Southgate Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Metropolis, Illinois.
- Location
- 900 East Ninth Street, Metropolis, Illinois 62960
- CMS Provider Number
- 145386
- Inspections on file
- 35
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Southgate Health Care Center during CMS and state inspections, most recent first.
The facility failed to ensure continuous and effective pain management for three hospice residents with significant pain needs. One resident at end of life with multiple comorbidities had an order for scheduled oral Dilaudid every two hours, but staff allowed the supply to run out and did not secure replacement for approximately six hours, during which family and staff described severe, uncontrolled pain, thrashing, and agitation. Hospice had warned in advance that the Dilaudid would not last and instructed staff to call if it was not delivered, but hospice and the physician were not timely notified when the medication was depleted. Two other residents on scheduled opioid regimens with PRN opioids had MARs showing pain scores of 0 and no PRN use over multiple days, despite one resident reporting constant pain and another being observed grimacing and flinching, and a hospice CNA stating she frequently had to alert nurses about their pain. These actions and inactions demonstrate a pattern of inadequate pain assessment, failure to recognize and document non-verbal pain behaviors, and failure to ensure availability and administration of ordered pain medications.
The facility failed to provide adequate incontinence and oral care to multiple dependent hospice residents. One resident with multiple serious conditions and total ADL dependence was repeatedly found with dried feces on the buttocks and reported infrequent checks and rare oral care, despite being unable to perform self-care. Another resident with advanced cancer and incontinence was observed by a family member with bowel movement pasted to the bottom, and a CNA reported that dried stool on this resident was a common occurrence. A third resident with Parkinson’s disease, severe dementia, and total ADL dependence was observed with poor oral hygiene and was reported by staff to often have dried stool and be soaked in urine. Several CNAs acknowledged that residents are sometimes found with dried bowel movements and that oral care should be part of AM care, while facility policy on perineal care emphasizes cleanliness, comfort, and prevention of infection and skin irritation.
A non‑licensed CNA independently accessed the medication cart and medication room, prepared medications, and delivered them to cognitively intact residents without an LPN or RN present, while documentation in the EMR and MARs showed an LPN as the person who administered those medications. Video surveillance captured the CNA using medication keys, entering the medication room, preparing medication cups, taking them to resident rooms, and documenting on a facility laptop. Several residents reported that this CNA, whom they believed to be a nurse, brought their evening medications without another nurse present. The CNA acknowledged holding the medication keys and taking medications to residents, and the LPN later admitted giving the CNA her EMR login and not being present during administration, contrary to facility policies that only licensed personnel may administer and document medications and that the administering individual must document under their own credentials.
A CNA was observed on video independently accessing the medication cart and medication room, handling keys, opening the Schedule II controlled drug box, preparing medications, and delivering them to residents without an LPN or RN present. Several cognitively intact residents reported that this CNA, whom they believed to be a new nurse, brought their evening medications without another nurse present. Medication administration records and controlled drug logs showed that the CNA co-signed removals of controlled substances with an LPN, while the LPN later stated she was not present during administration and only signed the count at shift end. The DON confirmed that only licensed nurses are authorized to access medications and controlled substances, and that the CNA was not licensed, contrary to facility policy.
A CNA who had completed an LPN program but had not yet passed boards or obtained an LPN license was assigned a group of residents and independently performed licensed nurse duties, including accessing the med cart and med room, handling Schedule II controlled substances, and administering medications to several cognitively intact residents without an overseeing nurse. Video footage, resident interviews, and staff statements confirmed that this staff member was functioning as an LPN under a "license pending" designation that did not meet Illinois Nurse Practice Act requirements, and the facility’s own job description required current LPN or RN licensure for charge nurse duties.
The facility failed to maintain safe hot water temperatures in multiple shower rooms and a shared resident bathroom, where surveyors measured hot water at over 120°F using a calibrated thermometer despite mixing valves being set to lower temperatures or lacking functional controls. A plumber later determined that recirculation pumps on two halls were incorrectly plumbed so that they bypassed the mixing valves, and one hall’s mixing valve was nonfunctional. Facility logs showed prior weekly checks with no temperatures above 110°F, and the Administrator identified numerous confused and ambulatory residents, including those sharing the affected bathroom, while also acknowledging the absence of a hot water temperature policy.
A resident with ALS and a documented full code status was found unresponsive and without vital signs by an LPN, who, assuming the resident was DNR due to hospice care, did not initiate CPR. Despite clear documentation and physician orders for CPR, staff failed to provide basic life support, contrary to facility policy and the resident's wishes.
