Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Loft Rehab Of Peoria, The during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions reported to the ADON that two CNAs had used foul language and called her a derogatory term. The DON directed that corporate leadership be notified, and corporate staff interviewed the resident and decided it did not qualify as an abuse allegation, though they reassigned the CNAs to another hallway. The CNAs were not suspended, no other staff or residents were interviewed, and no official investigation or documentation was completed, resulting in a failure to conduct a thorough abuse investigation and to fully remove the alleged perpetrators from resident care as required by facility policy.
A resident reported to the ADON that two CNAs used foul language and called her a derogatory name. The ADON relayed the allegation to the DON and then to corporate leadership, who interviewed the resident and concluded it did not qualify as abuse. The facility’s own policy required reporting all alleged violations, including abuse, to the state agency within specified timeframes, but no report of this verbal abuse allegation was submitted, despite the resident later reiterating that staff had called her the derogatory name.
A resident with a history of hypersexual behavior and cognitive impairment was admitted without adequate screening, leading to an incident where he exposed himself and placed his genitals on the lips of another nonverbal, cognitively impaired resident. Staff intervened upon witnessing the event, and subsequent review confirmed that gaps in the admission process contributed to the failure to prevent this abuse.
A resident with a right-hand contracture and impaired mobility did not receive physician-ordered hand protector use or documented range of motion (ROM) services. Staff were unaware of the resident's need for the hand protector, and no assessments or restorative programs were in place, despite facility policy requiring such interventions for contracture prevention.
A resident with multiple chronic conditions and severe cognitive impairment experienced a significant decline in gait, balance, and mental status over two days. Despite clear documentation of these changes, the RN did not promptly notify the physician, instead relaying the information in a shift report. The physician was only informed after the resident was hospitalized and diagnosed with a UTI and altered mental status. Both the LPN and administrator confirmed that timely physician notification was required.
A resident with a known sulfa drug allergy was repeatedly administered Sulfamethoxazole-Trimethoprim (Bactrim), despite clear documentation of the allergy in the care plan and MAR. The pharmacy flagged the allergy and notified nursing staff, but the medication was still given, resulting in the resident developing a rash, sore throat, and difficulty swallowing. Interviews revealed that staff did not appropriately respond to allergy warnings, and the medication was only discontinued after adverse reactions occurred.
A resident reported being hit by a CNA to an Activities Aide, who then informed the Administrator. Despite initiating an investigation, the Administrator did not report the alleged abuse to the State Agency, violating the facility's policy requiring immediate reporting of such incidents.
A resident with multiple medical conditions did not receive prescribed Oxycodone due to a narcotic diversion incident. The facility's investigation revealed that a full card of Oxycodone was missing, and video surveillance showed suspicious behavior by an LPN. Narcotic medications were not consistently counted, and the facility was unable to identify who ordered the medication. The LPN was terminated, and the incident was reported to the police.
The facility failed to provide grievance forms and post grievance procedures in prominent locations, affecting all 89 residents. During a resident council meeting, several residents stated they did not know how to file a grievance. A tour with the Administrator confirmed the absence of posted grievance procedures and readily available forms, indicating non-compliance with the facility's grievance policy.
The facility did not have a Registered Nurse (RN) on duty for at least eight hours on four days, affecting the care of 89 residents. The Administrator and Director of Nursing confirmed the deficiency, acknowledging the requirement for daily RN coverage.
The facility failed to provide adequate personal hygiene care for several residents, including not shaving or showering them as needed. One resident reported not receiving regular showers or shaves due to staff time constraints. Another resident had not been shaved since admission, and documentation for care was lacking. Additional issues included a resident with long chin whiskers and another with untrimmed fingernails, both requiring assistance with personal hygiene.
A resident's call device was found on the floor and out of reach while the resident was in a wheelchair beside his bed. The resident attempted to retrieve the device with his cane but was unsuccessful. A CNA confirmed the device was out of reach and should have been accessible, violating the facility's policy on call light accessibility.
