Nexus At Alton
Inspection history, citations, penalties and survey trends for this long-term care facility in Alton, Illinois.
- Location
- 3523 Wickenhauser, Alton, Illinois 62002
- CMS Provider Number
- 145427
- Inspections on file
- 50
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Nexus At Alton during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain an adequate supply of towels and washcloths on multiple halls and in linen rooms, with carts often empty or nearly empty and the laundry lacking clean linens ready for use. Staff reported that the facility frequently ran out of towels and washcloths, particularly when only one washer was available, and that they were always short on these items. Cognitively intact residents with complex medical conditions, including CHF, COPD, neuromuscular bladder dysfunction, spinal muscular atrophy, cerebral infarction, DM, HTN, and MDD, reported not receiving regular showers or bed baths and, in one case, having to use a pillowcase to dry off due to the lack of towels. The facility assessment stated that necessary bed and bath linens would be provided for routine care and emergencies, but observations and interviews showed this was not occurring.
Surveyors found that medications scheduled for morning administration were given several hours late and one ordered medication was omitted for three cognitively intact residents with complex medical and psychiatric conditions. An RN, working with fewer nurses than usual, combined morning and later medication passes and appeared flustered while administering multiple cardiac, psychotropic, respiratory, diabetic, and seizure medications well past their scheduled times. Residents reported that medications were sometimes late or missed, and the facility’s own policy required medications to be administered at the proper time and dose, with documentation and provider notification when orders could not be followed.
The facility failed to ensure food was appetizing and maintained at safe, palatable temperatures for two residents, one with dementia and weakness on a regular diet and another with diabetes, prior cerebral infarction, and COPD on a carbohydrate-controlled diet. Both residents, who were cognitively intact and used wheelchairs, complained that the food was terrible and always cold. Meal observation showed chicken at 118°F and broccoli casserole at 114°F, below the facility’s policy requirement to hold food at 135°F or greater. A cook acknowledged food should be around 170°F, the dietary manager attributed low readings to end-of-service timing, and two LPNs reported that nurse aides routinely rewarm residents’ food in the microwave.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternatives provided. Staff and maintenance confirmed the ongoing hot water supply issues, which impacted residents' ability to receive safe and comfortable care.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were either given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternative provided. Staff and maintenance confirmed the hot water shortage and equipment failure, which impacted the facility's ability to meet residents' basic needs.
Two residents did not receive their prescribed oxycodone for pain management due to lapses in medication reordering, pharmacy delivery, and prescription renewal. Both residents, who were cognitively intact, experienced missed doses, with one resident missing six doses and reporting significant pain. Staff interviews and documentation confirmed that medication shortages sometimes occurred, particularly during pharmacy changes or when new orders were needed, and that facility policy for handling such situations was not consistently followed.
Five residents with various medical conditions did not receive their physician-ordered health shakes or dietary supplements during meal service. Although the dietary manager prepared the supplements, staff delivering trays failed to check meal tickets and ensure the correct items were provided, leading to the omission of required supplements for residents needing assistance or supervision with eating.
A resident with chronic respiratory failure and tracheostomy status, who relies on staff for daily care, was found with a soiled pillowcase and stained towel that were not changed over multiple days. Facility staff confirmed that dirty linens should be replaced, but the linens remained unchanged during the survey period.
Two residents did not receive complete incontinent care, as staff failed to cleanse all necessary areas and did not use proper technique, such as using new towels for each area and ensuring the skin was dried before applying a new brief. These actions did not follow facility policy for perineal care and hygiene.
A resident with a tracheostomy and chronic respiratory failure was found with soiled trach ties and collar, drainage, and a rash, while performing his own trach care using improper technique. An LPN assisting did not follow sterile procedures or proper hand hygiene, and the DON was unaware the resident was self-performing care without appropriate education or monitoring, contrary to facility policy.
A resident with a tracheostomy and chronic respiratory failure received care from an LPN who did not wear a protective gown, failed to perform hand hygiene when changing gloves, and did not clean multi-use equipment after use. The LPN also touched her hair with gloved hands and did not encourage or assist the resident with hand hygiene, contrary to facility infection control policies.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Three residents did not consistently receive wound treatments as ordered, with multiple days lacking documentation of dressing changes on their TARs. Residents with conditions such as diabetes, obesity, and cellulitis reported missed or inconsistent wound care, and staff confirmed that treatments should be documented immediately after completion according to facility policy.
A resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cataract did not receive a timely ophthalmology appointment despite multiple physician orders and urgent referrals. Staff cited insurance issues and difficulty finding a provider, and documentation showed a lack of consistent follow-up, resulting in the resident's worsening vision and continued impairment.
Several residents with no cognitive deficits reported that staff did not answer call lights in a timely manner, resulting in prolonged waits for assistance, including one instance where a resident remained on a bedpan for an hour and another left unattended in the shower. The ADON stated call lights should be answered within two minutes, in accordance with facility policy.
The facility did not follow its fall prevention policy for three high-risk residents, failing to complete root cause analyses, update care plans, or implement new interventions after each fall. Incident reports were incomplete, and required fall prevention measures were not consistently in place or documented. Staff interviews confirmed that these deficiencies occurred, and activity assessments were not completed as required.
Two residents with a history of incarceration together, both identified as offenders, were involved in repeated incidents where one resident bullied, threatened, and sexually abused another. The victim, who had multiple medical and psychiatric diagnoses, became fearful, isolated, and refused therapy after the abuse. Staff and other residents observed ongoing intimidation, but care plans and facility actions failed to address the bullying or provide adequate protection.
Four residents with severe cognitive and medical conditions did not receive the physician-ordered diets, such as pureed or mechanical soft diets, and instead were served regular meals identical to other residents. Staff were unaware of dietary orders, meal tickets were missing or outdated, and the dietary manager acknowledged the special diet list was not current. Residents and staff confirmed that individualized dietary needs were not met, contrary to facility policy.
Two residents with a history of incarceration together were involved in allegations of sexual assault and ongoing bullying, which were not thoroughly investigated or consistently documented by the facility. Staff and another resident reported knowledge of bullying and threats, but the facility failed to follow its abuse prevention policy, did not report the allegations to the state agency, and conducted an inconsistent investigation, resulting in a deficiency.
A resident with multiple complex medical conditions was admitted with specific hospital discharge medication orders, but these were not transcribed or administered for several days due to failures in the admission process and lack of oversight. The resident did not receive critical medications, resulting in significant adverse effects, including an untreated UTI and hospitalization. Staff interviews confirmed that the required triple check system was not completed and that agency nurses did not ensure timely medication administration.
A resident with multiple chronic conditions was admitted and did not receive several critical medications, including antibiotics, antihypertensives, and diabetes treatments, due to the facility's failure to transcribe hospital discharge orders and obtain medications from the pharmacy. The resident experienced symptoms such as shortness of breath and heart palpitations, and was ultimately hospitalized for untreated infection and other complications. Staff interviews and documentation revealed that the admission process was not completed as required, and established procedures were not followed.
A resident with multiple complex medical conditions did not receive several critical medications after admission due to a failure to timely transcribe hospital discharge orders and complete required medication administration processes. Agency nurses did not complete the transcription or triple check procedures, resulting in missed doses of antibiotics and other essential medications. The resident subsequently experienced shortness of breath, heart palpitations, and an untreated UTI, leading to hospitalization.
A resident with multiple complex medical conditions was admitted and did not receive prescribed medications as ordered by the physician because the admitting nurse failed to transcribe hospital discharge orders to the POS and MAR in a timely manner. The orders were not entered or sent to the pharmacy for several days, and the facility's required triple check system for new admissions was not completed, resulting in a lapse in medication administration.
Multiple incidents occurred in which residents were subjected to physical and sexual abuse by other residents, including inappropriate touching in a dining area, physical altercations involving hitting and object throwing, and insufficient supervision in common areas. Staff and dietary aides often witnessed these events, but were not always able to intervene promptly, and documentation was sometimes incomplete for the residents involved.
A resident with severe cognitive impairment and dependence on dialysis missed multiple dialysis sessions and exhibited a significant change in condition. Facility staff failed to send the resident for evaluation and treatment after repeated refusals, despite policy requiring action after a pattern of treatment refusals. Communication breakdowns among nursing, dialysis staff, and the nephrologist led to a delay in hospital transfer, resulting in the resident's acute deterioration and ICU admission.
A resident with chronic pain and multiple medical conditions did not receive several scheduled doses of prescribed Oxycodone because the medication was out of stock and unavailable in the dispensing machine. Nursing staff confirmed the shortage and the resident reported increased pain and frustration, resulting in him staying in bed and being unable to participate in daily activities.
