Chicago Ridge Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago Ridge, Illinois.
- Location
- 10602 Southwest Highway, Chicago Ridge, Illinois 60415
- CMS Provider Number
- 145639
- Inspections on file
- 58
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Chicago Ridge Snf during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and other comorbidities had Seroquel doses progressively increased without documented informed consent from the resident or his guardian and without behavior documentation or evidence of non-pharmacological interventions, despite facility policy requiring these steps. The resident reported concern about receiving higher doses than expected and stated he had not consented and was refusing the medication. Behavior monitoring sheets over several months showed no behaviors, while the guardian reported concerns about the resident’s worrying and frequent calls to police and believed the dose remained at 100 mg. The ADON, psychiatrist, psych NP, and an LPN all acknowledged either the absence of documented behaviors or the requirement for informed consent and behavior documentation, which were not met.
A resident with a contracted left hand and wrist was repeatedly observed sitting in a wheelchair with the hand clenched in a fist and no device in place to prevent further contracture, despite a care plan stating the resident would perform AROM to all extremities. The resident reported that staff had not encouraged arm or hand exercises. The restorative nurse stated they were unaware of the contracture and had not assessed the resident’s restorative needs, and the therapy manager reported that therapy had not been informed of the condition until the surveyor’s inquiry. On assessment, the resident experienced pain when attempting to open the hand, and the therapy manager indicated the resident would benefit from a resting hand splint, contrary to facility policies and the restorative nurse job description requiring timely restorative evaluation, coordination with therapy, and management of splints.
The facility did not follow its own Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and when outside passes are requested. Record review showed that several residents had not received a community skills assessment for many months beyond the required frequency. During interview, Social Services staff described a practice of completing these assessments quarterly, annually, and with outside pass requests, while a separate internal document listed them as admission, significant change, and annual assessments, which conflicted with the written policy. The DON and ADON later clarified that this internal document was not a formal policy, yet the documented assessment schedule still did not match the policy requirements, resulting in missed assessments for multiple residents.
A resident reported that her personal cell phone went missing from her room and stated she informed the Social Service Director, an RN, and CNAs, but did not receive follow-up or a written response. The resident documented the report and later noted that a phone was found in a medication storage room, while staff interviews confirmed that the concern had been reported but not pursued. The grievance binder contained no written grievance about the missing phone, and a grievance form produced by the facility lacked the preparer’s name and only suggested another resident might have taken the phone. Review of belongings inventories showed the resident’s phone and other personal items were not listed, and the inventories were not signed by the resident, despite facility policies requiring complete documentation and resident signatures for belongings and written, timely handling of grievances.
The facility failed to implement its abuse prevention policy when a resident with psychosis, schizophrenia, and bipolar disorder, who had been frequently refusing ordered psychotropic medications, entered another resident’s room, became upset about spoiled milk, and physically assaulted her by hitting her head with a milk carton, pushing her onto the bed, and violently shaking her until another resident intervened and staff arrived. Multiple residents provided consistent statements that the aggressor was on top of and hitting the victim, who reported pain to her arm and behind her ear. Despite repeated medication refusals and a recent hospitalization for aggressive behavior, there was no documentation that the physician or psychiatrist was notified with each refusal, and NP notes indicated no nursing concerns. The facility’s abuse investigation did not include staff interviews and concluded there was no credible evidence of abuse, contrary to the resident witness accounts.
A resident with severe mental illness, documented poor impulse control, and a history of physically abusive behavior was not adequately supervised, despite care plans calling for daily monitoring and psychotropic medication management. The resident, who was known to be noncompliant with medications and exhibited delusions, disorganized thought processes, and auditory hallucinations, was able to enter another resident’s room, become agitated over a milk carton he believed was spoiled, and verbally and physically assault the resident by striking her with the carton, pushing her onto the bed, and violently shaking and hitting her until other residents and staff intervened.
The facility failed to prevent illicit drugs from being brought in, distributed, and used by residents, resulting in two residents testing positive for fentanyl and opiates and experiencing medical emergencies, including one requiring Narcan. Multiple residents and staff reported ongoing drug distribution within the facility, and drug paraphernalia was found in resident rooms and ceilings. The facility lacked an effective plan to identify how drugs were entering, did not consistently enforce its contraband policy, and staff were unclear about when to administer Narcan.
A resident receiving hydrocodone-acetaminophen for pain did not have consistent documentation in the MAR at the time of administration, and staff failed to consistently monitor and record the effectiveness of the pain medication. Interviews with the ADON and an LPN confirmed that facility policy for medication administration and documentation was not followed, resulting in incomplete records for controlled substance administration.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors observed that window drapes in the rooms of several residents were falling from curtain rods or tracks, with some rooms using towels to cover window openings. Maintenance staff acknowledged the issue but did not resolve it during the survey, and a resident reported making repeated requests for assistance with her curtains. The DON confirmed that rooms should be clean and homelike, and the facility's housekeeping policy requires a safe and sanitary environment, which was not met in this instance.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
One of two elevators was nonfunctional, causing delays for residents, staff, and visitors who rely on elevator access for daily activities and services. Maintenance staff reported ongoing issues with elevator breakdowns and could not specify which elevator was serviced or the cause of repeated failures. The facility's maintenance policy lacked protocols for elevator operation.
A resident with a history of substance abuse and a care plan restricting unsupervised passes was allowed to leave on a supervised community pass without proper verification of the escort's identity. The staff failed to ensure the person taking the resident matched the name on the pass request form, and the resident did not return to the facility.
Two residents with diabetes did not receive timely podiatry care or follow-up visits as ordered, resulting in long, thick, and discolored toenails. Despite requests for podiatry services and physician orders for regular follow-up, there was no documentation of recent podiatrist visits or adherence to the facility's policy for diabetic foot care.
A resident with a history of substance abuse obtained and used illicit drugs within the facility, resulting in an overdose that required Narcan administration and hospital transfer. Despite clear signs of drug use and staff and resident reports of suspicious behaviors, the facility did not investigate how the drugs entered the facility or how the resident accessed them, nor did they follow up with involved parties or document the incident as required by policy.
Two residents with histories of substance abuse did not receive required group programming or consistent behavioral health services, despite facility policies and care plans indicating these supports. One resident was excluded from substance abuse groups due to lack of admission documentation, and another did not receive regular counseling, resulting in illicit drug use and an overdose requiring hospital transfer.
A resident with chronic ischemia and vascular disease did not have physician orders to monitor her right foot for discoloration, pedal pulse, and temperature changes transcribed or implemented. Despite a nurse practitioner's verbal order and the presence of a blister, there was no documentation of monitoring or assessment in the medical record, and staff were unaware of the specific orders. This failure was contrary to facility policy requiring all physician orders to be recorded and followed.
A resident with a fractured ankle was physically assaulted by another resident in the dining room when no staff were present to monitor. Both residents had intact cognition and no care plans addressing abuse risk. Staff interviews and records confirmed that the dining room was often left unsupervised, especially during shift changes, and the assaulted resident required hospital evaluation for facial trauma.
A resident with a history of falls and cognitive impairment developed new right hip pain and became non-ambulatory. Despite therapy and nursing staff being notified, there was no timely or documented pain assessment, and PRN pain medication was not administered or recorded as required. The resident remained in pain for about 24 hours before being hospitalized for a hip fracture and surgery, with facility records and staff interviews confirming a lack of adherence to pain management policy.
A resident with a history of psychiatric disorders and intact cognition refused a scheduled long-acting injectable psychotropic medication. The LPN did not document the refusal or notify the physician, as required by the care plan and facility policy. The psychiatric nurse practitioner was unaware of the missed dose, and the DON confirmed that such refusals should be reported and documented.
A resident was verbally abused by a former Social Service Aide/Smoking Monitor during smoking time when the aide refused to provide a cigarette and used derogatory language. The incident was witnessed by another resident and reported to an LPN, who informed the Administrator and filed a police report. The resident involved was cognitively intact and had multiple diagnoses, including anxiety and depression.
The facility's pest control program failed to effectively manage a cockroach infestation, as evidenced by live cockroaches observed in resident rooms and frequent complaints from residents and staff. Despite scheduled pest control visits and actions taken in response to grievances, the issue persisted, affecting the facility's cleanliness and resident satisfaction.
A resident with a history of falls and multiple risk factors experienced repeated falls due to the facility's failure to implement care plan interventions and appropriate fall prevention measures. Despite requiring substantial staff assistance and having specific interventions outlined, the resident fell during unassisted transfers, and the facility could not provide evidence of required physical therapy evaluations.
The facility failed to promptly respond to call lights, affecting five residents, including those with significant health issues. Observations showed staff ignoring activated call lights, despite being nearby, leading to residents experiencing discomfort and potential health risks. The Director of Nursing confirmed that all staff should respond to call lights immediately, as per policy.
A resident with reduced mobility was left in a chair for 17 hours due to an uncharged mechanical lift. The family member reported the grievance, but the facility failed to document or resolve it promptly, violating their grievance policy.
