Axiom Gardens Of Flora
Inspection history, citations, penalties and survey trends for this long-term care facility in Flora, Illinois.
- Location
- 701 Shadwell Avenue, Flora, Illinois 62839
- CMS Provider Number
- 145624
- Inspections on file
- 34
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Axiom Gardens Of Flora during CMS and state inspections, most recent first.
The facility allowed uncertified Unit Aides (UAs) to perform CNA-level direct care despite job descriptions and the DON’s statements limiting UAs to non–hands-on helper tasks. Multiple alert and oriented residents reported that a UA assisted them with bed baths, incontinence care, transfers (including use of a mechanical lift), showering, and dressing. A CNA confirmed that, when short-staffed, UAs were used as additional CNAs and performed ADL care and transfers, and that another UA on nights escorted residents requiring one-person assist to the restroom. The DON stated that CNAs must be certified or enrolled in an LPN program and that UAs have no formal training requirement and should not provide resident care, while facility job descriptions showed UAs are intended only for cleaning, transport, and simple assistance at meals, and CNAs are responsible for ADLs and direct resident care.
Surveyors found that the facility failed to consistently implement fall-prevention measures for two cognitively impaired, high fall-risk residents. One resident with a history of hip fracture and dementia had care-planned hip protector underwear when out of bed, yet CNAs gave conflicting information about the number and location of the padded underwear, and the resident was repeatedly observed in bed and in a wheelchair without them, including during wheelchair use for meals. Another resident with atrial fibrillation, Parkinson’s disease, dementia, and unsteadiness on feet had a care plan and fall note requiring the room door to remain open for increased observation after a prior fall, but surveyors twice observed the door fully closed while the resident was in the room, once sitting at the bedside with a walker within reach. Staff interviews showed incomplete recall of specific fall interventions, despite a facility fall-prevention policy assigning responsibility to nursing personnel to ensure that identified safety interventions are consistently maintained.
A resident with cognitive deficits and a history of rash was hospitalized and treated for a diffuse pruritic rash resembling scabies, placed on contact isolation, and discharged back with orders indicating possible scabies and contact precautions. On readmission, an RN documented a generalized rash but did not review the hospital paperwork or obtain verbal report, so no contact isolation, infection tracking, contact tracing, or environmental cleaning was initiated. The infection control nurse did not add the case to the infection control log because the diagnosis and treatment occurred at the hospital, and housekeeping/laundry were not informed of any need for isolation-level cleaning or laundry. The facility’s scabies control policy, which requires resident inspections, DON/infection control assessment, hot washing of linens, environmental disinfection, and simultaneous treatment of affected individuals, was not followed.
Nonfunctioning Shower Room Call Light: The call light in a south hall shower room did not work and was not accessible from the floor during observation. A CNA stated it had been broken for a couple of days, and Maintenance confirmed there was no work order and that the call light did not function. The two south hall shower rooms are used for all residents on that hall, which included 36 residents.
A resident with Alzheimer's dementia, severe cognitive impairment, and a care plan for potential physical aggression received PRN lorazepam for combativeness. The MAR showed the medication was given, but there were no progress notes for the day and behavior tracking showed no observable behaviors. An LPN stated she did not attempt non-pharmacological interventions before giving the PRN psychotropic, and the DON stated staff were expected to perform and document such interventions first.
Failure to provide nail care for three residents with significant cognitive and physical impairment. Two residents with dementia and severe cognitive impairment had black substance under their fingernails on repeated observations, and a third resident with multiple medical conditions and impaired cognition had long toenails that needed trimming. A CNA stated the residents’ nails were dirty and should be cleaned, and the facility’s nail care policy required nail condition to be observed during bathing and debris to be cleaned from around and under finger and toenails.
Failure to provide nutritional supplementation for an underweight resident. A resident with severe protein calorie malnutrition, COPD, respiratory failure, and hospice services had a BMI of 15.3 and ate about 50% of meals, but the care plan did not address nutritional or weight status. The resident reported not receiving extra protein or supplement items, and the Dietary Manager confirmed no supplementation was provided despite knowing the resident was very thin and underweight.
Failure to perform pain assessments for a resident with ongoing pain. A resident with multiple diagnoses including a fracture, OA, and depression had a BIMS score indicating moderately impaired cognition and was receiving PRN analgesics and non-medication interventions. Staff observed grimacing, back pain, and pain affecting eating and positioning, but the MDS Coordinator stated there were no pain assessments beyond the MDS. The facility's pain policy required assessment and documentation when pain was indicated or pain meds were used, but this was not done.
The facility failed to follow infection control practices during wound care for two residents with chronic wounds. An LPN did not perform hand hygiene between glove changes while treating one resident’s leg wound, and during another resident’s foot dressing change the LPN used the same scissors that had cut off the old dressing to cut sterile packing without sanitizing them or using a clean pair. The IP and DON stated both practices were inappropriate and increased infection risk, and the facility policy required hand hygiene and standard precautions during resident care.
A resident with dementia, agitation, and a known history of aggressive behavior repeatedly verbally, physically, and sexually abused several cognitively impaired residents. In one episode, the resident slapped another resident in the face in the dining room while calling her derogatory names and stated he would hit her again. On another occasion, he was found in a resident’s room attempting to tip her out of her wheelchair while yelling and cursing, after having been agitated and disruptive throughout the day. He also grabbed a male resident by the throat and pushed him in his wheelchair out of the dining room, and in a separate incident, came up behind a female resident and grabbed her breast after following her around much of the day. These events occurred despite an existing abuse-prevention policy and a behavior-focused care plan for the aggressive resident.
A resident with dementia and dysphagia was served a whole bratwurst on a bun instead of the ordered mechanical soft diet with thickened liquids. The incorrect meal texture led to a choking incident during lunch, requiring emergency intervention and hospital transfer. Staff interviews and facility records confirmed the diet order was not followed, resulting in the deficiency.