A resident with chronic pain and multiple medical conditions did not receive several scheduled doses of prescribed Oxycodone because the medication was not available in the facility. The resident experienced significant pain, was unable to participate in daily activities, and expressed frustration. Staff confirmed the medication was out of stock and awaiting pharmacy delivery, and the contingency supply was also depleted.
Several residents with medical needs, including diabetes and renal disease, were not consistently offered nighttime snacks as required. Some reported never receiving snacks at night, while others noted that available snacks were quickly taken by a few individuals, leaving none for the rest. Staff confirmed that snacks were only provided upon request, and meeting minutes reflected ongoing concerns about snack availability after dietary staff hours.
A resident with severe cognitive impairment was prescribed Tramadol for pain and discharged from therapy after repeated refusals, but the Power of Attorney was not notified or asked for consent regarding these significant changes. Staff interviews and record review confirmed the lack of documentation and communication, despite facility policy requiring notification of responsible parties in such situations.
The facility did not provide a final written report of an abuse investigation after an altercation between two residents, despite initial reporting and assessments showing no injuries. The required final report documenting the investigation's results and any corrective actions was not completed or submitted to the Department of Public Health, as mandated by facility policy.
Two residents were involved in an alleged altercation in the dining room, with reports of coffee being thrown and possible physical contact. Although assessments showed no injuries and both residents denied the incident, a dietary staff member reported witnessing physical aggression and intervened. The incident was reported to administration, but there was no evidence that a full investigation was conducted as required by the facility's abuse policy.
A resident, who was cognitively intact and had certain medical conditions, experienced verbal abuse from a dietary staff member during breakfast. The staff member used inappropriate language in response to a conversation about the facility's food. The incident was confirmed by another staff member and documented in the facility's report. Despite the facility's policy against abuse, this incident occurred, highlighting a failure to prevent verbal abuse.
A cognitively intact resident reported being inappropriately touched by another resident, but the facility failed to conduct a thorough investigation or report the incident to authorities. Despite the presence of witnesses and available camera footage, the facility did not adhere to its abuse policy, resulting in a deficiency.
The facility failed to follow its Abuse Prevention policy for a resident involved in alleged sexual abuse incidents. Despite being informed of incidents, no investigations were conducted, and they were not reported to an outside agency. The facility's cameras were not reviewed, and the incidents were not reported as required by the facility's policy.
A facility failed to measure, assess, monitor, and treat wounds for a resident with osteomyelitis and diabetes. The resident's left elbow wound was not treated until days after admission, and a right toe wound was not documented or treated promptly. Staff interviews revealed uncertainty in wound assessment procedures, and the facility's policy on wound management was not followed, leading to inadequate documentation and treatment of the resident's wounds.
Two residents in a facility received inadequate care for pressure ulcers due to improper assessment, monitoring, and treatment. One resident had a dressing that was not changed timely, leading to bleeding and drainage, while another received incorrect treatment due to a discrepancy in physician orders. The facility's failure to follow its own wound care policies resulted in these deficiencies.
A facility failed to replace a loose PICC line dressing for a resident with osteomyelitis and diabetes mellitus. An RN observed the loose dressing but did not change it immediately, instead informing the night RN to do so. The facility's policy required dressings to be changed if they were loose, but this was not followed.
A resident's POA repeatedly requested access to medical records without success, despite the facility's policy requiring records to be accessible within 24 hours. The resident, with a complex medical history, had been waiting since early 2024 for the records, with no documentation of the request being fulfilled. Interviews revealed a lack of communication and follow-through by the facility staff.
A resident with multiple medical conditions was discharged from the facility without proper coordination, resulting in a lack of medication provision. The care plan indicated a need for long-term care, but the discharge was not documented or planned accordingly. The family was not informed about the discharge timing, leading to confusion and distress over the lack of medication, which was not documented as sent with the resident.
A resident, who is cognitively intact and frequently incontinent, was not provided with appropriate toileting assistance, compromising his dignity. Despite being independent with toileting before, his care plan did not address his needs, and his wheelchair could not fit through the bathroom door. Staff did not assist him with using a bedside commode, urinal, or bedpan, leading to feelings of helplessness and embarrassment. Facility policies on maintaining dignity and providing adaptive equipment were not followed.
The facility failed to obtain informed consent for psychotropic medications for two cognitively intact residents. One resident received Zoloft without consent, and another was prescribed Trazodone and Duloxetine without being informed or consenting. The facility's policy requires informed consent and documentation, which was not followed.
A resident with a tracheostomy did not receive consistent care as outlined in their care plan, leading to respiratory issues and hospitalization. The resident reported irregular trach care and staff reluctance to perform necessary procedures. Facility documentation and staff interviews confirmed lapses in care, contributing to the resident's health decline.
A resident with ESRD missed a critical vascular clinic appointment due to the facility's failure to arrange transportation, leading to ineffective dialysis procedures. The resident's dialysis access points were compromised, and the facility's lack of communication and coordination resulted in the resident being sent to the ER without receiving necessary intervention.
The facility failed to provide appropriate food portions to residents, leading to dissatisfaction and potential nutritional issues. Observations and interviews revealed that residents received smaller portions than specified on the menu, and the cook confirmed inconsistencies in portion sizes due to a lack of measurement tools. The facility lacked a policy for serving appropriate portion sizes, resulting in varied meal servings.
The facility failed to obtain and properly document code status for five residents, leading to discrepancies in their electronic health records and POLST forms. The issue was acknowledged by the DON and Administrator, who stated that code status should be addressed promptly after admission.
The facility failed to ensure palatable and appetizing meals for five residents, with reports of cold and unappetizing food. Test tray temperatures were below the facility's policy requirements, indicating non-compliance with food service policies.
The Facility failed to follow their alternative menu for six residents, who reported dissatisfaction with the limited food alternatives provided, specifically noting that grilled cheese was often the only option available. Despite the Facility's policy to offer alternative selections of comparable nutritional value, staff interviews and resident feedback indicated that the Facility did not adhere to its own policies.
The facility failed to maintain proper infection control practices during dialysis treatment for seven residents. Staff members were observed not wearing appropriate PPE, improperly storing syringes, and failing to use sterile gauze and tape for dialysis sites. Additionally, inadequate hand hygiene and cleaning practices were noted.
The facility failed to transcribe and carry out a physician's order for a specialist appointment for a resident with multiple serious diagnoses, including cirrhosis of the liver and thrombocytopenia. The appointment was not scheduled, despite critical lab results indicating low white blood cell and platelet counts. The facility's policy did not cover the making of initial appointments, leading to a lapse in care.
The facility failed to provide timely access to medical records for two residents. Despite multiple requests and follow-ups by the residents' representatives, the facility's staff and corporate office did not coordinate effectively, resulting in significant delays and lack of communication. The facility's policy lacked a specified time frame for processing such requests, contributing to the issue.
Failure to Maintain Adequate Supply of Towels and Washcloths for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of towels and washcloths, resulting in residents not receiving safe, clean, and comfortable care and bathing. Surveyors repeatedly observed linen carts and clean linen rooms on multiple halls with few or no towels and washcloths over two consecutive days. On one day, three of four hall linen carts had no towels or washcloths and the fourth had only one towel; the clean linen room for two halls contained only three towels and eight washcloths. The following day, several carts and linen rooms still had minimal or no towels and washcloths, and the laundry room had no clean towels or washcloths ready for distribution, with the laundry aide folding only a few items. A CNA reported that the facility runs out of towels and washcloths, especially when only one washer is available, and the laundry aide stated they are always short on these items and was unsure if linens had been ordered recently. Cognitively intact residents reported that the lack of linens directly affected their bathing and hygiene. One resident with encephalopathy, a right below-knee amputation, chronic systolic CHF, and HTN stated the facility ran out of towels and washcloths and she had to use a pillowcase to dry off after bathing. Another resident with COPD, abnormal posture, depression, neuromuscular bladder dysfunction, and weakness stated she had not received a shower since the previous week because staff told her there were no towels or washcloths. A third resident with neuromuscular bladder dysfunction, Arnold Chiari syndrome, spinal muscular atrophy, and congenital spinal cord malformations stated showers were offered only "once in a blue moon" and that the facility never had towels and washcloths for showers or bed baths. A fourth resident with cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis stated there were never enough towels and washcloths. The administrator acknowledged awareness of linen supply issues and referenced prior lapses in ordering under previous administration, while the facility assessment documented that the facility would provide necessary bed and bath linens for day-to-day operations and emergencies.