Staff failed to follow infection control protocols for two residents on contact precautions, including not wearing required gowns during linen changes for a resident with an MDRO infection and placing incontinence care supplies directly on a bedside rail without a barrier for a resident with severe cognitive impairment. These actions did not comply with the facility's infection prevention policies.
The facility failed to provide sufficient staffing, resulting in delayed care for residents. Several residents, including those with cognitive impairments and physical limitations, did not receive timely assistance with bathing and toileting. Staff reported being unable to meet residents' needs due to inadequate staffing, with some residents waiting hours for help. Despite these issues, the facility administrator believed staffing was adequate, although documentation did not support this claim.
A facility failed to provide timely showers and toileting assistance to residents due to staffing shortages. Four residents experienced significant delays in receiving showers, with gaps ranging from six to sixteen days. Staff confirmed prioritizing fall risks over other care needs, leading to extended wait times. Despite the facility's policy for twice-weekly showers, staffing issues resulted in delays, and the administration was unaware of complaints related to showers.
The facility failed to timely report and investigate abuse allegations involving two residents. One resident, cognitively intact, reported mistreatment by an LPN during medication administration, which was not investigated or reported promptly. Another resident with severe cognitive deficits was verbally abused by a CNA, but the incident was not reported to the Administrator until days later. Both cases violated the facility's abuse policy requiring immediate reporting and investigation.
The facility failed to investigate abuse allegations involving two residents. One resident, who is cognitively intact, reported mistreatment by an LPN during routine care, while another resident with severe cognitive deficits was reportedly verbally abused by a CNA. The facility did not conduct thorough investigations or ensure resident protection, as required by their abuse policy.
A facility failed to safely transfer four residents, leading to significant harm to one resident who sustained a large hematoma due to improper transfer techniques. Another resident fell in a transport van due to improper securing, and the incident was not reported promptly. Observations revealed that staff did not consistently use gait belts during transfers, contrary to facility policy.
Two residents with severe cognitive impairment experienced injuries that were not promptly reported to their families or physicians. One resident fell in a transport van, resulting in a shoulder bruise, while another was found with a large bruise during a shower. The facility's policy requires immediate notification of such incidents, but delays occurred, leading to a deficiency in communication and reporting procedures.
A resident with multiple health conditions, including malnutrition and Parkinson's Disease, experienced significant weight loss due to the facility's failure to monitor and implement interventions. The resident's weight loss was not addressed by the Registered Dietitian, who was unaware of the issue due to not being informed by the dietary manager. Observations showed inadequate food consumption and lack of dietary supplements, highlighting deficiencies in the facility's weight management practices.
A facility failed to ensure adequately trained CNA staff were present to meet residents' needs, particularly for a resident with multiple diagnoses and high fall risk. Unqualified Resident Assistants, who were CNA students, were observed assisting with ambulation, leading to a fall incident. Interviews confirmed that RAs were not qualified for such tasks, and the lack of a formal skills checklist contributed to the deficiency.
A resident with a history of falls and cognitive impairment was improperly positioned in a mechanical lift sling, leading to a fall during a transfer attempt. Two CNAs were involved, but the resident slid out of the chair before being lifted, resulting in a minor injury. The facility's policy on sling positioning was not followed.
The facility failed to accurately label and securely store medications for four residents. Insulin pens and eye drops were found without open dates, and one insulin vial was used beyond its expiration date. Additionally, an unlocked refrigerator contained an emergency medication box with controlled substances, contrary to facility policy.
The facility failed to conduct a proper skin assessment on a resident upon admission, resulting in undetected pressure ulcers under a walking boot. Nursing staff did not remove the boot during assessments, despite the resident being at high risk for pressure ulcers. The issue was only discovered when the resident was transferred to the hospital.
The facility failed to conduct smoking safety assessments for two residents, leading to inadequate supervision. Both residents, who were cognitively intact and allowed to smoke unsupervised, had no smoking assessments in their clinical records. The facility's smoking policy requires these assessments, but they were not performed.
A facility failed to provide proper urinary catheter care for a resident with multiple diagnoses. A CNA did not follow aseptic techniques or perform hand hygiene during and after catheter care, contrary to the facility's policy. The DON confirmed that staff are expected to follow these guidelines to prevent infections.
A resident with multiple diagnoses was given nifedipine ER in a crushed form by an LPN, contrary to pharmacy recommendations and facility policy. The DON confirmed that extended-release medications should not be crushed.