A resident with severe cognitive impairment and behavioral issues physically assaulted two other residents, resulting in one sustaining a fractured coccyx. Staff and administration were aware of the resident's unpredictable aggression but were unable to identify or implement effective interventions to prevent repeated altercations, leading to physical harm and risk of abuse.
A resident with severe cognitive impairment and multiple comorbidities was pushed by another resident, resulting in a fall and subsequent pain complaints. Nursing staff administered pain medication but did not notify the physician of the pain or later x-ray findings indicating a coccyx fracture. The physician and NP were not informed until the family reported the injury, and hospital records documenting the fracture were not promptly reviewed or acted upon by staff.
A resident who was totally dependent on staff for transfers and required two-person assistance was left suspended in a mechanical lift sling by a CNA who exited the room after a disagreement, leaving the resident unable to reach the call light. The transfer was performed without a second staff member, contrary to the care plan, and the incident was not immediately reported or documented, resulting in a failure to protect the resident from neglect.
A resident dependent on staff for transfers was left suspended in a mechanical lift sling by a CNA who became upset and left the room, leaving the resident unattended for about ten minutes until other staff intervened. The incident was not immediately reported to the Administrator, and no incident report was filed, contrary to facility policy requiring prompt internal reporting of suspected neglect.
A resident who was totally dependent on staff for transfers was left suspended in a mechanical lift sling by a CNA who became upset and left the room. The resident, unable to reach the call light, called for help until two staff members arrived to complete the transfer. The incident was not documented or investigated, despite facility policy requiring all allegations of neglect to be investigated.
A resident who was totally dependent on staff for transfers was left suspended in a mechanical lift sling by a single CNA, contrary to the care plan and facility policy requiring two staff for such transfers. The CNA became upset during the transfer, left the resident unattended above a shower chair, and exited the room. The resident remained in the lift for about ten minutes until other staff responded and completed the transfer. The incident was not documented in the nursing notes, and no incident report was filed at the time.
The facility failed to ensure that a physician visited residents as required, affecting 64 residents. The Medical Director only visited for quality assurance meetings, while a nurse practitioner, who recently resigned, was responsible for resident visits. The facility's administrator and DON were unaware of the regulatory requirement for physician visits, leading to non-compliance.
The facility experienced significant staffing shortages, leading to delayed response times to resident call lights, particularly during night shifts. Residents reported waiting over 30 minutes for assistance, and the DON acknowledged the staffing challenges, noting reliance on agency staff to fill gaps. Observations confirmed numerous unfilled shifts, impacting the facility's ability to provide timely care.
The facility failed to maintain a safe and homelike environment, with issues such as a cracked windowpane in the shower room and multiple residents experiencing problems with their wheelchairs, including missing armrests and worn seats. These deficiencies affected residents' ability to safely and comfortably navigate their environment.
A resident, who is cognitively intact, experienced repeated delays in meal service compared to her tablemate, leading to a lack of dignity in dining. The facility's Dietary Manager attributed the issue to an outdated tray card system that had not been updated to include newer admissions, causing the resident to wait for her meal while her tablemate finished eating.
The facility failed to follow dietary orders for two residents, resulting in inadequate nutrition. One resident did not receive the prescribed double protein at meals, while another did not consistently receive fortified pudding. Additionally, the facility did not adhere to its weight policy for a resident with significant weight loss, failing to communicate the change to the dietitian or physician.
A facility failed to maintain accurate narcotic records for a resident with multiple medical conditions. An oxycodone bottle labeled with the resident's information was found in the medication cart without a count sheet, and the resident had no order for the medication. The RN and DON acknowledged the oversight, noting the medication should have been destroyed or returned to the family. Facility policy requires narcotic counts with a partner, which was not followed.
A facility failed to securely store medications for a resident prescribed Lorazepam, as the medication refrigerator was found without a lock on multiple occasions. The Director of Nursing acknowledged the oversight, and a Registered Nurse was unaware of the locking requirement, indicating a lapse in adherence to the facility's medication storage policy.
A resident with severe dementia and Type 2 Diabetes Mellitus was not provided with a therapeutic diet as ordered. The resident's care plan required a mechanically altered diet with bite-sized pieces to prevent choking. However, observations revealed that the resident was served meals with pieces larger than recommended, leading to difficulties in eating. The dietary manager and speech-language pathologist acknowledged the issue, but there was no formal documentation or training to ensure compliance.
The facility failed to maintain aseptic technique during wound care for two residents. A resident's leg was placed on a bed comforter without a barrier during wound care, contrary to infection control expectations. Another resident's wound care involved improper hand hygiene, as the nurse did not change gloves or wash hands after touching potentially contaminated surfaces. These actions were inconsistent with the facility's infection control program.
A resident sustained a leg laceration during transport in a facility van when their motorized scooter was not secured. The Social Service Director, who was driving, missed a turn and abruptly braked, causing the scooter to move forward and injure the resident. The resident required emergency medical attention and treatment for an infected wound. The facility's policy mandates securing all residents and wheelchairs during transport, which was not followed.