Late and Omitted Medication Administration Due to Inadequate Nurse Staffing
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the specified time frames and as ordered for three residents during a medication pass. On 2/19/26, an RN was observed administering multiple morning medications scheduled for 9:00 AM to three residents between 11:36 AM and 12:04 PM. For one resident, loratadine, nicotine patch, metformin, atorvastatin, buspirone, famotidine, hydrochlorothiazide, lisinopril, Seroquel, and a mometasone furoate inhaler, all ordered for 9:00 AM, were not administered until 11:36 AM. This resident had diagnoses including paranoid schizophrenia, hyperlipidemia, hallucinations, mild intellectual disabilities, depression, shortness of breath, and weakness, and the care plan included interventions to administer statin, psychotropic, and respiratory medications as ordered. A second resident’s medications, including Anora Ellipta inhaler, atorvastatin, cetirizine, cholecalciferol, lisinopril, a multivitamin with minerals, levetiracetam, and metformin, all ordered for 9:00 AM, were not administered until 11:44 AM. This resident, who was cognitively intact, reported that nurses were sometimes late with medications. The resident’s diagnoses included cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis, and the care plan documented risks related to diabetes, hypertension, statin use, psychotropic use, COPD, and seizure activity, with interventions to administer medications as ordered. For a third resident, iron sulfate, divalproex, duloxetine, cyanocobalamin, metoprolol, Abilify, furosemide, potassium chloride, Entresto, and hydroxyzine, ordered for 9:00 AM (with Entresto ordered at 7:00 AM and 7:00 PM), were not administered until 12:04 PM, and dapagliflozin ordered for 9:00 AM was not available and therefore not given. This resident had multiple diagnoses including multiple sclerosis, pulmonary nodule, polyosteoarthritis, anemia, thyrotoxicosis, muscle spasm, hyperlipidemia, PTSD, congestive heart failure, low back pain, hypokalemia, vitamin deficiency, anxiety disorder, and bipolar disorder, with a care plan calling for administration of statin and psychotropic medications as ordered. The RN administering medications appeared flustered and stated that only three nurses were working instead of the usual four, causing her to run behind and combine morning and 11:00 AM medications, and stated that having only three nurses was affecting the quality of care. The facility’s medication administration policy required medications to be given at the proper time and dose, with documentation and provider notification if medications were not given as ordered or not present.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide appetizing food at palatable and safe temperatures for residents receiving food and nutrition services. One resident with dementia and weakness, who was cognitively intact, used a wheelchair, and was on a regular therapeutic diet, reported that the food was horrible and always cold. Another cognitively intact resident with diabetes mellitus, cerebral infarction, and COPD, who also used a wheelchair and was on a carbohydrate-controlled diet, stated that some of the food was terrible and that they would not even give that food to a dog. During observation of a meal service, food temperatures were taken with a calibrated metal thermometer after the last resident tray was served. The chicken measured 118°F and the broccoli casserole measured 114°F, while the cook stated the temperature should be around 170°F. The dietary manager later stated that the temperatures may have been lower because they were taken at the end of service. Two LPNs reported that the food is always cold and that nurse aides always have to rewarm residents’ food in the microwave. The administrator stated she expects dietary staff to follow the facility’s undated Food Temperatures Policy, which requires food to be held at 135°F or greater throughout the service process.
Failure to Provide Consistent Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide consistent access to hot water for bathing for four cognitively intact residents, each with significant medical conditions such as fractures, diabetes, cerebral infarction, multiple sclerosis, and malnutrition. Over a period earlier in the month, these residents experienced a lack of hot water for several days, with some reporting up to two weeks without hot water. During this time, residents were either given cold showers, wet wipe baths, or had to refuse bathing altogether, with no alternative options consistently offered. Staff interviews and documentation confirmed that the facility experienced ongoing issues with its hot water supply due to malfunctioning water heaters, which were unable to meet the demand. Maintenance staff and administration acknowledged the problem, noting that one of the two hot water tanks was out of order and that the facility had a history of running out of hot water under normal conditions. The lack of hot water affected both the men's shower room and general bathing routines, resulting in residents not receiving safe and comfortable bathing as required by resident rights policies.
Failure to Provide Consistent Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide consistent access to hot water for bathing for four cognitively intact residents, each with significant medical conditions such as fractures, diabetes, cerebral infarction, multiple sclerosis, and malnutrition. Over a period earlier in the month, these residents reported having no hot water for several days, with some stating the issue lasted up to two weeks. During this time, residents were either forced to take cold showers, refuse showers, or were only offered wet wipe baths as an alternative. Documentation and interviews confirm that staff were aware of the lack of hot water, and that the issue affected both the men's shower room and the general hot water supply after a water tank failure. Staff interviews and facility records indicate that the hot water shortage was due to malfunctioning water heaters, with one tank completely out of order and the facility unable to meet hot water demand under normal conditions. The maintenance director and regional maintenance director confirmed the problem, noting that the facility ran out of hot water after a few showers and that professional services were required to replace the faulty equipment. During the outage, there was no consistent alternative provided to residents for bathing, and the facility's own policy requires a safe, comfortable, and homelike environment, which includes access to hot water.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to two residents, resulting in missed doses and unmanaged pain. One resident, who was cognitively intact and suffered from phantom limb pain and a wound infection, missed six doses of oxycodone over a three-day period. The resident reported significant pain during this time, stating that the medication had run out and expressing uncertainty about whether the issue was due to a failure to reorder or a delay in pharmacy delivery. Documentation confirmed the missed doses, and staff interviews indicated that the prescription had expired and there was a possible change in providers. Another cognitively intact resident also missed three doses of prescribed oxycodone. Nursing notes revealed that the pharmacy had only partially filled the order, and a new prescription from the physician was required. Staff interviews acknowledged that running out of pain medication sometimes occurred, especially during pharmacy transitions or when new prescriptions were needed. The facility's policy required staff to check for misplaced medications, contact the pharmacy, use contingency supplies if available, and notify the physician if orders could not be followed, but these steps were not effectively implemented, resulting in the residents not receiving their prescribed pain management.
Failure to Provide Physician-Ordered Dietary Supplements During Meal Service
Penalty
Summary
The facility failed to provide physician-prescribed health shakes to five residents during meal service. On observation, none of the five residents received their ordered dietary supplements with their meals, despite having physician orders specifying the need for health shakes or supplements such as diabetic shakes or Med Pass 2.0. Interviews revealed that the dietary manager had prepared the shakes and placed them on the cart, but the aides delivering the trays did not check the meal tickets to ensure the correct supplements were provided. One resident reported that the shakes are often forgotten. The affected residents had various diagnoses, including aphasia, cerebrovascular disease, diabetes, dementia, schizoaffective disorder, hemiplegia, and alcohol-induced disorder. Their cognitive and physical abilities ranged from severely impaired to cognitively intact, with most requiring some level of assistance or supervision with eating. Facility policy required staff to verify that the correct tray and diet matched the resident's needs at delivery, but this procedure was not followed, resulting in the omission of prescribed dietary supplements.
Failure to Provide Clean Linens for a Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic respiratory failure, hypoxia, and tracheostomy status, was observed to have soiled linens that were not changed over multiple days. The resident, who is cognitively intact and dependent on staff for activities of daily living and mobility, was found lying in bed with a pillowcase that had a large brown stain on two consecutive days. Additionally, a white towel with dried green and brown stains was observed on the resident's bed rail. Interviews with facility staff, including the DON and Administrator, confirmed that linens should be changed when dirty, but the soiled linens remained in place during the observations.
Incomplete Incontinent Care and Perineal Hygiene
Penalty
Summary
Staff failed to provide complete incontinent care for two residents who were always incontinent of bowel and bladder. For one resident with severe cognitive impairment and total dependence on staff for toileting, a CNA missed cleansing the left buttock during perineal care after removing a soiled brief containing urine and feces. The CNA acknowledged missing this area due to nervousness. For another resident, who was cognitively intact but required supervision and assistance with toileting, a CNA used the same portion of a washcloth to cleanse multiple areas, did not cleanse the right buttock, and did not dry the resident before applying a new brief after removing a urine-soiled brief. The facility's policy requires complete cleansing of the perineal area with appropriate cleansers, use of multiple towels for cleaning, rinsing, and drying, and cleansing from front to back. The Director of Nurses confirmed that staff should be performing complete incontinent care, including using new towels for each area and ensuring residents are dried before a new brief is applied. These requirements were not followed during the observed care for both residents.