The facility failed to provide wound care per current standards of practice for three residents, leading to deficiencies in infection prevention and control. An LPN did not perform hand hygiene between glove changes and used the same bandage scissors without sanitizing them. The DON acknowledged that the staff is expected to follow clean aseptic techniques and good hand hygiene per facility policy to prevent infections.
The facility failed to offer pneumococcal vaccinations to two residents as per CDC recommendations and did not update its Pneumonia Vaccine policy to include the latest guidelines. Both residents had received a Prevnar 13 vaccination but did not receive any subsequent pneumococcal vaccinations or document any refusals. The facility's policy did not reflect the most recent CDC recommendations, and staff confirmed that the new vaccines had not been offered.
The facility failed to administer the updated (2023-2024 Formula) COVID-19 vaccine to three residents, despite their eligibility and medical conditions. The Infection Preventionist confirmed the absence of consent or refusal documentation, and the DON cited delays in vaccine scheduling and reliance on CDC recommendations.
Failure to Ensure Continuous and Effective Pain Management for Hospice Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management for three residents receiving pain control, including one hospice resident at end of life. One resident with multiple myeloma, pulmonary embolism, chronic pain, spinal stenosis, osteoporosis with pathological fractures, fibromyalgia, and other comorbidities was on hospice care with orders for a Fentanyl patch, scheduled oral Dilaudid every two hours, and PRN Hydrocodone for breakthrough pain. Her care plan called for evaluation of pain, monitoring for non-verbal indicators, and assessing the effectiveness of pain interventions every shift. Despite this, the facility allowed her oral Dilaudid supply to be depleted and did not ensure timely replacement, resulting in a period of approximately six hours without the ordered narcotic while she was actively dying. Family members reported that on the day in question the resident was in severe, uncontrolled pain, thrashing and crawling in bed, attempting to get out of bed, and requiring family to hold her to prevent falls. Multiple family members stated that the facility could not get her Dilaudid all day, that they repeatedly called hospice and even a hospital seeking help, and that the resident suffered intensely until medication finally arrived later in the afternoon. The hospice RN had identified the day before that the Dilaudid supply would not last, sent refill orders to the facility’s pharmacy before noon, and instructed facility staff to notify hospice if the medication was not delivered so alternate arrangements could be made. The hospice RN reported she never received such a call and only learned the medication was depleted after the last partial dose was given around 10:00 a.m. Facility nurses confirmed that the last dose from the bottle was given that morning, that no additional Dilaudid was available in the building, and that they relied on hospice to locate an open pharmacy and bring replacement medication, which did not arrive until mid- to late afternoon. During the period without Dilaudid, staff documented that the resident’s scheduled doses at noon and 2:00 p.m. were not given and coded as “other/see progress notes,” while the resident exhibited restlessness, grimacing, and agitation as described by CNAs and family. An agency LPN caring for the resident stated she considered sending the resident to the emergency room for pain relief but did not do so, and another nurse reported that the facility’s pharmacy did not make Sunday deliveries. The primary physician/medical director stated he was not notified that the resident was out of Dilaudid or that her pain had increased. The facility’s own pain management policy required recognition of behavioral signs of pain and review of the MAR to determine the effectiveness and frequency of pain medication use, but the resident’s MDS documented no receipt of scheduled or PRN pain medications or non-medication interventions despite concurrent documentation that she was receiving an opioid. Two additional hospice residents with pain needs also did not receive adequate pain assessment and management. One resident with multiple sclerosis, contractures, and other serious conditions was on a scheduled Norco regimen three times daily and had PRN Dilaudid ordered for moderate to severe pain and dyspnea. He reported that he was always in pain, that staff did not routinely ask him about pain, and that he had to request medication himself, sometimes forgetting until his pain became severe. His MAR showed all scheduled Norco doses documented with a pain level of 0 over multiple days and no use of PRN Dilaudid during the review period, while a hospice CNA stated she always asked him about pain and that he consistently reported being in pain. Another hospice resident with Parkinson’s disease, severe dementia, heart failure, and other diagnoses had orders for scheduled Oxycodone four times daily and PRN Hydromorphone every four hours. His care plan required monitoring and recording pain characteristics every shift and observing for non-verbal signs of pain such as changes in breathing, facial expressions, and vocalizations. However, his MAR documented pain scores of 0 on all shifts over several weeks and no administration of PRN Hydromorphone. A hospice CNA reported that this resident complained of pain at times and that she had to notify the nurses. During observation, the resident was seen flinching in his legs, grimacing, gritting his teeth, and trying to adjust his feet, yet he was unable to answer questions, indicating reliance on staff to recognize and respond to non-verbal pain behaviors that were not reflected in the recorded pain assessments.