A resident with a history of seizures and dementia eloped from a facility unsupervised, despite requiring supervision for community access. The resident was later found intoxicated by police, highlighting deficiencies in the facility's supervision and safety protocols. The facility lacked an authorized pass policy, and the resident exited through a basement back door without staff noticing.
On Christmas Day, insufficient staffing led to a failure in administering medications to 34 residents on the third floor of an LTC facility. Only one LPN was available, who did not cover the entire floor, resulting in missed medications for residents with various medical conditions. The DON was aware of the staffing issue but did not provide additional support, and the facility lacked a holiday staffing plan.
A facility failed to administer medications to 34 residents on the third floor during the day shift on Christmas Day due to understaffing. An LPN was responsible only for her assigned residents and did not cover the entire floor, while the DON was aware of the staffing issue but did not ensure all residents received their medications. The facility's policy requires supervision of medication administration, but the failure was not communicated to prescribers, highlighting a breakdown in communication and protocol adherence.
The facility failed to administer seizure medications to five residents on Christmas Day due to staffing shortages and communication issues. An LPN only administered medications to a portion of the residents, while the DON was aware of the staffing issue but did not ensure all residents received their medications. This resulted in missed doses for residents with conditions like dementia and seizures.
A resident with severe cognitive impairment was physically abused by his roommate, resulting in a chest contusion. The incident was not witnessed by staff, but the resident reported being punched, leading to a hospital transfer. The facility's failure to prevent this altercation highlights a deficiency in their abuse prevention program.
The facility failed to serve the planned meals to all 211 residents on two occasions. Residents were served white bread instead of garlic Texas toast for lunch and cream of wheat and scrambled eggs without cheese instead of oatmeal and scrambled eggs with cheese for breakfast. Additionally, there was a shortage of cold cereal and toast, leading to some residents not receiving their requested meals.
The facility failed to provide adequate dining supplies during a lunch meal service, affecting 75 residents. Initially, 45 residents received meals on plastic plates, but the staff ran out, serving the remaining 30 on Styrofoam plates. Additionally, 10 residents received coffee in Styrofoam cups without handles, and 25 residents were not given napkins. The dining room staff did not notify the kitchen to replenish supplies, despite sufficient stock being available.
A facility failed to initiate a timely falls care plan for a resident with a history of falling and generalized weakness. Despite the resident's ability to communicate needs, fall precautions were not implemented immediately upon admission. The resident was observed with injuries from a fall, and the call light cord was repeatedly out of reach. The restorative nurse did not investigate the fall or document necessary interventions in the care plan, which was initiated days later and backdated.
A resident with a history of falls was not accurately assessed for fall risk upon admission, and necessary fall prevention interventions were not implemented. The resident's call light was out of reach, and visible injuries indicated a fall. The Restorative Nurse did not investigate the fall or update the care plan, and the Director of Rehabilitation failed to prioritize the resident for skilled therapy. The facility's fall risk and post-fall assessment policy was not followed, resulting in a deficiency.
The facility failed to maintain a clean and homelike environment, with pervasive urine odors and unclean conditions affecting several residents. Staffing shortages and insufficient cleaning supplies contributed to the issue, as only one housekeeper was available for the third floor. Residents reported unclean rooms and soiled linens, while the facility's owner was unaware of the supply and staffing problems.
The facility did not follow its policy for serving food under sanitary conditions, affecting 66 residents on the 2nd floor. Meal trays were observed uncovered, with gnats present, despite available clean lids. CNAs reported lids were often unavailable or unnoticed, risking contamination. The DON confirmed the need for covered trays to prevent contamination and maintain temperature, as per the facility's policy.
A resident with limited speech due to medical conditions was not provided with a communication board, despite documentation indicating it was needed. Staff, including an LPN and CNA, struggled to understand the resident, and the DON noted that social services should supply the boards. The Social Services Worker used a board but did not leave it with the resident, leading to unmet communication needs.
Two residents with mental health diagnoses were involved in an altercation over a water bottle, during which one resident claimed to have been physically assaulted. Despite staff witnessing aggressive behavior, the facility did not identify or investigate the incident as abuse, contrary to its policy. The lack of communication and awareness among staff contributed to this oversight.
The facility failed to implement effective COVID-19 precautions and infection surveillance, affecting multiple residents. Discrepancies in resident tracking, lack of proper signage and PPE, and inadequate monitoring of vital signs were observed. Visitors were not consistently informed of the outbreak or provided with masks, and infection control policies were not adequately followed.
The facility did not follow its policy to notify a resident's responsible party about the resident's hospitalizations. A survey revealed that the family member of a resident was not informed of two hospitalizations, and the Director of Nursing confirmed this oversight. The facility's policy requires notifying the resident, their physician/NP, and the responsible party of any change in condition, with documentation in the resident's medical record.
The facility failed to maintain effective pest control, leading to widespread issues with roaches, gnats, and flies affecting all residents. Observations and interviews revealed pests in residents' rooms and common areas, with reports of food and clutter contributing to the problem. The facility's pest control policy was not consistently followed, with treatments occurring every other week instead of weekly as recommended.
The facility failed to maintain a safe environment by not addressing mold in resident living areas. Mold was observed in the rooms of three residents, with the Maintenance Director confirming the presence of mold and acknowledging that staff should have reported the issue. The facility's Preventative Maintenance Policy, which requires regular audits to identify concerns like discolored ceiling tiles, was not effectively implemented.
The facility failed to provide daily wound treatments as ordered for two residents, leading to missed care and altered records. One resident with chronic ulcers reported infrequent bandage changes, while another with dementia called the police due to lack of care. Treatment records showed missing entries, and staff confirmed nurses were responsible for weekend care if no wound nurse was available.
A resident with multiple mental health diagnoses was reportedly handled roughly by a CNA during a brief change. The family member reported the incident to nursing staff, but it was not escalated to the Administrator as required by the facility's policy. The DON acknowledged a conversation with the CNA but claimed not to have been informed about the rough handling. The LPN confirmed the report was made to her and relayed to the DON. The Administrator stated an investigation should have been initiated, and the incident reported to the state.
A resident with multiple health conditions had stained bed linens that were not changed as needed, despite being reported by a family member to the nursing staff and social services. Observations confirmed the presence of old stains on the linens. The DON was unaware of the reports, and there was no indication of the resident refusing linen changes.
A resident with severe malnutrition and multiple health issues was not provided with adequate nutritional care. The facility failed to follow dietary orders, document food intake accurately, and honor the resident's food preferences. Despite recommendations for advanced nutritional shakes, the facility did not implement these or consult with the resident's family about dietary preferences. Observations showed the resident struggled with meals due to missing teeth and hand contractures, leading to insufficient food intake.
A resident with multiple health issues, including rheumatoid arthritis and hand contractures, was not provided with the appropriate mechanical soft diet as ordered. The resident struggled to eat tough, uncut chicken due to missing teeth, and the assisting LPN did not offer alternative foods or cut the meat, resulting in the resident consuming only a small portion of the meal. The facility's policy on dietary orders was not followed, leading to this deficiency.
A resident dependent on staff for toileting was sent to the hospital without receiving necessary incontinent care, resulting in a dignity issue. The LPN had instructed a CNA to provide care, but the CNA failed to do so and did not inform the nurse of the need for assistance. The DON confirmed the resident should have been cared for before the transfer.
A resident with a history of self-harming behavior and multiple medical conditions sustained a fracture to her right arm due to inadequate supervision and failure to follow behavior management policies. Despite exhibiting aggressive and self-harming behaviors, the facility did not provide one-to-one monitoring or administer prescribed interventions, resulting in the resident's injury.
Two residents were involved in an incident where one resident, admitted with Schizophrenia, physically assaulted another resident in the hallway. The facility failed to conduct adequate pre-admission screening and assessment of the assailant's potential for aggressive behavior, as required by their abuse policy. The incident occurred during an admission assessment, and the assailant was discharged against medical advice later that day.
Failure to Obtain Informed Consent and Document Behaviors for Psychotropic Dose Increases
Penalty
Summary
The deficiency involves the facility’s failure to follow its psychotropic medication policy by not obtaining informed consent for multiple increases in a resident’s Seroquel (quetiapine) dosage and by not documenting behaviors or non-pharmacological interventions to justify those increases. The resident, who has a history of major depressive disorder, schizoaffective disorder, morbid obesity, iron deficiency anemia, and vitamin D deficiency, reported being concerned that staff were giving him higher doses of Seroquel than the 100 mg he believed he should receive and stated he did not consent to the dosage changes and had been refusing the medication. Record review showed that his Seroquel dose was progressively increased from 100 mg at bedtime to as high as 600 mg at bedtime over several physician orders. When surveyors requested consent documentation for these increases, the facility produced a form that the resident had refused to sign, and there was no documentation that the resident’s guardian had been informed of or consented to the dosage increases, despite the facility’s policy requiring informed consent from the resident or guardian for psychotropic medications and dosage increases. Behavior monitoring records ordered for the resident showed no documented behaviors for the months reviewed, even though the resident’s guardian reported he had requested a medication review because the resident was always worrying about others and frequently calling the police, and believed the resident was on 100 mg of Seroquel without being informed of any increases. The ADON acknowledged that if a resident is not exhibiting behaviors, they probably should not be on psychotropic medications and confirmed that the behavior monitoring sheets showed no behaviors. A psychiatrist and a psychiatric nurse practitioner both stated that staff were supposed to document behaviors as ordered and that informed consent was required for psychotropic medications and dosage increases, but also indicated they based treatment decisions on their observations and staff reports. An LPN reported that the resident wanted the Seroquel decreased, but the psychiatric team refused, and she was not aware of any behaviors. The facility’s psychotropic medication policy required routine documentation of behaviors and resident response to the medication, as well as informed consent prior to prescribing psychotropic medications, which was not followed in this case.