Failure to Provide Complete and Sterile Tracheostomy Care
Penalty
Summary
The facility failed to provide complete and appropriate tracheostomy care for a resident with chronic respiratory failure and a tracheostomy. The resident was observed with wet, soiled tracheostomy ties and collar, yellow, green, and brown drainage, and a foul odor, as well as a red spotted rash on the neck and upper chest. There was no drainage sponge under the tracheostomy, and the resident was seen cleaning the area himself using the same gauze pad multiple times, without being offered hand hygiene. The LPN assisting the resident did not consistently perform hand hygiene between glove changes, touched her hair with gloved hands, and did not follow sterile technique as outlined in the facility's tracheostomy care policy. The resident, who is cognitively intact but dependent on staff for activities of daily living, reported that he has been caring for his tracheostomy for several years and prefers to do it himself, although staff will assist if asked. The DON was unaware that the resident was performing his own tracheostomy care and acknowledged that the resident should have been educated and monitored to ensure proper technique. The facility's policy requires daily cleaning of the inner cannula, changing of tracheostomy ties and collar when soiled, and strict adherence to sterile procedures, which were not followed in this instance.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection prevention and control protocols while providing tracheostomy care to a resident with chronic respiratory failure, hypoxia, and a tracheostomy. The LPN did not wear a personal protective gown as required for Enhanced Barrier Precautions, did not consistently perform hand hygiene when changing gloves, and failed to provide a sterile field for supplies. During the care, the LPN touched her hair with gloved hands, reused gloves without hand hygiene, and did not encourage or assist the resident with hand hygiene before, during, or after the procedure. Additionally, the LPN did not clean multi-use equipment, such as a pulse oximeter, after use on the resident. The resident, who was colonized for wounds, had visible drainage on the tracheostomy collar and neck. The LPN and the resident both handled supplies and performed parts of the care without appropriate infection control measures, including the reuse of gauze pads and lack of hand hygiene. Facility policies required the use of gowns and gloves for high-contact care, hand hygiene before and after resident contact, and cleaning of equipment between residents, but these protocols were not followed during the observed care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Perform and Document Wound Treatments as Ordered
Penalty
Summary
The facility failed to perform wound treatments as ordered for three residents, as evidenced by interviews and record reviews. One resident reported not always receiving dressing changes to his left knee as prescribed, with treatment administration records (TARs) showing multiple days in May and June without documentation of the required wound care. This resident had a history of left knee pain, morbid obesity, and a left artificial knee joint, and was assessed as cognitively intact but requiring assistance with mobility and hygiene. Another resident stated that dressing changes to his left middle finger were not performed daily as ordered, with TARs indicating several days in June and July without documentation of the treatment. This resident had diagnoses of type 2 diabetes and hypertension and was at risk for skin complications due to a cerebrovascular accident and malnutrition. A third resident reported that staff did not change the dressing on his left lower leg daily, sometimes going multiple days without a change. Review of TARs for this resident, who had cellulitis and congestive heart failure, showed several days in June and July without documentation of the required dressing changes. Facility staff, including the DON and wound nurse, confirmed that dressing changes are to be documented on the TAR as soon as they are completed, and that lack of documentation would indicate the treatment was not performed. The facility's policy requires consistent implementation of wound monitoring and documentation protocols.
Failure to Arrange Ophthalmology Appointment for Resident with Severe Vision Impairment
Penalty
Summary
The facility failed to arrange a specialty physician appointment for a resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cortical age-related cataract in the right eye. Despite multiple physician orders and care plan interventions indicating the need for ophthalmology evaluation and treatment for cataracts and worsening vision, the resident did not receive an appointment with an eye doctor for an extended period. Documentation showed repeated referrals and urgent requests for ophthalmology consultation, but the resident reported never having seen an eye doctor since admission. Staff interviews confirmed the resident's ongoing vision impairment and the lack of successful appointment scheduling due to insurance issues and difficulty finding a provider who accepted the resident's insurance and treated cataracts. Observations revealed the resident ambulating with a slow gait, using hands to navigate due to severely impaired vision. The resident expressed that his vision had worsened during his stay and described pain in his right eye. The facility's transportation staff kept only handwritten notes to track appointment attempts, and there was no documented evidence of consistent follow-up or outreach to ophthalmologists. The facility's policy required physician orders to be followed as written, but there was no proof that the necessary steps were taken to ensure the resident received timely ophthalmology care.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for six residents who were reviewed for call light response. Multiple residents, all documented as having no cognitive deficits per their Minimum Data Set (MDS), reported that staff did not respond promptly to their call lights. One resident stated they had to wait on a bedpan for an hour due to unanswered call lights, while another reported being left unattended in the shower. Additional residents confirmed during a resident council meeting that staff routinely ignored call lights, with one resident noting that they had to call out for their roommate because staff did not respond. The Assistant Director of Nursing stated that the expectation is for call lights to be answered within two minutes. The facility's call light policy, revised in September 2022, provides guidance for staff on responding to residents' requests and needs.
Failure to Follow Fall Prevention Policy and Update Care Plans After Falls
Penalty
Summary
The facility failed to follow its Fall Prevention and Management policy for three residents identified as high risk for falls. For one resident with severe cognitive impairment and multiple comorbidities, the care plan was not updated after a fall, and no new interventions were documented to reduce future fall risk. The fall was not recorded in the electronic medical record, and there was no documentation of post-fall monitoring or follow-up, despite the resident being sent to the emergency department for evaluation. The Director of Nursing confirmed that required documentation and monitoring were not completed as per facility policy. Another resident with moderate cognitive impairment and a history of repeated falls experienced multiple falls, but incident reports lacked root cause analyses and did not document new interventions to prevent further incidents. Required sections of the incident reports, such as environmental and physiological factors, were left blank. Observations revealed that prescribed fall prevention interventions, such as side rails and floor mats, were not in place at the time of surveyor inspection, and the care plan was not updated after each fall as required. A third resident, also severely cognitively impaired and dependent for all activities of daily living, experienced several falls. Incident reports for these events did not include root cause analyses or documentation of new interventions. The care plan was not updated following these incidents, and the activity director was unaware of the resident's fall interventions and had not completed an activity assessment since admission. The facility's policy requires a root cause analysis and care plan update with new interventions after each fall, but these steps were not followed for the residents reviewed.
Failure to Prevent Resident-on-Resident Abuse and Bullying
Penalty
Summary
The facility failed to protect two residents from abuse and the assertion of dominance by another resident, despite both individuals being identified offenders with a known history of prior incarceration together. One resident, who had diagnoses including cerebral infarction, cerebral palsy, epilepsy, schizophrenia, and major depressive disorder, reported being sexually assaulted in his room by another resident. The victim described being physically overpowered and sexually abused, recognizing the perpetrator by voice and sight. Multiple interviews with the victim, other residents, and staff confirmed ongoing bullying, threats, and physical intimidation by the alleged perpetrator, both in the facility and previously in prison. The care plans for the victim documented risks for abuse and prior allegations of sexual assault, but did not address the ongoing bullying or dominance by the other resident. There was no evidence of behavior tracking for the victim, and the care plan lacked interventions specific to the bullying and dominance issues. Staff and other residents reported witnessing the perpetrator's aggressive and intimidating behavior, including physical threats and harassment during smoke breaks and in common areas. Staff also reported that previous concerns about the perpetrator's behavior had been dismissed by prior administration. The facility's policies required the identification and care planning for residents at risk of abuse, as well as the incorporation of security measures for identified offenders. However, the care plans and progress notes for the perpetrator did not document the abuse allegations or the need for enhanced supervision. The facility failed to implement adequate measures to prevent further abuse, intimidation, and psychological harm, resulting in the victim becoming fearful, socially withdrawn, and refusing therapy and medical evaluation due to fear and embarrassment.
Failure to Provide Physician-Ordered Diets to Residents
Penalty
Summary
The facility failed to provide physician-ordered diets to four residents with significant medical conditions, including severe cognitive impairment, diabetes, stroke, and swallowing difficulties. Despite clear care plans and physician orders specifying specialized diets such as pureed, mechanical soft, and carbohydrate-controlled diets, these residents consistently received regular meals identical to those served to other residents. Observations revealed that meal tickets indicating dietary requirements were missing or not updated, and staff were unaware of the specific dietary needs of the residents. For example, one resident with a pureed diet order due to high aspiration risk was observed receiving and struggling to eat regular food items like toast and cereal. Staff, including CNAs and the DON, were unaware of the resident's dietary restrictions, and the dietary manager admitted the resident was not listed on the special diet roster. Other residents with orders for mechanical soft diets also received regular meals, such as noodles and beef, which were not appropriately modified according to their dietary needs. The dietary manager and cook acknowledged that the food provided did not meet the required texture modifications and that the list of residents on special diets was outdated. Interviews with residents confirmed that they routinely received the same food as everyone else, regardless of their prescribed diets. Staff interviews further revealed a lack of communication and understanding regarding residents' dietary orders. The facility's own policy required individualized diet modifications based on physician and speech-language pathologist recommendations, but these procedures were not followed, resulting in the failure to provide appropriate diets as ordered.
