Citations in Illinois
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Illinois.
Statistics for Illinois (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Illinois
- Re-educated all facility staff on the Abuse/Neglect & Exploitation policy and Abuse Prevention to reinforce correct recognition, intervention, and reporting practices (K - F0600 - IL)
- In-serviced all agency personnel on the Abuse/Neglect & Exploitation policy and Abuse Prevention prior to each shift to ensure temporary staff met the same prevention standards as facility employees (K - F0600 - IL)
- Reviewed and revised abuse policies to include resident-to-resident altercations so preventive expectations are clearly defined for this risk area (K - F0600 - IL)
- Updated abuse-investigation and documentation procedures and trained staff on the revisions to strengthen timely, comprehensive follow-up of any allegations (K - F0600 - IL)
- Educated nurse aides and licensed nurses on behavior documentation and instituted ongoing monitoring of their charting by the Social Services Director/MDS to ensure aggressive behaviors are accurately tracked and addressed (K - F0600 - IL)
Failure to Prevent Burns from Hot Liquids Due to Lack of Individualized Interventions and Hazard Identification
Penalty
Summary
The facility failed to implement individualized care planned interventions to prevent a resident with significant physical disabilities from sustaining multiple burns. The resident, who had diagnoses including Spastic Cerebral Palsy, Scoliosis, Dysphagia, and Muscle Spasms, required supervision or assistance with eating and was dependent on staff for all other activities of daily living. Despite these needs, the resident was allowed to handle hot coffee independently, resulting in two separate incidents where hot coffee was spilled on her left posterior thigh, causing second-degree burns on both occasions. The care plan did not include a hot liquid risk assessment, and interventions to prevent such injuries were either not in place or not followed by staff. The facility also failed to identify the hot water/coffee dispenser in the main dining room as a potential burn hazard. The dispenser was accessible to all residents, and the coffee and hot water were routinely served at temperatures ranging from 170 to 177 degrees Fahrenheit, well above the threshold known to cause burns. There were no protocols or adequate monitoring in place to ensure that hot liquids were served at safe temperatures. Staff interviews revealed a lack of awareness regarding residents' care plans and the need for assistance with hot liquids, and some staff did not know how to access or update care plans. Additionally, the dining room doors were sometimes left open or unlocked, allowing residents unsupervised access to the hot beverage dispenser. The facility did not have a Hot Liquids Policy in place prior to the incidents, and staff were not in-serviced on the risks associated with hot liquids or the need for individualized interventions. The lack of a systematic approach to assessing residents' risk for hot liquid injuries, combined with inadequate staff training and supervision, directly contributed to the resident's repeated injuries. The failures affected not only the resident who was burned but also placed all 59 residents who accessed the hot beverage dispenser at risk.
Removal Plan
- All residents were interviewed by V8/Wound Nurse, V22/Restorative Nurse, V23/Business Office Manager, and V24/Social Service Director for hot liquid spills with injury.
- R1 was removed from the dining room, laid down, clothes were removed, and a head-to-toe skin assessment was completed. V7/R1's Physician and V25/R1's Family member was notified. A wound dressing was ordered, R1's care plan was updated to ensure staff assisted R1 with a waterproof clothing protector and lap blanket to be worn during all meals and as needed for food and fluid intake and to continue Occupation therapy three times a week for twelve weeks.
- A Hot Liquid Policy was developed and implemented.
- A Hot Liquid Risk Assessment was developed and implemented.
- V1/Administrator in-serviced Department Managers (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the facility's Hot Liquid Policy. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- All residents, including R1, were assessed with the facility hot liquids assessment to determine if they are at risk of being injured.
- R1's care plan was updated to include interventions for hot liquid spills with injury and for Speech Therapy to Evaluation and Treat.
- The facility implemented utilizing colored napkins to alert each member of the team that the resident is at high risk for burn injury.
- All at risk residents for being injured due to hot liquids were identified on meal tray cards.
- V4/MDS Coordinator updated all resident care plan with interventions that were identified as at risk for spilling hot liquids causing injuries.
- The coffee machine in the main dining room was disconnected.
- The coffee machine was removed from the main dining room. Coffee and other hot liquids are being served from the kitchen and temped prior to being served.
- A new coffee machine was ordered and will be dispensed at 150 degrees Fahrenheit.
- Waterproof adult clothing protectors and waterproof blankets were ordered for the residents identified at risk for injury from hot liquid.
- A Food Temperature Log for Meal Services was implemented with coffee/hot water to be served at 150 degrees Fahrenheit or less.
- V1 in-serviced each department manager (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, and that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- A system was put in place for an audit to be done by V2/Director of nursing, for five residents daily, five days a week, for six weeks to ensure compliance with interventions being put in place. V2/Director of Nursing is utilizing the audit tool to ensure care plan interventions are being followed. These are monitored/audited for compliance by V1/Administrator one time per week.
- V4/MDS Coordinator reviewed and updated R1 and the residents identified to be at risk for injury from hot liquids care plans.
- V1/Administrator provided all staff in-servicing regarding the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- V1/Administrator in-serviced all Agency Staff regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit, and the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- A copy of the facility's Hot Liquid Policy was added to the new orientation manual and the agency orientation manual.