Uncertified Unit Aides Performing CNA-Level Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that only staff with appropriate competencies and certification provided resident care, despite having 62 residents in the building. A CNA reported that Unit Aides (UAs) were supposed to perform only non–hands-on tasks such as taking vital signs, answering call lights, making beds, and passing snacks and ice water. However, multiple residents who were alert and oriented to person, place, and time stated that a specific UA had assisted them with direct care tasks. One resident reported that the UA helped with bed baths by washing areas the resident could not reach. Another resident, who required a two-person assist for incontinence care, stated that the UA worked as another CNA when surveyors were not present and had assisted CNAs with incontinence care. Additional residents reported that the UA had helped with transfers to a wheelchair, provided support during transfers, assisted with incontinence care and rolling in bed for cleaning, and helped with showering and dressing, including putting on underwear, socks, pants, and shoes. A CNA confirmed that, prior to the survey, they had been working with the UA as another CNA on a hall where they were short-staffed due to CNA call-ins, and that the UA assisted with CNA duties such as transferring residents with a mechanical lift, performing other transfers, and dressing residents while the CNA supported them. The CNA also reported that another UA on night shift had performed CNA duties, including escorting residents who required one-person assist to the restroom. The UA in question told the surveyor that she was not involved in patient care. The DON stated that CNA duties include ADL assistance such as hygiene, bathing, transfers, and incontinence care, and that working as a CNA requires formal certification or enrollment in an LPN program, while the UA role requires no formal training or education. The DON stated that UAs performing CNA duties is not acceptable because they are not properly trained or certified and could cause injury or other adverse effects, and that UAs should only perform tasks such as making beds, stocking supplies, passing ice water and snacks, brushing hair, and painting nails. Facility job descriptions for UAs and CNAs corroborated that UAs are intended to perform helper and non-direct-care tasks, while CNAs are responsible for resident care and ADLs, confirming that UAs were used outside their defined scope of duties.
Failure to Consistently Implement Fall-Prevention Interventions for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and consistently maintain fall-prevention interventions for two cognitively impaired residents identified as being at risk for falls. One resident had diagnoses including a displaced right femur fracture and dementia, with an MDS showing a BIMS score of 0, indicating lack of cognitive intactness and unawareness of safety needs. This resident had an unwitnessed fall in the dining room that resulted in an acute right hip fracture requiring hospitalization and surgical repair. The care plan, revised after prior serious injury, included interventions such as use of pillows/positioning devices for bed positioning and the use of hip protector clothing when out of bed. However, staff interviews and observations showed that these hip protectors were not consistently applied when the resident was up in a wheelchair, despite the resident being up for meals and observed attempting to stand from the wheelchair without the protective underwear in place. Multiple CNAs gave conflicting or incomplete information about the resident’s hip protector underwear. One CNA reported that the resident had only one pair, which had been in the laundry for two days, while another CNA on the same hall was unaware of any special padded underwear. On several observations, the resident was seen either in bed or in a wheelchair without the hip protector underwear, even though staff acknowledged the resident should wear them when out of bed. One CNA stated the resident had two pairs of padded underwear but admitted they were not placed on the resident when she was up in her wheelchair for breakfast because one pair was in the washer and the other was not clean. Another CNA stated they knew the resident was supposed to have hip protector underwear but did not know where they were and had never placed them on the resident since her return from the hospital. The second resident had diagnoses including atrial fibrillation, Parkinson’s disease, dementia, and unsteadiness on feet, with an MDS BIMS score of 3 indicating impaired cognition and unawareness of safety needs, and required substantial/maximal assistance for mobility. This resident’s care plan identified high fall risk related to poor cognition, impaired balance, and safety awareness, with interventions including ensuring appropriate footwear and following the facility fall protocol. After a fall in which the resident was found on the floor by the bed while attempting to ambulate without assistance, the IDT fall note added an intervention for staff to always leave the resident’s door open for increased observation. Despite this, surveyors twice observed the resident’s door completely shut while the resident was in the room, once lying in bed and once sitting on the side of the bed with feet on the floor and walker within reach. A CNA could not recall specific fall interventions for this resident beyond escorting when ambulating, and the DON stated that all staff should know or know where to find fall precautions, referencing communication books and electronic records. The facility’s Fall Prevention Program policy states that safety interventions will be implemented for each resident at risk and that all assigned nursing personnel are responsible for ensuring ongoing precautions are consistently maintained, which did not occur for these two residents.
Failure to Implement Scabies Infection Control Measures After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including infection tracking, contact tracing, and environmental precautions, for a resident with a presumptive diagnosis of scabies. The resident was admitted with diagnoses including paranoid schizophrenia and unspecified convulsions and had a care plan problem for a rash on multiple body areas related to allergies, eczema, and psoriasis. During a subsequent hospital stay, the resident developed a diffuse pruritic rash resembling scabies and was treated with permethrin cream and placed in contact isolation due to a history of MRSA and the current rash. The hospital transfer orders back to the facility documented contact isolation status and possible scabies. On readmission, nursing notes described a generalized rash, but the RN who readmitted the resident did not review the hospital discharge or transfer paperwork, did not obtain a verbal report from the hospital, and was therefore unaware of the scabies diagnosis and treatment. As a result, the resident’s scabies diagnosis and treatment were not entered into the facility’s March infection control log, and no follow-up skin checks or contact tracing were conducted to determine if other residents were affected. The infection control nurse stated she did not log the case because the diagnosis and treatment occurred at the hospital rather than in the facility. Housekeeping/laundry staff reported they had not been notified of any scabies cases or the need for isolation-level room cleaning or laundry processing, and the APN stated she was not informed of the hospital’s scabies treatment until the survey date. The facility’s own scabies control policy requires inspection of residents who had contact with the affected resident, assessment by the DON and infection control nurse to determine preventive measures, bagging and hot washing of linens and clothing, thorough environmental cleaning and disinfection of furniture and equipment, and simultaneous treatment of affected individuals. None of these specified infection control measures were implemented for this resident upon return to the facility, despite documented possible scabies and contact isolation orders from the hospital.
Nonfunctioning Shower Room Call Light
Penalty
Summary
The facility failed to provide a functioning call light in the south hall shower room. During observation, the call light in the shower room across from the nurses' station on the south hall did not function and was not accessible from the floor. The shower stall had water on the floor and walls, giving the appearance that it had just been used. Staff interviews confirmed that the two shower rooms on the south hall are used for all residents on that hall, and a CNA stated that the call light in that shower room had not worked for a couple of days. During record review and interview, Maintenance stated there was no work order for the shower room call light and that he was unaware it was not working. He tested the switch and confirmed the call light did not work. The facility policy for Preventive Maintenance and Inspections states that routine inspections and work orders are used to keep fixtures and equipment in good working order and to provide rapid communication regarding equipment problems. The Midnight Census report documented 36 residents on the south hall.
