Allure Of Geneseo
Inspection history, citations, penalties and survey trends for this long-term care facility in Geneseo, Illinois.
- Location
- 704 South Illinois Street, Geneseo, Illinois 61254
- CMS Provider Number
- 145789
- Inspections on file
- 24
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Allure Of Geneseo during CMS and state inspections, most recent first.
A cognitively impaired resident with multiple fall risk factors, including ataxia, osteoporosis, and muscle weakness, was left in a wheelchair near the nurse’s cart close to a shower room while a CNA was showering another resident. The CNA left the shower room door open with the water running while preparing to return to clean up, even though the door is normally kept closed and requires a code. During this time, the resident, known to wander and get up without permission, entered the open shower room unsupervised and was later found on the floor between the toilet and her wheelchair with a head laceration. She was assisted back to her wheelchair, monitored near the nurse’s station, and later reported right leg pain; hospital evaluation showed a closed displaced fracture of the right femoral neck requiring surgery.
Surveyors found that the facility’s Dietary Manager did not hold the Food Handler Certification or Certified Food Protection Manager certification required by the facility’s own job description. Review of the job description confirmed that such certification is a qualification for the role, and facility census records showed that 62 residents were in the facility. During a kitchen tour, the Dietary Manager stated that since being hired several months earlier, he had not obtained the required certification, creating a deficiency related to ensuring sufficient staff with appropriate competencies and skill sets in the food and nutrition service.
The facility failed to follow its antibiotic stewardship and infection surveillance policies by not consistently applying McGeer criteria, not completing required infection assessment forms, and not accurately tracking infections and culture data. Multiple residents received antibiotics for pneumonia, sepsis, skin infections, and UTIs, yet their infections were often missing from the infection logs, and culture results—when obtained—were not reliably recorded or trended. In several UTI cases, antibiotics were started based only on urinalysis or without any culture, and documentation in the infection reports conflicted with progress notes regarding whether cultures were completed and which organisms were identified.
A resident with dementia, insomnia, and a history of falls was prescribed quetiapine (Seroquel) 25 mg at bedtime for “dementia with behavioral disturbance,” despite the facility’s psychotropic policy requiring specific, documented indications and the drug reference stating it should not be used in elderly patients with dementia-related psychosis. The MDS showed the resident was cognitively intact with no documented behaviors, while the care plan listed psychotropic use for dementia with behavioral disturbance and insomnia. Staff described the resident as mainly exit seeking with lack of safety awareness, usually easily redirected, and requiring supervision at night. The DON acknowledged that antipsychotics should not be used in dementia patients and felt the resident was appropriate for dose reduction, but there was no clear, appropriate indication documented for the ongoing antipsychotic use.
A resident with multiple urologic conditions, including BPH, urinary retention, prostate cancer, hematuria, and a history of UTIs, had an indwelling urinary catheter and was on Enhanced Barrier Precautions. Surveyors observed the urinary drainage bag hanging from the bed frame, uncovered and facing the hallway, despite facility policy requiring catheter bags to be covered with privacy bags. During observed catheter care, a CNA performed hand hygiene and used PPE but did not retract the foreskin while cleansing the uncircumcised penis, contrary to facility expectations later confirmed by the administrator and DON. These actions resulted in a failure to provide appropriate catheter care and to maintain the resident’s privacy and dignity.
Staff failed to follow infection prevention and control practices during wound and catheter care for two residents on Enhanced Barrier Precautions. In one case, nurses performed sacral pressure ulcer treatment using the same pair of gloves from room entry through removal of soiled materials, wound cleansing, medication application, and placement of a clean dressing, without changing gloves or performing hand hygiene between dirty and clean tasks. In another case, CNAs provided catheter and incontinence care with an untied gown, reused contaminated gloves to handle clean washcloths and water, discarded stool-contaminated water and urine into the resident’s sink, placed a urine container on the bedside table, changed gloves multiple times without hand hygiene, and left the room without disinfecting the bedside table or bathroom sink.
A resident with severe cognitive impairment and multiple health conditions experienced new onset pain that was not properly assessed, documented, or communicated to the provider. Nursing staff administered pain medication without a thorough assessment and failed to notify the provider in a timely manner, resulting in a delay in identifying a femur fracture. The facility did not follow its policy for notification of significant changes in condition.
The facility did not follow its policy for labeling and dating opened food items, as observed in the reach-in cooler where a bag of shredded cheese and a salad bag were undated. Additionally, the walk-in cooler had dust and debris on the fan covers and surrounding areas. The Dietary Manager confirmed these issues, which could impact all 63 residents.
