch. The DON documented that the day shift nurse would notify the POA due to the non-emergent nature of the situation, but the notification was not made. The DON communicated the incident to an RN during the shift report, indicating that she would complete the paperwork and notify the POA. However, the notification was not done, and the facility's policy requiring prompt notification was not followed.
A resident's Hydrocodone medication was mishandled due to inadequate procedures and documentation at the facility. Despite having a prescription, the medication was unaccounted for, and staff were unclear about its administration. The investigation suggested the medication was accidentally discarded, revealing lapses in controlled substance management.
A resident's Hydrocodone was found missing during a narcotic count, but the facility delayed reporting the potential misappropriation. The DON, who was off due to COVID-19, forgot about the issue upon returning to work, leading to a late report to authorities. The facility's policy requires immediate reporting of such incidents, which was not followed in this case.
A facility failed to promptly investigate missing controlled substances for a resident with chronic pain. Despite a nurse discovering a potential diversion during a narcotic count, the investigation was delayed due to the Director of Nursing being out with COVID. The facility's policy mandates immediate investigation of such incidents, which was not followed.
The facility failed to properly account for and document the administration of controlled substances for two residents. One resident, with multiple health issues, had discrepancies in the documentation and administration of Hydrocodone, with staff unaware of the medication's status. Another resident, with a fracture, had missing records for Hydrocodone delivery. The facility's policies on controlled substance management were not followed, leading to a significant deficiency in pharmaceutical services.
A resident received extra doses of Clonazepam due to a transition from paper to electronic medication records, leading to altered administration times. The nurse responsible administered the medication based on memory, not the updated eMAR, resulting in multiple additional doses. Despite the error, the resident showed no adverse effects.
The facility failed to store chemical products properly and did not implement person-centered fall interventions after a fall incident for two dementia care residents. One resident ingested an odor eliminator, resulting in nausea and vomiting, while another resident's care plan was not updated following a fall.
The facility failed to maintain a clean and sanitary ice machine, with black substance and hard water buildup observed. The Dietary Manager and Maintenance staff could not confirm the last cleaning date, and the cleaning procedures were not adequately followed.
The facility failed to maintain a safe, clean, and comfortable environment for its residents, with multiple areas of disrepair and uncleanliness observed. Residents and a family member confirmed their expectations for better maintenance, and the maintenance staff acknowledged the need for repairs but cited a lack of materials, funding, and time as reasons for delays.
A facility failed to develop a person-centered comprehensive care plan for a resident with multiple diagnoses, including being underweight. The care plan lacked specific details about the resident's nutritional needs and gastrointestinal tube feedings, which were critical for the resident's care. The MDS/Care Plan Nurse admitted to rushing and not completing the care plan properly.
The facility failed to timely update the care plan for a resident with multiple diagnoses, including Diabetes and Dementia, who had wounds on the left toes and heel. Despite physician's orders for specific treatments, the care plan had not been revised to reflect these wounds and their treatments.
The facility failed to follow its policy for enhanced barrier precautions for three residents requiring infection control measures. One resident with MRSA was not properly isolated, and housekeeping staff did not wear appropriate PPE. Additionally, two residents with wounds were not placed on enhanced barrier precautions as required by the facility's policy.
The facility failed to ensure that quarterly assessments were completed timely for six residents, with delays in completing and transmitting the Minimum Data Set (MDS) assessments. The residents had various medical conditions, including hypertension, Alzheimer's, diabetes, and more, but their assessments were not updated by the required due dates.
