Allure Of Sterling
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling, Illinois.
- Location
- 612 West St Mary's Street, Sterling, Illinois 61081
- CMS Provider Number
- 145615
- Inspections on file
- 29
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Allure Of Sterling during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, who was cognitively intact and dependent on staff for transfers using a mechanical lift, sustained a scalp abrasion and severe pain when a newer CNA allowed the mechanical sling lift to strike the top of the resident’s head during a transfer. The incident report documented a scraped scalp, pain level of 10, neuro checks, and wound care, and indicated that the physician was notified. However, subsequent interviews with the RN who completed the report, several LPNs, the wound nurse, and the DON showed that no nurse could identify who actually contacted the physician, and the medical director did not recall any notification. This established that the facility failed to notify the resident’s physician of the injury as required.
A resident with multiple comorbidities and dependence on a mechanical lift for transfers sustained a scalp abrasion when the lift struck her head during a transfer. Several staff, including an RN, LPNs, the wound nurse, and the DON, viewed the injury but did not complete or document a thorough wound assessment with measurements or detailed description in the EMR, and no treatment was initiated. The incident report noted a scraped scalp, neuro checks, and severe pain, but lacked a full wound assessment, and subsequent skin documentation only briefly mentioned a closed abrasion without size or appearance details, while the resident reported that the wound was not measured or treated and still had a scab weeks later.
A resident with multiple mobility-related diagnoses, dependent on staff for transfers and care-planned for a mechanical lift with two-person assistance, was transferred by a single CNA using a mechanical sling lift. The CNA, unable to find another aide and aware the resident was fearful of the lift, proceeded alone, and while adjusting the sling and aligning the resident with a wheelchair, the lift tipped, causing the resident to drop into the chair and be struck on the top of the head. The resident cried out in pain, had active bleeding and blood in her hair and on her clothing, and later had a painful scalp wound that remained scabbed and measurable weeks afterward. Staff interviews and documentation confirmed that facility policy required two staff for mechanical lift transfers and that this requirement, as well as the resident’s care plan, was not followed.
A resident with multiple comorbidities, fragile skin, and a care plan requiring assistance/escort to activities was placed at the nurses’ station after a meal and left unsupervised. The resident attempted to return to her room independently, became entangled in a meal tray cart, and another resident in a motorized wheelchair tried to help by moving the cart. When the wheelchair’s controller was accidentally bumped, the chair moved and the first resident’s hand became caught, causing a large multilayer right-hand laceration that required emergency room treatment, suturing, splinting, and pain management. Staff and the DON later confirmed that no staff were present in the hallway at the time and that the resident was normally pushed back to her room after meals, demonstrating a failure to provide adequate supervision and to control the hazard posed by the meal cart.
The facility did not ensure that an RN was on duty for at least eight consecutive hours each day as required. Review of the nursing schedule for part of a month showed two days with no RN coverage, and the facility could not produce documentation that an RN worked on those days. The DON confirmed in an interview that there was no RN coverage on those dates and acknowledged the requirement for daily RN presence under the facility’s staffing policy.
Surveyors found that the facility did not consistently post current daily nurse staffing information and did not maintain at least 18 months of these postings as required. On review, the only posted direct care staff report was two days old, and the Regional Nurse Consultant reported that no daily staffing reports were available for more than four months, since late summer. The prior DON had kept copies of daily postings, but the current DON did not, despite an existing policy requiring sufficient licensed nurses and nurse aides on a 24-hour basis to provide care to all residents.
The facility failed to follow its policy requiring nursing staff to offer bedtime snacks daily to all residents according to their needs, preferences, and requests. Multiple residents without cognitive impairment reported they do not receive bedtime snacks unless they specifically ask, that staff do not pass snacks room to room, and that a prior practice of offering bedtime snacks stopped after concerns that staff were taking snacks for themselves. The Dietary Manager stated a snack cart is placed in a locked nutrition room on the LTC unit and that CNAs, not dietary staff, are responsible for passing snacks, while the DON stated CNAs should offer snacks during the water pass. Because the nutrition room is locked with a coded system, residents cannot independently access snacks, resulting in snacks not being routinely offered at bedtime as required.
Surveyors found that staff failed to follow infection control practices during wound care and PPE use for several residents. One resident with separate sacral and coccyx pressure injuries had both wounds cleansed, treated, and covered together, contrary to the facility’s stated practice of treating each wound individually to avoid cross-contamination. An LPN performing multiple dressing changes on another resident did not wear a gown for one wound and did not change gloves between different wounds and body areas, despite facility policy requiring glove changes and appropriate gown use. For a resident on enhanced barrier precautions with a diabetic foot ulcer, a wound nurse performed dressing changes wearing only gloves instead of both gown and gloves as required for high-contact care activities. Another resident on contact isolation for an ESBL wound infection had staff entering the room without gowns or gloves, even though signage and policy required full PPE upon room entry, and the resident’s bleeding toe was not fully covered by the dressing.
A resident who was dependent on staff for personal hygiene, including shaving, was repeatedly observed with coarse, 1–2 inch chin hair despite being otherwise clean and appropriately dressed. Her MDS and care plan documented an ADL self-care deficit and the need for staff assistance with bathing and grooming, with scheduled showers twice weekly and shower sheets requiring notation of facial hair removal. Facility records showed missed or undocumented shower days and indicated that facial hair was not removed on some documented shower days, with no notes of care refusal. The ADON/Infection Preventionist reported that residents are typically groomed on shower days and that any refusal should be charted, and the facility’s policy required assistance with grooming facial hair to maintain proper hygiene.
A resident with type 2 DM, vascular dementia, and a diabetic neuropathic ulcer on the right plantar foot did not receive weekly wound measurements and complete assessments as required by the care plan and facility policy. During wound care, the wound care nurse reported that the resident’s diabetic ulcer was managed by an outside podiatrist but had no wound notes or assessments available, and the ADON later acknowledged that staff should have been monitoring and documenting the wound weekly. Review of weekly skin assessments over several months showed only that the resident was followed by a physician and had a treatment order, without any wound measurements or descriptive details, despite a podiatry note documenting a full-thickness ulcer with specific dimensions and the facility policy requiring ongoing assessment of wound size and characteristics.
