Morgan Park Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 10935 South Halsted Street, Chicago, Illinois 60628
- CMS Provider Number
- 145764
- Inspections on file
- 65
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 24 (1 serious)
Citation history
Health deficiencies cited at Morgan Park Healthcare during CMS and state inspections, most recent first.
The facility failed to adequately monitor and supervise residents with known substance use disorders and to prevent accidents such as falls. Multiple cognitively intact residents and staff reported that illicit drugs, including heroin and crack cocaine, were brought into the building and sold by residents, with small baggies of white powder repeatedly found in rooms and on bedside tables. Several residents with histories of opioid and other substance abuse were found unresponsive in their rooms, some requiring Narcan and hospitalization, and one resident was found cold and rigid in the morning after an apparent overdose, with other residents stating that staff had not performed rounds. Care plans and substance abuse assessments lacked specific monitoring interventions, incidents were sometimes not documented, and drug screening was not consistently performed when contraband was discovered. Separately, a resident sustained a left femur fracture after a fall inside the facility, and another resident’s fall care plan was not updated and assessments were not followed after a fall, demonstrating broader failures in supervision and accident prevention.
Two cognitively intact residents reported ongoing verbal abuse and bullying by a neighboring resident with a documented history of verbal aggression and manipulative behavior, including sexually explicit name-calling, derogatory comments that they "stink," and intimidation over use of a shared bathroom, leading them to use a bedside commode in their room instead. Another resident described the alleged aggressor as disrespectful, prone to picking on others, and believing they "run" the floor, and reported hearing about conflicts over the shared bathroom. Despite prior progress notes and a care plan describing the aggressor’s verbal altercations and threatening behavior, staff interviewed denied awareness of any bullying or abuse, and no concerns about the shared restroom had been brought forward, indicating the facility did not follow its abuse prevention policy to protect residents from verbal and psychological abuse.
Staff failed to follow the facility’s cell phone policy by using personal phones in resident care areas and ignoring the nurses’ station phone. A central supply manager was observed talking on a personal cell phone at the nurses’ station while the unit phone rang, and a restorative CNA was simultaneously texting on a personal phone and not responding to the ringing phone, despite stating that everyone is responsible for answering it. On another unit, a CNA assigned to monitor the hallway for resident safety was observed scrolling on a personal phone instead, and acknowledged this was against expectations and could interfere with resident monitoring. The employee handbook prohibits personal cell phone use while on duty except in designated break areas, and the DON confirmed that CNAs and nurses are not allowed to use cell phones on the units due to distraction, potential HIPAA issues, and interference with proper resident care.
A resident’s right to retain and use personal property was not honored when the resident’s television was broken in the facility and not properly assessed or addressed by staff. A CNA reported that the family had purchased both the original and replacement TVs and had heard that a nurse broke the first TV by hitting it with a bathroom door. An LPN acknowledged the TV fell during a mechanical lift transfer but did not inspect it afterward and later heard she was being blamed for the damage. The Administrator, contacted by the family about the broken TV, assumed the TV had simply stopped working and did not verify its condition in the room, while the Maintenance Director confirmed the TV had been broken in the facility and that the family supplied the replacement, which he installed.
A resident with confusion, gait/balance problems, incontinence, and a history of falls had an existing fall care plan with multiple interventions such as low bed, floor mat, frequent checks, and environmental safety measures. After the resident experienced another fall, the Restorative Nurse, who is responsible for entering fall-prevention interventions, acknowledged that the care plan was not updated with new or revised interventions, despite her understanding that interventions should change after each fall. Review of the care plan confirmed that no new fall-prevention measures were added following the subsequent fall, contrary to facility policy requiring review and updating of the care plan after a significant change in condition.
Two residents did not receive proper indwelling catheter care, leading to infection control concerns and a catheter-related hospitalization. One resident with urinary retention and obstructive uropathy was observed in bed with a half-full catheter drainage bag placed directly on the floor, despite staff, including an LPN and the DON, acknowledging that catheter bags must be hung off the floor on the bed frame below the kidneys to prevent contamination and backflow. Another resident with a Foley catheter and neurogenic bladder, care planned for infection risk, was found lethargic and hypoxic and was sent to the hospital, where the Foley was reported as non-draining for an unknown period, the urine was dark brown and turbid with large leukocyte esterase and many bacteria, and the resident was diagnosed with AMS, sepsis, hypotension, and UTI; the Foley was found clogged and was replaced to restore drainage.
Surveyors identified environmental hazards and inadequate cleaning practices, including a broken picture frame with exposed glass shards on an upper-floor hallway and a shower room toilet area with apparent feces on the wall and urine-like debris on the toilet and floor. Staff, including a housekeeper and a CNA, acknowledged that the broken frame posed a danger and could be used as a weapon, and housekeeping staff confirmed that the bathroom should have been cleaned more frequently. Facility policies required that all areas be kept clean, safe, and properly disinfected, but these conditions were not met.
Surveyors identified multiple failures in food sanitation and temperature control during a meal service. A dietary aide and a cook prepared meal trays with uncovered beards despite facility policy requiring beard guards. The aide licked his ungloved hand and then handled menu tickets and prepared about 20 trays before sanitizing and donning gloves, and later adjusted his face mask with gloved hands and continued tray preparation without changing gloves or sanitizing. When a meal cart was checked, hot ham on a tray was found well below required hot-holding temperatures. The cook stated he had taken food temperatures but had not documented them, leaving no required temperature log, despite policies mandating temperature checks and recording for hot and cold foods.
Surveyors found that the dietary department failed to maintain clean and sanitary conditions in the kitchen and food storage areas, with dirty floors, trash, and debris throughout and glue traps for pests under storage racks. The Dietary Manager and a dietary aide both confirmed that dietary staff are responsible for cleaning and verified the presence of dirt, trash, and pests, including roaches on a counter. These conditions conflicted with facility policies and job descriptions that require the Food Service Supervisor and dietary aides to keep food service areas clean, orderly, and compliant with infection control and food sanitation standards for all residents.
The facility failed to properly manage its dumpster area, where surveyors twice observed foul odors, two dumpsters with all lids open, and scattered trash on the ground. A maintenance staff member stated that dumpster lids should be closed and that housekeeping was responsible for the area, and acknowledged that open lids and trash could allow pests into the building. The housekeeping supervisor confirmed the area should be cleaned more than daily and that leaving trash and lids open can attract animals and rodents. These conditions occurred despite a written waste management policy requiring trash bags to be placed inside the dumpsters, lids kept closed, and the dumpster area kept clean by maintenance and housekeeping staff, with the potential to affect all 213 residents.
Surveyors identified widespread environmental deficiencies, including missing baseboards and floor panels, broken tiles, holes in walls, stained and unsecured ceiling tiles, and dirty, poorly maintained shower rooms with brown splatter, debris, standing water, and missing drywall. Staff interviews confirmed that maintenance is responsible for repairs and floor techs for cleaning common areas, and leadership acknowledged that walls with holes and stained ceiling tiles do not provide a homelike environment. Review of the work order binder showed these issues were not documented, despite facility policies and job descriptions requiring that all areas be kept clean, safe, and in good repair.
The facility failed to maintain effective pest control for roaches and mice, as multiple residents reported seeing roaches in hallways, rooms, dining areas, and shower rooms, and mice in rooms, hallways, and a nourishment room. Staff, including CNAs and housekeeping, acknowledged frequent roach sightings and incidents involving dead or trapped mice that residents sometimes had to dispose of themselves. Surveyors observed rodent droppings under a nourishment room sink, dead roaches near a bedside, and live roaches in a shower room, as well as dumpsters with open lids and trash scattered around them. These conditions conflicted with facility policies requiring closed, clean dumpsters and a pest control program conducted regularly and as needed, while the administrator reported limited awareness of mouse issues and confirmed pest control visits only twice monthly.
Surveyors found that multiple residents were living in rooms with trash on the floors, dirty bathroom surfaces, and inadequate window coverings, as well as broken or missing furniture such as damaged drawers and a hanging call light box. Several rooms had baseboards pulled away from walls, large holes or missing drywall, and unsecured wall cut-outs exposing plumbing, while a shared room lacked a toilet lid. One resident reported seeing a mouse enter through an open wall hole and stated that only hot water worked at the sink and sprayed everywhere despite having reported it weeks earlier. Shower rooms were observed with dirty floors, brown splatter on walls, standing water with debris in a tub, and missing drywall, even though staff acknowledged their responsibility for cleaning and maintenance and facility policies required a safe, clean, and homelike environment.
The facility failed to protect residents from physical abuse and to ensure complete documentation and reporting of resident-to-resident incidents. A resident with significant psychiatric diagnoses and moderate cognitive impairment was involved in multiple aggressive episodes toward other residents, including hitting a wheelchair-dependent resident and throwing a pitcher of ice water into another resident’s face after being refused money or items. One cognitively intact resident reported being struck from behind and having belongings knocked from a bedside table, but this event was not documented in the medical record. Another resident with chronic respiratory and cardiac conditions and hemiplegia clearly reported having ice water thrown in his face, which was reflected in progress notes. Despite staff being told of these events, the administrator and DON later stated they were unaware of the incidents until reviewing documentation days later, indicating failures in timely internal reporting and adherence to the facility’s abuse policy.
The facility failed to timely investigate and report two resident-to-resident physical abuse allegations to the state agency. One resident reported that a roommate entered the room, knocked belongings to the floor, grabbed the resident from behind, and struck the resident’s jaw, but this was not documented as a physical assault in the EHR. Another resident reported that a peer entered the room, demanded money, then cursed and threw a water pitcher into the resident’s face, which was documented in a progress note. An RN and an LPN each stated they reported these incidents to the administrator/abuse coordinator, while the administrator stated they were not informed and only later saw documentation of one incident and did not report it because it was "too late," and also denied being told about the alleged hitting. This occurred despite existing abuse education, resident rights, and abuse prevention policies requiring immediate reporting of alleged abuse.
A resident in a fully occupied four-bed room was observed without a ceiling-suspended privacy curtain around the bed after the curtain and track had fallen months earlier and were never replaced. The resident reported having no privacy and being unable to change clothes at the bedside. The Administrator stated that all residents should have privacy and window curtains for privacy and a homelike environment, while the Housekeeping Supervisor reported that housekeeping is responsible for replacing privacy curtains. Facility policies and job descriptions assign responsibility for maintaining a safe, comfortable, and homelike environment, including ensuring privacy curtains are present and in good condition.
Two residents reported that staff used paper towels instead of appropriate towels or wipes for peri care, causing them distress and anger. CNAs acknowledged using paper towels and even torn shirts, blankets, and sheets to clean residents when linens were unavailable. An LPN confirmed that staff should not use paper towels and should use proper towels or wipes. This practice conflicted with residents’ rights materials stating that individuals must be treated with dignity and respect and cared for in a manner that promotes quality of life.