A facility failed to maintain a resident's dignity by not ensuring her clothing was clean and free of debris. The resident, who was severely cognitively impaired, was observed with dried food debris on her pants. Her husband expressed concern about the lack of clothing protectors during meals, leading to frequent soiling. The facility administrator confirmed that staff should change soiled clothing after meals.
A resident with chronic heart failure and edema did not receive physician-ordered compression stockings, as staff failed to apply them. Observations showed significant bilateral pitting edema, and the resident confirmed the stockings were not put on by staff. The facility's RN/Administrator verified the existence of the order, highlighting a lapse in care.
The facility failed to provide adequate range of motion exercises and contracture care for three residents. One resident with a contracted hand did not receive therapy or devices, another resident's splint was inconsistently applied, and a third resident did not receive restorative exercises after therapy discharge. The facility's staff acknowledged deficiencies in care planning and execution.
A facility failed to change and properly store a resident's nebulizer mask and tubing every 72 hours and oxygen tubing weekly, as per its policies. The nebulizer mask was found undated and unbagged, and the oxygen tubing was undated. A nurse confirmed these lapses, indicating non-compliance with the facility's respiratory care protocols.
An LPN failed to disinfect a shared glucometer between uses on three residents with diabetes, contrary to the facility's infection control policy. The glucometer was used consecutively on residents requiring regular blood glucose monitoring without being cleaned, as confirmed by the LPN.
The facility failed to provide written notices of transfer to residents and their representatives, as required. Two residents were transferred to a hospital without receiving the necessary documentation. The administrator confirmed the lack of a process to ensure these notifications are given.
The facility failed to provide bed hold policy notices to residents or their representatives during hospital transfers, as required by their policy. This was confirmed through interviews and record reviews, revealing a lack of documentation in residents' medical records and an ineffective process to ensure compliance.
Failure to Keep Shower Room Door Closed Leads to Unsupervised Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to keep a shower room door closed, allowing a cognitively impaired resident to access the room unsupervised and fall. The resident had diagnoses including ataxia, cognitive communication deficit, macular degeneration, depression, chronic kidney disease, and protein calorie malnutrition, and was assessed as having moderate cognitive impairment, requiring partial to moderate assistance for transfers, and using a manual wheelchair. Her care plan identified her as at risk for falls due to a history of falls, osteoporosis, difficulty walking, muscle weakness, unsteadiness, and other musculoskeletal issues. On the evening of the incident, the resident was placed in her wheelchair near the nurse’s cart close to the shower room after being taken to the bathroom. A CNA was in the process of showering another resident and had left the shower room door open while warming the water and preparing to return to clean up towels and supplies. The shower water was running, and the door, which normally required a code and was usually kept closed, was left open or propped open. During this time, the cognitively impaired resident, known to wander and get up without permission, moved from the area near the nurse’s cart into the open shower room without staff immediately noticing. Staff later found the resident on the floor of the shower/bathroom area, positioned between the toilet and her wheelchair, on her right side, with a laceration to the right temple and the shower water still running. She was initially assessed as alert and oriented to person, with vital signs stable, and treatment was provided for the head laceration. She was assisted from the floor back into her wheelchair by staff and kept near the nurse’s station, where she was monitored and given acetaminophen for pain. By the following morning, she complained of right leg pain, and subsequent evaluation at an acute care hospital revealed a closed displaced fracture of the right femoral neck, for which she was admitted and underwent surgery before returning to the facility.
Dietary Manager Lacks Required Food Safety Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager possessed the required Food Handler Certification or Certified Food Protection Manager certification as specified in the facility’s Dietary Manager job description. The undated job description states that Food Handler Certification or Certified Food Protection Manager certification is required for the position. CMS Form 671, signed by the Administrator, documents that 62 residents reside in the facility. During the initial kitchen tour, the Dietary Manager reported that since being hired in October 2025, he had not yet obtained the required certification, resulting in a deficiency related to employing sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietitian. This failure was identified through record review of the job description and facility census information, as well as an interview with the Dietary Manager confirming the lack of required certification since the start of his employment. The report notes that this deficiency has the potential to affect all 62 residents residing in the facility.