- A system was put in place for an audit to be done by V3/Dietary Manager, for five residents daily, five days a week, for six weeks to ensure compliance with temperatures of hot liquids prior to being served to ensure they are below the appropriate temperatures. V3/Dietary Manager is utilizing this audit form to ensure hot liquids are being served at appropriate temperatures. These are monitored/audited for compliance by V1/Administrator once time per week.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions and Staff Education
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse after a resident with severe cognitive impairment and a history of agitation and aggression was not provided with appropriate interventions or increased supervision. Despite documented behaviors such as wandering, suspicion, agitation, and combativeness, there was no behavior care plan for aggression in place for this resident until after multiple incidents occurred. Staff were not educated on increasing supervision or on specific interventions following an initial altercation where the resident threw a handheld radio, striking another resident. Subsequently, the same resident was involved in a second incident where he physically shoved a trash can into another resident's face, resulting in a bleeding laceration to the upper and lower lips. Staff interviews revealed that there were no individualized interventions for residents on the dementia unit, and that staff had not been educated on communication, redirection strategies, or monitoring for signs of agitation after the altercation. Additionally, the two residents involved in the altercation continued to have rooms next to each other, despite ongoing conflict and aggressive behaviors. The facility's own policies required the identification, assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, as well as staff training and ongoing supervision. However, these policies were not implemented as written, and there were system failures regarding care plans, documentation, and communication of interventions to floor staff. The lack of timely and effective interventions resulted in physical harm to a resident and placed all residents in the dementia unit at risk.
Removal Plan
- The DON/Director of Nursing, Social Services Director and designee assessed all residents in memory care to determine their level of risk with the Abuse assessments and Aggressive behavior assessment.
- 15-minute checks for R1 changed to 1:1 supervision.
- R1 was evaluated by V13's team with inpatient hospital evaluation/treatment and review of medications.
- R1's care plan updated with individualized interventions for aggressive behaviors.
- R1 is not to be seated by other residents with activities, dining etc. when agitated.
- Social Services Director, DON and Administrator re-educated staff on Abuse/Neglect & Exploitation policy and Abuse Prevention.
- All Agency staff being in-serviced on Abuse/Neglect & Exploitation policy and Abuse Prevention prior to start of next shift.
- R1's abuse and aggression assessments completed/updated.
- R1's care plan reviewed and revised by facility interdisciplinary team and revisions and interventions communicated to front line staff caring for R1.
- Abuse policies reviewed/revised to include resident to resident altercations.
- Abuse investigation procedures and documentation process reviewed/revised, and Education provided to all staff.
- DON and designee educated Nurse Aids and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director/MDS/Minimum Data Set Coordinator or designee and care plans to be updated as indicated. Staff will be educated on new interventions either verbally or in writing by Care Plan Coordinator or designee.
- An emergency QAPI (Quality Assessment Performance Improvement) meeting was held to develop and implement plans to prevent further resident abuse.
Failure to Monitor Anticoagulant Therapy Leads to Hospitalization
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident who was receiving Warfarin for a diagnosis of pulmonary embolism. Despite having a physician order dated 4/23/25 to check PT/INR levels weekly, the resident's PT/INR was not monitored as required. The last PT/INR test was completed on 3/26/25, and no further tests were performed after that date, even though the resident continued to receive Warfarin. This lapse in monitoring was identified when the resident was admitted to the hospital with a supratherapeutic INR greater than 10, well above the target therapeutic range of 2-3. Hospital records documented that the resident suffered from acute blood loss anemia, probable gastrointestinal bleed, and required reversal of Warfarin with Kcentra, as well as multiple blood transfusions. The resident's family member expressed concern that the required INR checks were not being performed, and the attending physician confirmed that the weekly monitoring order had been given but not followed. Facility staff interviews and record reviews confirmed that the PT/INR tests were not conducted as ordered, and the Director of Nursing acknowledged that the tests should have been performed but were not. The facility's own anticoagulant policy required regular monitoring of PT/INR for residents on Warfarin, but this was not adhered to in this case, resulting in the resident experiencing significant medical complications.
Removal Plan
- Audit of all resident laboratory orders was completed by Director of Nursing.
- Audit of all residents that have physician orders for Warfarin were identified and have active lab orders for PT/INRs to monitor for therapeutic effectiveness was completed by Director of Nursing.
- Facility licensed nursing staff were educated by phone or in person in the following categories: Obtaining laboratory testing as ordered by the physician, with special consideration for those residents on Warfarin by Director of Nursing.
- Audit of all scheduled labs was completed, including PT/INRs by Director of Nursing.
- Audit of all residents with Warfarin medication orders were ensured to have scheduled laboratory testing of PT/INRs to monitor for therapeutic effectiveness by Director of Nursing.
- Director of Nursing initiated a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary.
- Licensed agency staff will not work at the facility until they are educated by the Director of Nursing/Designee on the importance of ensuring PT/INR levels are ordered with Warfarin to monitor for therapeutic effectiveness.
- The facility will educate all Agency and Facility licensed nursing staff on a quarterly basis and during orientation on the order process for labs, with emphasis on the need for therapeutic monitoring for effectiveness for residents with medication orders for Warfarin, by the Director of Nursing or Designee.
- The Director of Nursing or designee has put into place a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary.
- The Director of Nursing or designee will complete random audits of scheduled laboratory testing as ordered by the physician, with special consideration for those residents on warfarin until compliance is achieved.
- Results of the above reviews will be discussed at a weekly quality assurance meeting that the Administrator is the head of/holds and will provide additional education as needed and implement interventions for improvement until resolution.
Failure to Provide Prescribed Pain Management Medications
Penalty
Summary
The facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants for pain control to two residents who required such services. Both residents had documented histories of severe, chronic pain and complex medical conditions, including spinal muscular atrophy, neuralgia, muscular dystrophy, and chronic pain syndrome. Despite physician orders for scheduled pain medications, there were repeated instances where these medications were not available or not administered as prescribed, as evidenced by gaps in the Medication Administration Records (MARs) and Controlled Substances Proof of Use logs. One resident experienced ongoing, uncontrolled, and severe pain, rating it as a 9 out of 10, and reported that the pain became unbearable when pain medications were not available. The resident stated that no alternative interventions were provided, and he simply had to wait until the medication arrived. Another resident, with similar complex pain management needs, described her pain as excruciating and continuous, leading to an emergency room visit for pain relief after not receiving scheduled medications. She reported symptoms of medication withdrawal, a significant decrease in quality of life, and expressed feelings of being forgotten and wanting to die. Interviews with staff, including the DON and LPNs, confirmed that there were ongoing issues with pharmacy transitions, medication ordering, and delivery, resulting in delays and missed doses of critical pain medications. Staff acknowledged that the system required documentation for each medication administration, and blanks in the MAR indicated missed doses. The facility's own policies required timely administration of medications as ordered, but these were not followed, leading to significant unrelieved pain and withdrawal symptoms for the affected residents.