The facility failed to provide written notification of hospital transfers to a resident's representative and did not notify the Ombudsman of discharges/transfers for three residents. One resident's discharge to a new facility was not documented, and another resident's hospital transfer was not recorded in the Admission/Discharge Log. The Administrator in Training admitted the Discharge Report was completed incorrectly, omitting hospital transfers.
The facility failed to provide a copy of the bed hold policy to a resident or their representative when the resident was transferred to a hospital. During a review, it was found that the clinical record for a hospitalized resident did not contain documentation of written notice of the facility's bed hold policy. The administrator was unable to produce any documentation that the policy was provided.
A resident with severe cognitive impairment and a history of aspiration pneumonia was left unsupervised during meals, despite being on a mechanically altered diet requiring supervision. The CNA acknowledged the dietary change but did not provide the necessary supervision, leading to a deficiency in care. The DON confirmed the resident's risk for choking, underscoring the need for adherence to the care plan.
A facility failed to adhere to its Catheter Care policy by not covering a resident's urinary catheter bag and allowing the tubing to touch the floor. This was observed by a CNA and confirmed by the DON, both acknowledging the need for the catheter bag to be covered and elevated.
The facility failed to place oxygen warning signs outside the rooms of two residents receiving oxygen therapy and lacked a physician order for one resident's oxygen use. Additionally, another resident's nebulizer equipment was not changed weekly or stored properly, as required by facility policy.
The facility did not maintain proper documentation of communication with the dialysis center for a resident receiving dialysis. Despite the policy requiring daily communication, the resident's records lacked dialysis communication forms for an extended period, with only two forms available for early and mid-August. The administrator confirmed the deficiency in documentation.
The facility failed to adhere to infection control protocols for a COVID-19 positive resident and a resident with an indwelling urinary catheter. A CNA entered a COVID-19 isolation room without proper PPE and did not perform hand hygiene before interacting with other residents. Additionally, there was no Enhanced Barrier Precautions signage for a resident with a catheter, despite the requirement for such precautions. The DON confirmed the need for proper PPE and signage.
A cognitively impaired resident with a known history of wandering exited the facility without staff knowledge for 40 minutes, resulting in a fall and complaints of head and back pain. The facility failed to provide adequate supervision, did not develop or implement a care plan for the resident's elopement risk, and did not ensure the front door was alarmed or locked.
The facility failed to obtain scheduled medications for two residents, leading to significant health issues. One resident missed his seizure medication for at least two days, resulting in multiple falls, a seizure, and broken ribs. Another resident did not receive prescribed pain medication due to delays in obtaining a signed prescription and issues with the new pharmacy.
The facility failed to prevent verbal/mental abuse when an Activity Assistant made derogatory comments to a male resident with cognitive impairments and an intellectual disability. The resident became upset when he could not go on an outing, and the assistant told him to 'stop crying like a little girl' and 'don't be a baby,' leading to increased distress. The assistant was terminated for unprofessional conduct.
The facility failed to report an allegation of verbal abuse to the State Agency for a resident. Another resident reported that a CNA used inappropriate language towards the resident during the night. The incident was investigated, and the resident in question denied it occurred. No report was made to the State Survey Agency, leading to a deficiency being noted during the survey.