The facility failed to follow its policies for community survival skill assessments, physician orders, and care plan interventions for residents leaving on community passes. Several residents were allowed to leave on independent passes without proper assessment or authorization, and responsible parties or families were not notified when residents left against medical advice or did not return. These failures affected residents with histories of substance abuse, psychiatric diagnoses, and prior incidents of not returning from passes.
A resident left the facility on a community pass and did not return, but the facility failed to notify the family or provide timely cooperation with law enforcement. Despite documentation showing family involvement in care, only the physician was notified, and there was no evidence of notification to the State Ombudsman. Required documentation and communication per facility policy were not completed.
A resident with multiple psychiatric and medical diagnoses, but intact cognition, left the facility on an independent pass and did not return. The facility failed to respond to law enforcement requests for information and did not notify the resident's involved family members, resulting in an inability to report the resident's whereabouts or status.
Surveyors found that staff did not ensure call lights were within reach for several residents, leaving some unable to call for assistance and unaware of their call light's location. In one case, a resident was not provided with a properly sized wheelchair despite repeated requests, resulting in discomfort and risk of skin breakdown. Staff and care plans indicated that call lights should be accessible and wheelchairs properly fitted, but these requirements were not met.
A resident with a gastrostomy and severe cognitive impairment did not receive tube feeding as ordered when staff failed to turn the feeding pump back on after care. The pump was found off and the resident was not receiving the prescribed continuous feeding, contrary to the physician's order and care plan.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to safeguarding residents from harm.
A resident with chronic kidney disease alleged inappropriate behavior by another resident with schizoaffective disorder and mild cognitive impairment. Although immediate protective actions were taken and authorities were notified, the facility failed to report the abuse allegation to the state health department within the required timeframe, resulting in a deficiency.
A facility failed to investigate an incident involving a verbal and physical altercation between a resident and the Maintenance Director to rule out abuse. The administrator did not interview the resident or consider the possibility of abuse, relying only on staff accounts and not following facility policy requiring investigation of all such incidents.
Two residents with significant respiratory and cardiac conditions were found to be receiving supplemental oxygen without active physician orders. Both the LPN and DON confirmed the absence of required orders, despite facility policy mandating physician authorization for oxygen therapy. The facility's oxygen report included these residents, but their medical records did not reflect any current orders for oxygen.
Multiple areas within the facility, including resident rooms and common spaces, were found with chipped paint, exposed drywall, missing outlet covers, clogged sinks, broken plaster, peeling paint, brown stains, loose and stained ceiling tiles, missing wall tiles, and missing hand railings. Staff and residents reported that much of the damage was caused by beds and wheelchairs, and maintenance staff indicated that repairs had been neglected and were difficult to keep up with. Facility policies requiring regular environmental audits and hazard identification were not effectively followed, resulting in ongoing environmental hazards and a lack of homelike conditions.
Two residents engaged in a physical altercation resulting in scratches and a bruise after staff failed to intervene in time, despite being present on the unit. Staff responded only after hearing yelling, and both residents were found with injuries. The facility's abuse policy, which requires immediate intervention to prevent abuse, was not followed.
A resident with Alzheimer's and a left below-the-knee amputation was injured during a transfer when a CNA attempted to move them without a Hoyer lift or additional staff, contrary to the care plan. The facility had insufficient mechanical lifts, contributing to the unsafe transfer and resulting in a leg fracture requiring surgery.
A resident with Alzheimer's and a left leg amputation fell during a transfer due to inadequate staffing and lack of equipment. The incident was inaccurately documented, with discrepancies in the date and staff involved. The facility's administration could not clarify these inconsistencies, impacting the credibility of the records.
The facility failed to provide adequate linen and towels for 205 residents, impacting daily care activities. Staff reported frequent shortages, leading to delays in resident care and discomfort. CNAs used makeshift solutions like cutting sheets for towels, and some purchased supplies themselves. Residents expressed frustration over waiting for care due to the lack of supplies.
The facility failed to administer medications as ordered, maintain secure medication storage, and provide adequate nursing coverage, leading to residents not receiving timely care. A nurse's absence resulted in delayed medication administration, and a lack of linen hindered incontinence care. Additionally, a medication cart was left unlocked, compromising resident safety and privacy.
The facility failed to protect residents from abuse, with multiple incidents of physical altercations and alleged abuse occurring. Residents with cognitive impairments and behavioral issues were involved in altercations, and a CNA was accused of abusing a resident during toileting. The facility's abuse prevention policy was not effectively implemented, leading to deficiencies in resident safety.
A resident with a history of falls and cognitive impairment sustained a leg fracture due to inadequate supervision and care plan management. The LPN discovered the injury after noticing the resident's pain, but the care plan lacked updated fall interventions. Additionally, a CNA was distracted by a personal device while responsible for monitoring residents, violating facility policy and compromising safety.
The facility failed to thoroughly investigate abuse allegations involving three residents. In one case, key witnesses were not interviewed following a physical altercation between two residents. In another incident, a resident reported being abused by a CNA during toileting, but the facility did not obtain witness statements. The resident involved has a complex medical history and requires substantial assistance.
A facility failed to maintain a clean environment for three residents, as brown stains were found on their shared bathroom wall. A resident reported the issue, suspecting the stains to be feces, but the housekeeping staff was unaware of the problem. The Director of Nursing and Housekeeping Director acknowledged the responsibility to maintain cleanliness, highlighting a lapse in communication and action.
A resident with significant mobility impairments and a BIMS score of 15 experienced a delay in receiving incontinent care due to an uncharged mechanical lift. The resident remained soiled for over an hour, despite informing staff of the need for assistance. The facility's policies emphasize timely care to prevent skin breakdown and maintain dignity, which was not met in this case.
A resident with a history of aggression assaulted another resident, despite the facility's knowledge of their behavior and the need for 1:1 supervision. The incident occurred without the required supervision, leading to a physical altercation in the dining room.
The facility failed to provide adequate catheter care for three residents, resulting in health issues such as UTIs and purple urine bag syndrome. Residents with indwelling catheters lacked proper documentation and monitoring, leading to adverse outcomes. The facility did not follow its catheter care policy, contributing to these deficiencies.
The facility failed to ensure accurate fall risk assessments for two residents. One resident with hemiplegia fell while being assisted, and their post-fall assessment did not reflect their balance and coordination issues. Another resident with paraplegia was inaccurately assessed as ambulatory and continent, despite using a wheelchair and having a catheter. The DON acknowledged these inaccuracies during the survey.
The facility failed to maintain the community shower room on the third floor North-Wing, affecting 53 residents. Observations included a leaking sink, soiled towels, missing ceiling tiles, and a broken soap dispenser. The housekeeper acknowledged these as maintenance issues, but the Maintenance Director was unaware of them. The facility's Preventative Maintenance Program policy was not effectively implemented.
A resident with a surgical wound did not receive proper wound care as ordered, resulting in unclean dressings and increased infection risk. The wound care nurse and coordinator had not performed the necessary care, despite records indicating otherwise. Additionally, a housekeeper improperly handled waste by dragging an unsecured garbage bag, risking cross-contamination. These actions reflect a failure in the facility's infection prevention and control program.
A facility failed to provide adequate linen and towels for 197 residents, leading to unmade beds and improvised solutions by staff. CNAs and nurses reported shortages, with some purchasing towels themselves. The laundry department struggled with limited supplies, and the Housekeeping Director cited a restricted budget. Residents expressed dissatisfaction, noting delays in their routines due to the lack of towels. The Administrator and DON were aware, but the issue persisted, impacting residents' rights to a safe and homelike environment.
The facility failed to secure Soiled Utility rooms containing sharps and infectious waste, posing a safety hazard to residents. Surveyors found doors open or unlocked, with access to biohazard bags, full sharps containers, and cleaning chemicals. Staff acknowledged the rooms should be locked, and the facility's policies on safety and sharps disposal were not followed.
The facility failed to maintain a clean and sanitary kitchen environment, affecting all 196 residents. Observations showed dirty fans and air conditioners, stagnant water attracting insects, and expired testing strips for the three-compartment sink. The Food Service Director and Maintenance Director had conflicting views on cleaning responsibilities, and the facility lacked a policy for kitchen cleaning.
The facility failed to provide functional hot water for four residents, with reports of cold or lukewarm water persisting for about two weeks. The Maintenance Director acknowledged the issue, citing the need for a second water heater. Additionally, a resident was exposed to sharp metal edges from an uncovered air conditioner unit, posing a safety risk. The facility's policies on maintenance and safety were not effectively implemented, leading to these deficiencies.
The facility failed to maintain an effective pest control program, resulting in unsanitary conditions in the kitchen and pest sightings in resident rooms. Observations revealed dirt and food wrappers under kitchen equipment, stagnant water with insects, and a cockroach near food preparation areas. Two residents reported seeing roaches in their rooms, and a pest was observed by an LPN. The pest control company visits twice a month, but documentation lacked specifics, and no traps were found. The facility's pest control policy was not effectively implemented.
The facility failed to refer six residents with serious mental disorders for PASRR Level II assessments, as required. The Social Service Director was unaware of the need for referrals upon new diagnoses, leading to missing documentation for several residents. The facility's policy requires compliance with PASRR standards, but lapses in the process were acknowledged by both the Social Service Director and the administrator.
The facility failed to provide adequate incontinence care and scheduled showers for several residents. A resident reported not receiving a shower for weeks due to inconsistent water temperatures, with no documentation of showers being provided. Another resident was left in soiled incontinence briefs for hours, despite having a stage three pressure ulcer. A third resident was found with soiled briefs and bed sheets due to a lack of timely care, as staff admitted to not having towels available. The facility's policy of checking residents every two hours was not followed.
A facility failed to follow its tracheostomy care policy for a resident who frequently manipulated his tracheostomy cannula, risking infection. Additionally, oxygen tubing for three residents was not labeled with the date and time of the last change, contrary to protocol. These deficiencies in respiratory care could affect residents' health, as confirmed by staff observations and interviews.