Removal Plan
- Medical Director consulted regarding the availability of pain medication for R1 and R2.
- Medication for R1 and R2 were ordered, received, and administered as prescribed.
- All medication orders received by pharmacy from the physician for R1 and R2 and delivered STAT to the facility.
- An audit for all resident medications for pain was completed by the ADON.
- Medical Director provided pain medication orders to pharmacy.
- Education provided to nursing staff by the Administrator to ensure appropriate identification, documentation, and timely treatment for pain, as well as processes and procedures that assure the accurate acquiring, receiving, dispensing, and administering of medication for pain.
- The Director of Nursing or Designee will provide on-going education to any new or agency nursing staff, not in-serviced, prior to the start of their next shift.
- Pain assessment on the MAR/TAR to be completed by nurse every shift and addressed if pain noted.
- Director of Nursing or designee will conduct audit of pain medication administration to ensure appropriate knowledge and understanding of narcotics delivery, documentation, and administration practices.
- The Director of Nursing or designee will address all concerns identified during the audit.
- The Director of Nursing or designee will report audit findings to the Quality Assurance and Performance Improvement Committee monthly and thereafter as determined by the QAPI Committee.
Failure to Secure Front Entrance Results in Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the front entrance was safely supervised and/or secured, resulting in a resident with severe cognitive impairment and multiple medical conditions exiting the building without staff knowledge. The resident, who was at high risk for falls and had a care plan indicating the need for a safe environment and supervision, was last seen in bed by a CNA during the night shift. Staff discovered the resident missing approximately 45 minutes later and began searching the facility, initially believing that door alarms would have sounded if the resident had exited. Upon checking, staff found that the front door alarm was not activated or not functioning, and the alarm did not sound when tested. The resident was eventually found by police across a four-lane highway, wearing only a hospital gown, a brief, and shoes, in cold weather conditions. The resident was confused, had sustained injuries including a missing tooth and abrasions, and was hypothermic with a body temperature of 93.2°F. Emergency department records confirmed an acute subdural hematoma, hypothermia due to cold environment, and an unwitnessed fall. The resident was admitted to the hospital for further care. Interviews with staff and review of video footage confirmed that the resident exited through the front door during the early morning hours, and that the door alarm system was not functioning as required. The facility's elopement policy required adequate supervision and a safe environment for all residents, but these measures were not effectively implemented, allowing the resident to leave the facility undetected.
Removal Plan
- Conducted a full house audit of all residents to identify those who are an elopement risk.
- Conducted in-services with all staff on the elopement policy.
- Evaluated and inspected the front door alarm system and found it to be in good working condition.
- Installed a lock box over the kill switch located in the ceiling, with access limited to supervisory/authorized staff.
- Installed a new code panel on the internal set of glass doors requiring a code to exit the facility.
- Checked all other exit doors and found them to be fully engaged and functioning.
- Checked all bed/chair/personal alarms and found them to be in good working condition.
- Checked doors equipped with the Wander Guard system and found them to be properly functioning.
- Initiated a QA audit tool for maintenance to check the alarmed doors and wander guard equipped doors for proper functioning.
- In-serviced all staff on the importance of immediately responding to exit door alarms.
- In-serviced all staff on ensuring that the front exit door alarm is consistently activated.
- Initiated a QA audit tool to ensure that the front alarm door is properly functioning.
- Held an emergency QAPI meeting attended by the Medical Director to develop and approve the plan of correction.
- Agreed to discuss all trends identified in the monthly QAPI meeting until resolution.
Failure to Assess and Respond to Resident's Change in Condition Leading to Respiratory Distress
Penalty
Summary
A deficiency occurred when staff failed to assess and appropriately treat a significant change in condition for a resident with multiple complex medical diagnoses, including end stage renal disease, heart failure, and dependence on oxygen therapy. The resident, who was cognitively intact, began experiencing respiratory distress, with oxygen saturation levels dropping to 76% despite being on supplemental oxygen. Staff did not document vital signs in the medical record, did not notify the physician, and did not initiate timely interventions or transfer to a higher level of care, despite the resident's ongoing complaints of shortness of breath and visible distress. Certified nursing assistants and licensed nursing staff reported that they typically only took and documented vital signs if specifically asked, and in this case, vital signs were either not taken or not properly recorded in the electronic medical record. The nurse on duty interpreted the resident's distress as a panic attack, attempted to calm her, and did not escalate care or notify the physician as required by facility policy. The resident's family was called to assist, but upon arrival, found the resident in severe respiratory distress and called 911 themselves. Emergency Medical Services found the resident cyanotic, with a pulse oximetry reading of 50%, and required advanced airway management and intubation en route to the hospital. Facility documentation and interviews confirmed that the care plan did not address the resident's oxygen use or respiratory issues, and there was no evidence that the physician was notified of the resident's deteriorating condition. The facility's change of condition policy required timely communication with the physician and family in the event of significant changes, but this was not followed. The failure to assess, document, and respond to the resident's acute respiratory distress resulted in a delay in emergency intervention and transfer to the hospital.
Removal Plan
- Admin/DON were inserviced by VP of Clinical
- Admin inserviced IDT team
- Current staff inserviced on change of condition and notifying nurse. Change of condition, notifying MD, document vitals, SBAR, head to toe assessment, full set of vitals, and continued vitals.