A resident with dementia, severe cognitive impairment, and high fall risk was observed seated unsafely at a dining table wearing worn slipper socks with most grip dots missing, despite a care plan intervention for nonslip footwear. Staff acknowledged the socks were unsafe, and the DON reported that high fall-risk residents should have individualized interventions followed as care planned, yet the facility lacked a dedicated fall-prevention policy and relied only on an incidents/accidents policy used after events. In a separate observation, the same resident, care planned as dependent for transfers and requiring two-person assistance with a mechanical lift, was transferred from wheelchair to bed by a single CNA using the lift while the second CNA was in the bathroom, contrary to facility policy requiring two staff for all mechanical lift transfers.
A resident with severe cognitive impairment was not protected from sexual abuse by another cognitively impaired resident. Staff discovered both individuals naked in a compromising situation, but the incident was not promptly reported to the state, and documentation and investigation were incomplete. Multiple staff and family members expressed concerns about the residents' inability to consent, and the facility's response was delayed and inconsistent.
Staff failed to report allegations of sexual abuse involving two cognitively impaired residents after a CNA found them partially undressed together. Despite facility policy requiring immediate reporting to authorities, the administrator chose not to report the incident, and no documentation was found of any report or investigation. A review of prior incidents revealed a similar failure to report and investigate when two other cognitively impaired residents were found together in a private room.
A facility failed to investigate an incident where two cognitively impaired residents were found together in a private room, despite staff reporting the event to management. The incident was not documented or formally investigated, contrary to facility policy requiring immediate action and thorough documentation for suspected abuse.
A resident's medical record lacked complete and accurate documentation regarding an incident involving two residents in the memory care unit. Staff and a family member described the residents being found together in bed, but the chart only noted a romantic interest and omitted key details. An LPN reported being told by the previous administrator not to document the incident, resulting in a record that did not reflect the actual events as required by facility policy.
A resident with a history of elopement and a diabetic foot ulcer was not properly assessed or care planned for elopement risk. After being observed seeking to leave, a wander guard was placed without proper documentation or orders. The resident removed the device, exited the facility, and traveled to a gas station before being located and returned by staff, highlighting a failure in supervision and adherence to elopement protocols.
A resident with moderate cognitive impairment and physical limitations reported being hit by her roommate, who had a history of behavioral issues. Staff interviews referenced the alleged incident, but there was no documentation in the progress notes about the altercation or the circumstances leading to the room change, despite facility policy prohibiting abuse.
The facility did not timely report allegations of abuse and a resident-to-resident altercation to the appropriate authorities as required by policy. A resident with cognitive impairment reported being thrown against a wall by a CNA, and two other residents were involved in an unreported physical incident. Staff were aware of these allegations but failed to escalate or document them until notified by a surveyor.
A resident alleged that a night shift CNA threw her against the wall while assisting her to bed, but the CNA continued to work with the resident after the allegation was reported to multiple staff members. Required protective measures, such as suspension of the alleged perpetrator and increased supervision, were not implemented, and several staff failed to report the allegation to administration as required by facility policy.
A resident with severe cognitive impairment experienced two falls, with the second resulting in injury and transfer to a hospital. The LPN involved could not confirm that the resident's representative was notified, and the family only learned of the hospital transfer from the emergency room doctor. Facility records did not document any notification to the family, despite policy requiring prompt notification after such incidents.
A resident with multiple health issues developed a Stage 3 pressure injury due to the facility's failure to assess and implement pressure-relieving interventions. The resident was observed leaning in her wheelchair, causing a wound on her back, which was not assessed or documented for a week. The facility's policy for prompt assessment and treatment was not followed, and the care plan was not updated.
The facility failed to monitor and record food and dishwasher temperatures, crucial for preventing foodborne illnesses. The Dietary Manager noted the dishwasher should reach 200 degrees, but logs showed gaps in temperature monitoring. Similarly, food temperatures were not consistently logged before serving, as required by facility policy. These deficiencies affected all 90 residents.
The facility failed to secure hazardous materials in a dementia unit shower room, leaving items like mouthwash and razors accessible to residents. Additionally, staff did not use a gait belt during the transfer of a resident with coordination issues, despite the resident's risk for falls and the presence of a gait belt in the room.
A resident, who is cognitively intact, was denied privacy during medical appointments as the transportation coordinator insisted on accompanying her despite her requests to be alone. The facility's administrator confirmed that residents who are alert and oriented have the right to privacy, aligning with the facility's policy supporting residents' privacy in communications.
The facility failed to provide proper respiratory care for residents, including a lack of physician orders for oxygen therapy and improper handling of equipment. A resident received oxygen without a current order or care plan, while another had undated and improperly stored oxygen tubing. A third resident's breathing treatment equipment was not dated or stored correctly, with the LPN unaware of proper procedures.
A resident with a history of UTIs and other medical conditions returned to the facility with a discharge order for amoxicillin. The facility failed to administer two doses of the antibiotic, despite having it available in their stock drug convenience box. The DON acknowledged the oversight, which violated the facility's Medication Administration Policy.
The facility failed to ensure proper use of PPE for infection control, as staff did not adhere to required protocols for residents under modified droplet and enhanced barrier precautions. Despite clear signage and policy guidelines, staff entered COVID-19 positive rooms wearing only surgical masks instead of the required N-95 masks, eye protection, gowns, and gloves. Additionally, during high-contact care activities for a resident on enhanced barrier precautions, staff wore gloves but failed to wear gowns.