Failure to Control Illicit Drug Use and Provide Adequate Supervision Leading to Overdoses and Falls
Penalty
Summary
The deficiency involves the facility’s failure to monitor, supervise, and intervene for multiple residents with known substance use disorders, and to provide adequate supervision to prevent accidents such as falls. Several residents with documented histories of opioid and other substance abuse were able to obtain and use illicit drugs within the facility, resulting in episodes of unresponsiveness and suspected overdoses. One resident with diagnoses including opioid dependence, anxiety disorder, obstructive sleep apnea, and major depressive disorder was found unresponsive during morning rounds with no respirations or pulse, and resuscitation efforts were unsuccessful. Another cognitively intact resident reported that this resident had overdosed, was found on the floor with liquid coming from his nose, and that staff did not check purses or conduct searches, making it easy to bring drugs into the building. Multiple residents and staff reported that this was not the first overdose death in the facility and that drugs such as heroin and crack cocaine were being sold by residents on specific units. Additional residents with substance use histories experienced overdoses or suspected overdoses while in the facility. One resident with a history of opioid abuse and withdrawal admitted to buying cocaine inside the facility and reported being given Narcan after overdosing. Another resident with diagnoses including abuse of psychoactive and non-psychoactive substances, and opioid abuse in remission, admitted to substance use and possession of contraband on more than one occasion, with contraband baggies found in the room and Narcan reportedly administered after an overdose requiring hospitalization. A resident with opioid abuse reported that illegal drugs, including crack cocaine and heroin, were sold by other residents, and that staff were supposed to check bags but did not. Staff interviews confirmed finding small clear baggies with white powdery substances in residents’ rooms and on bedside tables, sometimes inside narcotic boxes, and that some residents had tested positive for cocaine. One LPN acknowledged not documenting an incident where a resident dropped a baggie of suspected cocaine, despite recognizing the importance of maintaining a history of such events. The facility also failed to ensure adequate supervision and monitoring for residents at risk for accidents unrelated to substance use. One resident fell inside the facility and sustained a left femur fracture, and another resident’s fall care plan was not updated and assessments were not followed after a fall, despite being identified as at risk. For residents with substance use disorders, care plans and assessments were incomplete or lacked specific monitoring interventions. For example, one resident’s care plan documented substance use and a positive opioid test with relapse but contained no interventions regarding monitoring. The facility’s own substance abuse protocol, as described by the substance abuse counselor, called for drug screening when substance use was suspected, room searches, incident reporting, care plan updates, and substance abuse assessments, but in at least one case the counselor acknowledged that a required substance abuse assessment was not completed after contraband was found. Staff also reported that residents were supposed to be monitored every 30 minutes, yet a resident with a known substance use history was found cold, rigid, and unresponsive in the morning, with other residents stating that staff did not perform rounds or announce themselves that shift. Further, the report describes an incident where a newly admitted resident with a history of overdose and polysubstance abuse was found unresponsive shortly after a visitor left the room, with an unknown white powdered substance on the chest and additional baggies discovered under the sheets. The LPN on duty administered multiple doses of Narcan and called 911, and hospital records later confirmed polysubstance abuse with positive screens for fentanyl, heroin, and benzodiazepines. Another resident with severe cognitive impairment was found unresponsive with nasal flaring and no response to verbal or painful stimuli; Narcan was administered and the resident was transferred to the hospital, where records documented an opiate overdose despite a negative urine drug screen, with the physician noting that the naloxone response and history of opioid misuse suggested recent opioid exposure. The nurse practitioner stated that Narcan had been given to residents on multiple occasions due to the large population with illicit drug use history and that Narcan was used when nurses suspected opioid or illicit drug use. Staff across disciplines, including nursing, housekeeping, and social services, acknowledged that there were “a lot of overdoses,” that residents were “doing drugs,” and that some residents relapsed in the building, underscoring the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for residents at risk of overdose and falls.
Failure to Protect Residents From Ongoing Verbal Abuse and Bullying by a Peer
Penalty
Summary
The facility failed to protect two cognitively intact residents from verbal abuse and bullying by another resident and did not follow its abuse prevention policy. One resident and their mother, who share a room and bathroom with a neighboring resident, reported that the neighboring resident had repeatedly used foul and sexually explicit language toward one of them, including calling them a “b**l sucker” and “d**k sucker,” and made derogatory comments that they “stink.” The two residents stated that this behavior had been occurring for about two months, often when no staff were present, and that the neighboring resident did not want them to use the shared restroom. As a result, they chose to use a bedside commode in their room to avoid ridicule; surveyors observed a bedside commode with urine in it in their room. The two residents reported feeling unsafe, frustrated, angry, stressed, and anxious due to the ongoing bullying and verbal abuse, and one resident expressed fear that reporting the situation might make it worse. Another resident on the unit, who had been in the facility for nearly two years, described the alleged aggressor as someone who becomes “ignorant and disrespectful” when angry, “picks at people,” and “thinks they run this floor,” and reported having heard about conflicts involving the shared bathroom, including accusations that the two residents left the bathroom dirty. This resident also stated that the alleged aggressor knows about other residents’ diagnoses and suggested that this information may have come from staff. Despite these reports and the facility’s own documentation that the alleged aggressor had a history of verbal altercations, verbal aggression toward peers and staff, and manipulative, threatening, and disrespectful behavior, staff interviewed denied awareness of any bullying or abuse between the involved residents and reported no prior incidents or concerns regarding their shared restroom. Progress notes for the alleged aggressor from multiple prior dates documented episodes of verbal aggression and derogatory name-calling, and the resident was care planned for manipulative and aggressive behavior. The facility’s Abuse Prevention Program policy states that residents have the right to be free from abuse, defined as intimidation or punishment resulting in mental anguish, yet the ongoing verbal aggression and intimidation toward the two residents were not identified or addressed by staff prior to the surveyor’s involvement.
Staff Cell Phone Use in Resident Care Areas and Failure to Answer Nurses' Station Phone
Penalty
Summary
The facility failed to follow its employee handbook policy prohibiting personal cell phone use while on duty, resulting in staff using personal phones in resident care areas and ignoring the nurses' station phone. On the second-floor north nurses' station, a surveyor observed a central supply manager/transportation staff member talking on her personal cell phone while the nurses' station phone rang audibly nearby, and she did not initially answer it. At the same time, a restorative CNA was seated at the nurses' station, looking down and texting on his personal cell phone, also ignoring the ringing nurses' station phone and not looking up from his device. When they noticed the surveyor, both staff members stopped using their phones, and the central supply manager then answered the nurses' station phone. The central supply manager stated she did not hear the nurses' station phone because she was on her personal call, and the restorative CNA stated he did not hear the phone because he was texting and that, although everyone is responsible for answering the nurses' station phone, he typically does not answer it because calls are usually for the nurses. The census documented 57 residents residing on the second-floor north unit. On another unit (3N), a CNA was observed sitting in the hallway with her personal cell phone in her hands, scrolling on the phone while she was supposed to be monitoring the hallway for resident safety. This CNA stated she is not supposed to be on her personal phone when monitoring the hallway, acknowledging that if she is on the phone, she might not properly monitor residents, which can lead to residents not receiving needed care, sustaining injuries, or getting into confrontations. She reported she is assigned 20 residents and that 3N houses 58 residents in total, and that staff using personal phones while in the units is not part of her job description. The facility’s employee handbook states that cell phone usage while on duty is prohibited, that personal devices may only be used in designated areas while on break, and that employees who use personal devices while on duty may be subject to disciplinary action. The DON confirmed that CNAs and nurses are not supposed to use their cell phones on the units, that phones are only allowed in the break room when staff are on break, and that cell phone use in the units is distracting, can cause HIPAA violations, is unprofessional, and prevents CNAs and nurses from providing proper care to residents, which can lead to accidents and injuries.
Failure to Safeguard and Respect Resident’s Personal Television
Penalty
Summary
The facility failed to respect and safeguard a resident's personal belongings, specifically the resident's television (TV), and did not ensure the resident had appropriate access to this personal possession. A surveyor observed a functioning 32-inch black TV on a portable stand in the resident's room, which staff reported had been recently purchased by the resident's family because the previous TV had been broken in the facility. A CNA stated that the family had also purchased the prior TV and reported hearing that a nurse had broken it by bumping it with the resident's bathroom door. The LPN involved reported that, during a transfer using a mechanical lift with three CNAs present, the resident's TV fell from the bedside table onto a bag of dirty clothes and was then placed back on the table by a CNA; she stated she did not inspect the TV afterward and was unaware it was broken. She later heard that she was being blamed for breaking the TV but did not address these reports. The Administrator stated that the family had contacted her months earlier about the broken TV and that she believed the TV had simply stopped working after five years of use; she did not go to the room to verify the condition of the TV. The Maintenance Director confirmed that the resident's TV had been broken in the facility several months earlier, did not know how it broke, and stated that the family purchased the replacement TV, which he installed on the TV stand. The Ombudsman Residents' Rights document cited in the report affirms that residents may keep and use their own property.
Failure to Revise Fall Care Plan After Recurrent Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s fall care plan after a subsequent fall, as required by facility policy and care planning standards. Interview with the Restorative Nurse established that she is responsible for entering fall-prevention interventions into residents’ care plans and that care plans should be updated to reflect each fall, with different interventions added when a resident experiences multiple falls. She stated that if a resident continues to fall, maintaining the same interventions indicates they are not effective and that not changing them puts residents at greater risk of falling. The Restorative Nurse acknowledged that she did not update the fall interventions in the resident’s care plan after the resident experienced another fall. Record review showed that the resident’s care plan, dated 10/15/2025, identified the resident as being at risk for falls related to confusion, gait/balance problems, incontinence, and a history of falls. The care plan listed multiple fall-prevention interventions, including anticipating and meeting needs, proper positioning in bed, ensuring the call light is within reach, use of bed bolsters, safety education, appropriate footwear, following the facility fall protocol, frequent monitoring, keeping items within reach, maintaining a clutter-free environment, keeping the bed in a low position, monitoring medication side effects, use of dycem in the wheelchair, provision of a floor mat, and use of hip protectors. Additional interventions for history of falls included a floor mat on the side of the bed, frequent checks, and a low bed. However, review of the care plan dated 11/09/2025 showed no updates or new interventions added after the resident’s fall on the specified date, despite the facility’s policy stating that when a significant change occurs in a resident’s condition, the MDS coordinator or designee is notified and the care plan is reviewed and updated.