Failure to Assess and Provide Restorative Care for Hand Contracture
Penalty
Summary
The deficiency involves the facility’s failure to assess and address a resident’s restorative needs related to a left-hand contracture. During observations on two separate days, the resident was seen in a wheelchair with the left wrist contracted and the fingers tightly flexed into a fist, without any device in place to prevent further contracture. When asked, the resident reported that staff had not come to encourage exercises for the arm and hand. The resident’s care plan indicated that the resident would engage in active range of motion (AROM) to all four extremities, but there was no evidence that this was being implemented for the contracted left hand. The restorative nurse stated that they were new, worked with the therapy department to determine needed services, and were not aware that the resident’s hand was contracted. The therapy manager also reported that no one had informed therapy of the contracture. Upon direct assessment, the therapy manager asked the resident to open the hand and stretch the wrist, which the resident attempted but reported pain. The therapy manager stated the resident would benefit from a left-hand resting splint. Facility policies and the restorative nurse job description require evaluation of newly admitted residents for restorative appropriateness, quarterly and with change of condition, coordination with therapy disciplines for rehabilitation plans of care, and supervision of rehabilitative/restorative equipment such as splints, but these processes were not carried out for this resident’s hand contracture.
Failure to Complete Required Community Survival Skills Assessments per Policy
Penalty
Summary
The facility failed to follow its Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and additionally when residents request outside passes. During an interview, the Social Services staff member (V9) stated that these assessments are completed quarterly, annually, and when a resident requests an outside pass. However, review of the electronic medical records showed that for one resident (R10), the last documented community survival skills assessment was dated 3/31/25, and no subsequent assessments were present. V9 initially suggested that a more recent assessment might not be visible because it was not locked, but was informed that even in-progress assessments would appear in the record, confirming that no later assessment had been completed. Record review for three additional residents showed similar gaps in required assessments. R1’s last community skills assessment was dated 7/9/25, R17’s was dated 8/1/25, and R18’s was dated 9/8/25, with no evidence of quarterly assessments thereafter as required by the facility’s policy. The facility also produced a document titled “admission, quarterly, annual, and significant change assessments,” which indicated that community skills assessments are completed on admission, with significant change, and annually, a schedule that did not align with the written Community Access Determination policy. When asked if this document was a policy, the DON (V2) and ADON (V8) did not initially respond; after consulting with the Administrator (V1), V2 stated it was not a policy but a document listing assessments and their timing. The facility’s formal guidelines for community access determination, dated 2/8/23, specify that community skills assessments are to be completed by Social Services upon admission and quarterly for all residents, which was not followed for the four residents reviewed.
Failure to Follow Grievance and Belongings Policies for Missing Personal Phone
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance and belongings policies in response to a resident’s report of a missing personal cell phone. The resident reported that her phone went missing from her room during a specific time window while she was out of the room and stated she informed the Social Service Director, nurses, and CNAs. She reported that the Social Service Director wrote the information down but did not provide her a copy, and that staff told her they would find the phone and return it. The resident documented on an activity calendar the date and time she reported the missing phone to the Social Service Director and later noted that a cell phone was found in a medication storage room. She stated that the Social Service Director never followed up with her and that she was afraid to continue asking about her phone because she feared getting in trouble and not receiving help with a community pass and discharge. A pre-admission hospital record confirmed the phone number the resident reported as her personal phone number. Staff interviews and record review showed that the grievance process was not followed and belongings were not fully inventoried. An RN acknowledged that the resident had informed her months earlier about the missing phone and that she told the resident to talk to social services but did not follow up or report the concern. A CNA also stated the resident had reported the missing phone to her, yet the facility’s grievance binder contained no grievance related to the missing phone. A grievance/opportunity resolution form produced by the facility lacked the name of the person completing it and only noted that the resident had a phone since admission and that another resident may have taken it. The resident’s belongings inventories did not list the phone or several other personal items visible in the admission photo and in the resident’s room, and neither inventory sheet contained the resident’s signature. The facility’s belongings policy required all belongings to be recorded and signed for, and the grievance policy required all concerns to be documented in writing, overseen by the Social Service Director, with resolutions expected within 72 hours and maintained in a grievance binder for at least three years.
Failure to Prevent and Properly Investigate Resident-to-Resident Physical Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy to protect residents from resident-to-resident physical abuse. A resident with a history of psychosis, schizophrenia, bipolar disorder, auditory hallucinations, and prior hospitalization for aggressive behavior entered another resident’s room, became upset about what he believed was expired or spoiled milk, and began yelling. According to the assaulted resident and multiple resident witnesses, the aggressor struck the resident on the right side of the head with a milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently, continuing to hit her until another resident intervened and staff arrived. The assaulted resident reported pain in her right forearm and behind her right ear. Witness statements from two other residents consistently described the aggressor on top of and hitting the victim, and one resident physically pulled the aggressor away and stood between them. The aggressor’s medical record showed multiple psychotropic medications ordered for psychosis, schizophrenia, and bipolar disorder, but the MAR documented frequent refusals of these medications over an extended period, both before and after a recent hospitalization for aggressive behavior. There was no documentation that the attending physician or psychiatrist was notified each time these psychotropic medications were refused, and nurse practitioner notes during this period recorded “no concerns from the nursing staff.” The facility’s abuse investigation relied on written statements from residents but did not include any staff interviews regarding the event and concluded there was no credible evidence that abuse occurred, despite multiple resident accounts that the aggressor was hitting the victim. This sequence of events and omissions reflects a failure to follow the facility’s abuse prevention policy and to adequately address and monitor a resident with known psychiatric diagnoses and aggressive behavior, resulting in a resident-to-resident physical assault.
Failure to Supervise Aggressive Resident Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and monitoring for a resident with a known history of aggressive behavior, which allowed him to enter another resident’s room and assault her. The aggressive resident had multiple behavior care plans noting severe mental illness, including schizophrenia, psychosis with hallucinations, and bipolar disorder, with documented poor impulse control, lack of sound judgment, and a history of physically abusive behavior when agitated. His care plans included interventions such as administration of psychoactive medications as ordered, behavior tracking, reporting abnormalities to the physician, and daily monitoring and supervision. The medical record documented repeated noncompliance with medications, impaired comprehension, delusions, paranoid and disorganized thought processes, poor self-awareness, and auditory hallucinations, with social services counseling attempts that were not successful in improving his medication compliance. Despite these known risks and documented behaviors, the resident was able to access another resident’s room without effective supervision. The assaulted resident reported that the aggressive resident entered her room, became upset about a milk carton he believed was expired, yelled at her, struck her on the right side of the head with the milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently. Another resident reported hearing screaming and smacking sounds, then seeing the aggressive resident hitting the victim and intervening by pulling him off and standing between them. A roommate corroborated that the aggressive resident was hitting the victim, and another roommate stated she saw him on top of the victim punching her in the face before other residents and staff intervened. These events demonstrate that the facility did not provide adequate supervision and monitoring to prevent the aggressive resident from entering another resident’s room and engaging in physical and verbal assault, despite his known behavioral risks and documented need for close supervision.
Failure to Prevent and Control Illicit Drug Use and Distribution
Penalty
Summary
The facility failed to maintain an effective contraband policy to prevent illicit drugs from being brought into, distributed, and used within the facility. Multiple residents were found to have tested positive for fentanyl and opiates, with two residents experiencing significant medical emergencies as a result. One resident was observed slumping forward in a wheelchair, became cyanotic, and required Narcan administration after testing positive for opiates and fentanyl. Another resident was transported to the hospital for a change in condition and also tested positive for fentanyl and opiates metabolites. Both residents had a history of substance abuse and were cognitively intact at the time of the incidents. Interviews and record reviews revealed that the facility did not have a plan to determine how illicit drugs were entering the premises. There were reports and witness statements indicating that drugs were being brought in and distributed by both residents and possibly staff, including allegations of a female night staff member supplying drugs. The facility's investigation into staff involvement was inconclusive, and there was a lack of documentation regarding interviews and searches. Additionally, the facility's contraband policy was not effectively enforced, as evidenced by the discovery of drug paraphernalia in resident rooms and ceilings, and by multiple residents admitting to purchasing and using illicit substances within the facility. Staff interviews indicated gaps in communication and awareness regarding residents' substance use and related hospitalizations. There was also a lack of clarity among staff about when to administer Narcan, and the facility failed to present a policy or practice related to its use. The facility's response to suspicious behavior, drug screening, and supervision was inconsistent, and documentation of investigations and interventions was incomplete. These failures affected not only the residents who experienced overdoses but also had the potential to impact all residents reviewed for illicit substance or contraband issues.