- Last 30 days of change of conditions in residents have been reviewed to ensure that no other issues have been identified.
- All residents with change of condition reviewing medical records.
- Review of policy and procedures have been completed with MD. Reviewed & updated.
- Initial change of conditions in residents nurse will notify MD and follow MD orders at the time of change of condition.
- Noted change of condition where oxygen levels are below 92%, titrate it up 1L, recheck q 30 mins until O2 can reach 92%, if distress is noted notify MD. If no, change in condition MD is to be notified again. Standing order provided by MD. Being completed by VP of clinical, Director of Nursing, MD, and administrator.
- All working staff have been in-serviced on change of condition policy and procedure. Currently all staff on shift have been in-serviced. Total facility staff in-serviced at 75%. 100% completion will be done. Being Completed by IDT team, DON, administrator, and/or designee by start of next worked shift.
- No staff will work before being in serviced on change of condition. Ongoing - Being completed by IDT team, DON, administrator, and/or designee by start of next working shift.
- A Quality assurance tool was implemented; daily audit of the 24 hour report and dc notices for change of conditions, vitals, dc notes, and MD notification if there is a noted change of condition. Audits to continue daily to ensure that change of condition is documented. Audits complete by: DON/Designee
- Root Cause Analysis completed for Change of Condition
Failure to Assess, Notify, and Manage Pain and Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents, resulting in significant harm. In the first case, a resident with severe cognitive impairment and a diagnosis of dementia experienced sudden, severe pain with redness and swelling in the left knee. Despite multiple staff members observing and reporting the resident's pain and changes in condition over several days, there was no immediate physician notification, no comprehensive pain or physical assessment, and inadequate pain management. The resident continued to experience severe pain for five days before being hospitalized with a left femur fracture requiring surgical repair. Documentation was lacking for pain assessments, nursing assessments, and rationale for obtaining diagnostic imaging, and the resident's pain was not consistently managed or monitored as per facility policy. In the second case, a cognitively intact resident with a history of left femur fracture, hip replacement, diabetes, heart failure, and Alzheimer's disease suffered an unwitnessed fall. The initial assessment documented no complaints of pain or injury, but no neurological checks or post-fall assessments were performed for an extended period. Over the following days, the resident exhibited increasing pain, required more frequent pain medication, and demonstrated significant changes in mobility and function, including inability to bear weight and flaccid extremities. Multiple staff members observed and reported these changes, but there was a failure to recognize the change in condition and notify the physician in a timely manner. The resident was eventually sent to the hospital, where a subdural hematoma with midline shift and a dislocated hip were diagnosed, necessitating neurosurgical and orthopedic intervention. Both cases demonstrate failures to follow the facility's policies on notification of changes, pain management, and assessment following significant changes in condition or falls. Staff did not consistently assess, document, or communicate critical changes, resulting in delayed recognition and treatment of serious medical conditions. These deficiencies were confirmed through interviews, record reviews, and direct observations by surveyors.
Removal Plan
- The facility Nursing Staff was in serviced by Director of Nursing and Regional Nurse Consultant regarding pain management, evaluation and treatment, physician notifications, documentation and follow-up. All nursing staff who have not attended the in-service will be in-serviced prior to their start of next scheduled shift. Nursing staff not in-serviced will not be able to return to work until in-service has been completed.
- All residents were assessed for pain by Assistant Director of Nursing. All residents have a pain scale documented on their Medication Administration Record to be completed every shift. A nonverbal pain scale was added for residents who are not cognitively intact.
- Director of Nursing implemented daily clinical rounds with the nursing staff to ensure all acute/chronic pain is addressed, appropriate assessments are completed, and notification of the physician has been completed appropriately. Reports will be reviewed/addressed during morning clinical meeting each day. Daily morning Clinical sheets were reviewed and Director of Nursing has been completing daily.
- Director of Nursing and Assistant Director of Nursing in-serviced Nursing Staff regarding physician notification of changes by phone with follow up by fax and text message. Random review of progress notes confirm physicians have been notified by phone with condition changes.
- Each nurses station contained a list of hot rack charting for nurses to review daily. Director of Nursing is updating hot rack sheets daily with changes. Facility Nurses will use hot rack charting with their report sheet for shift to shift nursing report to assist with communication and follow up. The report sheets will be reviewed by Director of Nursing and discussed in morning QA (Quality Assurance) meetings.
- Director of Nursing provided a print out of the daily dashboard electronic clinical record. Director of Nursing is reviewing the Point Click Care Dashboard, 24-hour report, pain management, and physician notification of change, daily for four weeks, to ensure effective measures are implemented for quality resident care.
- Director of Nursing provided a pain management weekly audit sheet. This audit documents five residents are being reviewed weekly for pain management.
- The facility Pain, Change in condition, and notification of changes in-service documents Director of Nursing reviewed policies and procedures with all nursing staff. Director of Nursing will discuss pain management policy and procedure and notification of changes at monthly nursing meeting.
- Director of Nursing and Administrator held an interdisciplinary meeting to discuss changes in conditions of residents. Administrator provided quality assurance meeting notes.