Failure to Implement Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship and infection surveillance programs as required by its own policies. The Infection Surveillance policy required collection of data to identify infections, including infection site, pathogen, signs and symptoms, resident location, and tracking of all resident infections, as well as use of laboratory reports, antibiotic use, and culture results. The Antibiotic Stewardship Program policy required use of McGeer criteria to define infections, completion of assessment and data collection forms, and measurement of antibiotic use by monthly prevalence, antibiotic starts, and/or days of therapy. Despite these policies, the facility did not consistently complete McGeer forms, did not consistently obtain or document culture results, and did not consistently include infections and culture data on the Monthly Report of Resident Infections. For multiple residents who received antibiotics, there was no documentation that McGeer criteria were applied or that required surveillance forms were completed. One resident received Levaquin for pneumonia, another received antibiotics for sepsis secondary to a UTI with a documented Proteus mirabilis urine culture, and another received Ciprofloxacin for a UTI with a urine culture showing >100,000 cfu/mL Escherichia coli; none of these cases had McGeer forms completed, and several were not entered on the Monthly Report of Resident Infections. Additional residents received antibiotics for a thigh abscess, UTIs treated with Ciprofloxacin, Rocephin, Keflex, Ampicillin, Bactrim DS, and Macrobid, yet their records similarly lacked McGeer forms, and their infections or culture results were either omitted or incompletely documented on the Monthly Report of Resident Infections. In some cases, urine cultures were obtained but the organism and results were not incorporated into the infection logs, and in other cases antibiotics were started without any urine culture being completed prior to treatment. One resident’s progress notes documented that urology advised starting Ampicillin for a positive urinalysis and later confirmed that the current antibiotic was sensitive to the culture, but the Monthly Report of Resident Infections stated no urine culture was completed and did not list an organism. Two other residents received antibiotics for UTIs without any urine culture obtained before treatment, and their infections were not captured on the Monthly Report. During interview, the Chief Nursing Officer acknowledged that infection surveillance was not thoroughly conducted, did not meet the required criteria for antibiotic use, and that culture results were not obtained or reviewed to track and trend infections.
Inappropriate Use of Antipsychotic Medication Without Clear Indication
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate indication for the use of an antipsychotic medication for one resident. Facility policy on psychotropic medications states that such drugs are to be used only when nonpharmacological interventions are clinically contraindicated, to treat specific, diagnosed, and documented conditions, and not as chemical restraints. The drug reference used by the facility lists quetiapine (Seroquel) as an antipsychotic indicated for schizophrenia, with certain off-label uses, and specifies it is not to be given to elderly patients with dementia-related psychosis. The resident in question was admitted with diagnoses including unspecified dementia with other behavioral disturbance, cognitive communication deficit, insomnia, and a history of falls. The MDS assessment documented that the resident was cognitively intact and had no behaviors, while the care plan documented that the resident was on psychotropic medications for dementia with other behavioral disturbance and insomnia. Physician orders dated at admission documented Seroquel 25 mg at bedtime for dementia with behavioral disturbance. During interviews, an RN described the resident’s behaviors mainly as exit seeking and lack of safety awareness, noting that the resident was usually easily redirected and required supervision, especially at night. The DON stated that the resident had been “good” since admission, with dementia and lack of safety awareness as the primary issues, and indicated a belief that the resident was appropriate for dose reduction to discontinue Seroquel. The DON agreed that antipsychotic medications should not be used in dementia patients but did not clearly state that the indication for Seroquel in this case was inappropriate. Overall, the documentation and staff interviews did not establish an appropriate, specific, and documented indication for the antipsychotic medication consistent with facility policy and the drug reference.
Failure to Provide Proper Catheter Care and Maintain Privacy for a Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care policy and to maintain privacy and dignity for a resident with an indwelling urinary catheter. The facility’s undated catheter care policy states that residents with indwelling catheters are to receive appropriate catheter care, with dignity and privacy maintained, and specifies that privacy bags will be available and catheter drainage bags will be covered at all times while in use. During observation, the resident’s urinary collection bag was hanging on the bed frame facing the hallway, visibly showing pink-tinged urine, and was not covered by a dignity/privacy bag as required by the policy. The resident involved was admitted with diagnoses including hematuria, chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, presence of urogenital implants, prostate cancer, and a history of UTIs, and had an indwelling urinary catheter ordered for urinary retention. The care plan documented that the resident was on Enhanced Barrier Precautions due to the indwelling catheter. During observed catheter care, the CNA performed hand hygiene, donned gloves and a gown, and cleansed the resident’s penis; however, the resident was uncircumcised and the CNA did not retract the foreskin during cleansing, contrary to the facility’s policy and accepted practice as later confirmed by the administrator and DON. The CNA also acknowledged that the catheter bag should have been covered, confirming the failure to provide appropriate catheter care and to maintain privacy and dignity for this resident.