Failure to Document and Monitor Effectiveness of Controlled Substance Administration
Penalty
Summary
The facility failed to follow its medication administration policy and did not consistently monitor or document the effectiveness of pain medication for a resident receiving high alert medications. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse revealed that staff were not accurately documenting the administration of hydrocodone-acetaminophen in the Medication Administration Record (MAR) at the time of administration, as required by facility policy. The MAR and controlled substance sheets for the resident showed discrepancies, with the controlled substance being signed out twice daily but not always recorded in the MAR. The LPN acknowledged that documentation was not completed every time the medication was administered and could not provide a reason for the omission. Review of the resident's physician order sheet confirmed an order for hydrocodone-acetaminophen to be given every 12 hours as needed for pain, and the resident's care plan included interventions for pain management and monitoring effectiveness. However, there was no consistent documentation in the medical record indicating that nursing staff monitored the effectiveness of the pain medication as required. The facility's policy specified that the person administering medication must initial the MAR before administration and that late entries should be documented if missed, but these procedures were not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Homelike Environment Due to Improperly Secured Window Drapes
Penalty
Summary
The facility failed to maintain a homelike environment for residents by not ensuring that window drapes in multiple resident rooms were properly secured to the curtain rods, tracks, or hooks. During a facility tour, surveyors observed that the window drapes in the rooms of ten residents were falling from their fixtures, with some rooms using towels to cover window openings created by the fallen drapes. Maintenance staff acknowledged the issue when it was brought to their attention, attributing it to housekeeping, but the problem persisted throughout the day. One resident reported having repeatedly requested assistance from social services to have her curtains washed and rehung due to their condition. The Director of Nursing confirmed that resident rooms should be clean, sanitary, and homelike, and that window drapes should not be falling. The facility's housekeeping policy requires maintaining a safe and sanitary environment, but the observed conditions did not meet these standards.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the exact nature of the orders or preferences that were not followed, nor does it provide details about the resident's medical history or condition at the time of the deficiency.
Failure to Maintain Operational Elevators
Penalty
Summary
The facility failed to ensure that all elevators were operational, resulting in only one of two elevators functioning during the survey. On observation, the left elevator was not responding to the call button and displayed a static number. Maintenance staff confirmed that the elevator had been repaired the previous day but had broken down again, noting that elevator malfunctions have been an ongoing issue. The maintenance staff was unable to specify which elevator had been serviced and was unaware of the specific cause of the repeated breakdowns. Service records indicated recent work on one elevator, but documentation did not clearly identify which car was serviced. Multiple residents reported delays in elevator service due to only one elevator being operational. The facility census indicated 191 residents, and the elevators are used for transporting meals, staff, visitors, laundry, and housekeeping between floors. The Director of Nursing confirmed the reliance on elevators for daily operations. The facility's building maintenance policy did not include protocols or information specific to elevator maintenance or operation.
Failure to Verify Escort Identity for Supervised Community Pass
Penalty
Summary
The facility failed to follow its protocol for supervised community passes by not verifying the identity of the individual who signed out a resident for a community pass. Specifically, a resident with a significant history of substance abuse, multiple injuries, and a care plan indicating she was not capable of unsupervised outside pass privileges was allowed to leave the facility. The pass request form listed a specific individual as the escort, but the ID scanned and attached did not match the name on the form. Staff interviews revealed that the process for verifying the escort's identity was not followed because the receptionist, who was responsible for scanning the ID, was occupied with other duties and did not interact with the person taking the resident out. As a result, the resident left the facility on a supervised pass and did not return. The nurse on duty followed the process of scanning the ID and handing it to the receptionist, but the mismatch in identity was not caught. The facility's policy on community passes did not clearly outline the supervised pass procedure, contributing to the failure. The administrator confirmed that the police were not notified when the resident did not return, and did not consider the incident to be an elopement.
Failure to Provide Timely Podiatry Services for Diabetic Residents
Penalty
Summary
The facility failed to provide timely foot care treatment and ensure follow-up visits with a podiatrist for residents at risk for foot disorders, specifically for two residents with diabetes. One resident, who was cognitively intact, reported not having seen a foot doctor for a long time despite requesting to see one. Upon observation, this resident's toenails were found to be long, discolored, and thick. Physician orders allowed for podiatrist visits, and the last documented podiatrist visit was several months prior, with a recommendation for a follow-up in nine weeks that was not documented as completed. Another resident, also cognitively intact and with diabetes, showed the surveyor long, thick, discolored, and curling toenails, and stated not recalling the last podiatrist visit despite requesting one. Physician orders indicated the need for podiatry services, but the last documented visit was also several months prior, with a follow-up recommendation that was not documented as completed. Staff interviews revealed that residents are added to a list for podiatrist visits upon request, but there was no evidence provided that these residents received timely follow-up as ordered. The facility's policy requires regular foot assessments and podiatrist referrals for diabetics, which was not followed in these cases.
Failure to Monitor and Investigate Illicit Drug Use Resulting in Resident Overdose
Penalty
Summary
The facility failed to have a system in place for monitoring and investigating how illicit drugs entered the facility, to be alerted when illicit drugs were present, and to prevent resident use and possible drug overdose. This deficiency was identified after a resident with a known history of substance abuse obtained and used illicit drugs while in the facility, resulting in a drug overdose that required the administration of Narcan and emergent hospital transfer. Interviews and record reviews revealed that the facility did not conduct an investigation into how the drugs were brought in or how the resident accessed them, nor did they follow up with involved residents or staff regarding the incident. The resident involved had a documented history of substance abuse, including cocaine, marijuana, and alcohol, and had previously been admitted to behavioral health and substance abuse treatment centers. On the day of the incident, the resident was found unresponsive in another resident's room, and staff administered Narcan after observing symptoms consistent with opioid overdose. The resident later admitted to using heroin with another resident. Despite this, there was no documentation of an investigation into the overdose, and key staff members, including the DON and administrator, did not follow up with staff or residents to determine the source of the drugs or to assess the situation further. Other residents and staff reported knowledge or suspicion of drug use and distribution within the facility, including observations of abnormal behaviors and direct admissions of drug use. The facility's policies required reporting, recording, and investigating all accidents and unusual occurrences, including those requiring emergency services or resulting in hospitalization. However, these procedures were not followed in this case, as there was no accident report or investigation into the overdose incident, and the facility did not notify the appropriate parties or take steps to identify and address the source of the illicit drugs.
Failure to Provide Required Substance Abuse Services and Supports
Penalty
Summary
The facility failed to follow its own policies and procedures for providing services and supports for chemical dependence and substance abuse for two residents. One resident, a male with a history of schizophrenia, depression, suicidal ideation, and substance use disorder, was not offered substance abuse group programming despite expressing a history of substance abuse and a desire to participate. The resident reported that he was told he could not attend the group because his substance abuse history was not documented at admission, even though he later disclosed his history to staff. The care plan for this resident included individual counseling but did not address group participation, and attendance records confirmed he was not included in the substance abuse group sessions. Another resident, a female with diagnoses including epilepsy, psychotic disorders, bipolar disorder, and psychoactive substance abuse disorder, was not consistently provided with psychiatric, group, or behavioral health counseling and services as indicated by her history and care plan. Although her records documented a history of substance abuse and she was encouraged to participate in group sessions, documentation showed she only attended one group session and there was no evidence of one-to-one substance abuse counseling. Multiple staff interviews confirmed that discussions about her substance use were not consistently occurring during psychiatric or social work sessions, and her care plan interventions were not fully implemented. These failures resulted in the female resident using illicit substances within the facility, leading to an overdose that required emergent transfer to a local hospital. The facility's own policies required offering appropriate treatment and rehabilitative services to residents with substance abuse problems, but these were not consistently provided or documented for the residents in question. Staff interviews revealed gaps in communication, assessment, and follow-through regarding substance abuse history and the provision of necessary support services.