Failure to Thoroughly Investigate Verbal Abuse Allegation and Remove Alleged Perpetrators from Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse, Neglect, Exploitation Policy by not conducting a thorough investigation and not adequately removing alleged perpetrators from resident care after an allegation of verbal abuse. The policy requires immediate investigation of suspected abuse, including identifying and interviewing all involved persons, documenting the investigation, and protecting residents from harm, including room or staffing changes as needed. A moderately cognitively impaired female resident with COPD, anxiety disorder, bipolar disorder, osteoporosis, and generalized muscle weakness reported to the ADON that two CNAs had used foul language toward her and called her a derogatory term. The ADON reported the allegation to the DON, who directed her to notify corporate leadership covering for the Administrator. Corporate staff then interviewed the resident, during which they concluded the situation did not qualify as an abuse allegation after the resident’s account was perceived as changing. They reassigned the two CNAs to a different hallway but did not suspend them, did not document the incident, and did not conduct or document a complete investigation, including interviews of other staff or residents. The resident later reiterated that she had told corporate staff that two CNAs had called her the derogatory term, while both CNAs confirmed they were informed of the allegation and simply reassigned to another hall without being sent home. These actions and omissions demonstrate the facility’s failure to complete a thorough abuse investigation and to fully remove the alleged perpetrators from resident care while the investigation was underway, contrary to its written policy requirements.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse by staff to the State Agency as required by its Abuse, Neglect, Exploitation Policy. The policy, dated 1/23/26, states that the facility will report all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours after an allegation involving abuse. On 2/11/26, a resident (R2) reported to the ADON (V3) in the dining room that two CNAs (V6 and V7) had used foul language toward her and called her a c**t. V3 stated she immediately reported the allegation to the DON (V2), who instructed her to report it to corporate staff (V4 and V12), which she did. At the time of the survey on 3/20/26, a review of the facility’s reports to the State Agency showed no documentation that this verbal abuse allegation had been reported. Corporate staff (V4, President of Operations, and V12, Regional Director) confirmed they were covering for the Administrator during the week of the allegation. V12 stated that V2 informed her that R2 claimed two CNAs had called her a c**t and were being mean to her. V4 and V12 then interviewed R2 in an office; V12 reported that R2 changed her story and said no one called her names, but that she did not like the care she was receiving. Based on this, V12 did not believe it qualified as an abuse allegation, and no report was sent to the State Agency. In contrast, during the survey interview on 3/20/26, R2 stated she had told V3 that two CNAs had called her a c**t a few nights prior and that, when questioned later by two older women identified as V4 and V12, she again reported that the CNAs had called her a c**t, though she did not repeat their names because she had already given them to V3. Despite these allegations and the facility’s written policy, the incident was not reported to the State Agency.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Admission Screening
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. One resident, who had a history of hypersexual behavior following a stroke and was not cognitively intact (BIMS score of zero), was admitted to the facility from a hospital where his sexually inappropriate behaviors were documented. Hospital records indicated that the resident had been started on carbamazepine to address hypersexuality, and required interventions such as all-male nursing staff and a video sitter due to persistent inappropriate behaviors. Despite this, the facility's admission screening process did not fully identify or address these risks prior to admission. The facility's administrator later confirmed that, had they been aware of the extent of the behaviors, they would have taken additional precautions or reconsidered the admission. The incident occurred when a staff member observed the resident with his penis exposed, placing it on the lips of another resident who was nonverbal, unable to communicate, and cognitively impaired. The staff member immediately intervened and separated the residents. The victim was particularly vulnerable due to advanced dementia and inability to defend herself. Interviews with facility staff and review of records confirmed that gaps in the admission screening process contributed to the failure to protect the resident from abuse.
Failure to Provide and Document Contracture Prevention and ROM Services
Penalty
Summary
The facility failed to assess, monitor, and implement physician-ordered interventions for a resident with a right-hand contracture. Specifically, the resident had a physician order for a right-hand protector to be applied twice daily to prevent contracture, but the order lacked clear parameters for duration and removal. Observations revealed that the hand protector was not in use, and the resident's right hand was contracted and curled into a fist. There was no documentation in the medical record of any active or passive range of motion (ROM) exercises being performed for the resident's right hand, and the care plan did not address ROM interventions for this condition. Interviews with facility staff indicated a lack of awareness and assessment regarding the use of the hand protector. The MDS nurse confirmed that no quarterly assessments or restorative programs were in place for residents with splints or contractures, and the Assistant Director of Nursing was unaware of the resident's need for a hand protector or who was responsible for its assessment. The facility's policies required maintenance and restorative programs for residents at risk of contractures, but these were not implemented for this resident, who had a history of cerebral infarction, right-hand contracture, and impaired mobility.