Failure to Notify Physician After Resident Head Injury During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician after the resident sustained a head injury during a mechanical lift transfer. The resident had multiple medical diagnoses, including ulcerative colitis, prior fractures, chronic pain, muscle weakness, lack of coordination, osteoarthritis, and other conditions, and was assessed as cognitively intact, wheelchair-bound, and dependent on staff for transfers, requiring a mechanical lift with two staff assistance. During a transfer with a mechanical sling lift performed by a newer CNA, the lift hit the resident on the top of the head as she was being lowered into her wheelchair. The resident reported that her head was bleeding, it hurt a lot, and she cried when it happened. On observation days later, the resident had about a one‑inch dark, purplish scab on the top of her head. The initial incident report documented that the top of the resident’s scalp was scraped by the mechanical lift, with pressure applied to the scalp, neuro checks initiated, wound care provided, a skin check completed, an abrasion to the top of the scalp, and a pain level of 10. Despite the documented injury and pain, the facility did not ensure that the resident’s physician was actually notified of the incident. The incident report, completed by an RN, indicated that the physician was notified, but subsequent interviews with multiple LPNs and the wound nurse revealed that none of them notified the physician or knew who had done so. The wound nurse stated she did not update the physician, and the LPNs who were said to have taken over care denied notifying the physician or being aware of who did. The medical director, who was the resident’s physician at the time, did not recall being notified about the mechanical lift striking the resident’s head. The DON stated she was not sure which nurse would have notified the physician and only commented that the wound did not look like it needed treatment such as stitches. This combination of inconsistent documentation, lack of clear responsibility, and staff statements established that the physician was not notified of the resident’s head injury as required.
Failure to Assess, Document, and Treat Resident Head Injury After Mechanical Lift Incident
Penalty
Summary
The deficiency involves the facility’s failure to perform and document a thorough assessment and to initiate treatment for a head injury sustained by a resident during a mechanical lift transfer. The resident had multiple medical diagnoses, including ulcerative colitis, fracture of the right clavicle, chronic pain, muscle weakness, impaired balance, and limited mobility, and required a mechanical lift with two staff for transfers. During a transfer, the mechanical sling lift struck the top of the resident’s head, causing an abrasion that the resident later described as never having been measured or treated, and which remained as a dark, purplish scab approximately an inch long more than a month later. Following the incident, several nurses, including an RN, LPNs, the wound nurse, and the DON, viewed the injury but did not complete or document a comprehensive wound assessment in the electronic medical record. The wound nurse acknowledged she did not perform a full assessment, only looked at the wound, recommended the physician be called, measured the wound on paper without entering it into the record, and did not initiate any treatment. The RN reported she only looked at the injury briefly, obtained vital signs, and then allowed other nurses to take over, without documenting an assessment. Two LPNs stated they either did not assess the wound or only viewed it superficially and did not document any assessment. The DON stated she observed an approximately one‑inch abrasion on the scalp that was already scabbed and not bleeding, and told staff it did not appear to need treatment, but she did not complete or ensure a documented, detailed assessment. The initial incident report, completed by the RN, noted that the scalp was scraped by the mechanical lift, that pressure was applied, neuro checks were initiated, wound care was provided, and that the resident’s pain level was 10, but it did not include a full description or measurements of the wound. Subsequent documentation in the electronic medical record lacked a Weekly Skin Assessment on the day of the incident and later only referenced an abrasion to the top of the scalp without size or appearance details. The DON confirmed that the only later note described the abrasion as closed with no drainage, redness, swelling, or pain, and acknowledged this was not an acceptable assessment and that no treatment had been initiated despite the resident still having a scab over a month later.
Single-Staff Mechanical Lift Transfer Causes Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical sling lift transfer for a resident who required two-person assistance. The resident had multiple medical diagnoses, including fracture of the right clavicle, pain in the right shoulder, low back pain, right knee pain, muscle weakness, lack of coordination, and unilateral primary osteoarthritis of the left hip. Her facility assessment documented that she was cognitively intact, used a wheelchair for mobility, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfers. Her ADL care plan, initiated on 9/2/25, specified that she had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and limited mobility, and required a mechanical lift with two staff assistance for transfers. On the day of the incident, the CNA assigned to the resident attempted to transfer her from bed to wheelchair using a mechanical sling lift without obtaining the required second staff member. The CNA reported that she tried to find help but did not see any other CNAs available, and proceeded to perform the transfer alone. The resident had previously told the CNA that she was terrified of the mechanical lift. During the transfer, after the resident was lifted off the bed and while the CNA was trying to align the resident with the wheelchair and adjust the sling, the mechanical lift tipped, causing the resident to “plop” into the wheelchair and the lift to strike the top of her head. The resident cried, screamed that it hurt, and had bleeding at the site of impact. Multiple staff, including LPNs and the DON, later observed the injury. The resident was noted to have active bleeding on the top of her head immediately after the incident, with blood in her hair and on her shirt, and staff applied pressure and performed wound care. A wound nurse later described the wound as bleeding but not heavily, with a dime-sized amount of blood on gauze and the area being very sensitive and painful to touch for the first three weeks. On observation over a month later, the resident still had a scab on the top of her head measuring 1.9 cm by 0.2 cm. The facility’s written Safe Resident Handling/Transfers policy required that mechanical lifting equipment be used based on resident needs and explicitly stated that two staff members must be utilized when transferring residents with a mechanical lift and that transfers must be performed according to the resident’s individual plan of care, which was not followed in this incident.