Failure to Transcribe and Implement Physician Orders for Foot Monitoring
Penalty
Summary
The facility failed to follow professional standards of care by not transcribing and implementing physician orders to monitor a resident's right foot for increased discoloration, assess pedal pulse, and monitor temperature changes. The resident had a history of occlusion and stenosis of the right carotid artery, essential hypertension, anemia, and chronic ischemia. After the resident complained of discoloration in her right foot, a nurse practitioner assessed the foot, noted it was cool to the touch with edema, and ordered a doppler ultrasound, which was negative for DVT. Despite the negative result, the plan was to monitor the foot for changes, but the nurse practitioner did not specify a time frame for monitoring and only gave a verbal order to an unidentified nurse. Subsequent interviews revealed that the LPN who cared for the resident after an unwitnessed fall was unaware of any orders to monitor the right foot and did not perform a head-to-toe assessment. The CNA reported the presence of a blister and that the foot was wrapped by a nurse. The medical doctor confirmed the resident's chronic ischemia and agreed with the monitoring orders. However, review of the resident's physician order sheet and progress notes showed no documentation of orders or monitoring for the right foot on the relevant dates. The facility's policy requires all physician orders to be transcribed and implemented, but this was not done in this case.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in the assaulted resident being sent to the hospital for evaluation of facial trauma. The incident occurred in the dining room, where a resident with a fractured ankle was using a chair to elevate his leg. Another resident attempted to take the chair, and when told to leave it, physically assaulted the first resident by punching him in the face. At the time of the incident, there was no staff present in the dining room to monitor the residents, despite multiple residents being present in the area. Interviews and record reviews revealed that both residents involved had intact cognition according to their BIMS scores, and neither had care plans addressing susceptibility or predisposition to abuse prior to the incident. Staff statements confirmed that the dining room was not consistently monitored, particularly during shift changes or when staff were occupied with other duties such as charting. The only CNA on duty for the unit reported alternating monitoring duties with nurses, but at the time of the altercation, no staff were present in the dining room. Documentation from the LPN, hospital, and police corroborated the occurrence of a physical altercation, with the assaulted resident sustaining swelling to the left eye and being sent to the hospital for further evaluation. The facility's abuse prevention policy emphasized the need for resident assessment and staff supervision to prevent abuse, but observations and staffing records indicated inadequate supervision in common areas, contributing to the incident.
Failure to Assess and Manage Resident's New Onset Hip Pain
Penalty
Summary
A resident with multiple medical conditions, including a history of falls, cognitive impairment, and mobility issues, experienced a new onset of right hip pain that was first documented by the therapy director. The therapy director reported the pain and a change in the resident's ambulatory status to the interdisciplinary team and nursing staff. Despite this notification, there was a lack of timely and thorough pain assessment and documentation by nursing staff. The assistant director of nursing and the family nurse practitioner both assessed the resident and ordered an x-ray, with the nurse practitioner instructing nursing staff to administer PRN pain medication as ordered. However, there was no documentation of pain medication being administered, and the medication administration record did not reflect any pain medication given during the relevant period. Nursing staff interviews revealed inconsistent accounts regarding the administration of pain medication. One LPN stated that pain medication was given but not documented, while another nurse reported not administering any pain medication because the resident did not verbally complain of pain during their shift. There was also a failure to document pain assessments or reviews in the resident's records, despite clear changes in the resident's condition and reports of significant pain. The facility's pain management policy requires assessment and documentation of pain, including onset, location, severity, and use of a pain rating scale, but these steps were not followed in this case. The resident remained in pain for approximately 24 hours before being hospitalized, where a right femoral neck fracture was confirmed and surgical intervention was performed. The lack of timely pain assessment, documentation, and administration of PRN pain medication resulted in the resident experiencing unmanaged pain prior to hospitalization. Progress notes and interviews confirm that the facility did not adhere to its own pain management and assessment policy during this incident.
Failure to Notify Physician of Resident's Refusal of Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician after a resident refused a scheduled psychotropic medication. The resident, who had diagnoses including Schizoaffective Disorder, Paranoid Schizophrenia, and Obsessive-Compulsive Disorder, was assessed as having intact cognition and a history of refusing care, including medications. The resident's care plan required staff to carry out the prescribed medication regimen and report any changes or complications to the physician. On the scheduled date, the resident refused a long-acting injectable psychiatric medication, as documented in the Medication Administration Record. However, there was no documentation in the progress notes that the physician was notified of this refusal. Staff interviews revealed that the LPN on duty was unsure if the resident received the scheduled medication and admitted to not documenting or notifying anyone about the refusal. The psychiatric nurse practitioner confirmed that they were not informed of the missed dose, which could have contributed to the resident's subsequent behavioral decline. The DON stated that nurses are expected to re-offer the medication and notify the physician if refusal persists, as well as document the refusal in the resident's chart. The absence of documentation and physician notification following the medication refusal constituted the deficiency.
Verbal Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a former Social Service Aide/Smoking Monitor, identified as V3. The incident occurred when the resident, R1, requested a cigarette from V3 during designated smoking time. V3 refused the request and responded inappropriately by calling R1 a derogatory term. This interaction was witnessed by another resident, R2, who confirmed the use of inappropriate language by V3. The incident was reported to a Licensed Practical Nurse (LPN), V2, who then informed the facility's Administrator/Abuse Coordinator, and a police report was filed to document the verbal aggression. R1, who was cognitively intact with a BIMS score of 15, was admitted to the facility with multiple diagnoses, including mental and behavioral issues, anxiety, and depression. The facility's Abuse Prevention Program policy defines abuse as including verbal abuse, which was violated in this instance. V3's personal file revealed a prior disciplinary action related to unsatisfactory work and attitude, as well as dishonest practices concerning smoking materials. This history suggests a pattern of behavior that was not adequately addressed, leading to the incident of verbal abuse against R1.
Ineffective Pest Control Program Leads to Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches within the premises. The Facility Pest Control Agreement, dated 12/1/2002, outlined a targeted pest control service for roaches with bi-monthly visits, yet observations and interviews revealed ongoing issues. On 2/22/25, live cockroaches were observed in two separate rooms, and multiple residents reported seeing cockroaches in their rooms, with one resident stating they see them every day. Housekeeping staff on both the second and third floors confirmed seeing live cockroaches daily, indicating a persistent problem. The Facility Grievance Opportunity Resolution Forms documented resident concerns about pests, with actions taken including deep cleaning and pest control treatments. Despite these measures, the problem persisted, as evidenced by the continued presence of cockroaches and frequent complaints from residents. The Activity Director noted receiving complaints about roaches a couple of times a week from various residents, and although pest control services were reportedly called and scheduled, the issue remained unresolved. The facility's administrator acknowledged the pest control visits but could not explain why the cockroaches were not being eradicated.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow care plan interventions and implement appropriate fall prevention measures for a resident with a history of falls and multiple risk factors, including cerebral vascular attack, hemiplegia, and mild cognitive deficit. The resident required substantial staff assistance for transfers and had multiple falls related to general weakness, poly-pharmacy, poor coordination, and use of medications. Despite having a care plan with specific interventions such as ensuring the call light was within reach, reminding the resident to use the call light for assistance, and conducting physical therapy evaluations, these interventions were not consistently implemented. The resident experienced three falls in their room during unassisted transfers from bed to wheelchair, with no injuries noted. Each fall report documented the need for a physical therapy evaluation, but the facility could not provide evidence of these evaluations being conducted. The Director of Nursing confirmed that the falls occurred during unassisted transfers and acknowledged that care plan interventions and proper footwear should have been followed. The facility's administrator noted that the resident was non-compliant and that fall interventions need to be resident-specific and consistently followed.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its call light policy, resulting in delayed responses to residents' needs. This deficiency was observed in five residents, including a female resident with Schizoaffective Disorder, COPD, and Stage 3 Chronic Kidney Disease, who reported waiting up to an hour for assistance during the night. As a result, she experienced discomfort from being left wet for extended periods. Another resident with Polyneuropathy and Reduced Mobility also reported similar delays, expressing concerns about potential urine burns from prolonged exposure to wet diapers. During an observation, a male resident with Chronic Pain Syndrome and other significant health issues had his call light activated for an extended period without response from nearby staff, including a Licensed Practical Nurse and a Certified Nursing Assistant. Despite being in proximity, staff members did not respond to multiple activated call lights, including those of two other residents. The Director of Nursing confirmed that all staff are expected to respond to call lights promptly, regardless of the resident's assignment, as per the facility's policy.
Failure to Document and Resolve Grievance Regarding Resident Care
Penalty
Summary
The facility failed to adhere to its grievance policy and procedures by not documenting, investigating, or resolving a concern reported by a resident's family member. The resident, a female with a history of polyneuropathy, reduced mobility, and chronic embolism and thrombosis, was left in a chair for 17 hours due to a mechanical lift not being charged. The family member reported this grievance to the facility, but it was not documented or addressed in a timely manner. Interviews with staff revealed that the Assistant Director of Nursing was unaware of the complaint, and the Psychosocial Rehabilitation Services Coordinator had reported the grievance to the Director of Nursing or Assistant Director of Nursing. However, the grievance was not documented in the facility's records until several days later, indicating a failure to follow the facility's grievance policy, which requires documentation and resolution of concerns within 72 hours.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident from eloping, despite being assessed as unable to navigate safely and independently in the community. The resident, a male with a history of seizures, unspecified psychosis, dementia, and other medical conditions, was admitted to the facility with a care plan that required supervised smoking and community access. On the day of the incident, the resident left the facility unsupervised and was later found intoxicated by local police, having been without access to his ordered medical care. The incident was reported to the facility's Social Service Director by a staff member who noticed the resident was missing. The staff conducted a headcount after a bed alarm went off, realizing the resident was not present. Despite the resident's care plan indicating he required supervision, the facility did not have an authorized pass policy in place, and the resident was able to exit through a basement back door. The facility's supervision policy was not effectively implemented, as the resident was able to leave without being noticed by staff. The facility's response to the incident was delayed, with the resident's emergency contact being notified the following day. The police were called, and a missing person report was filed. The facility's administrator acknowledged that the resident was discharged in the system as if he had left against medical advice, although no AMA form was signed. The lack of immediate action and effective supervision contributed to the resident's elopement and subsequent intoxication, highlighting deficiencies in the facility's safety and supervision protocols.