Removal Plan
- The DON, ADON, and floor nurses began assessing residents for pain using a standardized scale; residents with pain received immediate intervention; physicians were notified and new orders obtained as needed.
- The DON began re-educating licensed staff; education included medication inventory and physician notification.
- Licensed staff were educated to notify the physician if any medication is not available.
- Licensed staff were educated to notify the DON immediately if medication is not available or if there will be a delay in receiving ordered/reordered medications immediately upon discovery of a medication shortage.
- All notifications and order changes are to be documented in real time.
- The DON and ADON will complete medication audits to ensure residents always have an adequate amount of pain medications available.
- If less than four days of medications are noted, an order/reorder will be submitted to the physician; this audit will include hospice residents.
- Licensed staff unable to attend the education were educated via phone with the DON and ADON as a witness.
- A message was sent to all licensed staff via Mediprocity with the education.
- The DON/designee initiated real-time audits.
- The DON and ADON completed a 100% house-wide audit comparing pharmacy-dispensed medication orders for pain management to on-hand inventory; reorders were processed and delivered; orders were clarified/updated as needed; care plans were revised as needed.
- The DON/designee will complete biweekly audits for 4 weeks.
- The Administrator and DON will submit the plan to QA for monthly review.
- The QAPI committee will review and offer recommendations as needed until compliance is met.
Failure to Provide Adequate Incontinence and Oral Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate incontinence and oral care to dependent residents. One resident with multiple serious diagnoses, including Multiple Sclerosis, paralytic syndrome, and dysphagia, was documented as totally dependent for ADLs and always incontinent of bowel with an ileostomy. During a bed bath, a hospice CNA observed a medium-sized bowel movement and dried feces on this resident’s buttocks, stating it was “really dried on” and required effort to remove with warm soap and water. The resident reported not being checked during the night or early morning, stated that dried stool was left on him very often, and that he sometimes had to wait long enough for stool to dry. The observed personal care did not include oral care, and the resident stated he does not receive oral care very often and is unable to perform it independently. Another resident, admitted with multiple myeloma, pulmonary embolism, and other chronic conditions, was documented as always incontinent of bowel and occasionally incontinent of urine, requiring substantial assistance with mobility. A family member reported that during a visit, this resident had a bowel movement that was pasted to her bottom. A CNA who worked that day stated they believed the resident was dying and that when they went in to turn her, she was resting. The hospice CNA reported having seen dried bowel movements on this resident and described it as “sort of a normal thing,” noting that the resident frequently complained of pain during care, which the CNA reported to the charge nurse. A third resident with Parkinson’s disease, severe dementia, heart failure, and adult failure to thrive was documented as totally dependent on staff for ADLs, including oral care, and always incontinent of both bowel and bladder. This resident was not on a bowel program and was not toileted. Observation found the resident in a geri chair with poor oral hygiene, including teeth covered in a whitish-yellow, fuzzy substance, after receiving personal care that did not include oral care. The hospice CNA stated she had found dried feces on this resident several times and that the resident was usually soaked in urine. Additional CNAs acknowledged that they have found residents with dried bowel movements, with one CNA stating that oral care should be part of morning care and another attributing the issue to some staff lacking compassion. The facility’s perineal care policy states that the purpose of the procedure is to provide cleanliness and comfort, prevent infections and skin irritation, and observe the resident’s skin.