Failure to Provide Proper Indwelling Catheter Care and Infection Control
Penalty
Summary
The deficiency involves failure to provide proper indwelling urinary catheter care for two residents, resulting in infection control concerns and a catheter-related hospitalization. One cognitively intact resident with multiple medical diagnoses, including urinary retention and obstructive/reflux uropathy, was observed in bed with an indwelling catheter whose drainage bag was approximately half full and placed directly on the floor. The resident stated he could not see what was on the floor and did not know the bag was there. An LPN confirmed during observation that catheter bags are not supposed to be on the floor, but should be hooked to the bed frame below the bladder to prevent germs from the dirty floor from entering the catheter and causing UTIs. The DON and another LPN separately stated that catheter bags should be hung on the side of the bed, away from the floor and below the kidneys, and that the catheter area is cleaned daily with normal saline and bags are positioned to allow downward urine flow and prevent backflow. The second resident had an indwelling Foley catheter and was care planned for risk of infection or complications related to catheter use due to neurogenic bladder. A nursing progress note documented that the resident was found lethargic, slow to respond, warm to touch, with abnormal vital signs including low oxygen saturation on room air and elevated temperature, and was sent to the hospital. Hospital records documented that the Foley catheter was reported as non-draining for an unknown period of time with a change in urine color to dark brown. On arrival to the ER, the resident had turbid urine, large leukocyte esterase, many bacteria, and was diagnosed with AMS, hypoxia on BiPAP, sepsis, hypotension, and UTI. The Foley catheter was found to be clogged and was changed, after which it drained freely, with urine described as dark brown. The resident’s catheter care order included changing the Foley catheter as needed for blockage, leaking, or malfunctioning.
Failure to Maintain Safe and Clean Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, functional, clean, and comfortable environment for residents, staff, and the public. On the third floor at the end of the North Hall, a surveyor observed a picture frame with its glass broken out at the top and middle, leaving glass shards at the bottom of the frame, partially covered by a bath blanket. A housekeeper confirmed that the picture frame was broken with glass shards and stated that if someone bumped into it, it could be dangerous. A CNA also described the frame as having glass shards protruding from the bottom and identified it as a hazard to residents that could be used as a weapon. On the second floor, in a shower room, the surveyor observed a wall behind a toilet with a brown substance splattered on it and yellowish gray and black debris on the bottom of the toilet and floor. A housekeeper stated that the brown substance looked like feces and the yellowish gray substance looked like urine, and acknowledged that the bathroom should be cleaned twice a day and that this mess should have been cleaned up. The Housekeeping Director later stated that the entire toilet and the wall behind it should be cleaned daily and as needed to disinfect the bathroom and allow it to appear homelike. Facility documents, including the Preventative Maintenance Program and a housekeeping performance evaluation, require that all facility areas be kept clean and in safe condition and that dirt and contaminants be removed from surfaces using proper cleaning and disinfecting solutions.
Food Sanitation, Hand Hygiene, and Temperature Control Failures During Meal Service
Penalty
Summary
The deficiency involves failures in food sanitation and handling practices during meal preparation and service. During a noon meal service, a dietary aide and a cook were observed preparing resident meal trays while both had full facial beards without beard coverings, contrary to facility policy requiring hair restraints and beard guards during food preparation. The dietary manager confirmed that both staff members should have been wearing beard coverings to prevent hair from falling into residents' food and described the lack of beard coverings as unsanitary. The cook stated he did not know beard hair nets were available and acknowledged he should have been using one. Additional unsanitary hand hygiene practices were observed on the tray line. The dietary aide was seen licking his hand and then using that same ungloved hand to pick up a menu ticket and place it on a resident’s meal tray, and he continued preparing multiple trays—counted by the dietary manager as 20 trays—before sanitizing his hands and donning gloves. The aide later stated he should not have licked his fingers and continued tray preparation, acknowledging that this was unsanitary. Later, while wearing gloves, the same aide adjusted his face mask at the ears and nose and then resumed preparing meal trays without removing his gloves and sanitizing his hands, which the dietary manager stated should have occurred before continuing the tray line. Temperature control and documentation deficiencies were also identified. When meal carts were delivered to a dining room, the dietary manager checked a random tray and found the ham at 87.8°F, below the facility’s stated expectations for hot food temperatures and below the policy requirement that hot food prepped for serving maintain a minimum of 135°F, or at least 120–135°F at time of service for palatability. The dietary manager stated the ham should have been at least 110°F and that serving food at the right temperature makes it safe and palatable. When the surveyor requested the temperature log for the lunch meal, the cook reported that he had checked food temperatures before serving but had not documented them and was unable to provide a temperature log. The dietary manager stated that food temperatures should be taken before serving and recorded on a log, consistent with facility policies requiring temperatures to be taken and documented prior to service and during meal service, and maintained on file for one year.
Unsanitary Kitchen and Food Storage Conditions in Dietary Department
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the kitchen and food storage areas, where floors and walls were not maintained in a clean state. Observations revealed dirty floors with trash and debris throughout the kitchen and along the walls, as well as mice and insect glue traps placed under storage racks in the food storage room. These conditions were determined to compromise safe and sanitary dietary conditions for the 213 residents residing in the facility. During interviews, the Dietary Manager stated that dietary aides and cooks are responsible for cleaning the floors in their assigned stations and acknowledged that the kitchen contained dirty floors with trash and debris. The Dietary Manager also confirmed the presence of mice and insect glue traps in the storage room. A Dietary Aide reported that all dietary staff are responsible for keeping the kitchen clean and sanitary, stated that she had mopped after breakfast, and acknowledged seeing roaches on the kitchen counter by the sink. She verified that the kitchen floor still contained dirt, trash, and debris. Facility policies and job descriptions for the Food Service Supervisor and Dietary Aides require maintaining the kitchen and storage rooms in a clean, safe, and sanitary manner and adhering to infection control and food sanitation practices, which were not followed as evidenced by the observed conditions.
Improper Dumpster Management and Open Lids with Scattered Trash
Penalty
Summary
The facility failed to properly manage its dumpster area, resulting in open dumpster lids and scattered trash in violation of its waste management policy. On 2/13/2026 at 10:01 a.m., the surveyor and a Maintenance Assistant observed the dumpster area with a foul odor, two dumpsters with all four lids open, and debris and trash scattered on the ground around the perimeter. The Maintenance Assistant stated that he believed the dumpster lids should be closed and identified housekeeping as responsible for the dumpster area, and further explained that leaving lids open and trash around the area could allow pests such as roaches and mice to enter the facility. At 10:07 a.m. the same day, the surveyor and the Housekeeping Supervisor again observed the dumpster area in the same condition, with foul odor, open lids, and scattered trash. The Housekeeping Supervisor stated that the dumpster area should be cleaned more than daily and acknowledged that leaving trash and lids open is not good and can attract cats, varmints, and rodents. The facility’s waste management policy dated 5/14 requires that plastic liners be tied and placed in outside dumpsters with lids kept closed, and that Maintenance and Housekeeping personnel ensure the dumpster area is kept clean, all trash bags are inside the dumpster, and dumpster lids are closed. This deficiency had the potential to affect all 213 residents residing at the facility, as the improper disposal and management of garbage and refuse occurred in a shared environmental area intended to prevent the spread of infection.
Failure to Maintain Safe, Clean, and Well-Maintained Physical Environment
Penalty
Summary
The facility failed to maintain a safe, functional, clean, and comfortable environment for all 213 residents, staff, and the public, as evidenced by multiple unrepaired structural issues and unclean areas throughout the building. On the first floor, surveyors observed missing baseboards by a resident room and along the hallway between two rooms, as well as missing floor panels in the center of the hallway. Additional observations included a missing baseboard and a hole in the wall by the medical equipment room, stained and unsecured ceiling panels in the first-floor dining room due to warped holding rails, and missing parts of floor squares in an elevator. On the third floor, tile was observed to be broken in front of an elevator. These issues were not documented in the facility’s work order binder when reviewed by the surveyor. On the second floor, surveyors observed environmental cleanliness and maintenance problems in the shower rooms, including a wall behind a toilet with brown substance splattered on it, a toilet and floor with grayish-black debris, a tub filled with water and debris, and missing drywall along the base of the floor behind the toilet. A CNA verified these observations and stated that maintenance is responsible for repairs, while a housekeeper stated that floor techs are responsible for cleaning shower rooms, bathrooms, hallways, dining rooms, elevators, and for taking out garbage, and that cleaning and sanitizing are for the health of residents. The Maintenance Director and Administrator both acknowledged via email that baseboards should not be peeling or pulled from walls, walls should not have holes, and residents should not have stained ceiling tiles, noting that such conditions do not provide a homelike environment. Facility policies and job descriptions in effect at the time required that all facility areas be kept clean and in safe condition, ceiling tiles be free from watermarks or spots, wall coverings be intact and free of tears or loose seams, and that maintenance ensure proper functioning and repairs in resident rooms and other areas not under housekeeping’s purview.
Failure to Maintain Effective Pest Control for Roaches and Mice
Penalty
Summary
The facility failed to maintain an effective pest control program to eliminate roaches and mice, affecting all 213 residents. Multiple residents reported seeing roaches in hallways, their rooms, the dining room on leftover food trays, and the shower room. Several residents also reported seeing mice in their rooms, in hallways, and in the nourishment room under the sink. One resident stated they had seen mice in their room since admission eight months prior, and another reported seeing mice coming through the baseboards every night despite foam being sprayed around the baseboards. Residents described instances where they personally disposed of dead mice or transported trapped mice to the nurses' station because staff did not respond to their reports. Staff interviews and direct observations further demonstrated ongoing pest issues and noncompliance with facility policies. CNAs reported seeing roaches throughout a third-floor unit, including resident rooms, and one CNA reported a resident killing a mouse and bringing it to the nursing station. Another CNA stated she sees roaches every day in all residents' rooms and that her response is simply to step on and kill them. A resident and the surveyor observed rodent droppings under the sink in the third-floor nourishment room, and the surveyor observed dead roaches next to a resident's nightstand and live roaches in the third-floor shower room behind a linen cart. Two residents reported a dead mouse in their room, with one placing it in a plastic bag and giving it to housekeeping, who then discarded it and stated they did not have glue traps. Environmental conditions around the dumpster area and administrative responses contributed to the deficiency. The surveyor and maintenance assistant observed two dumpsters with open lids and trash scattered around the area; the maintenance assistant acknowledged the lids should be closed and that such conditions can allow roaches and mice to enter the facility. The housekeeping supervisor also observed the same conditions and stated the dumpster area should be cleaned more than daily and that open lids and scattered trash can attract cats, varmints, and rodents. Despite facility policies requiring that outside dumpster lids be kept closed, the dumpster area kept clean, and a pest control program conducted on a regular and as-needed basis, the administrator stated she was unaware of mice in the facility, acknowledged only resident concerns about roaches, and confirmed that pest control services were limited to twice a month without additional treatment requests. These actions and inactions conflicted with the written pest control and waste management policies that assign responsibility to environmental services, maintenance, and housekeeping to prevent pest harborage and maintain closed, clean dumpsters.