Removal Plan
- The facility will continue to provide a safe environment for the residents through written policies and procedures to prevent elopement and to use as a baseline to maintain a secure resident environment.
- The facility initiated an investigation. It has been determined that the resident exited the facility from the basements back door.
- Director of Social Services, Assistant Director of Social Services and PRSCs has re-assessed facility residents' elopement risk assessment and community survival skill assessments.
- The facility has provided an elopement binder to all facility units with pictures identifying residents at risk for elopement.
- Director of Social Services, Assistant Director of Social Services and PRSCs have re-screened and assessed all residents to determine any factors that would put them at risk for elopement.
- Director of Social Services, Assistant Director of Social Services and PRSCs will continue to meet and assess all residents upon admission, quarterly, annually, and with change in condition or behavioral observations that may put the resident at risk for elopement.
- Administrator, Director of Social Services and all staff will continue to monitor residents for potential signs of elopement.
- Staff were re-educated but not limited to the facility elopement policy and procedures.
- DON/Designee will in-service all newly hired staff at the time of hire on the facility's elopement policy.
- DON/Designee will in-service staff out on leave or on vacation upon their return to work.
- Elopement binders have been placed on all facility units including the front reception area.
- All exit doors have been rechecked to ensure all alarms are functioning properly and to check staff response time.
- The facility Assistant Administrator conducted an ad hoc QA meeting which reviewed the facility elopement policy as it relates to safeguarding current and future residents from elopement.
- Quality Assurance will audit random resident files to ensure the risk for elopement has been properly assessed and care planned.
- The Administrator/Designee will perform weekly audits on all newly admitted and readmitted residents to ensure the risk for elopement has been properly assessed and care planned.
- As part of the Quality Assurance Committee the Administration/DON will in-service all staff monthly on the elopement policy for a period of two months.
Medication Administration Failure Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to administer medications as ordered to 34 residents on the third floor. On Christmas Day, only one nurse was assigned to the day shift on the third floor, which resulted in medications not being administered to residents in rooms 301-311 and 326-334. The Licensed Practical Nurse (LPN) on duty, responsible for rooms 312-325, did not accept responsibility for the other medication cart and informed management of her inability to cover the entire floor. Despite being aware of the staffing shortage, the Director of Nursing (DON) did not provide additional support or coverage. The deficiency affected residents with various medical conditions, including dementia, psychosis, seizures, depression, hypertension, and chronic obstructive pulmonary disease. One resident reported not receiving medications on Christmas morning, and the LPN confirmed that medications were not administered to the entire floor. The DON, who was new to the position, acknowledged the staffing issue but was under the impression that the LPN would cover the entire floor. The facility lacked a holiday staffing plan, and the absence of a second nurse on the third floor was attributed to a call-off and the DON's inability to find a replacement. The facility's administrator and DON were not aware of any complaints or issues with medication administration until the survey. The administrator stated that there was no staffing policy in place and acknowledged the need for a holiday rotation plan. The deficiency was considered an isolated incident, and the DON accepted responsibility for the situation, noting that the facility typically staffs two nurses per shift on each floor, except for nights when only one nurse is assigned to the first and third floors.
Medication Administration Failure on Holiday
Penalty
Summary
The facility failed to provide medications as ordered by the prescriber to 34 residents on the third floor during the day shift on Christmas Day. This deficiency was identified through interviews and record reviews, revealing that medications were not administered to residents from the front cart on the third floor. The residents affected included those with various diagnoses such as dementia, psychosis, seizures, depression, hypertension, and chronic obstructive pulmonary disease. The Medication Administration Records (MAR) for December 2024 documented that medications were not given on the specified day shift. Interviews with residents and staff highlighted the issue of understaffing on the third floor during the holiday. A Licensed Practical Nurse (LPN) working that day stated that she was responsible only for her assigned residents on the back hall and did not administer medications to the residents on the front cart. The Director of Nursing (DON) was aware of the staffing shortage and the LPN's refusal to cover the entire floor, yet no alternative arrangements were made to ensure all residents received their medications. The DON and the LPN had differing accounts of the expectations and communications regarding medication administration on that day. The facility's policy and procedure for administering medications emphasize the responsibility of the Director of Nursing Services to supervise medication administration and ensure compliance with physician orders. However, the failure to provide medications as ordered was not communicated to the prescribers, and no corrective actions were documented in the report. The lack of medication administration on Christmas Day was not reported to the Nurse Practitioner or the Administrator, indicating a breakdown in communication and adherence to established protocols.
Failure to Administer Seizure Medications on Christmas Day
Penalty
Summary
The facility failed to administer significant medications to five residents on the day shift of December 25, 2024. This deficiency was identified through interviews and record reviews, revealing that seizure medications were not given to the residents as prescribed. The residents affected included those with conditions such as dementia, psychosis, seizures, and other chronic illnesses. The Medication Administration Records (MAR) for December 2024 documented that medications like Divalproex Sodium, Levetiracetam, Keppra, and Depakote were not administered at the scheduled times. Interviews with residents and staff highlighted the absence of a nurse on the third floor during the day shift on Christmas Day, which contributed to the missed medication doses. One resident reported not receiving their seizure medication for about four days due to an insurance issue and the facility's inability to verify the medication they brought with them. The Licensed Practical Nurse (LPN) on duty confirmed that they only administered medications to a portion of the residents on their assigned side of the floor, as they were not responsible for the entire floor and did not have the keys for the other medication cart. The Director of Nursing (DON) was aware of the staffing shortage but did not ensure that all residents received their medications. The DON stated that they were not informed of any medication delivery issues or residents missing doses. The facility's policy on medication administration emphasizes the responsibility of the DON to supervise medication administration and ensure compliance with physician orders. However, the lack of communication and coordination among staff led to the failure in administering medications as required.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R3. R2, a male with severe cognitive impairment and multiple psychiatric diagnoses, reported being punched in the chest by his roommate, R3. This incident was not witnessed by staff, but R2 was found with a bruise on his chest by a CNA during morning care. R2 consistently reported that R3 was the assailant, although R3 denied any physical interaction with R2. R2's medical records indicate that he has severe cognitive impairment and is dependent on staff for most activities of daily living. On the day of the incident, R2 was found with discoloration on the left side of his chest, which was later diagnosed as a contusion. Despite R2's severe cognitive impairment, he was able to communicate that he was punched by his roommate, leading to his transfer to a hospital for further evaluation. The facility's response included separating the residents and notifying relevant parties, including the police. However, the initial failure to prevent the altercation and protect R2 from harm constitutes a deficiency in the facility's abuse prevention program. The facility's policy defines abuse as the willful infliction of injury, and the incident highlights a lapse in ensuring resident safety and adherence to this policy.
Failure to Follow Menu and Serve Planned Meals
Penalty
Summary
The facility failed to adhere to the planned menu, resulting in all 211 residents not receiving the specified meals on two separate occasions. On December 18, 2024, during lunch service across all nursing units, residents were served one slice of white bread instead of the planned 1/2 slice of garlic Texas toast. Similarly, on December 20, 2024, during breakfast service, residents were not served the planned oatmeal and scrambled eggs with cheese. Instead, they received cream of wheat hot cereal and scrambled eggs without cheese. Additionally, there was a shortage of cold cereal and toast, leading to some residents, such as one who requested cold cereal, leaving the dining room without eating breakfast. The dietary manager, V8, acknowledged the discrepancies in meal service, noting that additional cold cereal was available in the kitchen but was not requested by the staff. The kitchen staff, V13, confirmed the use of incorrect serving utensils and the absence of cheese in the scrambled eggs. These observations and interviews highlight the facility's failure to follow the menu and ensure residents received the meals as planned, impacting the nutritional needs of the residents.
Inadequate Dining Supplies During Meal Service
Penalty
Summary
The facility failed to provide adequate dining supplies during a lunch meal service on the third floor nursing unit, affecting all 75 residents. Observations revealed that initially, 45 residents received their meals on plastic plates, but the staff ran out of these plates, resulting in the remaining 30 residents being served on Styrofoam plates. Additionally, the staff ran out of plastic cups with handles, leading to 10 residents receiving coffee in Styrofoam cups without handles. Furthermore, 25 residents were not provided with napkins as the supply ran out. Despite the shortage, the dining room staff did not notify the kitchen to replenish the necessary items. A subsequent tour of the kitchen confirmed that there were sufficient supplies available, but they were not requested by the dining room staff.