Failure to Follow Hand Hygiene and PPE Protocols During Wound and Catheter Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, specifically improper hand hygiene, glove use, and PPE use during care of residents on Enhanced Barrier Precautions. Facility policies require changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and during wound care after removing soiled dressings and after cleansing the wound. Policies also require gowns to be fastened in the back and wound care to be performed in a manner that decreases potential for infection and cross-contamination. For one resident with severe cognitive impairment, morbid obesity, type 2 diabetes with hyperglycemia, and an unstageable sacral pressure ulcer, nurses performed sacral wound treatment while on Enhanced Barrier Precautions. The RN entered the room wearing gown, gloves, and mask, used her gloved hands to move the bed, and then proceeded directly to wound cleansing without changing gloves. Another RN, also wearing her initial pair of gloves, handled clean gauze, applied saline, and prepared a cotton swab with Santyl, handing these items to the first RN, who continued to use the same gloves throughout the procedure. The clean abdominal dressing was also handled and applied while both nurses continued to wear their original gloves placed upon room entry, without any glove change or hand hygiene between dirty and clean steps of the wound care. For another resident on Enhanced Barrier Precautions due to an indwelling urinary catheter, two CNAs performed catheter and incontinence care without adhering to PPE and hand hygiene standards. One CNA’s gown was not tied while providing care. After cleaning stool from the catheter with washcloths, the CNA used the same contaminated gloves to wet new washcloths in a pan of water, then emptied the stool-contaminated water into the resident’s bathroom sink, removed gloves, and donned new gloves without hand hygiene. The CNA then cleansed the resident’s bottom, removed a soiled brief, and again changed gloves without hand hygiene. The second CNA emptied urine from the catheter bag into a plastic container, placed the container on the bedside table, and then emptied it into the bathroom sink. Both CNAs removed PPE and exited the room without performing hand hygiene, and the bedside table and bathroom sink were not disinfected after being used for contaminated materials.
Failure to Assess, Document, and Notify Provider of New Onset Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and multiple comorbidities, including generalized osteoarthritis, dementia, and a history of right lower femur fracture. The resident, who was dependent on staff for most activities of daily living, experienced new onset pain that was not properly assessed, documented, or communicated to the provider in a timely manner. On the evening when the resident first exhibited significant pain, the nurse administered acetaminophen but did not perform or document a thorough pain assessment, nor did she notify the provider of the new onset pain. The following day, another nurse was alerted to the resident's pain, conducted an assessment, and identified pain in the right leg with movement, which was not typical for the resident. The nurse changed the resident's transfer method to accommodate the pain and attempted to notify the provider, but did not ensure that the provider received the notification before the end of her shift. The provider was not made aware of the situation until the next day, when an X-ray was ordered, ultimately revealing a right lower femur fracture. Throughout this period, there was a lack of documentation regarding the initial pain episode and insufficient communication with the provider about the resident's change in condition. The facility's policy required notification of significant changes in a resident's condition, but this was not followed. The delay in assessment, documentation, and provider notification contributed to a delay in identifying the cause of the resident's pain and in initiating appropriate interventions.
Failure to Date Opened Food Items and Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its Labeling and Dating policy, which requires that leftovers and opened food items be clearly labeled with the date they are to be discarded. During an inspection, it was observed that the walk-in cooler had multiple areas with dust and debris on the fan covers and surrounding walls and ceiling. Additionally, in the reach-in cooler, a large bag of shredded mild cheddar cheese and a large opened salad bag with browning lettuce were found without any indication of the date they were opened. The Dietary Manager confirmed these observations and acknowledged that the items should have been labeled with the date they were opened. This deficiency has the potential to affect all 63 residents currently residing in the facility.
Failure to Maintain Resident Dignity by Ensuring Clean Clothing
Penalty
Summary
The facility failed to maintain a resident's dignity by ensuring that clothing attire was clean and free of debris for a resident who was severely cognitively impaired. During an observation, the resident was found sitting in a high back wheelchair with dried, crusted debris on the lap of her pants. The resident's husband expressed concern that the facility was not using clothing protectors during meals, as he frequently found the resident wearing dirty pants with food spills. He noted that the pants worn on a previous day were similarly soiled. The facility administrator acknowledged that staff should change a resident's clothing if it becomes soiled after a meal.
Failure to Apply Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to apply physician-ordered compression stockings for a resident with a known history of acute/chronic heart failure, atrial fibrillation, chronic kidney disease, and edema. The resident's physician order sheet and care plan both specified the need for compression stockings to be worn on the bilateral lower extremities in the morning and removed at bedtime to manage edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings as ordered, and the resident reported that staff did not put them on her. On two separate days, the resident was observed with significant bilateral pitting edema in the lower extremities, and the compression stockings were not in place. The resident's feet and legs were not elevated, which could have contributed to the worsening edema. The facility's registered nurse and administrator confirmed the existence of the physician's orders for the compression stockings, yet they were not applied as required, indicating a failure in following the prescribed care plan for the resident.