Failure to Maintain Clean, Homelike Environment and Functional Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents by not providing adequate housekeeping and maintenance services. In one resident’s room, surveyors observed dried food, paper wrappings, disposable cups, and a dry black substance across multiple areas of the floor, along with window curtains that were too short to cover about one-third of the window. Staff, including an RN, the Maintenance Director, and the Administrator, acknowledged that the floor contained garbage that should have been picked up, that the resident’s bookshelf was broken and needed replacement, and that curtains should fully cover windows for privacy and comfort. Additional observations included trash along the walls in another resident’s bedroom and dirty bathroom floors in a different resident’s room. The facility also failed to maintain functional furniture and intact walls and fixtures in several resident rooms. One resident’s closet drawer front was detached and lying on the floor with bare screws or nails protruding, and the baseboard was pulled away from the wall with holes, held in place with masking tape. A rectangular cut-out in the wall providing access to sink pipes was not secured, and the resident reported seeing a large mouse come through the hole and stated that only the hot water worked at the sink and sprayed everywhere, which she said she had reported to staff three weeks earlier with no apparent repair documented. Another resident’s room had baseboards pulled away from the wall, disintegrating drywall, and a large hole in the wall behind the bed, with the entire call light box hanging from the wall. In a shared room, the toilet lid was missing and the baseboard was peeling away from the wall. Surveyors further observed environmental deficiencies in common-use areas. Both shower rooms on the second floor had dirty floors, brown splatter on the shower toilet wall, a tub filled with water and debris, and missing drywall along the base of the floor behind the toilet. A CNA confirmed these conditions and stated that housekeeping and floor techs are responsible for cleaning these areas, while a housekeeper stated that floor techs clean shower rooms, bathrooms, hallways, dining rooms, elevators, and remove garbage, and that cleaning and sanitizing are for residents’ health. Review of the facility’s work order binder did not show any of the identified room issues, despite the facility’s policies and job descriptions requiring a safe, clean, homelike environment, regular cleaning and maintenance, and staff responsibility to keep resident areas tidy and to detect and report hazardous conditions.
Failure to Protect Residents From Physical Abuse and Incomplete Documentation of Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident and to ensure accurate and complete documentation of such incidents. One resident with bipolar disorder, depression, delusional disorder, schizophrenia, heart failure, seizures, unspecified psychosis, and a BIMS score of 12 (moderate impairment) was identified as the aggressor in multiple resident-to-resident incidents. The facility’s abuse policy states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment, and that residents involved in possible abuse are to be immediately protected. Despite this, the resident’s care plan only addressed verbally abusive behavior and did not reflect physical aggression toward others. In one incident, a cognitively intact resident with anxiety, COPD, asthma, hypertension, substance abuse, and a left above-knee amputation reported that when she shared a room with the aggressive resident, the aggressive resident came into the room, hit her from behind in the jaw, and knocked items off her bedside table. The resident stated she was concerned due to her wheelchair dependence. A CNA heard commotion and heard the resident report to an RN that she had been hit. The RN later stated that the resident reported the aggressor had brushed past and bumped her shoulder and acknowledged that this contact was a form of abuse. However, review of the electronic health record for the resident who reported being hit showed no documentation of the incident in her progress notes, indicating a failure to document and formally recognize the reported physical abuse. In a separate incident, another resident with chronic respiratory failure, COPD, congestive heart failure, pulmonary embolism, hemiplegia, hemiparesis, and a BIMS score of 12 (moderate impairment) reported that the same aggressive resident entered his room, asked for money, and, after being refused, cursed at him and threw a water pitcher, striking him in the side of the face and covering him with water and ice. This resident reported the event to the nurse on duty and stated he was not physically hurt but was emotionally affected. Progress notes for both residents documented that the aggressive resident entered the room, begged for candy, and threw a pitcher of ice water into the resident’s face. Despite these documented and reported incidents, the administrator and DON stated they were not aware of the water-throwing incident or the reported hitting incident until much later, demonstrating a breakdown in timely reporting to facility leadership and failure to ensure residents were free from physical abuse.
Failure to Timely Investigate and Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate and report allegations of resident-to-resident physical abuse to the Illinois Department of Public Health (IDPH) within the required regulatory timeframe. One resident stated that a roommate entered the shared room, knocked belongings to the floor, swung the resident around from behind, and struck the resident on the right side of the jaw. The resident reported this incident to the nurse, and the alleged aggressor was sent to the hospital that day; however, review of the electronic health record progress notes showed no documentation that the aggressor hit the resident. Another resident reported that the same alleged aggressor entered the room, requested money, and when refused, became angry, cursed, and threw a water pitcher that struck the resident’s face, spilling water and ice. This second incident was documented in a progress note, which stated that the resident clearly verbalized that another resident threw a pitcher of ice water into the resident’s face. Nursing staff interviews revealed that one RN understood the contact as a form of abuse and stated that the incident was verbally reported to the administrator, and an LPN stated that the water-pitcher incident was reported to the administrator, who serves as the abuse coordinator. In contrast, the administrator reported not being informed of any abuse by the alleged aggressor, stating that the administrator only became aware of the water-throwing incident upon reviewing the progress note during the week of the survey and that the LPN said she did not know she was supposed to report it. The administrator also stated not being made aware of the alleged hitting incident and that the RN did not report it. This occurred despite existing facility documents, including an in-service on abuse education, a statement of resident rights requiring immediate reporting of alleged violations to the administrator and as required by state law, an abuse prevention policy, and a job description for the administrator that includes responsibility for compliance with federal, state, and local regulations.
Failure to Maintain Resident Bed Privacy Curtain in Multi-Occupancy Room
Penalty
Summary
The deficiency involves the facility’s failure to provide full visual privacy for one resident in a four-bed room by not maintaining a ceiling-suspended privacy curtain around the resident’s bed. On 08/03/25, the resident’s privacy curtain and attached track detached from the ceiling and fell while the resident was lying in bed watching television. A progress note from that date documents that the resident immediately notified staff, denied pulling on or laying against the curtain prior to the incident, and that a work order request was placed in the maintenance log. Despite this, on 02/13/26 at 12:00 p.m., surveyors observed the resident sitting in bed in a fully occupied four-person room with no privacy curtain around the bed. During an interview at the same time, the resident reported that the curtain had fallen months earlier and had never been replaced, stating that he had no privacy and could not change clothes at the bedside, and that he wanted some privacy. The Administrator stated that all residents should have privacy curtains and window curtains for privacy, comfort, and a homelike environment, and that maintenance should ensure all curtains are in place and in working order. The Housekeeping Supervisor stated that housekeeping is responsible for replacing privacy curtains and that all residents should have them for privacy. Facility policies and job descriptions reviewed by surveyors indicate that the facility is responsible for maintaining a safe, clean, comfortable, and homelike environment, including having privacy curtains that are clean and in good condition, and that the Maintenance Director is responsible for repairs and routine maintenance of the building and equipment. This failure affected one resident out of 22 residents reviewed.
Inadequate Peri-Care Supplies Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate peri-care supplies were available, resulting in staff using paper towels and torn linens instead of proper towels or wipes for residents’ personal care. On 1/29/2026 at 5:22 PM, R4 reported that staff had used paper towels to clean them, stating this made them feel bad and that staff should have towels or wipes. Later that day at 6:09 PM, R2 reported that staff used paper towels to clean them, expressing dislike and anger about this practice. At 6:27 PM, V9, a CNA, stated they had used paper towels to clean residents and had also ripped up shirts, blankets, and sheets to use for cleaning residents. At 6:38 PM, V10, another CNA, confirmed having used paper towels to clean residents when there was no linen available. On 1/30/2026 at 11:25 AM, V14, an LPN, stated that staff should not use paper towels to clean residents and should instead use towels or wipes. The Illinois Long-Term Care Ombudsman Program Residents' Rights booklet states that facilities must treat residents with dignity and respect and care for them in a manner that promotes their quality of life. These observations and interviews show that two of three residents reviewed for dignity experienced peri care with paper towels instead of appropriate supplies, and staff confirmed that lack of linens led to the use of paper towels and torn fabric items for resident cleaning, contrary to stated residents’ rights to dignity and respect.
Failure to Follow Community Pass Policies and Involve Responsible Parties
Penalty
Summary
The facility failed to follow its own policies and procedures regarding community survival skill assessments, physician orders for community passes, and involvement of responsible parties or families when residents left the facility against medical advice. Multiple residents were allowed to leave the facility on independent community passes without proper assessments or physician orders, and in some cases, despite having restrictions in place due to prior non-adherence or substance abuse. Documentation shows that at least two residents left on independent passes and did not return, while others were allowed out without the required physician authorization or in violation of care plan restrictions. One resident with a history of schizophrenia, substance abuse, and prior incidents of not returning from passes was allowed to leave on an independent pass, despite only being assessed as suitable for supervised passes. The resident did not return, and the facility did not notify the family or provide adequate cooperation with law enforcement. The care plan did not address the resident's history of not returning from passes, and there was no evidence of a current community survival skill assessment or physician order supporting independent pass privileges. Additionally, the facility failed to notify the responsible party or family, even though social service notes indicated family involvement in the resident's care. Other residents were also affected by similar failures. One resident with a restricted pass due to non-adherence was able to leave the facility, and staff could not confirm if family or police were notified. Additional residents were allowed out on independent passes without proper physician orders, and their care plans did not reflect the necessary restrictions or assessments. The facility's own policies require community survival skill assessments upon admission and quarterly, physician orders for pass privileges, and involvement of responsible parties in cases of discharge against medical advice or missing residents, but these procedures were not consistently followed.
Failure to Notify Family and Authorities During Resident Discharge
Penalty
Summary
The facility failed to follow its own policies regarding notification and documentation during the discharge process for one resident who left the facility on a community pass and did not return. The administrator confirmed that the resident had a history of not returning from passes and that, in this instance, the family members listed on the face sheet were not contacted when the resident failed to return. The administrator also stated that the resident's current location or status was unknown at the time of the interview. The Director of Nursing indicated that only the physician is notified when a resident responsible for themselves leaves against medical advice, and was unaware that the family was involved in the resident's care, despite documentation in the social service notes indicating family involvement. The family later confirmed they were not informed by the facility about the resident's departure and only learned of the situation through other means. Additionally, law enforcement reported difficulty in obtaining cooperation and communication from the facility when the resident was reported missing, with multiple attempts to contact the facility going unanswered. The facility's policies require notification of the physician and administrator in cases of discharge against medical advice, and suggest involving the responsible party, such as family, if available. However, there was no documentation that the family or the State Ombudsman were notified, and the facility was unable to provide evidence of such notifications or a physical copy of the police report. The lack of required documentation and notification to proper parties constituted a failure to meet regulatory requirements for discharge procedures.