Failure to Attempt Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to attempt non-pharmacological interventions before administering a PRN psychotropic medication for one resident. The resident was admitted with diagnoses of Alzheimer's dementia with behavioral disturbance, cerebrovascular disease, and oral phase dysphagia, and the MDS documented severe cognitive impairment with a BIMS score of 1 out of 15. The care plan identified a problem of potential physical aggression toward staff during care and included interventions to monitor and document behavior, intervene before agitation escalated, guide the resident away from the source of distress, engage calmly in conversation, and walk away calmly and approach later if the response was aggressive. The MAR documented an order for lorazepam 0.5 mg by mouth every 8 hours as needed for combativeness related to dementia with other behavioral disturbance, and the resident received the medication on 2/21/2026 at 4:14 p.m. The EMR contained no progress note entries for that date, and the behavior tracking for that day showed no observable behaviors. During interview, the LPN stated she did not attempt any non-pharmacological interventions before giving the PRN lorazepam and said she did not know such interventions were required before administering a PRN psychotropic medication. The DON stated she expected nursing staff to perform and document non-pharmacological interventions before administering a PRN psychotropic medication to any resident admitted to the facility.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide nail care for 3 of 3 residents reviewed for ADL care. R44, who had diagnoses including dementia, Alzheimer’s disease, depression, dysphagia, anemia, and moderate protein calorie malnutrition, had an MDS documenting a BIMS score of 01 and substantial/maximal assistance with personal hygiene. On multiple observations, R44’s fingernails had a black substance under both hands. R22, who had diagnoses including Alzheimer’s disease, dementia, muscle wasting and atrophy, osteoporosis, and multiple fractures, had an MDS documenting a BIMS score of 03 and substantial/maximal assistance with personal hygiene. On multiple observations, R22’s fingernails also had a black substance under both hands. R68, who had diagnoses including acute and chronic respiratory failure, severe sepsis with septic shock, a displaced fracture of the second metatarsal bone of the right foot, muscle wasting and atrophy, unsteadiness on feet, and major depressive disorder, had an MDS documenting a BIMS score of 10 and partial/moderate assistance with personal hygiene. R68 stated she needed her toenails trimmed, and her toenails were observed to be long and in need of trimming. The CNA stated that R22 and R44’s nails were dirty and needed to be cleaned, and that nails are supposed to be cleaned on shower days and anytime they are noticed to be dirty in between. The Administrator stated R68’s toenails did need to be trimmed and that someone would be sent to take care of it. The facility’s nail care policy required staff to observe nail condition during bathing and clean debris from around and under finger and toenails after bathing.
Failure to Provide Nutritional Supplementation for an Underweight Resident
Penalty
Summary
The facility failed to provide supplementation to maintain or gain weight for a resident with low body weight. R10 was admitted with multiple diagnoses including severe protein calorie malnutrition, COPD, respiratory failure, chronic diastolic heart failure, GERD, and essential hypertension, and the MDS documented moderate cognitive impairment. The care plan addressed pressure ulcers and hospice services, but it did not include a focus area for nutritional status or weight status. R10 told the surveyor he was tired of eggs, received what was on the dietary ticket, and was not aware of receiving extra protein, thickened drinks like a milk shake, or small cups of ice cream-like supplements. The resident’s admission weight was documented at 121.1 pounds, with subsequent weights of 119.0 pounds and 118 pounds reported by the RD. The nutrition assessment documented a height of 75 inches, weight of 122.3 pounds, BMI of 15.3, and oral intake averaging 50% of meals over the look-back period. The Dietary Manager stated the resident was very thin, knew he was underweight, and did not provide nutritional supplementation, though he referred the resident to the RD. The RD stated she initially monitored the resident because he was underweight and on hospice and had not yet lost weight, but later noted he had lost a couple of pounds.
Failure to Perform Pain Assessments for a Resident with Ongoing Pain
Penalty
Summary
The facility failed to follow its pain management policy and failed to perform pain assessments to support pain management for one resident. The resident had an admission record documenting diagnoses including acute and chronic respiratory failure, severe sepsis with septic shock, displaced fracture of the second metatarsal bone of the right foot, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, major depressive disorder, and unilateral primary osteoarthritis of the left knee. The MDS documented a BIMS score of 10, indicating moderately impaired cognition, and also indicated that the resident received PRN pain medication and non-medication interventions for pain. The care plan identified chronic pain related to depression, a fracture prior to admission to LTC, and medical and surgical procedures, with interventions including administering analgesics as ordered, giving medication before treatments or care, evaluating effectiveness, and monitoring pain characteristics and non-verbal signs of pain. However, on multiple observations the resident was seen grimacing, reporting that her back hurt, stating that pain medication sometimes helped and sometimes did not, and asking to move from her wheelchair to a regular chair because it might help her back pain. On another occasion, the resident stated she did not want breakfast because it hurt. During interview, the MDS Coordinator stated there were no pain assessments for the resident besides what was in the MDS and that a numerical pain value would be documented when pain medication was given. A CNA stated the resident complained of pain at times and seemed to complain more since returning from the hospital. The facility policy required pain assessment when there was any indication of pain, when the MDS triggered pain, and when the resident received routine pain medication or pain was not controlled, and it required documentation of assessments and the resident's response with each assessment.