Failure to Initiate Timely Falls Care Plan for Resident
Penalty
Summary
The facility failed to follow its care plan policy by not initiating an individualized falls care plan with interventions for a resident at moderate risk for falls. This deficiency was observed in a resident who had transferred from another long-term care facility and had a documented history of falling and generalized weakness. Despite the resident's ability to make needs known, as indicated by a perfect BIMS score, the facility did not implement fall precautions immediately upon admission. The resident was observed on multiple occasions with the call light cord out of reach, and had visible injuries consistent with a fall. The restorative nurse, responsible for investigating falls and updating care plans, did not investigate the resident's fall that occurred shortly after admission. Although the resident was educated on seeking assistance with transfers and physical therapy evaluation, these interventions were not documented in the care plan. The care plan was not initiated until several days after the fall and was backdated, indicating a lapse in timely and appropriate care planning as per the facility's policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow its fall risk and post-fall assessment policy, which resulted in a deficiency affecting a resident identified as R2. Upon admission, R2 was not accurately assessed for fall risk, and necessary fall prevention interventions were not implemented immediately. Observations revealed that R2's call light cord was consistently out of reach, and R2 had visible injuries, including discoloration and swelling on the left side of the face, indicating a fall had occurred. Despite these signs, the facility did not conduct a thorough investigation or update R2's care plan with appropriate interventions. The Restorative Nurse, V6, acknowledged responsibility for investigating falls and updating care plans but admitted to not investigating R2's fall on 12/11/24. Although V6 was informed of the interventions to be put in place post-fall, these were not documented in R2's care plan. Additionally, the Director of Rehabilitation, V7, failed to prioritize R2 for skilled therapy despite R2's history of falls and a decline in functional abilities noted in transfer paperwork. R2 was not evaluated by physical and occupational therapy, and the fall incident report was not provided to the surveyor. R2's medical records indicated a history of falls, generalized weakness, and a need for assistance with ambulation. However, the fall risk review and post-fall review inaccurately noted no history of falls within the last three months and did not account for R2's medications or predisposing conditions. The facility's policy required a fall risk assessment at admission and a post-fall assessment with immediate interventions, but these were not completed as required, leading to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by pervasive odors of urine and unclean conditions in several rooms on the third floor. Observations revealed that rooms were dirty, with garbage on the floors and brownish stains, and a strong urine smell was present in the hallway and several resident rooms. Residents reported that their rooms had not been cleaned for several days, and housekeeping staff confirmed that they were unable to clean all rooms due to staffing shortages. The housekeeping department was understaffed, with only one housekeeper assigned to the third floor, who could not clean all resident rooms. The Housekeeping Director reported that they were not receiving sufficient cleaning supplies, such as bleach, to maintain cleanliness standards. The facility's owner was unaware of the supply shortages and staffing issues, indicating a lack of communication and oversight. Several residents were affected by the facility's failure to provide clean linens and mattresses. Residents reported that their bed linens were wet and stained, and some mattresses were soiled and needed replacement. The Director of Nursing confirmed that soiled linens should be changed immediately, and mattresses should be replaced if stained. However, the facility's policies were not being followed, leading to unsanitary conditions for the residents.
Failure to Maintain Sanitary Conditions in Meal Service
Penalty
Summary
The facility failed to adhere to its policy and procedures for serving food under sanitary conditions, affecting all 66 residents receiving meals on the 2nd floor. Observations revealed that meal trays were left uncovered on skeleton carts, with gnats flying around the food. Despite the presence of clean lids on the dietary aides' food service cart, they were not utilized. A Certified Nursing Assistant (CNA) mentioned that meal tray lids were typically unavailable, which led to their non-use. Another CNA admitted to not noticing the absence of lids during meal delivery, acknowledging the risk of contamination. The Director of Nursing confirmed that food trays should be covered to prevent contamination and maintain appropriate temperatures, as per the facility's Food Handling Policy, which mandates covering food and beverages during transport from the Dietary Department to residents.
Failure to Provide Communication Board for Resident with Communication Barrier
Penalty
Summary
The facility failed to ensure that a resident with a communication barrier was provided with the necessary tools to communicate effectively. The resident, a male with a history of Cerebral Palsy, Epilepsy, Other Specified Disorders of the Brain, and Urinary Incontinence, was admitted to the facility and was noted to have extremely limited speech. Despite documentation in the social service progress notes indicating that a communication board would be provided, observations revealed that no such board was available for the resident's use. Staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, acknowledged the absence of a communication board and admitted to having difficulty understanding the resident's needs. The Director of Nursing indicated that social services are responsible for providing communication boards, but there was a lack of communication between departments to ensure the resident received the necessary support. The Social Services Worker confirmed using a communication board when interacting with the resident due to her own hearing difficulties but failed to leave the board with the resident for ongoing use. This oversight resulted in the resident's communication needs not being adequately met, as documented in multiple social service progress notes highlighting the resident's difficulty in making his needs known.
Failure to Investigate Resident Altercation as Abuse
Penalty
Summary
The facility failed to identify and investigate an altercation between two residents as abuse. Resident 1, a cognitively intact female with diagnoses including anxiety, depression, and PTSD, reported being physically assaulted by Resident 4, who has diagnoses including hypertension, panic disorder, and borderline personality disorder. The incident involved a dispute over a water bottle, during which Resident 1 claimed to have been punched in the chest by Resident 4. Despite the presence of staff members, including a Registered Nurse and a Certified Nursing Assistant, who witnessed the aggressive behavior, the facility did not recognize the incident as a physical altercation or abuse. Interviews with staff revealed a lack of awareness and communication regarding the physical nature of the altercation. The Social Service Director and the Assistant Administrator were not informed of the physical aspect of the incident, and the facility's abuse policy, which requires immediate reporting and investigation of potential abuse, was not followed. The Administrator/Abuse Coordinator stated that the incident was not considered abuse, despite the facility's policy defining abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. This oversight led to a failure in addressing the altercation appropriately as an abuse incident.
Inadequate COVID-19 Precautions and Monitoring
Penalty
Summary
The facility failed to implement effective transmission-based precautions and infection surveillance during a COVID-19 outbreak, affecting 14 residents and potentially impacting the entire resident population. Discrepancies were noted in the COVID-19 resident tracking system, with positive residents being placed in the same room as those whose isolation had ended. Additionally, a room identified as COVID-19 positive lacked a garbage bin for disposing of used PPE, and a resident expressed concerns about the facility's infection control measures. The facility's infection control policies were not adequately followed, as evidenced by the lack of contact/droplet signage and isolation setups for COVID-19 positive residents. For instance, a resident who tested positive for COVID-19 did not have the required signage or PPE setup outside her room, and her door was left open. Furthermore, the facility's entrance lacked available N95 and surgical masks, and visitors were not consistently informed of the outbreak or provided with masks upon entry. There was also a failure to monitor and document vital signs and symptoms for residents on COVID-19 isolation precautions. Several residents who tested positive for COVID-19 did not have their vital signs monitored or documented, and their care plans were not formulated promptly. The facility's policies on source control, PPE, and resident screening were not effectively implemented, contributing to the deficiencies observed during the survey.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to adhere to its policy regarding the notification of a resident's responsible party about a change in the resident's condition. This deficiency was identified during a survey when it was found that the responsible family member of a resident, referred to as R3, was not notified of the resident's hospitalizations on two separate occasions. The surveyor reviewed the documentation related to R3's hospitalizations and found no evidence that the family member had been informed. During an interview, the Director of Nursing acknowledged that the family member should have been notified about these hospitalizations. The facility's policy mandates that, except in medical emergencies, the resident, their physician or nurse practitioner, and the responsible party must be alerted to any change in the resident's condition, with such communication documented in the resident's medical record or other appropriate documents.
Inadequate Pest Control Measures in Facility
Penalty
Summary
The facility failed to adhere to its pest control policy and procedures, resulting in a widespread pest issue affecting all 202 residents. Observations and interviews revealed the presence of gnats, roaches, and flies in various areas, including residents' rooms and common areas. Multiple residents reported seeing roaches and other pests, with one resident even capturing a photo of a roach in their coffee. Family members also observed flies on food trays left in rooms. The housekeeping supervisor confirmed the presence of roach problems and noted that pest control was only called when notified, with treatments occurring every other week instead of weekly as recommended. The pest control logs and invoices from June to September 2024 documented numerous reports of roaches and other pests throughout the facility. The pest control company identified issues such as food on walls, clutter, and wall openings that hindered effective treatment. Despite these findings, the facility's pest control policy, which mandates regular and as-needed pest control measures, was not consistently followed. The policy also requires food to be covered and stored properly, and the facility to be maintained in a condition that prevents pest harborage, which was not adequately implemented.
Failure to Address Mold in Resident Living Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents by not addressing mold or mold-promoting conditions in resident living areas. This deficiency was observed in the rooms of three residents. One resident's room had four large dark discolored stains with fuzzy growth on the ceiling tiles, which appeared to be mold. The Maintenance Director confirmed that these stains were likely mold and acknowledged that staff should have reported the discolored ceiling tiles. Another resident's room had a large dark discolored stain with fuzzy growth on the ceiling tile directly outside their room, which was also identified as mold by the Maintenance Director. Additionally, a non-occupied room being prepared for new residents had a dark discolored ceiling tile, which the Maintenance Director identified as mold. The facility's Preventative Maintenance Policy requires regular environmental tours and safety audits to identify areas of concern, including ensuring ceiling tiles are free from watermarks or spots. However, the policy was not effectively implemented, as evidenced by the multiple discolored water-stained panels in another resident's room and bathroom, which were becoming discolored and should have been changed. The Maintenance Director admitted that the facility's air conditioning system causes moisture to drop onto ceiling panels, leading to mold growth, particularly in certain areas of the building. Despite the policy's requirement for staff to document observations of discolored ceiling tiles on work order forms, this was not done, resulting in the failure to address the mold issue promptly.