Failure to Thoroughly Investigate and Document Alleged Abuse and Bullying
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of abuse for two residents, both of whom were identified as offenders and had a history of incarceration together. One resident, who was cognitively intact and had multiple diagnoses including schizophrenia and cerebral palsy, reported being sexually assaulted and bullied by another resident. The care plans for both residents did not address the ongoing bullying or dominance behaviors, and there was no behavior tracking provided for the resident who reported the abuse. Multiple staff and another resident observed or were aware of the bullying and dominance behaviors, but these concerns were not consistently documented or investigated. Interviews with staff and residents revealed that the alleged perpetrator had a history of threatening and intimidating both residents and staff, including a nurse practitioner who reported being threatened. Despite these reports, the facility did not have documentation of any abuse investigations related to the bullying or the alleged sexual assault prior to the current administrator's tenure. The administrator and DON were both new to their positions and were unaware of previous allegations or investigations. The facility's abuse prevention policy required that all incidents and allegations be investigated and documented, but this was not followed in these cases. When the sexual assault allegation was finally investigated, the process was inconsistent, with residents being asked different questions and key witnesses not being asked about what they had observed. The investigation relied heavily on video surveillance, which did not substantiate the allegation, and the final report concluded the abuse was unsubstantiated. However, the lack of consistent and thorough investigation, as well as the failure to report the allegation to the state agency as required, constituted a deficiency in the facility's response to alleged violations.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that medications for a newly admitted resident were transcribed to the Physician Order Sheet (POS) and Medication Administration Record (MAR), obtained from the pharmacy, and administered as ordered by the physician. The resident, who had multiple complex diagnoses including chronic kidney disease, heart conditions, diabetes, and a recent urinary tract infection, was admitted with specific hospital discharge medication orders. However, these orders were not transcribed or acted upon for several days following admission. Record reviews and staff interviews revealed that the admission process was not completed in a timely manner. The admitting nurse, who was from an agency, did not transcribe the medication orders upon admission as required. The facility's triple check system, designed to ensure accurate and complete admissions, was not performed. As a result, the resident did not receive critical medications, including antibiotics, cardiac medications, and diabetes medications, for several days. Staff interviews confirmed that the medications were not available or administered, and that the issue was only discovered days later when a nurse attempted to give the resident his medications and found none available. The failure to transcribe and administer the prescribed medications led to the resident experiencing significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection. The resident reported feeling as though he was going to die. Both the facility's pharmacist and medical director confirmed that the missed medications constituted significant medication errors, with the lack of antibiotic administration resulting in hospitalization for a urinary tract infection.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
The facility failed to complete the admission process and transcribe physician-ordered medications to the Physician Order Sheet and Medication Administration Record for a newly admitted resident. As a result, the resident did not receive multiple critical medications, including antibiotics for a urinary tract infection, antihypertensives, diabetes medications, and other essential treatments for several days following admission. Documentation shows that the hospital discharge orders were not transcribed until several days after admission, and medications were not obtained from the pharmacy or administered as ordered. The resident, who had a complex medical history including chronic kidney disease, diabetes, heart disease, and a recent fracture, repeatedly reported not receiving medications and experienced symptoms such as shortness of breath, heart palpitations, and elevated blood glucose levels. Progress notes and interviews confirm that staff, including agency nurses, were aware that medications were missing and not available, and that attempts to contact the pharmacy were made but not successful in a timely manner. The facility's own policies required prompt assessment and medication reconciliation upon admission, but these steps were not completed as required. Ultimately, the resident's condition deteriorated, leading to hospitalization where it was confirmed that he had not received his prescribed medications for several days, resulting in untreated infection and other complications. Interviews with staff and review of records indicate that the failure to transcribe orders, obtain medications, and administer them as ordered was due to lapses in the admission process, lack of oversight, and failure to follow established procedures for new admissions.
Failure to Transcribe and Administer Medications Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident was admitted with multiple complex diagnoses, including chronic kidney disease, heart failure, diabetes, and a recent urinary tract infection. Upon admission, the resident's hospital discharge orders, which included several critical medications such as antibiotics, antihypertensives, anticoagulants, and diabetes medications, were not transcribed to the Physician Order Sheet (POS) or Medication Administration Record (MAR) in a timely manner. The orders were not entered until several days after admission, resulting in the resident not receiving prescribed medications for multiple days. The facility's process required the admitting nurse to transcribe orders into the electronic health record system and send them to the pharmacy, with a triple check system in place to ensure accuracy. However, the admitting nurse was from an agency, and subsequent care was also provided by agency nurses. The facility's Assistant Director of Nursing (ADON) and other staff confirmed that the transcription and triple check processes were not completed as required. The delay in transcription and medication procurement led to the resident missing essential doses of medications, including antibiotics for a urinary tract infection and medications for chronic conditions. As a result of these failures, the resident experienced significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection, which ultimately led to hospitalization. Interviews with facility staff and the medical director confirmed that the lack of timely medication administration constituted a significant medication error with serious consequences for the resident.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility and the admitting nurse failed to transcribe the hospital discharge medication orders to the Physician Order Sheet (POS) and Medication Administration Record (MAR) in a timely manner. The resident, who had multiple complex diagnoses including acute kidney injury, chronic kidney disease, hypertension, diabetes, and a history of cardiac issues, was admitted with specific medication orders from the hospital. These orders were not entered into the facility's records or sent to the pharmacy upon admission, resulting in the resident not receiving prescribed medications for several days. Record review showed that the hospital discharge orders, dated 4/2, were not transcribed to the POS and MAR until 4/5. The MAR for April documented no medication orders for the resident on 4/2, 4/3, and 4/4, and the orders only appeared on 4/5 and later dates. Interviews with facility staff, including the previous DON, interim DON, and LPNs, revealed that the admission process was handled by agency nurses, and the required triple check system for new admissions was not completed. The interim DON confirmed that medications should have been transcribed within the first few hours of admission, but this did not occur. The facility's policy requires that medication orders be documented and transcribed promptly upon admission, with orders entered into the electronic system and transmitted to the pharmacy. In this case, the process was not followed, and the resident did not receive their prescribed medications as ordered by the physician during the initial days of their stay. Staff interviews indicated a lack of clarity and follow-through in the admission process, particularly with agency nurses responsible for the resident's care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent multiple instances of physical and sexual abuse among residents, as evidenced by several documented incidents involving both cognitively impaired and intact individuals. In one case, a severely cognitively impaired resident was inappropriately touched by another resident in the dining room, with the incident being witnessed by dietary staff. The involved residents were separated, and the event was reported to authorities, but the medical record for the alleged perpetrator did not contain any documentation related to the incident. Staff interviews confirmed that there was no staff present in the dining room at the time of the incident, and dietary staff, who are not permitted to physically intervene, were the first to respond. Additional incidents included a cognitively impaired resident striking another resident with a phone, resulting in a visible red mark, and altercations between residents involving physical aggression such as hitting and throwing objects. In one instance, a resident with dementia wandered into another resident's room and was punched in the chest. In another, two residents engaged in a physical altercation in the dining room, with one throwing coffee and the other retaliating with a punch. Documentation and staff interviews indicate that these altercations were often witnessed by non-nursing staff or occurred in areas with insufficient supervision. The records show that the residents involved had varying degrees of cognitive impairment and behavioral issues, including dementia, schizophrenia, and mood disorders. The facility's documentation and staff statements reveal that supervision was lacking at critical times, and that staff were not always able to intervene promptly to prevent or stop abusive interactions. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the events described demonstrate failures in monitoring and protecting residents from physical and sexual abuse by others.
Failure to Send Resident for Evaluation After Multiple Missed Dialysis Treatments
Penalty
Summary
A resident with severe cognitive impairment and multiple complex diagnoses, including end-stage renal disease requiring dialysis five times per week, experienced a significant change in condition after repeatedly refusing dialysis treatments. Documentation shows that the resident last received dialysis on 3/11/25 and subsequently refused all care for approximately eight days. During this period, staff noted the resident's increasing lethargy and unresponsiveness, culminating in a medical emergency that required transfer to the emergency room, where the resident was admitted to the ICU and required central venous access and vasopressor support. Interviews and record reviews revealed that the facility failed to send the resident for evaluation and treatment after multiple missed dialysis sessions. The dialysis nurse reported informing the nephrologist about the refusals and was advised to do what she could, but also stated that after three missed treatments, the standard practice was to send the resident to the hospital. The nephrologist confirmed that the resident should have been sent to the hospital after the third missed treatment, as further dialysis would not be safe without updated lab work. However, there was a breakdown in communication between the dialysis nurse, nursing staff, and facility leadership, resulting in the resident not being sent out in a timely manner. Facility policy required nursing staff to notify the physician and responsible party in the event of a significant change in condition or a pattern of refusing treatments. Despite this, the necessary notifications and actions were not consistently carried out, as some staff were unaware of the need to send the resident to the hospital after missed treatments. This lapse in following policy and communication protocols directly contributed to the resident's acute deterioration and subsequent hospitalization.