Failure to Coordinate with Law Enforcement and Notify Family After Resident Does Not Return from Pass
Penalty
Summary
The facility failed to coordinate with law enforcement and provide necessary information regarding a resident who left on an independent community pass and did not return. Despite the resident having a history of not returning from passes and being reported missing, the facility was unresponsive to multiple attempts by law enforcement to obtain information. The administrator did not contact the resident's family members listed on the face sheet, and there was no documentation of family notification. The administrator also did not initially respond to emails or phone calls from law enforcement, and there was no physical copy of the police report maintained by the facility. The facility did not notify the state health department, as the incident was considered a discharge against medical advice rather than an elopement. The resident involved had diagnoses including schizophrenia, insomnia, auditory hallucinations, cocaine abuse, movement disorder, major depressive disorder, and suicidal ideations, but was assessed as having intact cognition. The DON stated that independent passes are based on cognitive status, not psychiatric diagnosis, and that family is only contacted if designated as POA. However, social service notes indicated that the family was involved in the resident's care. The lack of communication and coordination with both law enforcement and the resident's family contributed to the facility's inability to report the resident's whereabouts or status.
Failure to Ensure Call Light Accessibility and Proper Wheelchair Sizing
Penalty
Summary
Surveyors identified that the facility failed to follow its own policies to accommodate residents' needs by not ensuring that call lights were within reach for four residents and by not providing an appropriately sized wheelchair for another resident. Multiple observations revealed that call lights were either on the floor, at the foot of the bed, or otherwise out of reach for residents who required them to request assistance. In several cases, residents were unaware of the location of their call lights, and staff confirmed that the call lights should have been accessible but were not. Additionally, one resident's room was missing a second call light, and the call light system was observed to be malfunctioning, with the indicator light flashing but no sound being emitted. The report details that staff, including CNAs and LPNs, were either unaware of the call light's location or acknowledged that the call light was not within reach, contrary to facility policy and individual care plans. The Director of Nursing confirmed that call lights are expected to be within reach and that failure to do so could prevent residents from calling for help. Care plans for the affected residents specifically required that call lights be accessible and that residents be encouraged to use them for assistance, but these interventions were not consistently implemented. In addition to the call light deficiencies, one resident reported discomfort and skin irritation due to being provided with a wheelchair that was too small, despite repeated requests for a larger one. The resident demonstrated that the wheelchair was causing pressure on the thighs, and both the DON and a nurse confirmed that the wheelchair was not properly fitted. The resident's care plan included interventions to prevent skin breakdown, but the lack of an appropriate wheelchair was not addressed.
Failure to Resume Tube Feeding as Ordered After Care
Penalty
Summary
A resident with multiple diagnoses, including gastrostomy, dysphagia, vascular dementia, and severe cognitive impairment (BIMS score of 03), was observed in bed with a feeding pump at the bedside that was turned off. The feeding pump was connected to the resident and contained a bottle of Jevity 1.2. Upon inquiry, a registered nurse confirmed that the pump was off and stated that the tube feeding is supposed to run continuously for 24 hours, with flushes every 4 hours. The nurse indicated that the certified nurse assistant may have turned off the pump during patient care and did not notify the nurse to resume the feeding afterward. The facility's care plan required the resident to receive tube feeding as ordered, with the head of the bed elevated, and for the nurse to be responsible for turning the feeding pump on and off during care or therapy. The Director of Nursing confirmed that if the feeding pump is off when it should be infusing, the resident would not receive the scheduled feeding. The failure to ensure the feeding pump was turned back on after care resulted in the resident not receiving tube feeding in accordance with the physician's order.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for timely reporting of an allegation of resident-to-resident abuse. On 4/27/25, a resident with chronic kidney disease and no cognitive deficits alleged that another resident, who has schizoaffective disorder and mild cognitive impairment, engaged in inappropriate behavior toward him. The incident was documented in progress notes, and immediate actions were taken, including separating the residents, initiating 1:1 monitoring, conducting a body check, and notifying the medical doctor, family, and police. A petition for involuntary admission was also completed for the alleged perpetrator. Despite these actions, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required by its Abuse Prevention Program policy, which mandates immediate reporting, but not later than two hours after the allegation is made if abuse is involved. The incident, which occurred on 4/27/25, was not reported to IDPH until 7/17/25, well beyond the required timeframe. The administrator confirmed that this was a reportable incident and acknowledged the delay in reporting.
Failure to Investigate Resident-Staff Altercation for Possible Abuse
Penalty
Summary
The facility failed to investigate an incident involving a verbal argument and physical altercation between a resident and the Maintenance Director to rule out abuse. The incident began when the resident and the Maintenance Director had a confrontation in the elevator, which escalated to physical contact, with both parties reportedly swinging at each other and the Maintenance Director sustaining a contusion and muscle injury. The resident reported feeling harassed and being called derogatory names, while the Maintenance Director described attempts to deescalate the situation and reported the injury to human resources and the administrator. Despite the altercation and the resident's allegations, the administrator did not conduct an investigation into the incident, did not interview the resident, and did not consider the possibility of abuse, relying solely on staff accounts that the resident was the aggressor. The facility's policy requires that all incidents, whether or not abuse is alleged or suspected, be reviewed, investigated, and documented. However, the administrator, who also serves as the abuse coordinator, stated that incidents involving residents being aggressive toward staff are not reported to public health and are not investigated as abuse. The administrator did not follow the facility's investigation procedures, which include interviewing all parties involved, including the resident. As a result, the incident was not properly investigated to rule out abuse, contrary to facility policy and regulatory requirements.
Failure to Obtain Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that two residents who were receiving supplemental oxygen had active physician orders for this therapy. Both residents had significant medical histories, including chronic obstructive pulmonary disease, morbid obesity, anemia, congestive heart failure, malignant neoplasms, and muscle wasting. During the investigation, one resident was observed receiving oxygen via nasal cannula, and both residents confirmed ongoing use of supplemental oxygen. However, review of their medical records and order summaries revealed no active physician orders for oxygen for either resident. Nursing staff, including an LPN and the Director of Nursing, confirmed the absence of these orders and acknowledged that physician authorization is required for oxygen administration. The facility's own oxygen report listed both residents as receiving supplemental oxygen, yet their order summaries did not reflect any such orders. The facility's policies require that physician orders be transcribed and implemented according to professional standards and that necessary information for immediate care, including oxygen therapy, be provided at or before admission. Despite these policies, the lack of active physician orders for oxygen was not identified or addressed prior to the surveyor's investigation.
Failure to Maintain Safe and Homelike Environment Due to Environmental Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of chipped and damaged wall paint, exposed drywall, missing outlet covers, clogged sinks, broken plaster, peeling paint, brown stains from previous leaks, loose and stained ceiling tiles, missing wall tiles, and missing hand railings. These deficiencies were noted throughout resident rooms and common areas, including shower rooms and bathrooms. Staff interviews confirmed that the damage was often caused by beds and wheelchairs being pushed into walls, and that repairs had been neglected over time. The maintenance staff reported difficulty keeping up with repairs due to the extent of the damage and challenges accessing resident rooms. Residents and staff acknowledged the ongoing environmental issues, with some residents attributing the damage to routine activities such as moving wheelchairs. The facility's preventive maintenance and safety policies require regular environmental audits and prompt identification of hazards, but these were not effectively implemented, resulting in persistent environmental hazards and a lack of homelike conditions. The administrator acknowledged awareness of the environmental concerns and the need for significant improvements.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy for two residents, resulting in both sustaining scratches to their faces, necks, and arms after an altercation. Staff did not intervene in time to prevent the incident, despite being present on the unit. According to staff interviews, the altercation occurred when one resident entered another's room, and yelling was heard before staff responded. Upon entering the room, staff found both residents with visible injuries. Both residents were assessed, and their injuries were documented as scratches and a bruise, with one resident unable to verbalize what had happened due to poor cognition. The facility's abuse policy prohibits all forms of abuse, including physical and mental abuse, and requires immediate intervention to protect residents. Staff members on duty at the time reported hearing commotion and responding after the incident had already occurred. This was the first known altercation between the two residents, who were previously considered friends. The failure to intervene promptly allowed the situation to escalate, resulting in physical harm to both residents.
Inadequate Transfer Procedures Lead to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was transferred according to their care plan and proper procedures, resulting in a significant injury. The resident, who has Alzheimer's Disease, anxiety disorder, and a left below-the-knee amputation, was supposed to be transferred using a Hoyer lift with the assistance of two staff members. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone without the use of a Hoyer lift, as it was reportedly not working and no other staff were available to assist. This led to the resident falling and sustaining a fracture in the left leg, requiring surgery. Interviews with staff revealed that the facility had a policy against lifting residents manually and required the use of mechanical lifts for transfers. Despite this, the CNA proceeded with the transfer alone, citing the unavailability of a working Hoyer lift and the absence of additional staff. The facility's Director of Nursing and other staff members confirmed that the resident required a mechanical lift for safe transfers due to their medical condition and mobility limitations. The investigation also uncovered that the facility had an insufficient number of mechanical lifts available for the number of residents requiring them. Only one working Hoyer lift was found on the floor, which was inadequate for the needs of the residents. This lack of equipment and staffing contributed to the unsafe transfer attempt, ultimately leading to the resident's injury.
Inaccurate Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to accurately document a fall incident involving a resident, leading to inconsistencies in the resident's medical records. The resident, who has Alzheimer's disease, anxiety disorder, and a left below-the-knee amputation, reported that she fell while being transferred from a dialysis chair to her bed. The resident stated that the staff member assisting her did not use a gait belt and that it typically requires two people or a Hoyer lift to transfer her safely. However, on the day of the incident, only one staff member was available to assist her, leading to the fall. The documentation of the incident was inconsistent, with discrepancies in the date of the fall and the staff involved. The Licensed Practical Nurse (LPN) documented the incident as occurring on a different date than what was reported by the Certified Nursing Assistant (CNA) involved in the transfer. The facility's incident report and clinical notes also contained conflicting information regarding the date and staff involved. Despite inquiries, the facility's administration was unable to clarify these inconsistencies, affecting the credibility of the documentation.
Inadequate Linen and Towel Supply Affects Resident Care
Penalty
Summary
The facility failed to provide adequate supplies for activities of daily living, such as towels and linen, for all 205 residents. Observations on multiple days revealed that utility closets and rolling linen carts had very few linens and towels, with some lacking gowns, pads, or linen entirely. Staff members, including LPNs and CNAs, reported frequent shortages of linen and towels, which hindered their ability to perform necessary resident care tasks. CNAs resorted to using wet wipes or cutting sheets to make towels, and some even purchased supplies with their own money. The Director of Housekeeping confirmed the shortage and stated that orders for more supplies required approval from the owner, with a limited budget for purchasing these items. Residents expressed frustration and discomfort due to delays in receiving care, such as being cleaned or showered, because of the lack of towels and linen. Some residents reported having to wait for extended periods, even when soiled, which affected their dignity and quality of life. The facility's policies on laundry services and resident dignity were not adhered to, as there was not an adequate supply of clean linen maintained for resident care. The Assistant Director of Nursing and the Administrator acknowledged the issue but did not indicate any immediate resolution to the shortage.