Failure to Provide Safe Peritoneal Dialysis Care by Qualified Staff
Penalty
Summary
The facility failed to provide safe and appropriate peritoneal dialysis care for a resident who required such services, resulting in a serious adverse event. The resident, who had a history of sepsis, peritonitis, and dependence on dialysis, was admitted with moderate cognitive impairment and had recently been discharged from the hospital. On the day of the incident, the resident's peritoneal dialysis (PD) cycler was malfunctioning, and staff were unable to resolve the issue. Communication between the facility staff and the dialysis company led to instructions for a manual fill of dialysate fluid, with a specific order for 1.5 liters to be administered manually. Despite the order, the nursing staff involved were not properly trained in manual peritoneal dialysis procedures. The Director of Nursing (DON) was unfamiliar with manual fills and relied on a Registered Nurse (RN) and an LPN, neither of whom had received adequate training for the procedure. Miscommunication and lack of clarity regarding the correct volume to be infused resulted in the entire 2.5-liter bag of dialysate being administered, rather than the ordered 1.5 liters. The staff did not verify the order or ensure proper documentation in the resident's medical record, and there was confusion about who was responsible for the procedure and the amount to be infused. As a result of the over-infusion, the resident developed severe shortness of breath, hypotension, and hypoxemia, requiring emergency transfer to the hospital. Upon arrival, the resident was found to be in acute respiratory distress with significant abdominal distention and was subsequently intubated and placed on mechanical ventilation. Hospital records confirmed that over 3.9 liters of fluid were drained from the resident's abdomen, and the event was attributed to excessive dialysate instillation at the facility. The lack of proper training, failure to follow physician orders, and inadequate communication and documentation directly led to this Immediate Jeopardy event.
Removal Plan
- The contract for dialysis was terminated with the facility.
- Facility Administrator and Director of Nursing reviewed all the residents at the time of the event and no other residents were receiving PD services at the time of the event and no other residents have received PD services since this event.
- Facility Administrator and Director of Nursing were in-serviced by dialysis company on manual fill PD.
- Both nurses involved in the event were suspended pending investigation and terminated.
- Facility policy for dialysis was reviewed by Regional Director of Operations and found to be in compliance.
- QA meeting was held with dialysis company and policies and procedures were reviewed.
- Administrator or designee will review PD patients weekly times 4 weeks.
Failure to Seek Emergency Care for Resident with Critically High Blood Sugar
Penalty
Summary
A deficiency occurred when the facility failed to seek emergency care for a resident with Type 2 Diabetes Mellitus who was experiencing blood sugar levels too high to be measured by the facility's glucose monitoring device. The resident, who had a complex medical history including cerebral palsy, quadriplegia, chronic kidney disease, and a history of diabetic ketoacidosis (DKA), exhibited a significant change in condition with persistently elevated blood glucose readings that exceeded the glucometer's measurable range. Despite repeated 'HI' readings on the glucometer, which indicated blood glucose levels above 600 mg/dL, and observable changes in the resident's behavior and responsiveness, emergency medical intervention was not initiated in a timely manner. Throughout the day, certified nurse assistants (CNAs) reported to the agency LPN that the resident was not acting normally and recommended hospital transfer, but the LPN chose to administer insulin and wait for a physician's response instead. The LPN was unfamiliar with the facility's policies, the glucometer's limits, and had not received training on change in condition or emergency protocols. The DON was consulted and advised the LPN to use her judgment or wait for physician orders, but did not direct immediate transfer. Communication with the on-call physician was attempted, but there was no documented response or follow-up, and the facility's communication system was not effectively utilized. The resident's condition continued to deteriorate, with ongoing 'HI' blood sugar readings and increasing unresponsiveness. Later, the oncoming agency RN also observed the resident's critical state, continued to attempt to reach the physician, and administered additional insulin per verbal orders, but did not document the physician's name or the new orders properly. The resident's blood sugar eventually decreased to 488 mg/dL, but his condition worsened, culminating in respiratory distress, unresponsiveness, and ultimately death. Documentation and communication lapses were evident, including incomplete MAR entries and lack of proper notification or escalation. The cause of death was listed as probable diabetic ketoacidosis.
Removal Plan
- Facility administrator was in-serviced by Regional Reimbursement Consultant on ensuring that glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner.
- Facility administrator was in-serviced by Regional Reimbursement Consultant on ensuring that licensed nursing personnel will inform the physician or authorized designee with any change in condition of the resident in an effective, timely and efficient manner.
- Facility administrator was in-serviced by Regional Reimbursement Consultant on medications being administered in accordance with the good nursing principles and practices and only by persons legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system.
- Facility's administrator in-serviced by Regional Reimbursement Consultant on using nursing judgement to seek emergency treatment when appropriate.
- Facility Administrator initiated in-servicing for nursing staff on using nursing judgement to seek emergency treatment when appropriate.
- Facility Administrator initiated in-servicing for all nursing staff on ensuring glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner to be completed before the start of their next shift.
- Facility Administrator initiated in-servicing for all nursing staff on medications being administered in accordance with the good nursing principles and practices and only by legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system, to be completed before the start of their next shift.
- Facility policy for physician notification has been reviewed by Regional Director of Operations and has been found to be in compliance.
- Facility completed an audit of all diabetic residents to ensure that their blood sugars are within therapeutic range and a weekly audit will be performed by the DON or designee weekly for four weeks.
- Quality Assurance and Performance Improvement (QAPI) plan has been revised to include that the facility will ensure residents experiencing an acute critical situation receive timely emergency care and lacks a process for physician notification and receiving orders in an acute situation. QAPI revisions will be discussed at the next QAPI meeting.
- Monitoring will be ongoing in the morning Quality Assurance (QA) meeting by the QA team (Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS)), the QA team will review the 24-hour report and follow up on any changes in condition to ensure that proper care was received and proper procedures were followed.