Failure to Supervise Resident and Manage Meal Cart Hazard Resulting in Severe Hand Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards, resulting in a resident sustaining a significant right-hand laceration. The resident had multiple diagnoses, including heart disease, long-term use of anticoagulants, diabetes mellitus, major depressive disorder, anxiety disorder, morbid obesity, a need for assistance with personal care, a history of falling, muscle wasting, and fragile skin. Her care plan identified potential and actual impairment to skin integrity related to these conditions and documented that she required assistance or an escort to activity functions. Despite these identified needs, the resident was placed at the nurses’ station and later attempted to return to her room independently. On the date of the incident, nursing notes document that staff were called to the hallway and found the resident bleeding on the floor and from her hand. Assessment revealed a large skin tear and laceration on the right hand extending from the middle finger knuckles up between the second and middle finger to the wrist, with some areas too deep to approximate with steri-strips. The resident was transported to a local emergency room, where hospital records described a significant multilayer laceration exposing extensor tendons over the second and third metacarpals, measuring approximately 12 cm by 6 cm. The resident required 19 sutures, a nonstick dressing, and a splint to promote healing and prevent disruption of the sutures, and was started on antibiotics and narcotic pain medication. The facility’s root cause analysis and interviews show that the resident became entangled in a food tray cart while attempting to move herself from the nurses’ station back to her room without staff assistance. Another resident using a motorized wheelchair attempted to help by moving the food cart when he accidentally bumped his wheelchair controller, causing the chair to move and the first resident’s hand to become caught under the wheelchair controller, resulting in the laceration. Both the injured resident and the assisting resident reported that there were no staff present in the hallway at the time. The DON stated that staff usually push the injured resident back to her room after meals and that staff had placed her at the nurses’ station but were called away, and no staff observed that she was stuck in the tray cart. This sequence of events demonstrates that the resident was not adequately supervised in accordance with her assessed needs and the facility’s policy on accidents and supervision.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled and on duty for at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own Nursing Services and Sufficient Staff policy. The CMS-671 form dated 12/16/25 documented that 84 residents resided in the facility at the time of the survey. Review of the December 2025 nursing schedule for the period 12/1/25 through 12/16/25 showed there was no RN coverage on 12/6/25 and 12/13/25, and the facility was unable to provide any documentation that an RN worked on either of those days. During an interview on 12/18/25 at 12:19 PM, the Director of Nurses confirmed that there was no RN coverage on those two Saturdays and acknowledged the requirement to have an RN in the facility for at least eight consecutive hours each day.
Failure to Post and Maintain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nursing staff information and to maintain at least 18 months of daily staffing postings as required. Surveyors noted that the CMS 671 form dated 12/16/25 documented 84 residents in the building, but on 12/18/25 at 10:20 AM the posted direct care staff daily report was still dated 12/16/25. During the survey, the Regional Nurse Consultant stated there were no daily staffing reports available after 7/31/25, indicating a gap of over four months without maintained postings, and explained that the prior DON had kept copies of the daily posted reports but the current DON did not. The Administrator acknowledged the importance of posting daily staffing numbers to know who is working and to ensure appropriate staffing for the day. The facility’s undated Nursing Services and Sufficient Staff policy states that the facility will supply services by sufficient numbers of licensed nurses and nurse aides on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. This failure to post and maintain daily staffing information had the potential to affect all 84 residents residing in the facility, as identified in the CMS 671 form.
Failure to Routinely Offer and Provide Bedtime Snacks to Residents
Penalty
Summary
The deficiency involves the facility’s failure to offer bedtime snacks to residents in accordance with their needs, preferences, and requests, as required by facility policy. During a group meeting with residents and the facility ombudsman, residents reported that they do not receive bedtime snacks unless they specifically ask for them, and that staff do not routinely offer or pass snacks room to room. Residents stated that bedtime snacks had been offered in the past but this practice stopped after staff were allegedly taking snacks for themselves, and that this change occurred a long time ago. Residents also reported that if they want a snack after dinner, they must bring something back from lunch and keep it in their rooms until evening. Record review showed there were 84 residents in the facility, and assessment review for residents present at the group meeting revealed no cognitive impairment among them. The Dietary Manager reported that kitchen staff take a snack cart to the resident units daily and place it in the nutrition room on the LTC unit, and that CNAs are responsible for passing the snacks rather than dietary staff. Observation showed the nutrition room had a number-coded locking system, preventing residents from accessing snacks without staff assistance. The DON stated that CNAs should be offering bedtime snacks during the water pass because it is important for residents to have substance between the evening and morning meals. The facility’s undated “Offering/Serving Bedtime Snacks” policy states that nursing staff will offer bedtime snacks to all residents daily in accordance with their needs, preferences, and requests, which was not occurring as described by residents and staff.
Infection Control Failures in Wound Care and PPE Use
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control practices related to wound care and use of personal protective equipment (PPE) for multiple residents. For one resident with a stage 4 sacral pressure injury and a separate pressure injury to the coccyx, the wound care nurse cleansed and treated both wounds using the same gauze pad and the same sequence of products, and then covered both wounds with a single bordered foam dressing. The nurse confirmed that the sacral and coccyx wounds were considered two separate wounds that were measured and assessed individually, yet she routinely cleansed and treated both areas at the same time. The Assistant Director of Nursing and Infection Preventionist later stated that when a resident has multiple wounds, each wound should be cleansed, treated, and covered individually, starting with the cleanest to the dirtiest wound to avoid cross contamination and prevent infection. The facility’s wound treatment management policy stated that wound treatments would be provided in accordance with physician orders and current standards of practice. Additional deficiencies were observed in wound care and PPE use for another resident receiving multiple dressing changes. An LPN performed a dressing change on a leg wound wearing gloves but no gown, removed the soiled dressing, cleansed the wound, applied skin prep, and completed the treatment without changing gloves at any point. He then acknowledged he should have worn a gown. For the same resident’s subsequent wounds on the upper back and lower buttocks, the LPN donned a gown and gloves but again failed to change gloves between removing soiled dressings, cleansing wounds, applying skin prep, repositioning the resident, handling supplies, and repacking a wound. The facility’s PPE policy required changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and wearing gowns to protect exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Surveyors also found failures to follow enhanced barrier precautions and contact isolation requirements. For a resident on enhanced barrier precautions due to skin integrity issues and a diabetic foot ulcer, the wound nurse performed a dressing change and treatment to the diabetic foot ulcer wearing only gloves and no gown, despite an enhanced barrier precautions sign on the door specifying that gowns and gloves must be worn for high-contact care activities including wound care for any skin opening requiring a dressing. For another resident on contact isolation for an ESBL infection in a right lower extremity wound, a sign on the door instructed staff to wear gowns and gloves before room entry. A CNA entered the room twice to drop off bed sheets without wearing a gown or gloves, and the resident’s right lower leg dressing did not fully cover the toes, leaving a bleeding toe exposed. While one staff member stated gowns and gloves were only necessary for direct care, the Infection Preventionist stated that staff must wear gowns and gloves before entering the room, consistent with the facility’s transmission-based precautions policy requiring gown and glove use for contact precautions when interacting with the resident or potentially contaminated areas in the resident’s environment. The report also documented that the wound nurse who performed the wound care for the resident with sacral and coccyx pressure injuries did not have a current nursing license at the time of the survey. A license verification printout provided by the facility showed that this nurse’s license status was "not renewed," with an expiration date earlier in the year. This issue was cited separately under a different regulatory reference.