Failure to Promptly Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify a resident's physician of a significant change in condition, as required by both regulation and facility policy. The resident, who had diagnoses including metabolic encephalopathy, cerebral atherosclerosis, type 2 diabetes mellitus, chronic kidney disease, and Alzheimer's disease, was documented as being severely cognitively impaired. Progress notes indicated that the resident exhibited significant agitation, increased difficulty with gait and balance, and was highly resistant to care. Over the course of two days, the resident's condition declined further, with increased confusion, inability to stand, and repeated episodes of legs giving out during transfers, which was a notable decline from her baseline status. Despite these documented changes, the registered nurse did not notify the resident's physician at the time the changes were observed, instead passing the information along in a shift report. The physician was not informed until after the resident was sent to the hospital and admitted with a urinary tract infection and altered mental status. Both the LPN and the facility administrator confirmed that the physician should have been notified of the change in condition, in accordance with facility policy and regulatory requirements.
Significant Medication Error: Administration of Sulfa Antibiotic to Resident with Documented Sulfa Allergy
Penalty
Summary
A significant medication error occurred when a resident with a documented allergy to sulfa drugs, specifically Sulfasalazine, was administered Sulfamethoxazole-Trimethoprim (Bactrim), an antibiotic containing sulfa. The resident's care plan and Medication Administration Record (MAR) both clearly indicated the sulfa allergy, and the facility's policy required staff to check for allergies before administering medications. Despite these safeguards, the antibiotic was ordered and administered multiple times, even after the pharmacy flagged the allergy and communicated concerns to nursing staff. The resident, who had multiple diagnoses including MRSA UTI, kidney stones, and a history of antibiotic allergy, began receiving the sulfa-containing antibiotic as per physician and nurse practitioner orders. Nursing notes documented the resident's complaints of a sore throat, difficulty swallowing, and the development of a rash after administration of the medication. The allergy was noted in the records, and the pharmacy communicated the risk to the facility, but the medication continued to be given until it was eventually discontinued following further adverse reactions. Interviews with facility staff revealed a lack of appropriate response to the allergy warnings. The nurse practitioner admitted to carrying over the antibiotic order from a hospital consultation and did not consider the allergy significant, while the physician acknowledged that administering the medication was a mistake. The pharmacy confirmed that the allergy was flagged and communicated, but the medication was still dispensed and administered, indicating a breakdown in the facility's medication administration and allergy verification processes.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident to the State Agency, as required by their Abuse, Neglect, and Exploitation Policy. The policy mandates that any suspicion of abuse, neglect, or exploitation must be reported to the State Agency immediately, or within 2 hours if serious bodily injury is suspected, and within 24 hours if not. On January 6, 2025, a resident reported to an Activities Aide that they had been hit by a Certified Nursing Assistant. The Activities Aide informed the Administrator of the allegation. However, the Administrator confirmed that although an investigation was initiated, the alleged abuse was not reported to the State Agency. A review of the past six months of reports to the State Agency confirmed that the incident was not documented as required.