Infection control failures during wound care
Penalty
Summary
The facility failed to follow infection prevention and control practices during wound care for 2 residents with chronic wounds. One resident had diagnoses including type II diabetes mellitus, atherosclerosis of both legs, and lymphedema, with orders for daily treatment of a left lateral lower leg wound. During an observed dressing change, the LPN performed hand hygiene at the start, donned gown and gloves, and removed the old dressing, but after changing gloves she did not perform hand hygiene before cleansing the wound, and again did not perform hand hygiene after changing gloves before applying Santyl and completing the dressing. The LPN later stated she had forgotten to bring alcohol-based hand rub into the room and did not think she could stop to obtain it. The Infection Preventionist and DON both stated hand hygiene should have been performed between glove changes and that not doing so increased infection risk. A second resident had diagnoses including cellulitis of the right lower limb, type I diabetes, and a non-pressure chronic ulcer of the foot, with orders for contact/enhanced barrier precautions and daily wound care to the right plantar foot. During the observed dressing change, the LPN washed hands, donned gown and gloves, removed the old dressing with scissors, and placed the scissors on a clean barrier. After removing gloves and performing hand hygiene, she cleansed the wound, changed gloves again, and then used the same scissors that had been used to cut off the old dressing to cut sterile calcium silver alginate packing without sanitizing the scissors or using a clean pair. She then packed the wound with that material and completed the dressing. The LPN stated she should have sanitized the scissors or used a different pair, and the Infection Preventionist and DON stated using the same scissors for the sterile packing was not appropriate. The facility’s Infection Precaution Guidelines policy states that standard precautions apply to all residents, hand hygiene is the single most important precaution to prevent transmission of infection, hands should be washed before and after each resident contact, alcohol-based hand rub may be used if hands are not visibly soiled, and needed equipment and supplies should be gathered before entering the room. The observed wound care practices for both residents did not follow these stated infection prevention guidelines.
Failure to Protect Cognitively Impaired Residents From Repeated Abuse by an Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent repeated verbal, physical, and sexual abuse by one resident (R7) toward multiple cognitively impaired residents (R1, R6, R8, and R9), despite R7’s known history of aggressive behaviors. R7 was admitted with dementia with agitation, lack of coordination, anxiety, and depression, and had a care plan focus for behavior problems related to verbal/physical aggression and wandering/elopement risk. The care plan’s only reference to a resident-to-resident altercation was a single entry noting an altercation and referral to behavioral health, without further detail on specific protective interventions for other residents. Facility policy stated that residents who allegedly abused another resident should be immediately evaluated to determine suitable care approaches and placement, and that the facility would take all steps necessary to ensure resident safety, including separation of residents. In one incident, R7 approached R8, who had severe cognitive impairment due to Alzheimer’s disease and other psychiatric and neurologic diagnoses, while she was in the dining room talking out loud to herself. A CNA (V13) observed R7 walk to his usual dining spot where R8 was seated, then step back and slap her across the left side of her face while calling her a “stupid b**ch” and attempting to slap her again. R7 later stated he was annoyed by R8’s yelling and that he slapped her to “shut her up,” adding that he would have slapped her again if staff had not intervened. R8, who also had severe cognitive impairment, was unable to provide a description of the event. This incident was documented in resident-to-resident altercation forms and in a final report to the state agency. In another incident, R7 entered R1’s room, where R1, who had moderate cognitive impairment, major depressive disorder, generalized anxiety, dementia with behavioral disturbance, and unsteadiness on her feet, was in her wheelchair. A CNA (V12) responded to R1’s call light and found R7 holding the wheelchair handles and attempting to tip R1 out of the wheelchair while yelling and cursing at her. Documentation noted that earlier that day R7 had been very agitated, banging doors, attempting to exit the building, and verbally distressing other residents and staff in the dining room. R7 was reported to have walked out of R1’s room cursing and stating, “next time I will hurt her.” A further incident involved R7 and R9, who had severe cognitive impairment with diagnoses including Parkinson’s disease with dyskinesia, Alzheimer’s disease, chronic pain syndrome, and depression. While R9 was eating in the dementia unit dining room, staff reported that R7, who had been agitated and “bickering” and “mouthing” at others most of the day, stood up, went toward R9, grabbed him by the throat, and pushed him in his wheelchair out of the dining room into the hallway. A CNA (V9) stated she removed R7’s hand from R9’s neck and called for assistance. Facility documentation described R7 as visibly agitated and noted that staff had to separate the residents. In a separate event on the same date as the incident with R9, R7 sexually abused R6, a resident with severe cognitive impairment, anxiety disorder, anoxic brain damage, catatonic disorder due to a physiological condition, and depression, who was care planned as being at risk for abuse/neglect. A CNA (V10) reported that R7, who had been agitated and “targeting” R6 by following her around throughout the day, walked up behind R6, reached around from her back, and grabbed her breast. V10 stated she told R7 to let go, he initially said no, and she then removed his hand from R6’s breast and redirected him. R6 was unable to provide a description of the incident. These repeated episodes of physical, verbal, and sexual abuse by R7 toward multiple vulnerable residents occurred despite the facility’s abuse prevention policy and R7’s known behavioral history, demonstrating a failure to protect residents from abuse by another resident.
Failure to Provide Correct Diet Texture Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with dementia and oropharyngeal dysphagia was not provided with the correct textured diet as ordered. The resident's care plan and physician orders specified a mechanical soft texture with thickened liquids, but on the day of the incident, the resident was served a whole bratwurst on a bun, which did not meet the mechanical soft diet requirements. Multiple staff, including the CNA, cook, and dietary aide, confirmed that the resident received the incorrect diet texture, and the facility's dietary records and recipes indicated that the meal should have been ground bratwurst with gravy to ensure proper consistency. During lunch, the resident choked on the improperly prepared food, became unresponsive, and required emergency intervention. Staff performed abdominal thrusts and a finger sweep to remove the food obstruction, after which the resident regained consciousness and normal color. Emergency medical services were called, and the resident was transported to the hospital for further evaluation and care. The incident was documented in progress notes, incident reports, and confirmed by interviews with staff present at the time. The facility's own dietary policy and menu documentation outlined the requirements for mechanical soft diets, including that meats be ground or chopped into small, moist pieces. Despite these guidelines, the resident was served a regular texture meal, which directly led to the choking event. Staff interviews revealed a lack of awareness regarding the resident's current diet order at the time of meal service, contributing to the failure to provide the appropriate diet texture as ordered.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations involving a resident with severe cognitive impairment and behavioral issues. One resident, with a history of dementia, anxiety disorder, and repeated falls, exhibited aggressive behaviors that were documented in his care plan. Despite these known behaviors, the resident was able to push another resident, who also had severe cognitive impairment and Parkinson's disease, causing the latter to fall and sustain a fractured coccyx. The incident occurred while the second resident was loudly preaching in the hallway, which agitated the aggressive resident, leading to the physical altercation. Initial assessments did not reveal the fracture, and the injury was only discovered after the resident's family took him to an outside physician, who ordered an x-ray confirming the fracture. Further review revealed additional incidents involving the same aggressive resident. In another event, the resident pushed a different peer to the ground and struck him with a walker. Staff interviews indicated that the aggressive resident's behaviors were unpredictable and often triggered without warning, particularly in the late afternoon or early evening. Staff were unable to determine the root cause of the behaviors, and interventions listed in the care plan included medication management, redirection, and attempts to separate the resident from others. However, these interventions were not sufficient to prevent repeated altercations. Documentation and interviews showed that staff and administration were aware of the resident's escalating aggression but were unable to identify effective interventions or consistently implement measures to protect other residents. The care plans referenced behavioral issues and listed general interventions, but there was a lack of specific, individualized strategies to address the aggressive behaviors. The facility's failure to prevent these incidents resulted in physical harm to at least one resident and placed others at risk of abuse.