Delayed Pressure Ulcer Treatment and Missed Precautions
Penalty
Summary
The facility failed to timely treat and develop or implement interventions for a pressure ulcer for one resident with severe cognitive impairment, frequent bowel and bladder incontinence, and dependence for personal and toileting hygiene. The resident was admitted with a stage 2 pressure ulcer present on admission and had diagnoses including heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, thyroid cancer history, and lymphedema. The record showed a Braden score of 14 on admission, but the clinical suggestion section was left blank. The care plan did not include skin integrity, pressure wound, or Enhanced Barrier Precautions interventions until later in the stay. The wound documentation showed inconsistent measurements and progression from a stage 2 pressure ulcer on the coccyx and buttocks to worsening depth and later tunneling. Early treatment orders were documented for cleansing and Medihoney dressings, but there were no orders in the record for packing the tunneling when tunneling was later identified. The wound was documented as deteriorating on multiple assessments, with increasing depth, odor, slough, eschar, drainage, and surrounding tissue changes. Staff and leadership stated the resident’s wound had odor, that the resident needed a wound specialist, and that the wound was infected, but the wound culture obtained on 04/30/26 was not processed after the courier delay and had to be repeated. The culture later grew Escherichia coli, ESBL, and Enterococcus faecalis. Survey observations also found the resident was not placed on Enhanced Barrier Precautions when indicated, with no signage or PPE station outside the room and staff entering without PPE. The resident was observed with stool and urine contamination to the peri-area and coccyx, and at times there was no dressing on the wound. Staff reported the dressing was often off during care and overnight, and the wound was found wet with a large amount of serosanguinous drainage and tunneling when measured by the RN. The DON, NP, CNA, and other staff acknowledged gaps in wound follow-up, inconsistent measurements, delayed culture follow-up, and that the resident should have been on Enhanced Barrier Precautions related to the wound.
Inadequate pain assessment and pain relief for resident with pressure wound
Penalty
Summary
The facility failed to provide adequate pain assessment and pain relief medication for a resident with a coccyx pressure wound. The resident was admitted with diagnoses including heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, a personal history of malignant neoplasm of the thyroid, and lymphedema. The care plan addressed skin integrity related to the coccyx wound, with interventions to administer treatments as ordered, document wound size, and monitor the dressing, but it did not include a pain management focus area. The resident’s MDS coded a BIMS score of 07, indicating cognitive impairment, and documented a stage 2 pressure ulcer. The MDS pain interview section was coded as indicating no pain in the last 5 days. The resident’s orders included multiple PRN pain medications, including acetaminophen, hydrocodone-acetaminophen, and ibuprofen, with changes made over time as pain complaints increased. The MAR documented repeated pain scores ranging from 3 to 8 with administration of pain medication, but there were no regularly scheduled or daily pain assessments found in the EMR. On multiple occasions, the resident reported severe pain to staff, stating that the wound hurt really bad, that the medication did not help, that she felt helpless, and that she was miserable and wanted to sleep because the pain was so bad. A roommate stated the resident would cry out in pain during wound care, and a CNA reported the resident had been complaining of wound pain for weeks and cried out during care. Staff observations and interviews showed the resident crying out, moaning, tearing up, and moving in pain during incontinence and wound care. The RN stated the resident often cried out and that pain increased as the wound changed and tunneling was noted. The RN also stated he requested stronger pain medication because of the increased pain. The DON stated the facility did not do routine pain assessments on everyone and that if a resident was hurting during treatment, staff should provide medication before treatment or notify the physician for a change in the regimen. The NP stated she believed the resident’s pain was controlled based on nurse documentation and observed rest after medication, while the resident continued to report significant pain and staff observed distress during care.