Failure to Provide Grooming Assistance for Dependent Resident’s Facial Hair
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate grooming assistance for a dependent female resident by not removing coarse facial hair from her chin. On multiple observations over two consecutive days, the resident was seen in her wheelchair, appropriately dressed and appearing clean, but with visible coarse chin hair approximately 1–2 inches in length that remained unshaved throughout the day. The resident’s Minimum Data Set (MDS) indicated she was dependent on staff for personal hygiene tasks, including shaving, and her care plan documented an ADL self-care performance deficit related to impaired balance, with restorative programming for dressing, grooming, and bed mobility. Her care plan interventions specified that she required staff assistance with bathing and showering. Record review showed that the resident’s shower schedule was twice weekly, on Wednesdays and Sundays, with shower sheets requiring staff to indicate whether facial hair was removed. The facility-produced shower sheets for several dates over the prior three months showed that facial hair was not removed on at least two documented shower days, and there were no shower sheets provided for several other scheduled shower days immediately preceding the survey observations. Progress notes for the prior 30 days contained no documentation of the resident refusing care. The Assistant DON/Infection Preventionist stated that residents are typically groomed or shaved on shower days and that female residents should not have facial or chin hair, adding that any refusal of grooming should be charted. The facility had a policy stating it would assist residents with grooming facial hair to maintain proper hygiene, but the observed and documented care did not reflect consistent implementation of this policy for this resident.
Failure to Perform and Document Weekly Assessments of Diabetic Foot Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to complete weekly measurements and comprehensive assessments of a resident’s diabetic ulcer as required by facility policy and the resident’s care plan. During observation, the resident was seen seated in his room while the wound care nurse removed the dressing from the bottom of his right foot, revealing a large, round, dark-colored area on the ball of the foot below the right great toe with raised edges. The wound care nurse stated the wound was a diabetic ulcer related to a bone deformity and that the resident went out to a podiatrist for wound care, but she did not have any wound notes or assessments for the resident and deferred to the ADON for the location of podiatry notes. The ADON later stated that wound documentation should be scanned into the electronic medical record and that staff should be monitoring and documenting the wound weekly using the wound observation tool, acknowledging that the lack of documentation was likely a mistake. Record review showed that weekly skin assessments over several months documented that the resident was being followed by a physician for a diabetic wound to the right plantar foot and that a treatment order was in place, but these assessments did not include measurements or descriptions of the wound. The podiatrist’s note, which the ADON produced, documented a full-thickness diabetic neuropathic ulcer on the bottom of the resident’s right foot, with specific post-debridement measurements, confirming the presence and severity of the wound. The resident’s diagnoses included type 2 DM with foot ulcer and vascular dementia, and physician orders directed daily betadine application and use of a post-op shoe. The resident’s care plan and the facility’s wound treatment management policy required monitoring and documentation of wound location, size, and characteristics, including measurements and detailed assessment, but the facility’s own documentation lacked these required elements for this resident’s diabetic ulcer.
Failure to Implement Fall-Prevention Measures and Safe Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and effectively implement fall-prevention interventions for a resident at high risk for falls. During breakfast observation, the resident was seated forward in a dining chair with her buttocks not against the back of the chair, prompting a CNA to instruct her to scoot back due to safety concerns. The resident was wearing slipper socks that were worn on the bottom, with holes forming and very few grip dots remaining. Upon further inspection, staff acknowledged that the grips were worn off and that it would be safer for the resident to have socks with grips. The resident’s fall risk assessment showed a high-risk score of 15, and the care plan identified her as at risk for falls related to deconditioning and dementia, with an intervention specifying nonslip footwear as tolerated. The DON stated that residents with high fall risk scores should have specific interventions on the care plan that are to be followed. The facility did not have a fall prevention policy and instead had only an Incidents and Accidents policy that applied after an incident occurred. The facility also failed to provide a safe mechanical lift transfer consistent with its own policies and the resident’s care plan. The resident, who had diagnoses including dementia, lack of coordination, Alzheimer’s disease, depression, anxiety disorder, hyperlipidemia, hypertension, hypothyroidism, and sepsis, was documented on the MDS as having severe cognitive impairment, requiring substantial/maximal assistance for rolling in bed, and being dependent for transfers. The care plan specified that the resident required assistance by two staff for transfers and used a mechanical lift. During observation, two CNAs brought the resident to her room for incontinence care, with the resident seated in a wheelchair and a mechanical lift sling under her. After attaching the sling to the lift, one CNA went into the bathroom, and the remaining CNA completed the mechanical lift transfer from wheelchair to bed alone, without assistance. The CNA later stated that facility policy requires two staff for mechanical lift transfers for safety, and the DON confirmed that the mechanical lift policy mandates two staff members—one to maneuver the lift and one to watch and guide the resident—when using a mechanical lift.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another cognitively impaired resident. Both individuals resided in the memory care unit and lacked the capacity to consent to sexual activity, as confirmed by medical documentation and staff interviews. The incident occurred when a CNA entered the resident's room and found both residents naked, with one resident standing over the other and engaging in thrusting motions. The CNA intervened and separated the residents, but the event was not immediately reported to the state, and there was confusion and inconsistency in the accounts provided by facility staff and administration regarding the nature of the incident. The administrator conducted an internal investigation but did not report the incident to the state, reasoning that no intercourse had occurred. Documentation of the incident, including risk assessments and family notifications, was incomplete or missing from the resident's chart. Staff interviews revealed that the normal protocol for documenting and assessing such incidents was not followed, and there was a lack of clarity and consistency in communication with the resident's family. Multiple staff members, including the CNA and LPN involved, expressed concerns about the residents' inability to consent and described the event as sexual abuse, yet the facility's response was delayed and inadequately documented. Further interviews with the resident, her family, and other staff indicated that the resident reported being raped and expressed distress about the incident. The medical director and psychiatric nurse practitioner confirmed the resident's inability to consent due to her cognitive status. The facility's staffing levels were also called into question, as only one CNA was present on the unit during certain shifts, limiting the ability to monitor residents effectively. The failure to protect the resident from abuse, promptly report the incident, and properly document and investigate the event constituted a deficiency and resulted in an Immediate Jeopardy finding.