Failure to Provide Timely Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents, resulting in significant deficiencies. For one resident with Parkinson's Disease and Alzheimer's Disease, who was dependent on staff for toileting and transfers and at high risk for pressure ulcers, the facility did not implement required repositioning and incontinence care every two hours. Staff did not consistently report refusals of care or dislodged dressings to nursing staff, and there were lapses in maintaining wound dressings. The resident was observed sitting in a wheelchair for extended periods, experienced pain, and was found with a saturated brief and an uncovered, golf ball-sized pressure ulcer on the coccyx. Documentation revealed gaps in weekly skin assessments, lack of timely physician notification, and absence of pressure-relieving interventions for the heels, despite the presence of new wounds and deterioration of existing ones. The same resident developed heel blisters that progressed to stage two and three pressure ulcers, leading to hospitalization for infection and cellulitis. After returning from the hospital, the resident developed a sacral wound that deteriorated into a stage four pressure ulcer with necrosis and slough, requiring debridement. There was no documentation of ongoing wound assessments, timely physician or dietitian notification, or implementation of recommended interventions such as offloading, repositioning, and nutritional support. Staff interviews confirmed that wound care, monitoring, and communication were inconsistent, and that staffing shortages contributed to delays in care. The wound nurse and dietitian were not made aware of the resident's wounds in a timely manner, and treatment orders were not always implemented promptly. A second resident with a history of pressure ulcers was found to have a partial thickness wound on the right buttock that was not being treated or monitored. The wound had been present for more than two days, and there was no treatment order or documentation of physician notification until the wound was identified by staff during the survey. The facility's failure to follow its own policies for wound assessment, treatment, and communication with the interdisciplinary team resulted in unaddressed and deteriorating pressure ulcers for both residents.
Removal Plan
- R52 was assessed and treated by the Wound Care Physician.
- V22 Wound Nurse was hired as the facility's full time wound nurse.
- V2 Director of Nursing and V22 Wound Nurse conducted facility wide skin checks of all residents.
- V22 Wound Nurse initiated audits that included a review of the resident skin checks, provisions of incontinence care, turning and repositioning, notifications to the physician and Registered Dietician, and monitoring of wound treatments.
- V2 Director of Nursing conducted an inservice training for nurses and Certified Nursing Assistants on the topics of skin assessments, wound assessments, identifying and reporting new and deteriorating wounds, implementing and maintaining wound treatments, notification of physician and dietitian, incontinence care, and turning and repositioning. Any remaining staff will receive this training prior to their next scheduled shift.
- V22 was in-serviced by V2 on the facility's skin and wound management programs and notification of registered dietitian and physician. V22 will be responsible for monitoring/tracking/processing of physician orders and dietitian recommendations.
- V22 will bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team weekly, monthly, and quarterly.
Latest Citations in Illinois
Surveyors found expired milk cartons in the walk-in cooler and a wet sanitation cloth left on the food preparation counter instead of in the sanitizing solution, contrary to facility policy. These lapses in food safety and sanitation procedures had the potential to affect all residents receiving food from the kitchen.
The facility did not keep outside garbage dumpsters properly closed, resulting in overfilled containers with partially open lids. Multiple departments contributed to the issue, and staff were unsure who was responsible for leaving the dumpsters open, despite facility policy requiring dumpsters to remain closed and the area kept clean. This affected all residents in the facility.
Two residents with confirmed COVID-19 were not provided with trash receptacles for PPE disposal in their rooms, leading staff to discard used PPE in hallway trash cans. One resident used both a shared bathroom and a communal rehab bathroom despite orders for a dedicated bathroom, with no signage or clear cleaning schedules in place. Another resident on isolation was observed leaving their room, interacting with others, and using a cloth mask instead of a required disposable mask, contrary to facility policy. These failures were confirmed by staff and management, and were not in line with infection control protocols.
Surveyors found that the lint trap in the dryer used for residents' personal laundry was not being emptied, resulting in a large buildup of lint. Staff confirmed there was no log or procedure for cleaning this lint trap, and it was not being checked regularly, despite facility policy requiring lint screens to be cleaned and documented after every two loads. This failure created an unsafe environment and a fire hazard potentially affecting all residents.
Several residents' personal refrigerators lacked required temperature log sheets and thermometers, with staff failing to consistently document daily temperature checks as required by facility policy. Interviews confirmed that staff were responsible for these tasks, but the procedures were not followed, affecting residents with various medical conditions.
Surveyors found that several residents requiring oxygen therapy did not have their equipment properly contained, labeled, or dated, with tubing often left unbagged or touching the floor. Required oxygen-in-use signage was missing in some rooms, and at least one resident received oxygen at a higher flow rate than ordered by the physician. These deficiencies occurred despite clear care plans and facility policies, affecting residents with significant respiratory and medical needs.
Several dependent residents did not receive timely oral hygiene or incontinence care as required by their care plans and facility policy. Two residents were observed with significant dental debris and reported a lack of staff assistance with mouth care, while two others, both paraplegic and always incontinent, experienced prolonged waits for incontinence care, sometimes exceeding an hour. Staff interviews confirmed that care was not consistently provided every two hours as required.
A resident with multiple risk factors for pressure ulcers was found in bed on a non-functioning low air loss mattress, despite physician orders and care plan interventions requiring its use. The LALM was observed to be almost flat with the power off, and the ADON confirmed it was not working at the time, resulting in a failure to provide appropriate pressure ulcer prevention.
Surveyors found that medications, including insulin and eye drops, were not properly labeled with open dates, some were not refrigerated as required, and expired medications were not discarded. Temperature logs for medication refrigerators had missing entries, and staff did not consistently monitor temperatures as required, especially when vaccines were present. These failures affected multiple residents and had the potential to impact all residents on the affected floor.
Three residents with limited mobility and contractures did not receive required range of motion (ROM) exercises or restorative devices as specified in their care plans and physician orders. Staff confirmed that necessary splints and palm protectors were unavailable and that temporary alternatives were not used. Two residents reported not receiving ROM exercises, and staff cited outdated lists and time constraints as reasons for missed care. Facility policies and job descriptions require these interventions, but they were not consistently provided.