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to ensure infection prevention practices, including Enhanced Barrier Precautions (EBP), were implemented for a resident with severe cognitive impairment, occasional bowel and bladder incontinence, and a stage 2 pressure ulcer. The resident’s record showed an active order dated 4/13/26 for EBP related to wounds with dressing, bathing, transfers, changing linens, providing hygiene, toileting or pericare, device care, or wound care every shift. However, the care plan did not include any EBP focus areas or interventions until 5/13/26, when a focus area was added for actual impairment to skin integrity related to a buttock and coccyx pressure wound and another focus area was added for EBP related to the pressure wound. During observation on 5/13/26, the resident’s room did not have signage indicating isolation and did not have a PPE station outside the room. A CNA was observed providing a bed bath without PPE. The next day, a LPN stated the resident had been moved to a room because she had to be put on isolation precautions for an infection in her wound, but was not sure whether the resident was on EBP. Later that morning, a CNA entered the resident’s room without PPE, uncovered the resident, and looked at the adult incontinence brief. The CNA stated she was supposed to wear a gown in the room but did not, and said she knew the resident was on isolation. At another observation, a CNA donned PPE and provided perineal care, but used the same gloves while handling multiple wipes and cleaning different areas of the resident’s peri area and coccyx, including stool-soiled areas. The CNA then discarded gloves and applied new ones without performing hand hygiene. Staff interviews reflected confusion about the resident’s precautions: one CNA stated the resident was not on isolation the prior day, another CNA said the resident was on precautions because of the wound culture, the Administrator was unsure whether the resident was on EBP, and the RN stated the resident was not on EBP the previous day and should have been on EBP for the wound. The DON stated the resident should have been on EBP related to the wound and that signs should have been on the door, while also stating the facility did not have a policy on perineal care and used a checklist as a procedure guide.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Follow Stat Kit Policy for Emergency Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for obtaining emergency controlled medications from the electronic first-dose (stat) kit, resulting in a newly admitted resident not receiving ordered narcotic pain medication. The resident was admitted with multiple traumatic injuries, including fractures of the thoracic vertebrae, ribs, pelvis, sacrum, and left humerus, as well as traumatic pneumothorax, bilateral lung contusions, liver and spleen lacerations, and hemoperitoneum. Hospital discharge documentation listed outpatient and after-visit medications that included scheduled Percocet 5-325 mg three times daily and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s admission orders reflected ibuprofen 800 mg every 8 hours PRN and Percocet 5-325 mg every 8 hours PRN for pain, but there was no documentation of Percocet being administered after admission. On the evening and night following admission, the DON documented that the resident complained of pain and was given ibuprofen 800 mg around 11:06 p.m., which was recorded as ineffective in controlling the resident’s pain. The DON also documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication and that the pharmacy reported it had not received those prescriptions. The DON contacted the hospital regarding the missing prescriptions and was awaiting a call back. The DON noted that the resident was informed that the narcotic prescriptions had not been received and that only ibuprofen could be given at that time. The resident remained awake, complained of pain and inability to sleep, and later called 911 requesting transport to the hospital. The facility’s pharmacist later confirmed that the facility contacted the after-hours pharmacy service and was informed that, with a written prescription, Percocet could be sent STAT from a local pharmacy and that the correct dose of Percocet was available in the emergency kit, which also required an order to access. The facility’s Stat Safe Policy and Procedure stated that if a controlled substance is needed, facility staff should contact the pharmacy/after-hours service to retrieve an access code to remove doses from the electronic first-dose kit. The DON stated she was not aware that obtaining a verbal order from a provider to access the emergency kit was an option and acknowledged she did not contact a provider when she first realized the resident had arrived without narcotic prescriptions, citing that there was a lot going on that night. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access the emergency kit or ordered transfer to the ER. During the subsequent ER visit, the resident reported that no pain medication had been administered between arrival at the facility and arrival at the ER, and the ER documentation noted the resident presented for pain management and opioid withdrawal symptoms and was given Percocet 5-325 mg. The sequence of events shows that despite having a policy and an emergency kit process in place for controlled substances, the facility did not obtain the necessary order or access code to retrieve Percocet from the emergency kit for this resident. The DON relied solely on ibuprofen, which was documented as ineffective, and on attempts to obtain written prescriptions from the hospital, without promptly escalating to a provider for a verbal order to access the emergency kit as allowed by policy and pharmacy procedure. The pharmacist later clarified that an emergency verbal order from a provider would have allowed the facility to obtain a code to access the emergency kit for the resident’s pain medication. This failure to follow the Stat Safe Policy and Procedure and to secure timely access to ordered controlled pain medication for the resident with significant traumatic injuries formed the basis of the cited deficiency in pharmaceutical services.