Unauthorized Medication Administration and Inaccurate EMR Documentation by Non‑Licensed Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that only authorized, licensed personnel prepared, administered, and documented medications, and to ensure accurate documentation of who administered those medications. Video surveillance from the evening of 1/15/26 showed a certified nursing assistant (V5) removing medication cart and medication room keys from her pocket, opening the medication cart, popping medications into cups, entering the medication room without a nurse present, taking medication cups to resident rooms, and documenting on a facility laptop. The administrator (V1) stated that V5 did not have an EMR login and was unsure how V5 was documenting the medications. Additional surveillance footage showed V5 taking cups of medications to three residents’ rooms at specific times that evening, with no nurse visible accompanying her, despite V1’s statement that V5 was supposed to be working with another nurse and should not have been administering medications. Multiple cognitively intact residents reported that V5 personally brought and administered their medications that night without another nurse present. One resident (R1), admitted with anemia, atrial flutter, and hypertension and with a BIMS score of 15, stated that V5 brought his medications the evening of 1/15/26 and that he did not see another nurse with her; he believed V5 had finished her courses and was now a nurse working independently. However, R1’s MAR documented that an LPN (V7) administered his evening medications, including Atorvastatin, Melatonin, Tamsulosin, Iron Sulfate, Metformin, and Protonix. Another cognitively intact resident (R3), with COPD, type 2 diabetes, and fibromyalgia and a BIMS score of 15, reported that she believed V5 brought her medications and that V5 had not been working with another nurse recently; R3’s MAR documented that V7 administered multiple medications, including Hydrocodone/Acetaminophen, Olanzapine, Rosuvastatin, Docusate, Lactulose, Lamictal, Oxcarbazepine, Potassium, and Reglan. A third cognitively intact resident (R4), with type 2 diabetes, hyperlipidemia, and spinal stenosis and a BIMS score of 15, stated that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse, while his MAR also showed V7 as the person who administered his evening medications. Staff interviews further demonstrated unauthorized medication administration and inaccurate documentation. V5 stated she did not work independently and that V7 was present while she was administering medications, but acknowledged she held the medication cart and medication room keys, helped set up medication cups with V7, and then took the medications to residents without V7 accompanying her; she also stated she did not chart in the EMR because she had no login. In contrast, V7 later stated she had given V5 her EMR login and that V5 had taken the computer, and confirmed she was not present while V5 was administering medications to residents. V7 said it was not typical to share her EMR login but she trusted V5. The DON (V2) confirmed that V5 was not a licensed nurse, stated she had told V5 she could not administer medications, and said she would not expect a nurse to give their EMR login to another employee or to allow someone else to document medication administration under their name. These practices conflicted with facility policies requiring that only persons licensed or permitted by the state prepare, administer, and document medications, and that the individual administering the medication initial the MAR, as well as job descriptions specifying that LPNs and RNs accurately administer and document medications in compliance with facility and regulatory standards.
Unauthorized CNA Access to Medications and Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to restrict access to medications, including Schedule II controlled substances, to authorized licensed personnel only. Surveillance footage from the evening of 1/15/26 showed a CNA (V5) removing keys to the medication cart and medication room from her pocket, opening the medication cart, popping medications into cups, taking those cups to resident rooms, opening the Schedule II controlled medication box, popping Schedule II medications into cups, signing out Schedule II medications in the controlled drug count binder, and opening the medication room door, all without a nurse present. The Administrator (V1) confirmed these observations while reviewing the surveillance footage. Multiple cognitively intact residents reported that V5 personally brought them their medications that evening and that no nurse was present with her. One resident (R1), admitted with anemia, atrial flutter, and hypertension and with a BIMS score of 15, stated that the “dark-haired girl” who had previously been a CNA and whom he believed was now a nurse brought his medications on the evening in question, and he did not see another nurse with her. Another resident (R3), with COPD, type 2 diabetes, and fibromyalgia and a BIMS score of 15, stated she believed V5 brought her medications and that V5 had previously worked with another nurse but had not been doing so recently; she saw only CNAs when V5 brought her medications. A third resident (R4), also cognitively intact with diagnoses including type 2 diabetes, hyperlipidemia, and spinal stenosis, reported that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse. Medication records and controlled drug documentation further supported that V5 had access to and handled controlled substances. R3’s controlled drug record for hydrocodone/acetaminophen showed that two tablets were removed from the count on 1/15/26 with both V5 and an LPN (V7) signing the record. R2’s controlled drug record for pregabalin documented that one capsule was removed from the count with both V5 and V7’s signatures. V5 acknowledged holding the keys to the medication cart and medication room and stated that she and V7 both signed out Schedule II medications, claiming V7 had been present while she administered medications. However, V7 later stated she had not been present when V5 administered medications and that she signed the Schedule II count binder only at the end of the shift when they counted the medications together. The DON (V2) stated that only licensed nurses should have access to medication and controlled substance keys and confirmed that V5 was not a licensed nurse, which conflicted with the facility’s controlled substances policy and job description for charge nurses.