Expired Milk and Improper Sanitation Cloth Storage in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety and sanitation practices in the kitchen. Specifically, two 8-ounce cartons of skim milk with expired dates and one additional carton with a different expired date were found in the walk-in cooler. The dietary manager from the corporate office confirmed that dietary aides were responsible for checking and discarding expired food items but had not done so in this instance. Additionally, a wet kitchen sanitation cloth was found left on the food preparation counter rather than being stored in the sanitizing solution as required by facility policy. Facility documentation and policies reviewed by surveyors indicated that all towels must be returned to the sanitation bucket after use and that food products must be rotated and discarded by their expiration dates. The observed failures to discard expired milk and to properly store the sanitation cloth were not in accordance with these established procedures and had the potential to affect all 150 residents receiving food from the kitchen.
Improper Disposal and Management of Garbage Dumpsters
Penalty
Summary
The facility failed to ensure that outside garbage waste dumpsters were properly closed with lids, as required by facility policy, to prevent pest infestation and foul odor. Observations revealed that two out of three dumpsters were overfilled with garbage and had lids left partially open. Staff interviews indicated that multiple departments, including dietary and housekeeping, contributed to the use of these dumpsters, and there was uncertainty regarding who was responsible for leaving the lids open. The facility's policy specifies that dumpsters must be kept closed at all times and the surrounding area clean, with instructions to contact the garbage service if dumpsters become full. At the time of the deficiency, 150 residents were residing in the facility.
Failure to Implement Infection Control Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to follow infection control protocols for residents on transmission-based precautions for COVID-19. Specifically, two residents with confirmed COVID-19 diagnoses were not provided with trash receptacles in their rooms for the disposal of personal protective equipment (PPE), as required by facility policy. Staff, including CNAs, RNs, and housekeeping, reported that there was no designated place to discard used PPE in these rooms, leading them to dispose of PPE in hallway trash cans. Management and the infection preventionist confirmed that isolation rooms should have dedicated trash receptacles for PPE, but these were not present. Additionally, the facility did not maintain proper contact and droplet isolation for COVID-19 positive residents. One resident was observed using both their own bathroom, which was shared with other residents, and a communal rehab bathroom, contrary to orders and facility policy that called for a dedicated bathroom. There were no signs posted to redirect the resident to the appropriate bathroom, and staff were unaware of the cleaning schedules for these shared spaces. The infection preventionist and DON acknowledged the risk of infection spread due to improper bathroom use and lack of cleaning oversight. Furthermore, another resident on isolation for COVID-19 was observed leaving their room, interacting with other residents, and using a cloth mask instead of a required disposable mask. This resident was seen smoking outside near others and attending resident council while removing their mask and coughing. Staff confirmed that the resident was not supposed to be off isolation and should have been using a surgical mask and maintaining distance from others. These lapses in infection control protocols were observed and confirmed by multiple staff members, and were not in accordance with the facility's own policies and CDC guidelines.
Failure to Maintain Lint Trap in Residents' Personal Dryer Creates Fire Hazard
Penalty
Summary
The facility failed to ensure the lint compartment and filter of the dryer used for residents' personal laundry were emptied, resulting in a significant buildup of lint. During a tour of the laundry area, surveyors observed a large accumulation of lint in the lint trap/screen compartment of the residents' personal use dryer. The Housekeeping/Laundry Director confirmed that there was no log sheet or established procedure for cleaning the lint trap/screen for this dryer, and stated uncertainty about who checks it when not present. The Housekeeper/Laundry Aide also reported that laundry aides do not check or log the lint trap/screen for the residents' personal dryer, only for the main dryers, and had never checked it during their shifts. Facility policy requires that all dryer lint screens be cleaned by laundry staff after every two loads and documented on a daily cleaning form. Job descriptions for both the Laundry Aide and Director of Housekeeping specify responsibilities for safe equipment use and adherence to facility policies and procedures. Despite these requirements, the lack of a cleaning schedule, documentation, and staff awareness regarding the residents' personal dryer led to the deficiency, creating an unsafe environment and a fire hazard with the potential to affect all 150 residents.
Failure to Monitor and Document Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of personal refrigerators used by residents for food storage. Observations revealed that several residents' personal refrigerators were missing required temperature log sheets and thermometers. Specifically, one resident's refrigerator had multiple days with missing temperature checks and staff initials, while another resident's refrigerator had no documentation of temperature checks at all. Additional refrigerators were found without log sheets or thermometers, and in some cases, residents were unaware of the missing items or stated that staff were responsible for maintaining them. Interviews with staff, including the Director of Nursing (DON) and Housekeeping Director, confirmed that facility policy requires daily temperature checks and documentation for each resident's personal refrigerator. Staff are expected to record the temperature and their initials on a log sheet every shift, and each refrigerator should be equipped with a thermometer. The purpose of these checks is to ensure that food is stored at safe temperatures to prevent spoilage and potential illness. However, the observed lack of documentation and missing equipment indicated that these procedures were not consistently followed. The residents affected by these deficiencies had various medical conditions, including weakness, abnormalities of gait and mobility, repeated falls, diabetes, and other chronic illnesses. Some residents were cognitively intact and able to report on the situation, while others were unable to participate in interviews due to altered mental status. Despite the presence of food in the refrigerators, there were no immediate concerns about the condition of the food itself, but the absence of required monitoring and documentation represented a failure to comply with facility policy and safe food storage practices.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors observed multiple failures in the provision of respiratory care for six residents requiring oxygen therapy. Oxygen equipment, including nasal cannulas and tubing, was found not properly contained, labeled, or dated in several resident rooms. In some cases, oxygen tubing was left hanging on tanks or concentrators, touching the floor, or not stored in a clean manner, contrary to facility policy and infection control standards. Additionally, oxygen equipment was not consistently bagged when not in use, and there was a lack of labeling to indicate when tubing was last changed, despite physician orders and facility protocols requiring weekly changes and proper documentation. Further deficiencies included the absence of required signage indicating oxygen was in use in resident rooms, as observed with one resident receiving oxygen therapy without any visible warning sign. Staff interviews confirmed that signage should have been present and that its absence was an oversight. In another instance, a resident's oxygen concentrator was set at a higher flow rate than prescribed by the physician, with both the resident and a registered nurse acknowledging the discrepancy. This failure to follow physician orders for oxygen flow rates was noted as a direct deviation from the resident's care plan and medical orders. The residents affected had significant medical histories, including chronic obstructive pulmonary disease, emphysema, acute respiratory failure, and other serious conditions requiring careful respiratory management. Documentation reviewed by surveyors showed that care plans and physician orders specified the need for monitoring, proper storage, and regular changing of oxygen equipment. Despite these directives, staff did not consistently adhere to established protocols, resulting in lapses in safe and appropriate respiratory care for all six residents reviewed.