Failure to Obtain and Document Provider Orders for Skin Tear Treatment and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a provider’s order for treatment and ongoing monitoring of a skin tear. A male resident with diagnoses including end stage renal disease, type II diabetes, and epilepsy, and a BIMS score of 11 indicating moderately impaired cognition, was admitted with a care plan identifying risk for impaired skin integrity. A skin issue risk assessment documented that the resident sustained a skin tear to the right forearm when his arm became caught between two bathroom rails near the toilet. The RN cleansed the wound with normal saline and applied three steri-strips, and documented that the NP was notified, but there was no documentation of any provider order for the treatment or for monitoring the wound until healed. Review of the resident’s discontinued and current physician orders and the TAR for the relevant month showed no orders for treatment or daily monitoring of the right forearm skin tear and no documentation that treatments or monitoring were performed. On interview, the resident did not recall how the injury occurred, and the wound appeared to be healing without signs of infection. The RN stated she notified the POA, NP, and administration, and that the NP indicated the treatment she provided was appropriate, but she did not document any order or obtain an order for ongoing monitoring, believing it was a one-time, common-sense dressing. The NP confirmed she had been contacted and agreed the initial treatment was appropriate, but stated the treatment and daily monitoring should have been entered as provider orders in the electronic health record. The DON stated her expectation that such orders be documented and placed on the TAR for daily reminders, and the facility’s skin policy required notifying the healthcare provider for further treatment orders when a new wound is identified.
Failure to Maintain Licensed Administrator in Accordance with State Law
Penalty
Summary
The facility failed to ensure that a licensed administrator, in accordance with state law, was present and operating the facility. Review of records and interviews revealed that the individual serving as administrator held only a temporary license, which had expired. The administrator was unavailable for interview due to hospitalization, and there was no documentation provided to confirm recent attempts to take the licensing exam or to show that an extension for the temporary license had been filed or approved. The Administrator in Training (AIT) had only been at the facility for a few weeks and did not possess a temporary administrator license. The Regional Director of Operations confirmed that the administrator had applied for a licensure extension, but no documentation was available to verify this or to show that the extension was granted. At the time of the survey, there was no evidence of any other active administrator license connected to the facility. The facility's resident matrix indicated that 19 residents were residing in the facility during this period.
Failure to Notify Resident's Representative of Fall Incident
Penalty
Summary
The facility failed to promptly notify the resident's representative of a fall incident involving a resident. The resident, who was admitted with multiple diagnoses including osteomyelitis, dementia, and heart failure, experienced a fall in the bathroom, resulting in a head scratch that bled. The incident occurred early in the morning, and the Director of Nursing (V2) documented that the day shift nurse would notify the Power of Attorney (POA) due to the non-emergent nature of the situation. However, the notification was not made, and the responsible party was not informed of the fall. The Director of Nursing (V2) communicated the incident to the Registered Nurse (V3) during the shift report, indicating that V2 would complete the necessary paperwork and notify the POA. V2 later texted V3, apologizing for not making the notification. V3 assumed V2 would handle the notification, but it was not done. V2 later informed the facility administrator (V1) about the oversight, and V2 claimed to have informed the family during a visit, although this was not documented. The facility's policy requires the charge nurse to notify the attending physician and responsible parties promptly, which was not adhered to in this case.