Narcotic Diversion Incident in LTC Facility
Penalty
Summary
The facility failed to prevent the diversion of narcotic medication, specifically Oxycodone, for a resident with multiple medical conditions including quadriplegia, chronic obstructive pyelonephritis, and a history of hip fracture and pressure ulcer. The resident had a physician's order for Oxycodone to manage severe pain, but reported not receiving the medication when needed in early August. The Medication Administration Record (MAR) indicated that the resident did not receive any Oxycodone until August 8, despite having a prescription for it. The investigation revealed that a full card of Oxycodone, delivered on July 30, was missing from the narcotic drawer. The Director of Nursing (DON) and the Administrator were informed, and an investigation was initiated. Video surveillance showed suspicious behavior by a former LPN, who was seen placing something under her jacket and shuffling through papers. The narcotic shift count forms indicated that narcotic medications were not consistently counted by two nurses at shift changes, and there were several days when the narcotics were not counted at all. The facility's investigation included interviews with staff and residents, and it was determined that the missing medication was not accounted for. The pharmacy confirmed the delivery of the medication, but the facility was unable to identify who ordered it due to unidentifiable signatures. The former LPN was suspended and later terminated for not following facility policy and reasonable suspicion of involvement in the missing narcotics. The facility reported the incident to the local police, but there was insufficient evidence for criminal charges.
Failure to Provide Grievance Forms and Procedures
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal by not providing readily available grievance forms and not posting grievance/complaint procedures in prominent locations throughout the facility. This deficiency was identified through observations, record reviews, and interviews, indicating a potential impact on all 89 residents residing in the facility. The facility's policy, dated 5/6/24, requires that notices of residents' rights regarding grievances be posted prominently and that information on how to file a grievance be available to residents, including contact information for the grievance official and expected time frames for grievance resolution. During a resident council meeting, several residents expressed that they were unaware of where or how to file a grievance. A subsequent tour with the Administrator confirmed the absence of posted grievance procedures and readily available grievance forms in the facility. This lack of compliance with the facility's grievance policy and procedure highlights a significant oversight in ensuring residents are informed and able to exercise their rights to file grievances.
Failure to Ensure RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours daily, which is a requirement for the care of the 89 residents residing within the facility. This deficiency was identified through a review of the facility's nurse schedule for the period of August 4 to August 31, 2024. It was documented that the facility did not have RN coverage for at least eight hours on four specific days: August 4, August 11, August 17, and August 18, 2024. The deficiency was confirmed through interviews with the facility's Administrator and the Director of Nursing (DON). The Administrator acknowledged the requirement for eight hours of RN coverage daily, based on the staffing calculator and the number of skilled residents. The DON, who is responsible for scheduling nurses, verified the accuracy of the nursing schedules and confirmed the absence of RN coverage on the specified dates.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for several residents, as observed during a survey. One resident, identified as R62, reported not receiving regular showers or shaves, stating he had not been shaved in over three weeks and had not received his preferred twice-weekly showers for the past month. The resident expressed that staff often cited time constraints or insufficient staffing as reasons for the lack of care. This was corroborated by a Licensed Practical Nurse who confirmed the resident's beard and mustache were unusually long, and the facility's records showed inconsistencies in the bathing schedule. Another resident, R137, had not been shaved since admission to the facility, despite expressing a desire to be shaved. The Director of Nursing confirmed that residents should be shaved on shower days and upon request, even if they are in isolation due to COVID-19. However, documentation for R137's showers was lacking, with only one Skin Monitoring/Shower Review Sheet available, indicating a failure to maintain proper records of care provided. Additional deficiencies were noted with residents R40 and R66. R40, who is moderately cognitively impaired, was observed with long chin whiskers and expressed a preference for assistance with personal grooming, which was not provided. Similarly, R66, who requires assistance with personal hygiene due to physical impairments, had long, jagged fingernails that had not been clipped. A Licensed Practical Nurse confirmed that the resident's nails should have been trimmed, highlighting a lapse in the facility's adherence to its own care policies.
Resident Call Device Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call device was within reach, as required by their policy on call light accessibility and timely response. During an observation, a resident was found sitting in a wheelchair beside his bed, with his call device on the floor near the head of the bed, out of his reach. The resident attempted to retrieve the call device using his cane but was unsuccessful. A Certified Nursing Assistant (CNA) entered the room and confirmed that the call device was indeed out of reach and acknowledged that it should have been accessible to the resident while he was in his room.