Failure to Provide Prescribed Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to a resident with diagnoses including Spina Bifida, Anxiety, and Bipolar Disorder, who was cognitively intact and had a documented order for Oxycodone 10 mg every four hours for osteomyelitis of the lumbar vertebra. According to the Medication Administration Record, the resident did not receive multiple scheduled doses of Oxycodone over a two-day period. Nursing staff confirmed that the medication was unavailable due to running out of stock and awaiting pharmacy delivery, and it was not accessible from the automatic medication dispensing machine. As a result of not receiving the prescribed pain medication, the resident reported significant pain, with a pain level reaching 7 out of 10, and stated he had to remain in bed all day due to abdominal pain from multiple hernias. The resident expressed frustration at not receiving his medication, which impacted his ability to participate in normal daily activities. The facility's pain management policy emphasizes the importance of providing necessary comfort and promoting resident independence and dignity, which was not achieved in this instance.
Failure to Provide Prescribed Pain Medication Due to Unavailable Supply
Penalty
Summary
The facility failed to provide a physician-prescribed pain medication, Oxycodone 10 mg, to a resident with diagnoses including Spina Bifida, Anxiety, and Bipolar Disorder. The resident, who was cognitively intact, had an active order for Oxycodone to be administered every four hours for osteomyelitis of the lumbar vertebra. According to the Medication Administration Record, the resident did not receive multiple scheduled doses of Oxycodone over a two-day period because the medication was not available in the facility. The resident reported not receiving his morning dose due to the medication running out, and staff confirmed that the pharmacy delivery was pending and the medication was not available in the automatic dispensing machine or contingency supply. As a result of not receiving the prescribed pain medication, the resident experienced significant pain, reporting a pain level of 7 out of 10, and was required to stay in bed all day, leading to frustration and inability to participate in normal daily activities. The facility's policy required staff to check for misplaced medications and contact the pharmacy or use contingency supplies if a medication was not present, but these steps did not result in the resident receiving his scheduled doses.
Failure to Consistently Offer Nighttime Snacks to Residents
Penalty
Summary
The facility failed to consistently offer nighttime snacks to four out of six residents reviewed for snack provision. Interviews and record reviews revealed that residents with significant medical conditions, such as end stage renal disease, dependence on renal dialysis, diabetes mellitus, and bipolar disorder, were not routinely offered snacks at bedtime. One resident with diabetes reported that snacks were not available, and when their blood sugar was low, staff had to purchase snacks from a vending machine using their own money. Another resident stated that snacks were sometimes available but not every night, while others reported never being offered snacks at night. The Director of Nurses stated that snacks are kept at the nurse's station and are available upon request, but this practice did not ensure that all residents were offered snacks as required. Resident Council Meeting minutes also documented concerns about the lack of snacks after dietary staff leave. The facility's own policy indicated that nursing services are responsible for delivering individual snacks to identified residents and for offering evening snacks to all other residents, which was not consistently followed.
Failure to Notify Power of Attorney of Narcotic Use and Therapy Refusal
Penalty
Summary
The facility failed to notify the legal guardian (Power of Attorney) of a resident with severe cognitive impairment regarding the initiation of a narcotic pain medication (Tramadol) and the resident's refusal and subsequent termination of therapy. The resident, who has diagnoses including Schizophrenia, Dementia, Alzheimer's Disease, and End Stage Renal Disease, was prescribed Tramadol for pain management after staff reported ongoing pain issues. Documentation shows that the resident received multiple doses of Tramadol, but there is no evidence in the medical record that the Power of Attorney was informed or gave consent for this medication, despite the resident's cognitive status and the guardian's stated concerns about the use of pain medications. Additionally, the resident began and was later discharged from both speech and physical therapy, with records indicating frequent refusals of therapy. However, there is no documentation that the Power of Attorney was notified of these refusals or the termination of therapy. Interviews with staff confirmed that notification was not documented, and attempts to contact the Power of Attorney were either not completed or not properly documented. The facility's policy requires notification of the responsible party in cases of significant changes, including new medication orders and patterns of treatment refusal, but this was not followed in this instance.
Failure to Complete and Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to provide a final abuse investigation report for two residents involved in a reported altercation. According to incident and nursing notes, an altercation occurred between two male residents in the dining room, during which coffee was thrown and there were allegations of physical contact. Both residents denied the altercation, but an eyewitness from the dietary department reported seeing one resident hit the other and intervened to separate them. Assessments were completed for both residents, with no injuries or pain reported, and both residents were monitored following the incident. The initial report of the incident was made, and the administrator was notified at the time. Despite the initial reporting and assessments, the facility did not complete or provide a final written report of the results of the abuse investigation as required by their policy. The current administrator was unable to locate a file on the incident, and only the initial report was found in an email from the DON. The facility's policy requires that a final written report, including the results of the investigation and any corrective actions, be forwarded to the Department of Public Health within five working days, but this was not done for the incident in question.
Failure to Investigate Alleged Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged altercation between two male residents, both of whom were their own responsible parties. According to incident reports and nurses' notes, a possible altercation occurred in the dining room, during which coffee was thrown and there were allegations of physical contact. Assessments were completed for both residents, and no injuries were noted. Both residents denied the altercation, but an eyewitness from the dietary department reported seeing one resident hitting the other and physically intervened to separate them. The incident was reported to the administrator, and statements were obtained from both residents, who continued to deny any physical altercation. Despite the facility's abuse policy requiring a full investigation—including interviews with all involved parties and review of relevant documentation—there was no evidence that a comprehensive investigation was conducted for this incident. The Director of Nursing stated that the initial report was made, but the current administrator could not locate a file or documentation of an investigation beyond the initial report. The only available documentation was an email from the Director of Nursing confirming the initial report, with no further evidence of follow-up or a completed investigation as required by facility policy.
Verbal Abuse Incident Involving Dietary Staff
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident, identified as R3, who was cognitively intact and had diagnoses of Polyarthritis and Chronic Obstructive Pulmonary Disease. During breakfast in the dining room, a dietary staff member, V3, verbally abused R3 by cursing at him in response to a conversation about the facility's food offerings. This incident was witnessed by another staff member, V4, who confirmed that V3 used inappropriate language towards R3. The incident was documented in the facility's Long Term Care - Serious Injury Incident and Communicable Disease Report, which confirmed the occurrence of verbal abuse. The facility's policy, dated 9/2027, affirms the residents' right to be free from abuse, including verbal abuse, which is defined as the use of disparaging and derogatory language by staff. Despite this policy, the incident occurred, indicating a failure in preventing verbal abuse. The dietary staff member involved admitted to the verbal abuse in a written statement, acknowledging that her actions were wrong. The facility's response to the incident was to immediately suspend and subsequently terminate the employee involved.
Failure to Investigate and Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of sexual abuse involving a resident, identified as R2, who was cognitively intact and had a history of sexual abuse. The incident occurred when R2 reported being inappropriately touched by another resident, R3, while waiting for a smoke break. Despite R2's clear account of the incident and the presence of witnesses, the facility did not conduct a comprehensive investigation or report the incident to the appropriate authorities as required by their abuse policy. R2's care plan indicated a risk for abuse and neglect, and the facility's policy required immediate reporting and a thorough investigation of any allegations of abuse. However, the facility's response was inadequate. The Director of Nursing and the Wound Nurse were informed of the incident, but they did not pursue further investigation or report the incident externally. The facility also failed to review available camera footage that could have provided additional evidence. The facility's Regional Director of Operations acknowledged awareness of the incident but stated that no further investigation was conducted because a staff member did not witness the event. This lack of action and failure to adhere to the facility's abuse policy resulted in a deficiency, as the facility did not ensure the safety and protection of its residents by properly addressing and reporting the allegations of abuse.
Failure to Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to initiate its Abuse Prevention policy for a resident involved in an alleged sexual abuse incident. On 10/31/2024, the Regional Director of Operations, V9, stated that they were informed of an incident that occurred on 10/22/2024. Despite being notified, no further investigation was conducted, and the incident was not reported to an outside agency because the Staffing Coordinator, V6, did not witness anything. Additionally, V9 mentioned that they were later informed of another incident that occurred on 10/13/2024, which was also not reported or investigated. The facility has cameras, but the footage was not reviewed. The facility's Administrator, V2, confirmed that the incidents from 10/13 and 10/22 were not reported to an outside agency. According to the facility's Abuse Policy, any incident or allegation involving abuse should result in an investigation, and the Department of Public Health's regional office should be notified immediately. A complete written report of the investigation's conclusion should be sent within five working days. The facility's failure to follow these procedures resulted in a deficiency in handling the alleged abuse incidents.