Medication Management and Staffing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the residents' physician, maintain secure storage of medications, provide sufficient nursing coverage, and meet professional standards of care. On the day of the survey, a nurse did not show up for the morning shift, leading to inadequate nursing coverage. This resulted in some residents not receiving their medications on time, as observed by the surveyor. Additionally, a Licensed Practical Nurse (LPN) was found to have prepared medications for multiple residents simultaneously, which is against the facility's policy and increases the risk of medication errors. The facility also failed to provide timely incontinence care to a resident due to a lack of available linen. A Certified Nursing Assistant (CNA) reported not being able to change a resident because there was no linen available, which was corroborated by the laundry aide who stated that there was a shortage of linen in the building. This shortage was also noted in the resident council meeting minutes, where residents expressed concerns about the lack of linen and nursing staff during night shifts. Furthermore, the surveyor observed a medication cart left unlocked and unattended, with the electronic medication administration record (eMAR) visible, posing a risk to resident safety and privacy. The facility was unable to provide the surveyor with the requested HIPAA policy or medication audit report during the survey. These deficiencies highlight significant lapses in medication management, staffing, and adherence to professional standards, affecting the quality of care provided to the residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect seven residents from abuse, as evidenced by multiple incidents of physical altercations and alleged abuse. Resident 1, with a history of violent behavior and mental health disorders, was involved in a physical altercation with Resident 2, who has cerebral palsy and requires substantial assistance with activities of daily living. The altercation was witnessed by peers, and Resident 1 was noted to have made threats towards Resident 2. Additionally, Resident 3, with moderate cognitive impairment, was involved in a physical confrontation with Resident 4, who has severe cognitive impairment, during a smoking break. This incident was witnessed by an activity aide and several residents. Another incident involved Resident 5, who pushed Resident 6, a blind resident, after becoming frustrated with Resident 6's behavior. Resident 5 has a history of aggressive behavior and was noted to have lost their temper. The facility's response included separating the residents and conducting assessments, but the incident was substantiated as having occurred. Furthermore, Resident 7 alleged that a CNA, V9, physically abused them during a toileting incident, which led to a police report being filed. However, the facility's investigation did not substantiate the claim due to a lack of evidence and witness statements. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. Despite this policy, the facility failed to prevent multiple incidents of resident-to-resident altercations and an alleged staff-to-resident abuse. The report highlights deficiencies in the facility's ability to protect residents from abuse and ensure their safety, as evidenced by the repeated incidents and the lack of effective intervention to prevent such occurrences.
Inadequate Supervision and Care Plan Management
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, specifically for a resident identified as R8, who sustained a leg fracture. On the day of the incident, R8 was found by the restorative team to be in pain and unable to stand, which was unusual as R8 typically ambulated without assistive devices. Despite R8's insistence that he was fine, the LPN noticed facial grimacing and further assessed R8, leading to the discovery of a leg fracture through an x-ray. The care plan for R8 did not include updated fall interventions, such as a low bed and floor mat, which were documented elsewhere but not on the care plan itself. Additionally, the facility's supervision practices were found lacking. A CNA responsible for monitoring residents in the dining room was observed using a personal electronic device to watch social media videos, admitting that this distracted her from effectively monitoring the residents. This lack of attention could potentially lead to residents falling or injuring themselves, as the CNA acknowledged. The facility's policy prohibits cell phone usage while on duty, yet this was not adhered to, compromising resident safety. R8's medical history includes heart failure, a history of falling, dementia, and other conditions that place him at high risk for falls. Despite this, the facility did not adequately update his care plan following the incident, nor did they ensure proper supervision in common areas. The facility's policies on fall prevention and supervision were not effectively implemented, contributing to the deficiencies observed by the surveyors.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate abuse allegations involving three residents. For two residents involved in a physical altercation, the facility's investigation was incomplete as key witnesses, including a Certified Nursing Assistant (CNA) and other residents, were not interviewed. The administrator acknowledged the oversight, admitting that the investigation was not conducted thoroughly, which could lead to potential re-occurrence and inadequate care planning. In another incident, a resident reported being physically abused by a CNA during a toileting incident, which resulted in the resident being sent to the hospital and a police report being filed. The facility's investigation into this incident was also incomplete, as witness statements from the involved CNAs were not obtained. The resident involved in this incident has a complex medical history, including conditions such as chronic obstructive pulmonary disease, heart failure, and dementia, and requires substantial assistance with toileting.
Failure to Maintain Clean Environment in Resident Bathroom
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, as evidenced by the presence of brown stains on the bathroom wall shared by the residents. The issue was first brought to attention by a resident who complained about the stains, suspecting them to be feces from a previous roommate. The surveyor confirmed the presence of the stains during an inspection, and a housekeeper, upon being shown the stains, stated she was unaware of them and did not know what the substance was. The Director of Nursing acknowledged that such stains should not be present and emphasized the facility's expectation to maintain cleanliness. The Housekeeping Director confirmed that it was the responsibility of the housekeeping staff to clean and disinfect any marks on the bathroom walls. Despite a resident's report to a housekeeping staff member, the issue remained unaddressed, indicating a lapse in communication and action within the facility's housekeeping procedures.
Failure to Provide Timely Incontinent Care Due to Equipment Issues
Penalty
Summary
The facility failed to provide timely incontinent care to a resident, identified as R7, who is dependent on staff for assistance with activities of daily living due to significant mobility impairments. R7, who is cognitively intact with a BIMS score of 15, was observed by a surveyor sitting in the hallway, soiled with feces, and complaining about the delay in receiving care. The delay was attributed to the mechanical lift not being charged, which was necessary for transferring R7 to the bed for cleaning. Despite R7's complaints starting at 12:00 PM, the resident remained soiled until 1:06 PM when a CNA brought a mechanical lift from another unit to provide the necessary care. Interviews with staff revealed that the mechanical lift on the second floor was not charged, and there was only one working lift available, leading to delays in care. The LPN confirmed that R7 had informed them of the need for a change at 12:00 PM, but the issue with the lift prevented timely action. The facility's policies on activities of daily living and incontinence care emphasize the importance of timely care to prevent skin breakdown and maintain resident dignity, which was not adhered to in this instance. The Director of Nursing stated that the expectation is for residents to be changed as soon as possible when soiled, highlighting a failure in meeting this standard of care for R7.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident, R11, from abuse by another resident, R4. R11, who has a cognitive communication deficit and other health issues, reported that R4 pulled their hair and hit them with a bag of cups. This incident was witnessed by a CNA who confirmed that R4 had a history of violent behavior and had previously assaulted peers. Despite this history, R4 did not have a 1:1 aide at the time of the incident, and both residents were seated at the same table when the altercation occurred. R4, diagnosed with bipolar disorder and other conditions, has a documented history of verbal and physical aggression. The facility's records show that R4 had been physically aggressive towards peers on multiple occasions, necessitating 1:1 staff intervention. However, on the day of the incident with R11, such supervision was not in place. The facility's behavior management policy outlines preventative measures for agitated behavior, but these measures were not effectively implemented to prevent the altercation between R4 and R11.
Inadequate Catheter Care Leads to Health Issues
Penalty
Summary
The facility failed to provide appropriate catheter care for three residents, resulting in adverse health outcomes. Resident R2, who had a flaccid neuropathic bladder, was admitted with an indwelling catheter but lacked proper documentation and monitoring of catheter changes. The resident was transferred to the hospital with abdominal pain and diagnosed with a urinary tract infection (UTI). The facility's records did not include necessary details such as catheter size or documentation of catheter and drainage bag changes, leading to inadequate care. Resident R3, diagnosed with neuromuscular dysfunction of the bladder, also experienced insufficient catheter care. The resident's urinary catheter bag and tubing were observed to be purple and contained sediment, indicating a lack of timely changes. Despite having a care plan that required catheter and drainage bag changes as needed, there was no documentation of these changes, and the resident was unaware of when the last change occurred. Similarly, Resident R4, with a diagnosis of hydronephrosis and ureteral stricture, had a suprapubic catheter that was not properly monitored or documented. The resident's catheter bag and tubing were discolored and contained thick sediment, with no records of recent changes. The facility's catheter care policy, which mandates removal and reinsertion of catheters when urine contents are not visible, was not followed, contributing to the deficiencies observed.
Inaccurate Fall Risk Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate fall risk assessments for two residents, R2 and R3, as required by their fall prevention and management policy. R2, who had functional limitations due to hemiplegia and hemiparesis, experienced a fall while being assisted by a CNA. The post-fall risk assessment inaccurately scored R2 as a moderate risk, failing to select 'Exhibits loss of balance while standing' and 'Decrease in muscle coordination,' despite these being relevant to R2's condition. The Director of Nursing acknowledged these omissions during the surveyor's inquiry. Similarly, R3's fall risk assessment was inaccurate following a fall incident. R3, who has paraplegia and uses a wheelchair, was incorrectly assessed as having no history of falls within the last three months and was marked as ambulatory and continent, despite having an indwelling urinary catheter and neuromuscular dysfunction of the bladder. The Director of Nursing confirmed these inaccuracies when questioned by the surveyor.
Deficiencies in Shower Room Maintenance
Penalty
Summary
The facility failed to maintain the community shower room on the third floor North-Wing in good repair and a sanitary manner, potentially affecting all 53 residents on that floor. During an inspection, it was observed that the hand-washing sink was leaking and not properly affixed to the wall, two visibly soiled wet towels were on the floor of the shower stall, ceiling tiles were missing, and the soap dispenser by the sink was broken with no soap available for handwashing. These issues were confirmed by the housekeeper, who acknowledged that they were maintenance issues and stated that they would inform the maintenance team to address them. The Maintenance Director was unaware of the issues with the soap dispenser and other maintenance concerns, although he was working on resolving a hot water issue. The facility's Preventative Maintenance Program policy includes conducting regular environmental tours and safety audits to identify areas of concern, such as ensuring ceiling tiles are free from water marks or spots. However, the lack of communication between housekeeping and maintenance staff contributed to the oversight of these deficiencies in the shower room.