Failure to Notify Resident Representatives and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to the hospital to a resident's representative and failed to notify the facility Ombudsman of resident discharges/transfers for three residents. One resident was accepted to a new facility, but the discharge was not documented in the Admission/Discharge Log. Another resident, who experienced shortness of breath and chest pains, requested to return to the hospital, and although the transfer was documented in nursing notes, it was not recorded in the Admission/Discharge Log. Additionally, the facility did not provide written notification of transfer to the hospital for this resident's representative. The facility's Administrator in Training acknowledged that the Discharge Report was being completed incorrectly, and the Ombudsman was not notified of all resident discharges and their reasons. The facility's report submitted to the Ombudsman only included residents who went home and omitted those who were transferred to the hospital. This lack of documentation and notification represents a deficiency in the facility's compliance with regulatory requirements for resident transfers and discharges.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative when the resident was transferred to a hospital. This deficiency was identified during a review of the clinical records for three residents, specifically for one resident who was hospitalized. The clinical record for this resident did not contain documentation of written notice of the facility's bed hold policy. On a specified date, the facility's administrator was unable to produce any documentation that the bed hold policy was provided to the resident or their representative.
Failure to Supervise Resident on Modified Diet
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident on a mechanically altered diet, as required by their care plan and physician orders. The resident, who has severe cognitive impairment and a history of aspiration pneumonia, was observed eating alone in their room without supervision, despite being on a dysphagia puree texture and honey consistency diet. The Certified Nursing Assistant (CNA) responsible for the resident's care acknowledged the recent dietary change but left the resident unsupervised, contrary to the care plan's directive for meal supervision. The Director of Nursing confirmed that the resident is at risk for choking due to their modified diet and difficulty managing secretions, emphasizing the necessity of supervision during meals. The facility's policies and the resident's care plan clearly state the requirement for supervision to ensure safety during meals, yet this was not adhered to, leading to a deficiency in care. The facility's administrator also recognized the importance of supervising residents on modified diets, highlighting a lapse in following established protocols for meal supervision.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter. The facility's Catheter Care policy, revised on January 24, 2023, mandates that catheter drainage bags be covered with privacy bags and kept off the floor to maintain dignity and prevent contamination. However, observations on August 20, 2024, revealed that a resident's catheter bag was uncovered and the tubing was touching the floor. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the catheter bag should have been covered and elevated. The Director of Nursing (DON) also confirmed that the catheter bags should be covered and not in contact with the floor.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its oxygen policy by not placing oxygen warning signs outside the bedrooms of two residents who were receiving oxygen therapy. One resident, who had a physician order for oxygen at 2 liters per minute due to conditions such as Sleep Apnea and Chronic Obstructive Pulmonary Disease, was observed without the required signage on their door. Another resident was also found to be receiving oxygen without any signage, and there was no physician order documented for their oxygen use or care. The Director of Nursing confirmed that signage should be present and that a physician order is necessary for oxygen use. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment for another resident. The resident's nebulizer tubing and mask were found on the nightstand, undated and unbagged, despite the policy requiring weekly changes and proper storage when not in use. A Licensed Practical Nurse confirmed the oversight, noting that the equipment had not been changed since the previous week and was not stored correctly.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to provide adequate documentation of collaboration between the facility and the dialysis center for a resident receiving dialysis. The facility's dialysis policy requires nursing staff to report the resident's condition and treatment provisions to the dialysis provider each treatment day and to obtain a report upon the resident's return from dialysis. However, the clinical record for the resident, who receives dialysis three times a week, did not include any dialysis communication forms for a period from July 20, 2024, to the current date. Only two communication forms were provided for dates in early and mid-August 2024. The facility administrator confirmed the absence of additional required documentation.