Failure to Properly Assess and Treat Wounds
Penalty
Summary
The facility failed to properly measure, assess, monitor, and treat wounds for a resident identified as R4, who was admitted with osteomyelitis and diabetes mellitus. Upon admission, R4 had a left elbow infection and was on intravenous antibiotics. However, there was a lack of timely documentation and treatment for the wounds. The Treatment Administration Record showed no treatment for the left elbow wound before October 17, 2024, and no treatment for the right second toe wound before October 23, 2024. Additionally, the Skin and Wound Note from October 11, 2024, incorrectly documented that R4 had no open wounds, despite the presence of a left elbow wound noted upon admission. Interviews with facility staff revealed gaps in the wound assessment process. The Licensed Practical Nurse (LPN) responsible for wound care admitted uncertainty about whether wounds were measured upon admission or readmission. The Director of Nurses stated that wounds should be measured and described when found, with weekly follow-ups or if the condition worsens. The facility's policy on Skin and Wound Management Guidelines was not followed, as it required comprehensive nursing assessments, including skin integrity documentation and obtaining treatment orders for wounds present on admission. The policy also lacked documentation for ongoing wound or pressure ulcer assessment.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers, provide physician-prescribed treatment, and maintain clean dressings for two residents. One resident, who was at risk for developing pressure ulcers due to conditions such as Type 2 Diabetes Mellitus and End Stage Renal Disease, was found with a dressing that had not been changed in a timely manner, leading to bleeding and drainage. The resident's right heel dressing was improperly positioned, and the left heel had no dressing at all. The facility's records showed inconsistent documentation and assessment of the resident's pressure ulcers, with significant gaps in the medical record. Another resident, who had a Stage 4 pressure ulcer on the sacrum, received incorrect treatment due to a discrepancy between the physician's orders and the treatment administered by the staff. The staff member responsible for the treatment admitted to entering the wrong order into the system, which could have led to the resident receiving the wrong treatment if another nurse had performed the dressing change. The facility's policy on skin and wound management was not followed, as there was a lack of comprehensive assessment and documentation of the resident's wounds upon admission and readmission. The facility's failure to adhere to its own policies and procedures for wound care management resulted in inadequate care for residents with pressure ulcers. The lack of consistent assessment, documentation, and adherence to physician orders contributed to the deficiencies observed by the surveyors. The facility's staff, including the Director of Nurses and the Wound Nurse Practitioner, acknowledged the shortcomings in the wound care process, but the report does not mention any corrective actions taken to address these issues.
Failure to Secure PICC Line Dressing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident with a Peripherally Inserted Central Catheter (PICC) line. During an observation, the Assistant Director of Nurses, a Registered Nurse (RN), was seen disconnecting an IV antibiotic from a resident's PICC line and flushing it with normal saline. However, the PICC line dressing was noted to be loose at the bottom, and the RN did not replace it at that time. Instead, she informed the night RN to change it later. The resident, who was admitted with osteomyelitis and diabetes mellitus, had physician orders to change the PICC line dressing weekly and as needed using sterile technique. The facility's policy required dressings to be changed every seven days or more frequently if they were soiled, damp, or loose. The Director of Nurses later stated that RNs should change a PICC line dressing immediately if it is not secure.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to uphold a resident's right to access their medical records, as evidenced by the case of a resident whose Power of Attorney (POA) repeatedly requested access to the resident's medical records without success. The resident, who has a complex medical history including sepsis, transient cerebral ischemic attack, type 2 diabetes, and Alzheimer's disease, was admitted to the facility and later transported to the emergency room. Despite the POA's multiple attempts to obtain the records since February 2024, including filling out necessary forms and meeting with facility staff, the records were not provided, and no documentation of the request was found in the resident's progress notes. Interviews with facility staff revealed a lack of communication and follow-through regarding the request for records. The Medical Records staff member, who had been in the position for only three months, indicated that requests go through a legal process and require a fee, but there was no evidence that the records were sent or that the family was informed of any fees. The facility's policy states that records should be accessible within 24 hours of a request, yet the family had been waiting for months without resolution. The facility ultimately provided the records, but there was no documentation showing that the request had been fulfilled or communicated to the family.
Inadequate Discharge Planning and Medication Provision
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a safe and orderly discharge for a resident diagnosed with multiple medical conditions, including cerebral infarction, type 2 diabetes, and epilepsy. The resident, who required a wheelchair and had an impairment in the lower extremity, was discharged without proper coordination and communication. The care plan indicated a desire for long-term care, but the discharge was not documented or planned accordingly. The resident's family was not informed about the discharge timing, leading to confusion and a lack of medication provision at the time of discharge. The resident's family reported that they did not receive any medication or prescriptions upon discharge, which was confirmed by the facility's progress notes that lacked documentation of medication being sent with the resident. The facility's discharge policy requires that discharge instructions and medication lists be reviewed and signed by the resident or representative, but this process was not followed. The family expressed distress over the situation, highlighting the facility's neglect in ensuring the resident had necessary medications post-discharge.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance to a resident, R3, which compromised his dignity and self-determination. R3, who is cognitively intact and frequently incontinent, was not assisted with toileting despite being independent with toileting prior to his transfer to the facility. His care plan did not address his toileting needs, and his wheelchair could not fit through the bathroom door. The staff did not assist him with using a bedside commode, urinal, or bedpan, and instead, he was given an adult brief and told to use it. This lack of assistance led to R3 feeling helpless, ashamed, and embarrassed as he had to lay in his own body fluids. Interviews with R3 and his sister, who is his power of attorney, revealed that R3 was dissatisfied with the care he received, as he was not provided with the necessary support to use the toilet. R3 expressed that he felt demeaned and disgusted with himself due to the situation. Staff members, including CNAs, confirmed that R3 was not taken to the bathroom and that the full body mechanical lift used for his transfers could not fit in the bathroom. The facility's policies on resident rights and activities of daily living emphasize the importance of maintaining residents' dignity and providing necessary adaptive equipment, but these were not implemented in R3's case.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for two residents, R3 and R4, who were cognitively intact and part of a sample of eight residents reviewed. R3's care plan indicated the use of Zoloft for managing depression, and the medication was administered from August 31, 2024, to September 13, 2024, without documented consent. R3 stated that he was not informed about the medication or its risks and benefits, and he did not provide verbal or written consent. The Director of Nursing, V2, provided a blank consent form and claimed that consents were in the electronic health record, but upon review, it was found that multiple residents lacked consent documentation. Similarly, R4's care plan did not address psychotropic medication use, and the resident was prescribed Trazodone and Duloxetine for major depressive disorder without documented consent. R4, who was new to the facility, stated that he did not take antidepressants or antipsychotic medications and had not given consent for such medications. R4 mentioned that he was not informed about the new medications or their potential adverse reactions, assuming his hospital medications followed him to the facility. The facility's psychotropic medication program requires informed consent and documentation of the indication for medication use, which was not adhered to in these cases.
Inadequate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident, identified as R3, who was at risk for complications related to tracheostomy placement. R3's care plan required regular assessment for signs of infection and tracheostomy care, including changing the trach collar twice weekly and cleansing the trach every shift using sterile technique. However, documentation revealed that trach care was not consistently performed, with several instances where the procedure was not completed as ordered. This lack of care led to R3 experiencing shortness of breath and low oxygen saturation levels, necessitating increased oxygen support and medical intervention. R3, who was cognitively intact, reported that trach care was not provided regularly, leading to concerns about his health and safety. He expressed fear that the staff were not adequately trained or willing to perform the necessary care, resulting in his trach remaining capped when it should have been placed on a mask at night. R3 also reported experiencing drainage with an odor from his trach site, which was not addressed promptly by the facility staff. Interviews with facility staff, including LPNs, revealed inconsistencies in the provision of trach care. One LPN stated that she performed trach care when on duty, while another admitted to not performing the care, leaving R3 to manage it himself. The facility's equipment change schedule outlined specific procedures for trach care, which were not followed, contributing to R3's deteriorating condition and eventual transfer to a local hospital for further evaluation and treatment.
Failure to Arrange Transportation for Dialysis Appointment
Penalty
Summary
The facility failed to arrange necessary transportation for a resident, R16, who required dialysis treatment for a clogged dialysis shunt. This failure resulted in R16 missing a critical appointment at a vascular clinic, which was necessary to address the shunt issue. The missed appointment led to ineffective dialysis procedures, as the resident's dialysis access points were compromised, and the facility did not have an alternative plan to ensure the resident received the required medical attention. R16's medical history includes end-stage renal disease (ESRD), anemia, chronic obstructive pulmonary disease, and hypertension, among other conditions. The resident is cognitively intact and relies on dialysis to remove waste products and excess fluid from the blood. The report details that R16's dialysis shunt was clogged, and despite attempts to unclog it, the issue persisted. The facility's failure to provide transportation to the vascular clinic appointment meant that the resident's dialysis access remained compromised, posing a serious risk to their health. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the transportation issue was due to a lack of communication and coordination within the facility. The dialysis staff did not appropriately communicate the appointment details to the transportation coordinator, resulting in the missed appointment. Consequently, the resident was sent to the emergency room, where no intervention was performed, as the hospital preferred such procedures to be handled by specialists. This series of events highlights the facility's neglect in ensuring the resident's access to necessary medical care.