Failure to Notify Physician of Resident Pain and Injury After Altercation
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a resident's complaint of pain following a resident-to-resident altercation that resulted in a fall. The resident, an elderly male with severe cognitive impairment, Parkinson's disease, dementia, and other comorbidities, was pushed by another resident, causing him to fall and sustain an abrasion to his right elbow. Initial assessments documented that the resident denied pain and did not report hitting his head, and the incident was reported to the family, administration, and local authorities. However, subsequent documentation showed that the resident later complained of tenderness to the left buttock, for which pain medication was administered by nursing staff, but the physician was not notified at that time. The resident was later taken to a physician appointment by a family member, where he reported pain in the sacral area. The physician ordered an x-ray, which revealed a suspected non-displaced fracture of the coccyx. The facility did not become aware of the x-ray results until the spouse reported them several days later. Additionally, emergency department records faxed to the facility also documented the coccyx fracture, but these records were not reviewed or acted upon by facility staff in a timely manner. Multiple staff members, including the Assistant Director of Nursing and a Registered Nurse, stated they were unaware of the fracture documented in the hospital records. The facility's policy required timely communication of medical care problems to the attending physician and family. Despite this, the physician and nurse practitioner were not informed of the resident's pain complaints or the x-ray findings until after the family reported them. The nurse practitioner indicated that, had she been notified, she could have ordered the x-ray and adjusted pain management sooner. The lack of timely physician notification and review of hospital records led to a delay in appropriate assessment and treatment for the resident's injury.
Resident Left Suspended in Mechanical Lift Due to Staff Neglect
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, diabetes type 2, congestive heart failure, limited lower extremity range of motion, and total dependence on staff for transfers was left suspended in a mechanical lift sling during a transfer. The resident's care plan required two staff members to assist with mechanical lift transfers, but on the evening in question, only one agency CNA performed the transfer. During the process, the resident expressed concerns about back pain and the manner in which the transfer was being conducted. The CNA became upset, left the resident elevated in the sling above the shower chair, and exited the room, shutting the door and leaving the resident unable to reach the call light. The resident reported that he called for help for approximately ten minutes before two other staff members responded and completed the transfer. The incident was not documented in the resident's nursing progress notes, and there was no immediate incident report filed. The CNA involved admitted to performing the transfer alone and leaving the resident in the sling, stating he intended to de-escalate the situation. Other staff confirmed that the resident was found suspended in the sling and that the CNA had left the room, but they did not notify management at the time. The facility's abuse prevention and reporting policy prohibits neglect, defined as the failure to provide necessary goods and services to avoid physical harm, pain, or mental anguish. Despite the resident not reporting injury or emotional trauma, the actions of the CNA and the lack of adherence to the care plan and facility policy resulted in a failure to protect the resident from neglect during the transfer process.
Failure to Immediately Report Staff-to-Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an instance of staff-to-resident neglect to the Administrator. The incident involved a resident with morbid obesity, diabetes type 2, congestive heart failure, and limited range of motion in both lower extremities, who was totally dependent on staff for transfers. During a mechanical lift transfer, a Certified Nursing Assistant (CNA) left the resident suspended in a lift sling above a shower chair after becoming upset with the resident, who was expressing concerns about the transfer. The resident was left alone in this position for approximately ten minutes, unable to reach the call light, until two other staff members responded to his calls for help and completed the transfer. The resident was not injured and did not report emotional trauma from the event. The incident was not documented in the resident's nursing progress notes, and the CNA involved admitted to performing the transfer alone, contrary to the care plan requiring two staff members. The CNA stated he left the room to de-escalate the situation after the resident became verbally aggressive. Other staff members who witnessed the aftermath of the incident did not immediately notify management. The Administrator became aware of the event only after being informed by a nurse the following morning, and no incident report was filed because the resident stated he did not feel neglected or abused. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any incident, allegation, or suspicion of potential abuse or neglect to the Administrator, and timely external reporting to the state surveying agency. In this case, the required internal reporting procedures were not followed, as the incident was not reported immediately to the Administrator, nor was an incident report completed as required by policy.