Infection Control Deficiencies in PPE Usage and Signage
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for a resident diagnosed with COVID-19. A Certified Nursing Assistant (CNA) entered the room of a COVID-19 positive resident wearing only a gown and surgical mask, without the required N95 mask, gloves, or eye protection. After removing the gown, the CNA did not perform hand hygiene before continuing to deliver meal trays to other residents, which was against the facility's COVID-19 Prevention, Response, and Reporting policy. The Director of Nursing confirmed that staff should wear an N95 mask, eye protection, gown, and gloves when entering a COVID-19 isolation room and perform hand hygiene upon exiting. Additionally, the facility did not post Enhanced Barrier Precautions signage for a resident with an indwelling urinary catheter. The resident's room lacked the necessary signage to alert staff and visitors of the required precautions, despite the presence of red isolation bins and the resident being listed on the facility's Enhanced Barrier Precautions list. A Licensed Practical Nurse confirmed the absence of signage and acknowledged that it should have been posted. The Director of Nursing stated that for residents on Enhanced Barrier Precautions, a sign should be posted, and staff should wear a gown, gloves, and mask when providing care.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and did not develop or implement a care plan for a resident at risk for wandering and elopement. This resulted in a cognitively impaired resident with a known history of wandering exiting the facility without staff knowledge for 40 minutes. The resident was found outside the facility, having fallen in the mud and complaining of head and back pain. The facility is located near a busy four-lane road, increasing the risk of serious harm to the resident. The resident's care plan documented that they were an elopement risk and had impaired cognition, requiring assistance with decision-making. Despite this, the resident did not wear an alarm to prevent elopement, and the front door was not alarmed or locked when the receptionist left early. The resident had previously exhibited exit-seeking behavior and had been placed on 1:1 observation for safety, but this was not consistently maintained. On the night of the incident, the resident was able to leave the facility through the front door, which was not locked or alarmed, and was found outside 40 minutes later. Interviews with staff revealed that there was confusion and inconsistency in monitoring the resident. The Licensed Practical Nurse (LPN) on duty initiated 15-minute checks but was unable to consistently monitor the resident due to being the only nurse on duty for two halls. The receptionist did not lock or alarm the front door when leaving early, and there was no formal documentation of the 15-minute checks. The facility's failure to provide adequate supervision and implement effective interventions for the resident's elopement risk led to the resident's unsupervised exit and subsequent fall.
Removal Plan
- Reassessment of all residents for wander risk assessment by V27, Assistant Director of Nursing
- At risk residents for wandering/elopement had care plans reviewed and updated with safety measures and interventions by V28, Care Plan Coordinator
- Updated safety measures and interventions were added to Kardex by V28, Care Plan Coordinator
- Re-education on elopement policy and procedure as well as Identifying the signs and symptoms of wandering by V2, Director of Nursing
- Re-educate on the facility policy and procedure regarding elopement by V2, Director of Nursing
- Document Performance Improvement Plan/PIP implementation, PIP progress, and Quality Assurance Agency/QAA Committee Meeting Minutes where PIP is discussed by V2, Director of Nursing
Failure to Provide Scheduled Medications
Penalty
Summary
The facility failed to obtain scheduled medications from the pharmacy for two residents, resulting in significant health issues. One resident, who had a history of generalized idiopathic epilepsy, did not receive his prescribed seizure medication, Keppra, for at least two days. This lapse led to the resident experiencing multiple falls, a seizure, and ultimately breaking three ribs. The resident's medical records and progress notes indicated that the medication was on order but not available, and the facility staff were aware of the issue but did not take adequate steps to resolve it promptly. The resident's condition deteriorated, necessitating an emergency room visit where it was confirmed that his Keppra levels were critically low, and he had sustained rib fractures from the falls. The facility's Director of Nursing and other staff members acknowledged the problem but failed to secure the medication in a timely manner, despite multiple communications with the pharmacy. The pharmacy records corroborated that the medication was requested but not refilled due to a perceived early refill request, and the facility did not utilize alternative means to obtain the medication. Another resident, who was prescribed Norco for pain management, also did not receive the medication as scheduled due to issues with obtaining a signed prescription and delays from the new pharmacy. This resident's medical records showed multiple entries indicating the medication was not available, and the facility staff confirmed the delay in providing the necessary pain relief. The facility's failure to provide these essential medications as prescribed resulted in significant discomfort and health risks for the residents involved. The Immediate Jeopardy was identified when the first resident fell and broke three ribs due to the lack of seizure medication, highlighting the severe impact of the facility's deficiencies in pharmaceutical services.