Failure to Safeguard Controlled Substances
Penalty
Summary
The facility failed to protect and safeguard controlled substances for a resident, identified as R1, who was cognitively intact and had a prescription for Hydrocodone to manage chronic pain. The Controlled Drug Administration Record indicated that 24 Hydrocodone tablets were received, but discrepancies arose when the facility could not produce records for subsequent deliveries. Additionally, the Medication Administration Record showed no doses were given on certain dates, despite the presence of the medication. During a narcotic count, it was discovered that R1's Hydrocodone was missing, and no documentation of its destruction or discontinuation was found. Staff interviews revealed confusion and lack of clarity regarding the presence and administration of the medication. Several nurses stated they had not administered the medication to R1, who reportedly did not complain of pain. The Director of Nursing, who was absent due to illness, later found the narcotic sheet misplaced, indicating a lack of proper documentation and oversight. The investigation revealed that the facility's procedures for handling controlled substances were inadequate, leading to the misplacement and potential misappropriation of R1's medication. The facility's incident report concluded that the medication was likely accidentally discarded due to disorganization and lack of attention, highlighting significant lapses in the management and documentation of controlled substances.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property within the required time frames for one resident. The resident, who had a history of osteomyelitis, orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension, had an order for Hydrocodone for chronic pain. A registered nurse discovered that the slot for the resident's Hydrocodone was empty during a narcotic count, despite the medication not being discontinued or destroyed. The nurse notified the administrator and the Director of Nursing (DON) about the potential diversion. The DON was off work due to COVID-19 and did not immediately act on the information about the missing narcotic sheet, which was found folded under supplies in the medication cart. Upon returning to work, the DON forgot about the potential diversion due to other pressing issues. The administrator and DON began investigating the issue only after both returned to work, which led to a delay in reporting the incident to the appropriate authorities. The facility's policy requires immediate reporting of any suspected misappropriation of resident property to the administrator and other officials within 24 hours. However, the report to the Illinois Department of Public Health, police, physician, and Power of Attorney was not made until several days after the initial discovery of the missing medication. This delay in reporting constitutes a failure to adhere to the facility's abuse prevention program and state regulations.
Delayed Investigation of Missing Controlled Substances
Penalty
Summary
The facility failed to timely initiate an investigation into an allegation of missing controlled substances for a resident. The resident, who was cognitively intact, had an order for Hydrocodone for chronic pain. The Controlled Drug Administration Record indicated that 24 Hydrocodone tablets were received, but discrepancies were noted in the Medication Administration Record, which showed no doses given on specific dates despite records indicating otherwise. A Registered Nurse discovered the potential diversion during a narcotic count and reported it to the Administrator, but the investigation was delayed. The Director of Nursing was notified of a narcotic sheet found in the medication cart but did not begin investigating until several days later due to being out with COVID. The Administrator was informed of the potential drug diversion and, along with the Director of Nursing, began investigating the issue days after the initial report. The facility's policy requires immediate investigation upon learning of potential misappropriation of resident property, which was not adhered to in this case.
Deficiency in Controlled Substance Management
Penalty
Summary
The facility failed to properly account for, maintain records of, and document the administration of controlled substances for two residents, R1 and R3. R1 was admitted with multiple diagnoses including osteomyelitis, dementia, and chronic pain, and had an order for Hydrocodone as needed. However, there were discrepancies in the documentation and administration of this medication. The Controlled Drug Administration Record showed that 24 Hydrocodone tablets were received, but there was no documentation of administration on certain dates, and the narcotic count was inconsistent. Staff interviews revealed confusion and lack of clarity regarding the presence and administration of the medication, with some staff unaware of the medication's status or location. R3, who was admitted with a fracture and other health issues, also had an order for Hydrocodone. Although R3 reported a decrease in the need for pain medication, the facility failed to maintain accurate records of the controlled substances. A delivery slip indicated that 30 Hydrocodone tablets were delivered, but the corresponding controlled drug count sheet was missing. The facility's policies require a physical inventory of controlled substances at each shift change and proper documentation, which was not adhered to in this case. The Director of Nursing acknowledged the expectation for staff to accurately count and document narcotics, but the facility was unable to produce the necessary records for both residents. The lack of proper documentation and accountability for controlled substances indicates a significant deficiency in the facility's pharmaceutical services, as they failed to ensure the safe and accurate administration of medications to meet the needs of the residents.