Removal Plan
- R1 and R2 were immediately assessed for injury, changes in condition and psychosocial impact.
- R1 and R2 POAs, Police and MD were notified of the incident.
- R1 was sent to the ER for evaluation.
- R1 and R2 care plans were updated to reflect enhanced safety interventions.
- R1 and R2 had the Abuse, Neglect and Trauma assessment and Trauma Informed Care Assessment / PTSD was completed.
- The Social Services Director interviewed/assessed all residents with BIMS scores of 8 and above for potential abuse.
- All residents with a BIMs score of 7 or less were assessed using the Abuse Screening Adapted for Cognitive Impairment form.
- A hall monitor was added to the memory care unit to ensure no resident enters another resident's room.
- The Hall Monitor is a dedicated staff member and will have no other duties.
- R2 was immediately placed on a 1:1 until hall monitor was established.
- Abuse investigation procedure and documentation process were reviewed.
- DON, ADON, and Administrator re-educated all staff on facility abuse policies.
- DON, ADON, and Administrator educated all staff on the Intimate Resident Behavior, Privacy and Relationships policy updated to reflect residents within the memory care unit do not have the capacity to consent to sexual relationships.
- In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete.
- Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.
- DON, ADON, and Administrator educated staff on the Hall Monitor duties and responsibilities and that the Hall Monitor is a dedicated individual with no other responsibilities.
- Administrator was educated by Regional Nurse on abuse policy which includes thorough investigation immediately upon receiving report or allegation of abuse.
- Emergency QAPI meeting was held where the abuse policy and intimate relations policy were reviewed along with incident and root cause analysis.
- The Social Services Director or designee will continue to interview residents with BIMs score of 8 or higher on a monthly basis to ensure they have not experienced abuse.
- All residents with a BIMs score of 7 or less will be assessed using the Abuse Screening Adapted for Cognitive Impairment form.
- Any reports of abuse will be immediately reported and investigated.
- The finding to be presented to the Quarterly QAA Committee.
Failure to Report Allegations of Sexual Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse involving residents with cognitive impairments. In one incident, a CNA entered a resident's room and observed two residents, both partially undressed, in a compromising position. The CNA reported the situation to a nurse, and the administrator later conducted an internal investigation. Despite the facility's policy requiring immediate reporting of all abuse allegations to state authorities, the administrator decided not to report the incident, reasoning that no intercourse had occurred. The administrator later acknowledged that the incident should have been reported, as any allegation is required to be reported and then investigated. The residents involved had significant cognitive impairments. One resident had diagnoses including dementia, sleep disorder, general anxiety disorder, and severe cognitive impairment as documented in the Minimum Data Set (MDS). The other resident involved in the incident had moderate cognitive impairment and similar diagnoses. The facility's own policy mandates reporting all alleged violations to the administrator, state agency, and other required agencies within specified timeframes, but there was no documentation that the Illinois Department of Public Health was contacted regarding the initial allegation or the results of the investigation. A review of prior incidents revealed another episode involving two cognitively impaired residents found together in a private room. Staff separated the residents and reported the situation to the nurse, who then informed the previous administrator. However, the administrator instructed staff not to document the incident in the residents' charts, and there was no evidence of an abuse investigation or reporting to authorities. Interviews with staff and review of facility records confirmed that no abuse investigations had been conducted in the last six months, despite these incidents.
Failure to Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents with cognitive impairment in the memory care unit. In June 2025, a CNA discovered one resident in another resident's room and bed, with both residents present but clothed. The CNA immediately separated them and reported the incident to the nurse, who then informed the Administrator. However, the Administrator instructed the nurse not to document the incident in the residents' charts and indicated that Social Services would handle the situation. There was no evidence of a formal investigation, and no abuse investigation was initiated or documented for this incident. Interviews with staff and review of records revealed that key personnel, including the current Administrator and previous Social Services staff, were either unaware of the full details or could not recall the specifics of the event. The residents involved had diagnoses of dementia and demonstrated severe to moderate cognitive impairment, with one resident unable to consent for herself. The facility's policy required immediate investigation and thorough documentation of any suspected abuse, neglect, or exploitation, but this was not followed in this case.
Incomplete and Inaccurate Documentation of Resident Incident
Penalty
Summary
The facility failed to ensure that a resident's medical record contained complete and accurate information regarding an incident involving two residents in the memory care unit. According to the documentation, a social service note indicated that the residents were interested in a romantic relationship and were advised to spend time together only in public spaces, with both agreeing to this guidance. However, interviews with staff and the resident's power of attorney revealed that the actual incident involved the two residents being found together in bed, with conflicting accounts about whether they were clothed or unclothed. The note in the medical record did not accurately reflect the details of the incident as described by staff and the resident's family member. Further review showed that the LPN involved was instructed by the previous administrator not to document the incident in the residents' charts, and the previous social services staff could not recall specific details without her notes. The facility's policy requires that all assessments, observations, and care provided be documented accurately, objectively, and completely in the resident's medical record. The lack of accurate and complete documentation in this case resulted in a deficiency, as the medical record did not contain sufficient details about the incident or the residents' responses to care.