Failure to Investigate Alleged Staff-to-Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to investigate an allegation of staff-to-resident neglect involving a resident with morbid obesity, diabetes type 2, and congestive heart failure, who was totally dependent on staff for transfers. The resident, who was cognitively intact, reported that during a mechanical lift transfer, a Certified Nursing Assistant (CNA) left him suspended in a sling above a shower chair after becoming upset and leaving the room. The resident was unable to reach the call light and had to call out for help for approximately ten minutes before other staff arrived to complete the transfer. The incident was not documented in the resident's nursing progress notes. Interviews with staff confirmed that the CNA performed the transfer alone, contrary to the care plan requiring two staff members and use of a mechanical lift. After the CNA left the room, two other staff members entered and completed the transfer. The CNA later stated that he routinely performed transfers alone and left the room to de-escalate the situation, while other staff corroborated that the resident was left in the sling and required assistance. Despite these accounts, the incident was not reported to management by the staff who responded, and no incident report was completed. The facility's administrator became aware of the event the following day but did not initiate an investigation, citing the resident's statement that he did not feel neglected or abused. The facility's abuse prevention and reporting policy requires that all incidents or allegations involving abuse, neglect, exploitation, or mistreatment be documented and investigated, regardless of the resident's perception. The lack of documentation and investigation in this case constitutes a failure to respond appropriately to an alleged violation.
Failure to Provide Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for transfers due to morbid obesity, diabetes type 2, congestive heart failure, and limited range of motion in both lower extremities, was transferred using a mechanical lift by only one staff member, contrary to the care plan and facility policy requiring two staff for such transfers. During the transfer, the resident expressed concerns about back pain and the manner in which the transfer was being conducted. The staff member performing the transfer became upset, left the resident suspended in the mechanical lift sling above the shower chair, and exited the room, leaving the resident unattended and unable to reach the call light. The resident remained in the lift for approximately ten minutes, calling for help until two other staff members responded and completed the transfer. The resident was not physically injured or emotionally traumatized by the event, as reported in interviews, but the incident was not documented in the nursing progress notes, and no incident report was filed at the time. The staff member involved admitted to routinely performing transfers alone and stated he left the room to de-escalate the situation after the resident became verbally aggressive. Interviews with other staff confirmed that the transfer was performed by a single staff member and that the resident was left suspended in the lift. The facility's policy and the resident's care plan both required two staff members for mechanical lift transfers to ensure safety. The incident was reported to facility management the following morning, but there was a lack of immediate documentation and notification by the staff present at the time of the event.
Failure to Ensure Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that the physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter. This deficiency affected 64 residents out of a sample of 66. The Medical Director, identified as V17, was listed as the medical doctor for these residents but was reported to only visit the facility once every three months for quality assurance meetings and did not see the residents. Instead, a nurse practitioner was responsible for seeing the residents, but this practitioner had recently resigned, and a new nurse practitioner was conducting telehealth visits until a replacement could be found. Interviews with the facility's administrator and director of nursing revealed a lack of awareness regarding the regulatory requirement for physician visits. The director of nursing stated that the facility used an app to communicate with the nurse practitioner during the day and had an answering service for after-hours, which had not posed any issues. However, the director was unaware that the physician was required to see the residents, indicating a gap in compliance with the regulations. The facility's Medical Director and Management Agreement outlined responsibilities for overseeing medical care and ensuring compliance with regulations, but these were not being met as the physician was not conducting the required visits.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all 68 residents, as evidenced by multiple resident interviews and staff statements. Residents reported significant delays in response times to call lights, particularly during night shifts when staffing levels were lower. For instance, one resident mentioned having to wait over 30 minutes for assistance, while another reported waiting up to an hour. These delays were attributed to insufficient staffing, with residents noting that the issue was more pronounced during night shifts when fewer staff members were available. The Director of Nursing (DON) acknowledged the staffing challenges, stating that the facility often struggled to maintain adequate staffing levels, especially on night shifts. The DON mentioned that the facility typically aimed to have a certain number of certified nurse assistants (CNAs) and nurses on each shift, but there were instances where these numbers were not met. The facility relied on agency staff to fill gaps, but there were still numerous shifts with unmet staffing needs, as evidenced by the posted schedules showing unfilled shifts and the need for additional staff coverage. Observations during a facility tour further confirmed the staffing deficiencies, with multiple sheets posted near the time clock indicating numerous unfilled shifts for both nurses and CNAs. The facility's personnel policy stated the requirement to provide adequate staffing to meet resident needs, yet the documented schedules and staff interviews highlighted ongoing staffing shortages. These deficiencies in staffing levels directly impacted the facility's ability to provide timely care to residents, as evidenced by the residents' reports of delayed assistance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. A cracked windowpane in the Northwest Shower Room had been left unrepaired since November 2023, despite being known to the maintenance director, who had not informed the current owners. This affected multiple residents residing in the Northwest Hall, as documented in the facility's daily census sheet. Additionally, two residents, who were roommates, experienced issues with their wheelchairs. One resident's wheelchair was missing a right armrest and had a worn seat, making it difficult for her to propel herself, which was necessary for her rehabilitation. The other resident's wheelchair was also missing an armrest, with a protruding screw posing a potential risk. Another resident's wheelchair was observed to have a large chunk missing from the right armrest, further indicating the facility's failure to ensure equipment was in good repair.
Failure to Serve Meals with Dignity
Penalty
Summary
The facility failed to ensure that residents were served meals in a manner that promoted dignity, as observed with one resident, R35, who was cognitively intact with a BIMS score of 15. On multiple occasions, R35 was observed waiting for her meal to be served while her tablemate, R62, had already received and finished her meal. This pattern was noted over several days, with R35 expressing frustration about the delay and questioning why they could not be served simultaneously. The Dietary Manager, V4, explained that the facility used an assigned seating system to determine the order of meal service, but had not updated the tray cards to include newer admissions, resulting in the delay for R35.