Inadequate Food Portioning and Inconsistent Meal Service
Penalty
Summary
The facility failed to ensure that food was served in appropriate portions for several residents, leading to dissatisfaction and potential nutritional inadequacies. Observations and interviews revealed that residents received smaller portions than documented on the facility's menu. For instance, one resident reported receiving only four chicken nuggets and a few fries, contrary to the menu's specification of seven nuggets and a half-cup of fries. Another resident, at moderate risk for weight loss, also reported receiving insufficient portions and noted that sometimes the facility ran out of food. The cook confirmed that the main meal sometimes ran out and was substituted with an alternate, but there was no consistent portion control. Additionally, during a meal service observation, it was noted that the dietary staff did not weigh the meat portions, resulting in inconsistent serving sizes. Residents received varying amounts of pork and bread dressing, with no standardization in portion sizes. The cook admitted to not having a way to measure the portion size accurately and was unsure of the exact portion size to serve. The facility administrator acknowledged the absence of a policy related to serving appropriate portion sizes, contributing to the inconsistency in meal servings.
Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to obtain and properly document code status for five residents (R58, R261, R264, R265, R266) out of a sample of 43 reviewed for advanced directives. The deficiency was identified through interviews and record reviews. For instance, R261's electronic health record did not list a code status upon review, and the POLST form was only completed after the surveyor's request. Similar issues were found with R58, R264, R265, and R266, where their code statuses were not documented in their electronic health records until after the surveyor's inquiry. R261 was admitted with diagnoses including type 1 diabetes mellitus and end-stage renal disease, but their code status was not listed until a later date. R58, admitted with traumatic subdural hemorrhage and paranoid schizophrenia, also had no code status listed initially. R266, with diagnoses including encephalopathy and systolic heart failure, similarly lacked a documented code status. R264, admitted with a femur fracture and acute kidney failure, had a discrepancy between the POLST form and the electronic health record. R265, with acute myocardial infarction and substance abuse issues, also had no initial code status documentation. The Director of Nursing (DON) and the Administrator acknowledged the issue, stating that code status should be addressed as soon as possible after admission. The facility's policy on advance directives and DNR orders mandates that a discussion of advance directives should take place upon admission, and the POLST form should be scanned into the medical record. However, this policy was not followed for the five residents in question, leading to the deficiency noted in the report.
Failure to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure palatable and appetizing meals for five residents who were reviewed for food palatability and temperature. Resident 18, who was cognitively intact and on a regular diet, reported that the food was not good and often cold. Resident 13, also cognitively intact and on a regular diet, described the food as horrible and resorted to ordering meals from outside the facility. Resident 24, on a regular diet with double portions, referred to the facility food as 'crap on a plate.' Resident 33, on a regular diet with double portions and fortified pudding, stated that the food could be better. Resident 267, with diagnoses including protein calorie malnutrition and end-stage renal disease, had previously filed a grievance about cold breakfast food, which was confirmed. Additionally, a grievance from a Resident Council Meeting documented that vegetables were overcooked at times, which was also confirmed. On May 9, 2024, test tray temperatures were obtained on the 300 Hall after the last resident hall tray was served. The scrambled eggs measured 112°F, the orange juice measured 60°F, and the cranberry juice measured 61°F. These temperatures were below the facility's policy requirements, which state that hot foods should be served at 135°F or higher and cold foods should be served at or below 41°F. The facility's administrator stated that she expects staff to follow food service policies, but the observed temperatures indicated non-compliance with these policies.
Failure to Provide Adequate Alternative Food Choices
Penalty
Summary
The Facility failed to follow their alternative menu for six residents reviewed for alternative food choices. Residents reported dissatisfaction with the limited food alternatives provided, specifically noting that grilled cheese was often the only option available. For instance, one resident on a No Added Salt (NAS) diet expressed that there was too much pork served and no good substitutes offered. Another resident on a No Concentrated Sweets/No Added Salt (NCS/NAS) diet stated that the Facility never cooked enough food, and the substitute was always grilled cheese. Similar complaints were echoed by other residents, who mentioned that if they did not like the meal, they were only offered grilled cheese or leftovers, which they found unappealing. During a Group Resident Council Meeting, multiple residents confirmed that grilled cheese was the only alternative if they did not want the meal served. The Regional Ombudsman also corroborated these complaints, stating that for the past seven years, the only alternatives had been grilled cheese or leftovers, despite numerous discussions with the Facility about this issue. The Facility's Dining and Food Preferences Policy, revised in September 2017, mandates that individual dining, food, and beverage preferences be identified for all residents. The policy also requires that any resident who refuses food or beverage be offered an alternative selection of comparable nutritional value. However, the Facility's undated Always Available Menu listed limited options such as deli sandwiches, jelly sandwiches, grilled cheese, mixed fruit cups, cottage cheese, side salads, and mashed potatoes. Despite these listed alternatives, staff interviews revealed that grilled cheese was predominantly offered as the alternative meal. The Dietary Manager and a Certified Nursing Assistant confirmed the limited options, with the CNA mentioning that hamburgers had only recently been added as an alternative. The Administrator stated that she expects staff to follow food service policies, but the evidence indicates that the Facility did not adhere to its own policies regarding alternative food choices.
Infection Control Deficiencies During Dialysis Treatment
Penalty
Summary
The facility failed to maintain proper infection control practices during dialysis treatment for seven residents. Observations revealed that staff members, including a registered nurse and a patient care technician, were not wearing appropriate personal protective equipment (PPE) such as gloves, gowns, or masks while performing dialysis procedures. Additionally, syringes containing heparin flush solution were improperly stored on the counter behind the nurse's desk, labeled with the names of the residents. The staff also failed to use sterile gauze and tape to cover dialysis sites after needle removal, and there was a lack of proper hand hygiene practices observed among the staff members. For instance, a patient care technician was seen changing gloves without using hand sanitizer or washing hands in between tasks, and another staff member attempted to transfer a resident into a dialysis chair that had not been cleaned or sanitized after use by another resident. The cleaning process itself was inadequate, as a paper towel soaked in a bleach and water solution of unknown concentration was used to clean multiple surfaces. The Director of Nursing acknowledged that all staff, including dialysis staff, are expected to follow proper infection control practices. The facility's policy dated April 2024 was intended to provide guidance on caring for dialysis residents, but the observed practices did not align with this policy.
Failure to Schedule Specialist Appointment
Penalty
Summary
The facility failed to transcribe and carry out a physician's order for a specialist appointment for a resident diagnosed with unspecified cirrhosis of the liver, malignant neoplasm of the colon, ascites, thrombocytopenia, and decreased white blood cell count. The physician's order, dated 4/19/24, instructed a referral to a hematologist for leukopenia and thrombocytopenia. However, the appointment was not scheduled, as confirmed by the transportation/appointment coordinator and the Assistant Director of Nursing (ADON). The resident's lab results indicated critically low white blood cell and platelet counts, which were not addressed in a timely manner due to the missed appointment. The facility's policy on appointments and transportation, dated 8/2018, requires staff to verify and schedule appointments, but it does not cover the making of initial appointments. The failure to schedule the hematologist appointment was acknowledged by the transportation/appointment coordinator and the ADON. The physician noted that the delay in the appointment would not significantly impact the resident's chronic condition, but the facility's failure to follow through on the physician's order represents a lapse in the standard of care expected for the resident's medical needs.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for two residents, R3 and R4, as required by regulations. R3's daughter, V10, requested medical records on 2/9/2024 and provided all necessary documentation by 2/15/2024. Despite multiple follow-ups, V10 did not receive the records, and the facility's Medical Records worker, V5, stated that the request was sent to the corporate office, but no updates were provided. Similarly, R4's guardian, V9, requested medical records in early March and faced delays and lack of communication from the facility. V9 was informed about the need to pay for the records and received an invoice on 4/12/2024, but still did not receive the records by the time of the survey. The facility's policy did not specify a time frame for processing such requests, contributing to the delay and confusion. Interviews with staff revealed a lack of clarity and responsibility in handling medical record requests. V5, the Medical Records worker, and V11, the Corporate Consultant, indicated that the requests were forwarded to a data processing company, but they had no further information or updates. V12, an employee of the data processing company, confirmed receiving the request for R4's records and sending an invoice but had no record of R3's request. The facility's Administrator, V1, acknowledged awareness of the requests but was unaware of the status or any follow-up actions. This lack of coordination and communication resulted in the failure to provide timely access to medical records for the residents involved.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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