Removal Plan
- Audit of all resident's receiving seizure medications by Pharmacy.
- Resident's receiving seizure medications the medication is in house and being administered per the physician order by V2, Director of Nursing.
- All nursing staff have access to the backup medication machine by V2, Director of Nursing.
- Re-education on medication administration and contacting physician and pharmacy if medication is not available by V2, Director of Nursing.
- Document Performance Improvement Plan/PIP implementation, PIP progress, and Quality Assurance Agency/QAA Committee Meeting Minutes where PIP is discussed by V1, Administrator in Training.
Staff-to-Resident Verbal Abuse Incident
Penalty
Summary
The facility failed to prevent staff-to-resident verbal/mental abuse for one resident (R11) of four residents reviewed for abuse. The incident occurred when V25, an Activity Assistant, made a derogatory comment to R11, a male resident with mild to moderate cognitive impairments and an intellectual disability, who was also admitted to hospice care. R11 became upset when he could not go on an activity outing, and V25 responded by telling him to 'stop crying like a little girl' and 'don't be a baby.' This interaction was overheard by V23, the Therapy Director, and other residents and staff present in the dining room. V25 admitted to making the comment, which led to R11 becoming more tearful. The facility's policy on abuse, neglect, and exploitation clearly states that residents must not be subjected to abuse, including verbal and mental abuse, by anyone, including facility staff. The incident was documented in a state report and a summary of the investigation, which concluded that V25's actions constituted unprofessional conduct. V25 was subsequently terminated from employment. The facility's policy defines verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Mental abuse includes humiliation, harassment, threats of punishment, or deprivation. The report indicates that V23, the Therapy Director who witnessed the incident, is no longer employed with the facility.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency for one resident (R5) out of a sample of 17 residents reviewed for abuse. According to the facility's policy on abuse, neglect, and exploitation, any suspicion or report of abuse must be immediately reported to the administrator and other officials, including the State Survey Agency. The incident in question involved a report from another resident (R16) who claimed that a CNA (V29) had used inappropriate language towards R5 during the night. This report was investigated by the Administrator-In-Training (V1) and the Regional Nurse Consultant (V17). However, R5 denied that the incident occurred, and V1 concluded that there was no allegation of abuse to report, citing R5's history of false allegations and interjecting in other residents' care. Consequently, no initial or five-day report was made to the State Survey Agency regarding the allegation of verbal abuse by V29 to R5. The facility's failure to report the allegation of verbal abuse was based on the denial by R5 and the history of the resident who reported the incident. Despite the facility's policy requiring immediate reporting of any allegations or suspicions of abuse, the decision was made not to report the incident to the State Survey Agency. This inaction led to a deficiency being noted during the survey, as the facility did not comply with the mandated reporting requirements. The report highlights the importance of adhering to established procedures for reporting abuse, regardless of the perceived credibility of the allegation or the history of the residents involved.
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Nursing homes near Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Healthcare Of Peoria | 1.5 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Skylines | 1.5 mi | ★★★★★ | 0 | 0 |
| Lutheran Hillside Village | 2.3 mi | ★★★★★ | 1 | 0 |
| Arcadia Care Peoria Heights | 2.5 mi | — | 9 | 0 |
| Sharon Health Care Pines | 2.5 mi | ★★★★★ | 16 | 1 |
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