Failure to Provide Timely Oral and Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents who were dependent on staff for care, specifically in the areas of oral hygiene and timely incontinence care. Observations revealed that two residents had visible accumulations of brown sediments on their teeth, indicating a lack of oral care. One of these residents was unable to communicate due to cognitive impairment, while the other, who was cognitively intact, reported that staff had not assisted with mouth care for an extended period. Both residents had care plans indicating the need for staff assistance with oral hygiene due to self-care deficits related to their medical conditions. In addition, two other residents who were paraplegic and always incontinent reported and were observed to experience delays in receiving incontinence care. One resident stated that incontinence care was typically provided only twice daily, resulting in prolonged periods spent in wet undergarments while seated in a wheelchair. Another resident was found in bed with a strong odor of urine and feces, having activated the call light for assistance approximately five minutes prior to being attended to. This resident reported that wait times for incontinence care could exceed one hour, and staff interviews confirmed that care was not consistently provided every two hours as required by facility policy. The affected residents had significant medical histories, including hemiplegia, paraplegia, neuromuscular dysfunction of the bladder, and other conditions resulting in self-care deficits. Facility policies and job descriptions for CNAs, LPNs, and the DON outlined the expectation for regular oral care and incontinence care every two hours or as needed, but these standards were not met for the residents reviewed. The deficiencies were identified through direct observation, resident interviews, record reviews, and staff interviews.
Failure to Ensure Functioning Pressure-Relieving Mattress for At-Risk Resident
Penalty
Summary
A resident identified as being at risk for pressure ulcers was observed in bed with a low air loss mattress (LALM) that was not functioning, as the mattress was almost flat and the power was off. The Assistant Director of Nursing confirmed that the machine was not working due to the power being off and indicated that the mattress would not function unless the power was turned on. The resident's care plan and physician orders specified the use of a pressure-reducing mattress as an intervention for pressure ulcer prevention, and the facility's guidelines require adherence to such interventions for residents at risk. The resident's medical history included diagnoses such as protein calorie malnutrition, venous insufficiency, dementia, muscle wasting and atrophy, poly-osteoarthritis, and dermatitis, all of which increase the risk for pressure ulcers. The resident was assessed as being at risk for pressure ulcers, and the care plan included the use of a pressure-reducing mattress. Despite these documented needs and interventions, the required equipment was not operational while the resident was in bed, constituting a failure to provide appropriate pressure ulcer prevention as ordered.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices. During observations, it was found that several multi-dose medications, such as Latanoprost and Fluticasone nasal spray, were not labeled with open dates, making it unclear how long they had been in use. Additionally, artificial tears for two residents were found with open dates that exceeded the recommended 30-day usage period. These lapses in labeling and timely discarding of medications could result in the administration of expired drugs. Unopened insulin pens requiring refrigeration were found stored in the medication cart instead of the refrigerator, contrary to pharmacy auxiliary labels and facility policy. Staff interviews confirmed that unopened insulin should be refrigerated, and that failure to do so could compromise medication integrity. Furthermore, the daily refrigerator temperature logs on the 3rd floor had missing entries, and staff acknowledged that temperature checks were not consistently performed as required. This inconsistency in monitoring could affect the safety and efficacy of temperature-sensitive medications stored for all residents on the floor. Vaccines were also found stored in the refrigerator, but temperature monitoring was only performed once daily instead of the expected twice daily when vaccines are present. Staff were unclear about the correct monitoring frequency, indicating a lack of adherence to established protocols. The facility's own policies require medications to be stored according to manufacturer recommendations, with proper labeling and timely removal of outdated drugs, but these procedures were not consistently followed for the residents involved.
Failure to Provide Range of Motion Exercises and Restorative Devices
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate range of motion (ROM) exercises and apply restorative devices for three residents with limited mobility and contractures. One resident with contractures of both hands and quadriplegia was observed without hand protectors or splints in place, despite care plans and physician orders specifying the use of such devices. Staff confirmed that the required splints and palm protectors were not available, and temporary alternatives such as rolled towels were not implemented as directed. The restorative nurse acknowledged the lack of supplies and indicated that the administrator had been informed, but no interim measures were put in place. Another resident with left-sided weakness from a stroke reported that staff had not been providing ROM exercises for the affected limbs, expressing concern about developing contractures. A third resident also complained of not receiving ROM exercises for over two weeks. The restorative aide responsible for these residents stated that one of the residents was not on the current list for ROM exercises and admitted that the list was outdated. The aide also noted being unable to perform ROM exercises for all assigned residents due to time constraints and other duties, such as escorting residents or covering for staff absences. Record reviews for the affected residents showed documented diagnoses of contractures, hemiplegia, muscle weakness, and reduced mobility, with care plans and physician orders specifying the need for restorative interventions, including ROM exercises and the use of assistive devices. Facility policies and job descriptions for restorative staff and CNAs require the provision and documentation of ROM exercises and the use of restorative equipment to maintain or improve residents' mobility. Despite these requirements, the facility did not ensure that restorative care was consistently provided, and necessary devices were not available or used as ordered.
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