Deficiencies in Range of Motion and Contracture Care
Penalty
Summary
The facility failed to provide adequate range of motion exercises and contracture alleviation devices for three residents, leading to deficiencies in their care. One resident, who had a history of cerebrovascular accident and muscle weakness, was observed with a contracted left hand that had not been addressed in her care plan. Despite having an active range of motion program documented, she did not receive any therapy or devices to manage her contracture since her admission. The facility's Chief Nursing Operations director confirmed the lack of a formal therapy evaluation and the absence of specific interventions for the resident's contracted hand. Another resident, with a history of hemiplegia following a cerebral infarction, was supposed to wear a splint on his left hand to prevent worsening contractures. However, the resident reported that the splint was not consistently applied, and staff confirmed the lack of a consistent schedule for its use. The Director of Nursing acknowledged the deficiency in the restorative programming and the need for clear orders regarding the splint's application. A third resident, who had been discharged from skilled physical therapy, expressed a desire to continue exercises to regain mobility. Despite having a documented plan for restorative exercises, there was no evidence that these exercises were provided after the discharge from therapy. The Chief Nursing Officer was unable to provide documentation confirming the resident's participation in the restorative program, highlighting a gap in the facility's follow-through on care plans.
Failure to Maintain and Store Respiratory Equipment Properly
Penalty
Summary
The facility failed to adhere to its own policies regarding the maintenance and storage of respiratory care equipment for a resident. Specifically, the nebulizer mask and tubing for a resident were not changed every 72 hours as required, nor were they stored in a bag between uses. Additionally, the oxygen tubing was not changed every seven days as stipulated by the facility's Oxygen Administration Policy. These lapses were observed during a survey, where the nebulizer mask was found lying undated and unbagged on the resident's dresser, and the nasal cannula oxygen tubing was also undated. A registered nurse confirmed these observations, acknowledging that the nebulizer masks and medication cups should be changed, dated, and bagged after each use, and that oxygen tubing should be changed weekly and dated. The failure to follow these protocols indicates a lack of compliance with the facility's policies designed to ensure safe and appropriate respiratory care for residents, potentially compromising the quality of care provided to the resident involved.
Failure to Disinfect Shared Glucometer Between Uses
Penalty
Summary
Facility staff failed to disinfect a shared glucometer between resident use, which was observed during a survey. The facility's policy on glucometer disinfection requires that the device be cleaned and disinfected after each use with an EPA-registered healthcare disinfectant effective against HIV, Hepatitis C, and Hepatitis B. However, a Licensed Practical Nurse (LPN) was observed using the glucometer on three residents without disinfecting it between uses. This was noted during blood glucose monitoring for residents diagnosed with diabetes mellitus, who required regular finger stick blood glucose tests. The LPN was seen performing blood glucose tests on three residents consecutively without cleaning the glucometer. The LPN first used the glucometer on a resident with diabetes mellitus and hyperglycemia, then proceeded to use the same device on another resident with diabetic polyneuropathy, and finally on a resident with diabetic retinopathy. Each time, the LPN returned the glucometer to the medication cart without disinfecting it, confirming the failure to adhere to the facility's infection control policy. This oversight was confirmed by the LPN during the survey.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide residents and their representatives with a written notice of transfer, which is a requirement for ensuring proper communication and rights awareness. This deficiency was identified through interviews and record reviews, revealing that two residents, R12 and R219, were transferred to a local hospital without receiving the necessary written notification. R12's medical record showed a transfer on 11/5/24, but there was no evidence of notification to R12 or their representative. Similarly, R219 was sent to the emergency room due to a change in condition, yet their electronic medical record lacked documentation of a written notice of transfer. The facility's administrator confirmed the absence of a process to provide these notifications, acknowledging that residents have not been receiving them.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a proper process in place to ensure that residents or their representatives received the necessary bed hold notices. The facility's policy requires that written information regarding bed hold practices be provided well in advance and at the time of transfer for hospitalization or therapeutic leave. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the medical records of residents who were transferred. Specifically, the medical record of one resident, who was hospitalized, did not contain documentation of the bed hold policy being provided to the resident or their representative. Similarly, another resident's electronic medical record lacked documentation of a bed hold notice when the resident was sent to the emergency room due to a change in condition. The facility administrator confirmed that the residents had not been receiving bed hold notices upon discharge to the hospital, acknowledging the absence of an effective process to ensure compliance with the policy.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