Failure to Follow Dietary Orders and Weight Policy
Penalty
Summary
The facility failed to follow physician dietary orders for two residents, resulting in inadequate nutrition. One resident, diagnosed with hyperlipidemia, bipolar disease, and chronic obstructive pulmonary disease, was on a regular diet with double protein at meals. However, observations revealed that the resident was not consistently receiving the prescribed double protein during meals. The Dietary Manager confirmed that the kitchen missed providing the double protein on multiple occasions. Another resident, with depression, constipation, and congestive heart failure, was supposed to receive fortified pudding with meals due to weight loss. Observations showed that the resident did not consistently receive the fortified pudding, and the Dietary Manager acknowledged the oversight. Additionally, the facility failed to adhere to its weight policy for a resident with Type 2 Diabetes Mellitus, unspecified dementia, and essential hypertension. This resident experienced a significant weight loss of 6.23% in one month, which was not communicated to the dietitian or physician in a timely manner. The Registered Nurse was unsure why the weight loss was not reported, as the weight was entered by a Resident Care Aide instead of the Dietary Manager. The facility's weight policy requires re-weighing and reporting of unanticipated weight changes, which was not followed in this case.
Failure to Maintain Accurate Narcotic Records
Penalty
Summary
The facility failed to maintain accurate records of narcotics for a resident, identified as R15, who was part of a sample of 66 residents reviewed for controlled substance medication. R15, a [AGE] year-old resident with multiple medical conditions including a displaced oblique fracture of the right femur, multiple sclerosis, and dementia, was admitted to the facility on an unspecified date. During a review of the medication cart, an orange pill bottle labeled with R15's information was found in the narcotic box without an accompanying narcotic count sheet. The bottle contained oxycodone, a controlled substance, which was not documented in R15's order summary. The Registered Nurse, V6, acknowledged the absence of a count sheet and stated that the medication should have been destroyed or sent home with R15's family. The Director of Nursing, V2, confirmed that it is the facility's expectation for all narcotics to have a count sheet and for discontinued medications to be discarded. V2 further stated that R15 never had an order for oxycodone and that the medication was brought in by the family upon admission. The facility's policy on narcotic controlled substances requires counting with a partner to verify the accuracy of log sheets, which was not adhered to in this case. The failure to maintain accurate narcotic records and the presence of an undocumented controlled substance in the medication cart led to the deficiency identified by the surveyors.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure the secure storage of medications for a resident, identified as R28, who was prescribed Lorazepam (Ativan) oral concentrate. The medication was observed in a medication refrigerator without a lock, which is a requirement for storing controlled substances. The Director of Nursing (V2) acknowledged the absence of a lock and mentioned that the refrigerator had been changed out recently, but the lock was not installed on the new unit. Despite the expectation that the medication refrigerator should be locked, it was found unsecured on multiple occasions. The facility's policy on medication storage, which requires controlled substances to be stored in a secured, double-locked area, was not adhered to. The Registered Nurse (V6) was unaware of the requirement for a lock on the refrigerator, indicating a lack of communication or training regarding the facility's medication storage policies. R28's medical history includes multiple diagnoses such as type 2 diabetes mellitus, schizoaffective disorder, and chronic kidney disease, among others, highlighting the importance of proper medication management for this resident.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for a resident with severe dementia, depression, hypertension, and Type 2 Diabetes Mellitus. The resident's care plan required a mechanically altered diet with bite-sized pieces to prevent choking, as documented in the Minimum Data Set (MDS). However, during observations on two consecutive days, the resident was served meals that did not comply with these dietary requirements. On the first day, the resident struggled to eat meatballs that were too large, resulting in food spilling onto the table and the resident's lap. On the second day, the resident was served chicken cordon bleu casserole with pieces of ham and chicken that exceeded the recommended bite size. The facility's dietary manager and speech-language pathologist acknowledged the discrepancy between the prescribed diet and the food served. The dietary manager admitted that the recipe did not specify the correct size for bite-sized pieces, and the speech-language pathologist confirmed that the pieces served were larger than appropriate. Despite the speech-language pathologist's efforts to educate staff on the correct portion sizes, there was no formal documentation or in-service training completed to ensure compliance with the resident's dietary needs.
Failure to Maintain Aseptic Technique During Wound Care
Penalty
Summary
The facility failed to maintain aseptic technique during wound care for two residents, R13 and R45. For R13, who was admitted with chronic venous hypertension with ulcer and other related conditions, the Registered Nurse (RN) V10 did not use a barrier under R13's leg while performing wound care. The RN repeatedly laid R13's leg on the bed comforter without a barrier after removing the old dressing, cleaning the wound, and applying silver sulfadiazine cream. This was contrary to the facility's infection control expectations, as confirmed by the Infection Prevention Nurse, V16, who stated that a barrier should be used during such procedures. For R45, who had diagnoses including unspecified dementia and chronic obstructive pulmonary disease, the Infection Prevention Nurse, V12, and a Certified Nurse Assistant, V13, did not follow proper hand hygiene protocols during wound care. V12 moved a bedside table and touched an air mattress pump cord on the floor before cleaning R45's shoulder wound without changing gloves or washing hands. This action was inconsistent with the facility's Infection Prevention and Control Program, which requires routine hand washing and the use of appropriate barrier prevention to prevent infection transmission.
Resident Injury Due to Unsecured Transport
Penalty
Summary
The facility failed to safely secure a resident during transport, resulting in an accident. The resident, identified as R2, was being transported in a facility van to an eye appointment by the Social Service Director, V12. During the transport, R2's motorized scooter was not secured, and V12 did not buckle the scooter because they were not traveling far. On the return trip, V12 missed a turn and abruptly braked, causing R2's scooter to move forward, leading to R2 sustaining a laceration on her left leg. R2, who has a history of morbid obesity, atherosclerosis, lymphedema, and diabetes with neuropathy, was cognitively intact and used a motorized scooter for mobility. The incident occurred when V12 made a quick turn into a parking lot, causing R2 to hit her leg on a metal piece of the seat in front of her. R2's leg was cut, and she required emergency medical attention, including a wound vacuum and antibiotics, due to the injury becoming infected. The facility's investigation revealed that the van used was not the usual one, and R2's power chair did not fit into the lock mechanisms. Additionally, the emergency brake on R2's power chair was not engaged. V12 and other key staff members involved in the incident are no longer employed at the facility. The facility's policy requires all residents and wheelchairs to be safely secured during transport, which was not adhered to in this case.
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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.
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