Inadequate Wound Care and Improper Waste Handling
Penalty
Summary
The facility failed to adhere to a doctor's wound care order for a resident, identified as R442, who was admitted with a surgical wound and hospital discharge orders for IV antibiotics for a skin and soft tissue infection. The resident's wound dressings were not changed as ordered, leading to the dressings being saturated with dark brown drainage and appearing unclean. The wound care nurse, V16, and the wound care coordinator, V17, both confirmed that they had not performed any wound care for R442, despite the treatment administration record indicating otherwise. This neglect resulted in the resident experiencing significant pain and an increased risk of infection. Additionally, the facility failed to follow proper garbage handling procedures, as observed with a housekeeper, V38, who was seen dragging an unsecured garbage bag containing soiled incontinence wear and other waste across the floor of the second-floor North unit hallway. This action was acknowledged by V38 as unsanitary and a potential cause of cross-contamination and germ spread. The Housekeeping Director, V24, confirmed that the garbage should have been carried upright and placed in a designated compartment on the housekeeping cart to prevent infection control issues. The facility's policies on wound care and housekeeping were not followed, as evidenced by the lack of completed skin assessments and wound care documentation for R442, and the improper waste handling observed. These deficiencies highlight a failure in the facility's infection prevention and control program, which could lead to further harm to residents.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to provide an adequate amount of linen and towels to meet the care needs of all 197 residents. Observations and interviews revealed that there was a consistent shortage of linens, including fitted and flat sheets, pillowcases, bath and face towels, gowns, and pads. Certified Nursing Assistants (CNAs) reported that beds were not made due to the lack of linen, and some resorted to cutting up existing linens to create makeshift towels. The linen carts and supply closets were frequently found empty or inadequately stocked, affecting the ability to provide proper care. The laundry department was observed to have insufficient supplies, with aides acknowledging the need for more linen and towels. The Housekeeping Director confirmed a limited budget of $500-$600 per month for linen purchases, which was insufficient to meet the facility's needs. Staff members, including CNAs and nurses, reported improvising with available materials and even purchasing towels with their own money to ensure residents had necessary supplies. The facility's policy on maintaining an adequate supply of clean linen was not being met, as evidenced by the lack of documentation or invoices showing consistent linen orders. Residents expressed dissatisfaction during a council meeting, stating that they often had to wait for towels to be washed before they could shower. This delay affected their daily routines, with some residents having to attend breakfast before bathing due to the lack of available towels. The Administrator and Director of Nursing were aware of the issue, but the problem persisted, impacting the residents' right to a safe, clean, and homelike environment as outlined in the facility's policies.
Failure to Secure Soiled Utility Rooms
Penalty
Summary
The facility failed to secure Soiled Utility rooms containing sharps and infectious waste materials, posing a potential safety hazard to all residents. On multiple occasions, surveyors observed doors to these rooms left open or unlocked, allowing potential resident access. The rooms contained items such as biohazard bags, full sharps containers, and cleaning chemicals, which should not be accessible to residents due to safety concerns. Staff members, including floor techs and LPNs, acknowledged that the rooms should be locked and that residents should not have access to them. The facility's policy on Supervision and Safety emphasizes making the environment as free from hazards as possible, yet the observations indicate a failure to adhere to this policy. The Director of Nursing, who had recently started, was unable to provide specific details about the contents of the Soiled Utility rooms but confirmed that residents should not have access to potentially harmful items. The facility's Sharp Object Disposal policy also outlines proper storage for filled sharps receptacles, which was not followed as evidenced by the unsecured rooms.
Deficiencies in Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen, which has the potential to affect all 196 residents, with one resident not taking food by mouth. Observations revealed that fans and portable air conditioners used in the kitchen had dirt on their grills, and stagnant water was found in a dustpan, attracting insects. The Food Service Director (V18) acknowledged the unclean state of the equipment and the presence of stagnant water, which was not supposed to be left in such a condition. Additionally, the kitchen areas, including underneath the dishwasher, three-compartment sink, and stove, were found to be dirty and littered with food wrappers. The facility also failed to ensure that testing strips for the three-compartment sink were available and not expired. The Food Service Director (V18) was unable to find any non-expired testing strips, indicating a lack of awareness that these strips have expiration dates. The Maintenance Director (V14) stated that the fans were dusty and should be cleaned by dietary and housekeeping staff, while V18 believed it was the maintenance staff's responsibility. The facility was unable to present a policy related to environmental cleaning in the kitchen, further highlighting the lack of proper procedures and oversight in maintaining a hygienic food preparation environment.
Deficiencies in Hot Water Supply and Safety Hazards
Penalty
Summary
The facility failed to provide functional and comfortable hot water for four residents, as observed and reported by the residents themselves. One resident stated that the hot water did not work during her shower, and another mentioned that the water was lukewarm despite being told it was fixed. A third resident expressed a desire to shower but was unable to due to the cold water, and a fourth confirmed that the hot water was not working in the rooms and showers. The Maintenance Director acknowledged the issue, stating that the facility was installing a second water heater due to complaints about insufficient hot water, which had been ongoing for about two weeks. Additionally, the facility failed to maintain a safe environment for one resident, who was exposed to sharp metal edges from an uncovered window air conditioner unit. The resident reported that the unit had been in this condition since shortly after moving into the room, posing a risk of injury. The Maintenance Director confirmed awareness of the issue, noting that the air conditioners were not functional and were intended to cover window holes. He admitted that the sharp edges could be hazardous, although the unit was not plugged in. The facility's preventative maintenance program policy, dated November 2023, outlines the need for regular environmental tours and safety audits to identify areas of concern, including ensuring appropriate water temperatures. Another undated policy emphasizes the importance of making the environment as hazard-free as possible, with safety risks identified through ongoing employee training. Despite these policies, the facility's failure to address the hot water and safety issues in a timely manner resulted in deficiencies affecting the residents' comfort and safety.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations of unsanitary conditions in the kitchen and pest sightings in resident rooms. On October 1, 2024, during an inspection with the Food Service Director, dirt and food wrappers were found underneath kitchen equipment, and a dustpan filled with stagnant water and insects was discovered near the walk-in freezer. The Food Service Director was unsure of the last cleaning date and acknowledged that staff should not have left the dustpan in such a condition. Additionally, a cockroach was observed moving towards the food preparation area during a tray line food preparation session, causing alarm among the dietary staff. The pest control company had visited the facility on October 1, 2024, but the documentation provided by the Maintenance Director did not specify the areas serviced. Previous pest control records indicated activity in the main kitchen area, but no traps were found during a subsequent inspection. The facility's pest control policy emphasizes the importance of maintaining cleanliness to prevent pest harborage, yet these standards were not upheld, as evidenced by the presence of pests in the kitchen and resident rooms. Two residents, both with intact cognition, reported seeing roaches in their rooms and expressed dissatisfaction with the pest presence. A Licensed Practical Nurse observed a roach in one resident's room while adjusting medical equipment. The Maintenance Director, who has been with the facility since March 2024, stated that the pest control company visits twice a month and relies on pest logs maintained by nursing staff to determine treatment areas. However, the Director does not conduct inspections for pests, leaving the responsibility to the pest control company. The facility's housekeeping guidelines require monitoring of pest control services, but these procedures were not effectively implemented, leading to the deficiencies observed.
Failure to Conduct PASRR Level II Assessments
Penalty
Summary
The facility failed to refer six residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for a Pre-Admission Screening and Resident Review (PASRR) Level II assessment. The Social Service Director, V13, was responsible for handling PASRR Level I and Level II assessments but was unaware that residents with new serious mental illness diagnoses needed to be referred for a Level II assessment. This lack of awareness led to the failure to conduct necessary screenings for residents R21, R79, R97, R120, R127, and R135. The report highlights specific cases where the PASRR process was not followed. For instance, R21 and R127, both diagnosed with serious mental disorders, had no documentation of a PASRR Level II screening. Similarly, R79 and R97 had previous Level I screenings that indicated no need for Level II, but their conditions had changed, necessitating a new assessment. R120, who transferred from another facility, lacked any PASRR documentation, and R135's PASRR records were missing, with the administrator acknowledging a lapse in the process. The facility's policy mandates compliance with federal and state PASRR requirements, including obtaining complete screening documents and reviewing them to address residents' needs. However, the report indicates that these procedures were not followed, resulting in the absence of necessary PASRR documentation for the affected residents. The Social Service Director and the facility administrator both acknowledged gaps in the PASRR process, with the administrator noting that the corporate office was responsible for providing PASRR information, which was not on file for some residents.
Failure to Provide Adequate Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to provide adequate incontinence care and scheduled showers for several residents, leading to deficiencies in their care. One resident, who is dependent on assistance for activities of daily living, reported not receiving a shower for approximately three weeks due to inconsistent water temperatures in the facility's shower rooms. This resident's care plan indicated a need for regular showers twice a week, but there was no documentation of showers being provided, and the staff confirmed the issue with water temperature and lack of shower documentation. Another resident reported that their incontinence briefs had not been changed since the previous evening, resulting in them being left in their own feces for hours. This resident, who is incontinent of bowel and has a stage three pressure ulcer, expressed concern about the potential worsening of their wounds. Similarly, another resident was left soiled with urine and feces for an extended period, despite informing staff of their condition. The staff acknowledged the delay in providing care and confirmed the resident's soiled state upon finally attending to them. A third resident was found with visibly soiled incontinence briefs and bed sheets, indicating a lack of timely care. The staff admitted that they had not provided incontinence care for this resident due to a lack of towels, which were only delivered later in the day. The facility's policy requires residents to be checked every two hours and provided with perineal care after each episode of incontinence, but this was not adhered to, resulting in the resident being left in a soiled state for an extended period.
Deficiencies in Respiratory Care Protocols
Penalty
Summary
The facility failed to adhere to its tracheostomy care policy for a resident, identified as R49, who was observed manipulating his tracheostomy inner cannula in an unhygienic manner. R49, who has a medical history of bacterial pneumonia and infections, was seen inserting a transparent tube into his tracheostomy opening. Staff members, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing, acknowledged that R49 frequently removes and reinserts his tracheostomy inner cannula, sometimes sucking on it. Despite this behavior, there was no consistent monitoring or cleaning of the cannula, and the issue was not addressed in R49's care plan, which is crucial given his impaired immune status and history of respiratory infections. Additionally, the facility did not label and date oxygen tubing for three residents, identified as R8, R96, and R124, who were receiving oxygen therapy. Observations revealed that the oxygen tubing for these residents was not labeled with the date and time of the last change, contrary to the facility's protocol. The Director of Nursing confirmed that the tubing should be labeled to ensure timely changes, as failure to do so could lead to respiratory infections or insufficient oxygen delivery due to old or kinked tubing. The facility's policies on tracheostomy care and oxygen equipment were not followed, potentially affecting the respiratory health of the residents involved. The lack of adherence to these protocols highlights a deficiency in maintaining a clean and safe environment for residents requiring respiratory care, as evidenced by the observations and interviews conducted during the survey.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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