Medication Administration Error Due to eMAR Transition
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically involving a resident with a history of dementia, hypertension, and anxiety disorders. The resident was prescribed Clonazepam to be administered twice daily, but due to a transition from paper to electronic medication administration records (eMAR), the administration times were altered. This led to the resident receiving additional doses of Clonazepam on multiple occasions, as the nurse administering the medication did not adhere to the updated eMAR schedule. The error was discovered when a registered nurse noticed discrepancies in the medication administration and reported it to the Director of Nursing and the Administrator. The nurse responsible for the error admitted to administering the medication based on memory rather than consulting the eMAR, resulting in the resident receiving extra doses. Despite the error, the resident did not exhibit any adverse effects from the additional medication. The Director of Nursing initiated an investigation into the medication error and attempted to notify the resident's power of attorney and the nurse practitioner. The investigation confirmed that the error was due to the nurse's failure to follow the updated eMAR, which had changed the administration times for Clonazepam. The facility's medication administration policy requires medications to be administered safely and documented as required, which was not adhered to in this case.
Failure to Store Chemicals Properly and Update Care Plans
Penalty
Summary
The facility failed to ensure chemical products were stored according to current standards of practice and did not implement person-centered fall interventions after a fall incident for two dementia care residents. One resident, a female with early-onset Alzheimer's Dementia, ingested an odor eliminator that was improperly stored in her room. This resulted in the resident experiencing nausea and vomiting. The Director of Nursing confirmed that the product should not have been accessible to the resident and that all resident rooms were subsequently checked for hazardous liquids. The product is no longer used by the facility. Another resident, an elderly individual with multiple diagnoses including dementia, experienced a fall in the bathroom. The care plan for this resident did not include updated, person-centered fall interventions following the incident. The Minimum Data Set/Care Plan Nurse admitted to rushing and forgetting to update the care plan. The facility's policy requires comprehensive assessment and periodic reassessment to develop a person-centered comprehensive plan of care, which was not followed in this case. Both incidents highlight the facility's failure to adhere to safety protocols and ensure proper documentation and implementation of care plans. The lack of proper storage of hazardous materials and the failure to update care plans after significant events contributed to the deficiencies observed by the surveyors.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary ice machine, which has the potential to affect all 20 residents residing in the facility. During an initial tour of the kitchen, surveyors observed a black substance on the inside flap of the ice machine and a white hard water buildup along the hinges and edges of the lid. The Dietary Manager stated that the maintenance man cleans the ice machine once a month but could not confirm the last cleaning date due to the absence of a 2024 monthly cleaning log. The Maintenance staff confirmed that he had cleaned the machine in April but acknowledged difficulties in thoroughly cleaning certain parts of the machine and mentioned the need for pressure washing. The facility's Ice Machine Cleaning and Sanitizing Procedures policy requires thorough cleaning and sanitizing of all interior surfaces, which was not adequately followed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. Observations revealed multiple areas of disrepair and uncleanliness, including peeling carpet, chipped paint, and discolored floor tiles in various parts of the facility such as hallways, communal bathrooms, the nurses' station, and the dining room. Specific issues included missing baseboards exposing a black/brown substance, bowing wall tiles, and missing blind slats in a resident's room. Interviews with residents and a family member confirmed their expectations for a well-maintained facility, and the maintenance staff acknowledged the need for repairs but cited a lack of materials, funding, and time as reasons for the delays in addressing these issues. The Director of Nursing confirmed that multiple residents could potentially use the communal bathroom that was found to be in disrepair, except for one resident who only receives bed baths. The facility's policy emphasizes the importance of maintaining a safe, clean, and organized environment to provide the best care and comfort for residents. Despite this policy, the facility's physical environment was found to be lacking, affecting the quality of life and care for the residents. The facility's application for Medicare and Medicaid documented that 20 residents reside in the facility.