Failure to Supervise and Prevent Elopement for At-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident at risk for elopement. The resident, admitted with a diabetic foot ulcer and cellulitis, had a documented history of elopement or attempted elopement at home. Despite this, the elopement evaluation did not identify risk factors or suggest interventions. Staff observed the resident attempting to leave the facility and placed a wander guard bracelet on him, but there was no clear documentation of who ordered or applied the device, and no corresponding assessment, care plan, or physician order was completed as required by facility policy. The resident was able to remove the wander guard and exit the facility in his wheelchair without staff knowledge. He traveled to a nearby gas station, crossing a highway with the assistance of bystanders, before being located and returned by staff and family. Interviews confirmed that staff were unaware of the resident's whereabouts until after he had left, and the incident was not immediately reported to the administrator. The resident was found without injury, but the lack of supervision and failure to follow established protocols for elopement risk contributed to the deficiency.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving a resident with moderate cognitive impairment and mild intellectual disabilities. According to the comprehensive cognitive assessment, this resident required total assistance with transfers and had limited use of her right arm due to hemiplegia/hemiparesis. Incident investigation reports and interviews revealed that the resident stated her roommate had hit her "all over," although she denied being physically hurt. The roommate, who was independent with mobility and had a history of manipulative and rude behavior toward past roommates, denied hitting the resident but stated that if she did, it was unintentional. Documentation showed that the two residents were roommates until one was moved to another room, with the move attributed to roommate preferences and behavioral concerns. Staff interviews indicated that there were reports and gossip among staff about the alleged physical altercation, with some staff recalling hearing that one resident was on the other's bed and may have hit her. However, there was no documentation in the progress notes regarding the potential physical altercation or the behavioral incidents leading up to the room change. The facility's policy prohibits abuse, neglect, and exploitation, including physical abuse such as hitting, slapping, and punching, but the lack of documentation and follow-up on the reported incident demonstrates a failure to fully investigate and address the alleged abuse.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of abuse involving three residents to the Abuse Coordinator as required by policy. One resident, who was moderately cognitively impaired and diagnosed with mild intellectual disabilities, consistently reported that a female CNA had thrown her against a wall, causing her to hit her head. The resident relayed this allegation to multiple staff members, including a hospice RN and an LPN, but the information was not reported to the Administrator or properly escalated internally. Staff interviews revealed confusion about the identity of the alleged perpetrator and a lack of clarity regarding reporting responsibilities. Internal reporting of the abuse allegation only occurred after the State Agency surveyor brought it to the Administrator's attention. Additionally, two other residents who were previously roommates were involved in an unreported incident where one resident allegedly hit the other. Staff members were aware of rumors or gossip about the incident, and one resident confirmed being hit by her former roommate, though she denied being physically hurt. There was no documentation in the progress notes regarding this potential physical altercation, and no internal report was made until the State Agency surveyor informed facility leadership. The facility's own policy requires immediate reporting of such allegations, but this was not followed in these cases.
Failure to Protect Resident from Further Potential Abuse
Penalty
Summary
The facility failed to protect a resident from further potential abuse after the resident alleged that a night shift CNA had thrown her against the wall while assisting her to bed, causing her to hit the left side of her head. The resident reported the incident to multiple staff members, including a hospice RN, an LPN, and another CNA. Despite these reports, the alleged perpetrator, identified by the resident as a night shift CNA (though the name used was not found on the staff roster), continued to work primarily as the resident's CNA until resigning from the facility. The facility did not suspend the alleged perpetrator pending investigation, nor did they implement protective measures such as increased supervision or staffing changes as outlined in their abuse prevention policy. Multiple staff members failed to report the resident's allegations to facility administration as required. The hospice RN stated she reported the allegation to the ADON, who denied receiving it, and another CNA admitted to not reporting the allegation at all. The facility's policy requires immediate action to protect residents from further harm during abuse investigations, including examining the alleged victim and making staffing changes if necessary. However, these steps were not taken, and the alleged perpetrator remained in contact with the resident until her resignation.
Failure to Notify Resident Representative After Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall with injury and was subsequently sent to a local hospital. The resident, who had diagnoses including unspecified dementia, malignant neoplasm of the head, face, and neck, and hypertension, was assessed as confused with severe cognitive impairment affecting all areas of judgment. The clinical admission assessment also noted wandering behaviors and incontinence. On the day in question, the resident had two falls: the first occurred while family was present in the building, and the second happened later that night after the resident was put to bed. After the second fall, the resident complained of left hip and knee pain and was sent to the emergency room. The LPN involved stated she believed she had notified the family but could not recall specific details and admitted uncertainty about whether the notification occurred. Interviews with the resident's daughters, who are also the resident's powers of attorney, revealed that they were not informed by the facility about the second fall or the transfer to the hospital. They only learned of the hospital transfer when contacted by the emergency room doctor regarding surgery for a fractured hip. Review of the resident's progress notes and incident reports confirmed that there was no documentation of family notification regarding the fall or hospital transfer. The facility's policy requires prompt notification of the resident's representative in the event of accidents resulting in injury or transfer, but this was not followed in this instance.
Failure to Assess and Intervene in Pressure Injury
Penalty
Summary
The facility failed to identify and assess a pressure injury on a resident, which progressed to a Stage 3 pressure injury before any assessment or intervention was conducted. The resident, a female with multiple diagnoses including mild protein calorie malnutrition, intellectual disabilities, and cognitive communication deficit, was observed leaning to the left in her wheelchair over several days. Despite the presence of a wound on her left mid-back, no assessment was performed until a week later when the wound doctor identified it as a Stage 3 pressure injury. The wound was attributed to the resident's back rubbing against a metal bar on the wheelchair, and no pressure-relieving interventions were implemented until after the wound was assessed. The Director of Nursing confirmed that there was no documentation or care plan interventions initiated after the wound was discovered. The facility's policy requires prompt assessment and treatment of pressure injuries, but this was not followed. The resident's care plan had not been updated since May, and there was no documentation of the wound in the wound doctor's notes. The facility's failure to assess and document the wound promptly, as well as to implement necessary interventions, contributed to the deterioration of the resident's condition.