Missed Wound Treatments for Residents
Penalty
Summary
The facility failed to adhere to its wound care policy and procedures, resulting in missed wound treatments for two residents. One resident, a male with a history of skin infection, rheumatoid arthritis, and chronic ulcers, reported that his bandage was changed infrequently, with visible reddish-brown stains on the bandage. His treatment records for July, August, and September 2024 showed multiple missing entries for wound care treatments as ordered by the physician. The records were later modified after a surveyor's review, indicating an attempt to fill in the missing information. Another resident, a male with dementia and peripheral vascular disease, also experienced missed wound treatments. He reported calling the police due to the lack of wound care, with his bandage showing similar reddish-brown stains. His treatment records for August and September 2024 documented missing entries for wound care on specific days. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that nurses were responsible for wound care on weekends if no wound nurse was available. The Director of Nursing acknowledged that the absence of documentation indicated that wound care was not provided or refused by the resident.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its internal reporting requirements for abuse allegations, as outlined in its Abuse Prevention Program Facility Policy and Procedure. This deficiency involved a resident, a male with a history of Schizoaffective Disorder, Adult Failure to Thrive, Dementia, Major Depressive Disorder, Bipolar Disorder, and a History of Falling, who was admitted to the facility. A family member reported that a Certified Nursing Assistant (CNA) handled the resident roughly during a brief change, which led to the resident raising his fist in protest. The family member reported the incident to several nursing staff members, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON). However, the report was not escalated to the Administrator as required by the facility's policy. The Director of Nursing acknowledged having a conversation with the CNA about the family member's dissatisfaction with the CNA's communication but claimed not to have been informed about the rough handling. The LPN confirmed that the family member reported the rough handling to her and that she relayed this information to the DON. The Administrator confirmed that an investigation should have been initiated based on the report of rough handling, and the incident should have been reported to the state within two hours. The failure to report the incident to the Administrator resulted in a lack of investigation and appropriate response to the abuse allegation.
Failure to Change Stained Bed Linens for Resident
Penalty
Summary
The facility failed to ensure that bed linens were changed as needed for a resident who required assistance with activities of daily living. This deficiency was observed in a male resident with a history of local infection of the skin, rheumatoid arthritis, chest pain, cellulitis of the right lower limb, non-pressure chronic ulcer of the right ankle, pulmonary nodule, and pericarditis. The resident was admitted to the facility on April 11, 2024. Observations on September 10 and September 18, 2024, noted that the resident's bed linens and pillowcases had stains that appeared old. A family member reported observing the stained linens during a visit a couple of weeks prior and stated that she had informed all the nurses present and the social services designee. Despite multiple reports to the staff, the issue persisted, and the family member submitted a written report to the state agency. The Director of Nursing was unaware of any reports regarding the soiled linens and stated that certified nursing assistants should change stained linens. There was no indication that the resident refused to allow staff to change his linens.
Failure to Provide Adequate Nutritional Care for Resident
Penalty
Summary
The facility failed to adhere to its policies and procedures for weight management, resulting in inadequate nutritional care for a resident identified as R1. R1, a male resident with multiple health issues including rheumatoid arthritis and severe malnutrition, was not provided with the necessary dietary support. Observations revealed that R1 had difficulty chewing due to missing teeth and hand contractures, yet his meal was not appropriately prepared or assisted with, leading to insufficient food intake. Despite being on a mechanical soft diet, R1's meal preferences were not documented or honored, and he was not encouraged to eat or offered alternatives when he refused his meal. The facility also failed to accurately document R1's food consumption and supplement administration. R1's point of care reports inaccurately recorded his meal intake, and his medication administration record showed inconsistencies with the actual administration of his prescribed protein supplements. R1 expressed a preference for nutritional shakes, which were not provided, and he often declined the facility's protein supplements, describing them as tasting like medicine. Despite recommendations from hospital records for advanced nutritional shakes, the facility did not implement these recommendations or consult with R1's family about his dietary preferences. Interviews with staff and family members highlighted a lack of communication and follow-through on dietary interventions. The dietary manager did not engage with R1's family to determine his food preferences, and the dietitian acknowledged the importance of providing supplements and alternatives that R1 would accept. The facility's policies on weight assessment and resident tray delivery were not followed, contributing to R1's continued weight loss and compromised nutritional status.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to adhere to its policy and procedures for providing specialized diets, specifically for a resident who required a mechanical soft diet. The resident, a male with multiple health issues including rheumatoid arthritis and contractures in both hands, was observed struggling to eat his meal due to the toughness of the food provided. Despite having a mechanical soft diet order, the resident was served uncut, tough chicken, which he could not chew due to multiple missing teeth. The Licensed Practical Nurse assisting him did not cut the meat or offer alternative foods, resulting in the resident consuming only 15-20% of his meal. The resident's care plan indicated the need for assistance with meals, including cutting meat and vegetables, due to his physical limitations. The dietitian confirmed the importance of the resident receiving supplements and adequate nutrition, noting his low weight and compromised nutritional status. The facility's policy on resident tray delivery emphasized checking diet orders to avoid errors, which was not followed in this case, leading to the deficiency in care provided to the resident.
Failure to Provide Incontinent Care Before Hospital Transfer
Penalty
Summary
The facility failed to follow the plan of care and provide necessary assistance with activities of daily living for a resident who was dependent on staff for incontinent care. The resident, identified as R4, was noted to be dependent for toileting according to their Minimum Data Set (MDS) and care plan, which specified the need for total assistance in all aspects of hygiene and dressing, including toileting with two assists. On the day of the incident, R4 was sent to the hospital for a change in mental status without receiving the required incontinent care, resulting in the resident being transferred while soiled in urine. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for R4's care had instructed a Certified Nursing Assistant (CNA) to clean and change the resident before the hospital transfer. However, the CNA admitted to not providing the necessary care and failing to notify the nurse of the need for assistance. The Director of Nursing (DON) acknowledged that the resident should have been provided with incontinence care prior to the transfer, highlighting the issue as a matter of dignity. The facility's policies on activities of daily living and incontinence care emphasize the importance of preserving function, promoting independence, and maintaining dignity, which were not adhered to in this instance.
Failure to Provide Adequate Supervision for Resident with Self-Harming Behavior
Penalty
Summary
The facility failed to adhere to its behavior management policy for a resident with a history of self-harming behavior, resulting in the resident sustaining a fracture to her right arm. The resident, a female with a history of quadriplegia, multiple sclerosis, anxiety disorder, and recurrent major depressive disorder, was admitted to the facility in March 2022. On the evening of May 5, 2024, the resident became verbally aggressive and attempted to block her room door with her wheelchair, refusing to go to bed. Despite her protests, staff transferred her to bed, during which she attempted to harm herself by trying to slide out of her wheelchair and later out of her bed, resulting in her arm getting caught in the bed rail and sustaining a fracture. The facility's behavior management policy requires one-to-one supervision for residents exhibiting self-harming or aggressive behaviors, which was not provided in this case. The resident's care plan and physician orders included behavior monitoring due to her history of self-harm ideation and suicidal risk. However, during the incident, there was no documentation of one-to-one monitoring or administration of medication for anxiety or aggression, as outlined in the facility's policy. Staff interviews revealed that the resident was known to exhibit such behaviors, yet the necessary interventions were not implemented. The incident report and witness statements indicate that the resident was combative and attempted to harm herself multiple times during the evening. Despite the staff's efforts to prevent her from falling, the lack of continuous monitoring and failure to administer prescribed interventions contributed to the resident's injury. The facility's Director of Nursing acknowledged that one-to-one monitoring was necessary given the resident's behavior, but this was not executed, leading to the deficiency in care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. One resident, who was admitted with diagnoses including Major Depressive Disorder and Anxiety Disorder, was physically assaulted by another resident who had been admitted from the hospital with a diagnosis of Schizophrenia. The incident occurred when the second resident, during an admission assessment, abruptly left the office of the Psychiatric Rehabilitative Services Coordinator and hit the first resident in the hallway without provocation. The assaulted resident did not sustain injuries requiring hospitalization, and the assailant was discharged against medical advice later that day. The facility's failure to prevent this incident was partly due to inadequate pre-admission screening and assessment of the second resident's potential for aggressive behavior. The facility's abuse policy requires a criminal history background check and assessment of residents' vulnerability to abuse or aggressive behavior, but these steps were not adequately followed. The Psychiatric Rehabilitative Services Coordinator admitted to not probing the hospital records to determine if the second resident was at risk for abusive behavior, which contributed to the incident. The facility's policy also emphasizes creating a resident-sensitive environment, but this was not effectively implemented 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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