Failure to Develop Person-Centered Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident (R18) who was admitted with multiple diagnoses including Odynophagia, Diabetes Mellitus Type II, Chronic Pancreatitis, Superior Mesenteric Artery Syndrome, Distal Esophageal ulceration with possible Barrett's, and microcytic anemia. The resident's care plan did not specify the reason for the nutritional problem focus area, which was due to the resident being underweight. Additionally, the care plan lacked information regarding the resident's gastrointestinal tube and the feedings ordered as needed according to meal intake. The care plan also did not document the most recent information indicating that the resident was no longer using enteral feedings as of 04/11/24. This oversight was acknowledged by the MDS/Care Plan Nurse, who admitted to rushing and forgetting to complete the care plan properly. The resident's nutritional status was critical, with a BMI of 16.7 indicating underweight, and the Registered Dietitian had recommended additional nutritional interventions. However, these recommendations were not reflected in the care plan. The facility's Comprehensive Care Planning policy mandates a thorough assessment and periodic reassessment to develop a person-centered care plan, but this was not adhered to in the case of R18. The care plan was incomplete and did not address the resident's specific needs, leading to a deficiency in providing appropriate care.
Failure to Update Care Plan for Resident with Wounds
Penalty
Summary
The facility failed to add identified problem areas and to revise care plans timely for one resident reviewed for care plan timing and revision. The resident, who was admitted with multiple diagnoses including Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia, was observed to have a betadine treatment applied to the left toes and a pressure wound to the left heel. Despite these observations and the physician's orders for specific treatments, the resident's care plan had not been updated to reflect these wounds and their treatments. The care plan, which was initiated on 06/02/2022, had not been revised to include the wounds to the left great toe and left heel, nor did it document the current treatment orders or any person-centered interventions for pressure ulcer care. The MDS/Care Plan Nurse admitted to rushing and forgetting to complete the care plans. The facility's Comprehensive Care Planning policy mandates that care plans be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychosocial needs, but this was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its policy and procedure for enhanced barrier precautions for three residents (R2, R12, and R18) who required infection control measures. During an initial tour, no isolation rooms were observed, and the Resident Matrix did not indicate any residents on transmission-based precautions. R18, who had MRSA in his gastrointestinal tube site, was not properly isolated, and housekeeping staff did not wear appropriate PPE while in his room. The Director of Nursing acknowledged that enhanced barrier precautions had not been implemented and that R18 should have been on precautions earlier. Additionally, R2, who had a venous wound, and R12, who had wounds on her left foot and toe, were not placed on enhanced barrier precautions as required by the facility's policy. The Enhanced Barrier Precautions policy, dated 7/13/23, mandates the use of gown and gloves during high-contact resident care activities for residents with open wounds, indwelling medical devices, or MDRO infections. Despite this, the facility did not implement these precautions for R2, R12, and R18. The Director of Nursing admitted that the facility had only discussed enhanced barrier precautions but had not yet put them into practice. This lack of adherence to infection control protocols led to the observed deficiencies in the care of these residents.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly assessments were completed timely for six residents. Specifically, the quarterly Minimum Data Set (MDS) assessments for residents R5, R10, R12, R13, R14, and R15 were not completed and transmitted by their respective target due dates. For instance, R5's quarterly MDS, which had a target due date of 2/18/24, was not completed and transmitted until 4/24/24. Similarly, R15's quarterly MDS, due on 3/20/24, was not completed and transmitted until 4/28/24. These delays were confirmed by V6, the Care Plan Coordinator/MDS, and documented in MDS validation reports provided on 5/2/24. The report details the specific medical conditions of each resident, such as hypertension, Alzheimer's, diabetes, renal insufficiency, hyperlipidemia, coronary artery disease, peripheral vascular disease, osteopathic conditions, alcohol abuse, seizures, adjustment disorder, and mild cognitive impairment. Despite these conditions, the facility did not adhere to the required timelines for updating the residents' assessments, leading to a deficiency in maintaining timely and accurate records. This lapse in timely assessment could potentially impact the quality of care provided to these residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cisne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairfield Senior Living & Rehabilitation Llc | 10.2 mi | ★★★★★ | 15 | 0 |
| Fairfield Memorial Hospital | 10.3 mi | ★★★★★ | 0 | 0 |
| Axiom Gardens Of Flora | 11.1 mi | ★★★★★ | 19 | 0 |
| Axiom Healthcare Of Flora | 11.4 mi | ★★★★★ | 0 | 0 |
| Richland Nursing & Rehab | 24.8 mi | ★★★★★ | 9 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.