Failure to Monitor Food and Dishwasher Temperatures
Penalty
Summary
The facility failed to adequately monitor and record both food and dishwasher temperatures, which are critical for ensuring sanitary conditions and preventing foodborne illnesses. The Dietary Manager, identified as V14, acknowledged that the dishwasher is a hot water sanitizer with a booster to reach temperatures up to 200 degrees. However, the dishwasher logs for September 2024 revealed gaps in temperature monitoring, with no records from September 6 to September 11 and on September 17. The facility's policy mandates that water temperatures be measured and recorded before each meal or after the dishwasher is emptied or refilled, but this was not consistently followed. Additionally, the facility did not consistently log food temperatures before serving meals. The Cook, identified as V16, stated that it is their responsibility to check and log food temperatures prior to serving. However, the food temperature log for the week of September 22, 2024, showed missing entries for dinner temperatures over the past two nights. The facility's policy requires that food temperatures be checked before serving and again after half of the meals have been served to ensure proper serving temperatures. These lapses in monitoring and recording temperatures for both food and dishwashing processes apply to all 90 residents residing in the facility.
Failure to Secure Hazardous Materials and Use Gait Belt
Penalty
Summary
The facility failed to ensure the safety of residents by not securing hazardous materials and not using proper transfer techniques. On the dementia unit, a shower room door with a keypad lock was found unlocked on multiple occasions, allowing access to hazardous liquids and disposable razors. These items, which included mouthwash, skin and hair cleanser, hand sanitizer, body lotion, baby powder, shaving cream, and a glass and surface cleanser, were labeled with warnings to keep out of reach of children. Staff acknowledged that the door should always be locked to prevent residents, who are known to wander and take items, from accessing these potentially dangerous supplies. Additionally, the facility did not use a gait belt during the transfer of a resident with a history of lack of coordination, hypertension, and obesity, who was at risk for falls due to deconditioning and gait/balance problems. During a toileting and peri care session, the resident was unsteady and required verbal cues to use a walker and transfer to a wheelchair. Despite the presence of a gait belt in the room, staff did not use it, which the Director of Nurses later confirmed was necessary for the resident's safety during transfers. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer.
Failure to Ensure Resident Privacy During Medical Appointments
Penalty
Summary
The facility failed to ensure privacy for a resident, R13, during physician appointments. R13, who is cognitively intact and has multiple diagnoses including spinal stenosis and difficulty walking, expressed that the transportation coordinator, V5, accompanied her into the doctor's office despite her requests for privacy. R13 stated that she asked V5 to remain in the lobby, but V5 insisted on accompanying her, citing responsibility for R13's safety. V5 claimed that no resident had ever requested privacy during appointments. The facility administrator, V1, acknowledged that residents who are alert and oriented, like R13, have the right to decide whether they want privacy during medical appointments. The facility's policy supports residents' rights to privacy in communications, both within and outside the facility.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by the lack of physician orders and improper handling of oxygen and breathing treatment equipment. One resident, a female with acute respiratory failure and other chronic conditions, was observed receiving oxygen without a current physician order or a care plan for oxygen administration. The facility's policy mandates that oxygen therapy must be administered under a physician's order and that equipment should be changed weekly and stored properly to prevent contamination. However, the resident's oxygen tubing was not dated or stored correctly, indicating a lapse in adherence to these guidelines. Another resident, a female with acute respiratory failure and other health issues, had an oxygen tank attached to her wheelchair with undated tubing that was not stored in a plastic bag, as required. Additionally, the oxygen concentrator in her room had a nasal cannula lying on the floor, also undated and improperly stored. A third resident, with asthma and other chronic conditions, had a breathing treatment machine with tubing that was not dated or stored in a bag. The LPN administering treatments was unaware of the tubing's age or the need for proper storage, further highlighting the facility's failure to follow its own infection control policies.
Failure to Administer Antibiotic to Resident
Penalty
Summary
The facility failed to administer two doses of an ordered antibiotic to a resident, identified as R32, who was reviewed for hospitalization. R32, a male resident with a history of urinary tract infection, multiple sclerosis, neuromuscular dysfunction of the bladder, calculus of the kidney and ureter, and chronic obstructive pulmonary disease, was diagnosed with sepsis likely sourced from a urinary tract infection, osteomyelitis, and infected decubitus ulcers. After a 14-day hospital stay, R32 returned to the facility with a discharge order to receive amoxicillin 500 mg by mouth three times a day for eight days. However, the facility's records showed that the amoxicillin was not administered on the evening of his return or the following morning. The Director of Nursing acknowledged that there was no excuse for the missed doses, as the facility had amoxicillin available in their stock drug convenience box. The facility's Medication Administration Policy requires medications to be administered by a licensed nurse as ordered by the physician and in accordance with professional standards of practice. Despite this policy, the failure to administer the antibiotic as ordered represents a deficiency in the facility's pharmaceutical services, impacting the resident's care and treatment.
Failure to Adhere to PPE Protocols for Infection Control
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) to prevent cross-contamination for two residents within the sample and one resident outside the sample. Specifically, residents R71 and R72 were under modified droplet precautions due to COVID-19, requiring the use of N-95 masks, eye protection, gowns, and gloves by anyone entering their room. Despite clear signage indicating these requirements, staff members V11 and V13 entered the room wearing only surgical masks, failing to don the necessary PPE. This occurred during multiple interactions, including delivering meals and engaging in close contact with the residents. Additionally, resident R84 was on enhanced barrier precautions due to a wound on his left foot, necessitating the use of gloves and gowns during high-contact care activities such as transfers and toileting. However, staff members V11 and V12 only wore gloves while performing these activities, neglecting to wear gowns as required. The facility's policies clearly outlined the PPE requirements for both COVID-19 precautions and enhanced barrier precautions, yet these were not adhered to by the staff, as confirmed by the Administrator/Infection Control Preventionist.
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.