Unlicensed Staff Functioning as LPN and Independently Administering Medications
Penalty
Summary
The facility failed to ensure that staff functioning in licensed nursing roles held active licensure in accordance with state law. Video surveillance from the evening of 1/15/26 showed a CNA, identified as V5, removing keys to the medication cart and medication room from her pocket, opening the medication cart, popping medications into cups, taking the cups to resident rooms, opening the Schedule II controlled medication box, popping Schedule II medications into cups, signing out Schedule II medications in the count binder, and accessing the medication room without a nurse present. The licensed nurse schedule for that date documented that V5 was assigned a portion of the resident population, with no specific licensed nurse assigned to oversee her. Multiple cognitively intact residents confirmed that V5 independently administered their medications that evening. One resident (R1), with a BIMS score of 15 on the 1/9/26 MDS, stated that V5, whom he recognized as a former CNA who had “finished her courses” and was now “a nurse,” brought his medications on the evening of 1/15/26 and that he did not see another nurse with her. Another resident (R3), also with a BIMS score of 15 on the 12/13/25 MDS, reported that V5 brought her medications that night and that V5 had previously worked with another nurse but had not been doing so recently; she saw only CNAs when V5 brought her medications. A third resident (R4), with a BIMS score of 15 on the 11/25/25 MDS, similarly reported that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse. Staff interviews and record review confirmed that V5 did not hold an active LPN license and did not meet Illinois requirements for “license-pending” practice. V5 stated she had completed an LPN program on 12/15/25 and was scheduled to sit for boards on 1/23/26, and that she was working as “LPN License Pending” and was supposed to be shadowing another nurse, not working independently. The DON (V2) stated that V5 was working as an LPN License Pending and that this status meant she did not yet have a license and should work under another nurse; V2 acknowledged V5 had not presented any documentation indicating she had passed the NCLEX. Another LPN (V7) reported that she had not been present when V5 administered medications on 1/15/26 and that V5 had been working independently as a licensed nurse for about a week, based on information that V5 was on a provisional license. The Illinois Nurse Practice Act excerpt in the report specifies that a license-pending LPN must have passed the licensure exam and presented official written notification of successful passage, among other criteria, and the facility’s job description for charge nurses requires maintaining current state nursing licensure, conditions that were not met in V5’s case.
Failure to Maintain Safe Hot Water Temperatures in Resident Areas
Penalty
Summary
A deficiency occurred when the facility failed to maintain safe hot water temperatures in multiple resident care areas, including shower rooms and a shared resident bathroom. Using a calibrated digital metal stemmed thermometer, surveyors measured hot water temperatures of 121.4°F at the A hall shower room hand sink, 128.0°F at the 200 hall shower room hand sink (which then slowly dropped below 110°F after about one minute), and 119.6°F at the B hall shower room hand sink. In the shared personal bathroom of three residents on the 200 hall, the hot water temperature was 120.7°F. At the time of these readings, the A hall mixing valve was set at 104°F, the 200 hall mixing valve was set at 126°F, and the B hall mixing valve lacked a functioning gauge or knob, making its setting indeterminable. The facility’s Maintenance Director reported that the B hall mixing valve was an older style with a knob that had broken off, so the temperature setting could not be known. The facility’s Weekly Water Temperature Log documented that hot water temperatures had been checked on all halls on three earlier dates in the same month, with no recorded temperatures higher than 110°F. However, during the survey, a plumber later identified that the B hall and 200 hall hot water heater recirculation pumps had been incorrectly plumbed, causing the recirculation pumps to bypass the mixing valves and rendering the mixing valve settings irrelevant to actual water temperatures. The plumber also stated that the B hall mixing valve was not working at all, as adjusting it did not change the water temperature. The Administrator provided a census list identifying 45 of 90 residents as confused and ambulatory, including two of the three residents whose shared bathroom had elevated hot water temperatures, and confirmed that these three residents lived in adjacent rooms sharing that bathroom. The Administrator also stated that the facility did not have a hot water temperature policy.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate life-sustaining measures, specifically CPR, for one resident who was identified as a full code, despite clear documentation and orders indicating that CPR should be performed in the event of cardiac arrest. The resident had a complex medical history, including Amyotrophic Lateral Sclerosis (ALS), and was under hospice care. The resident's care plan and POLST form both indicated that CPR was to be performed if cardiac arrest occurred, and the chart was marked accordingly to reflect this status. On the evening in question, an LPN entered the resident's room to administer medications and found the resident pale, cold to the touch, and not breathing. The nurse checked for a pulse and, finding none, called another nurse to verify the absence of vital signs. Both nurses confirmed the resident had expired, but no attempt was made to initiate CPR. The LPN later stated she assumed the resident was a DNR due to hospice enrollment, despite the documentation indicating otherwise. The incident was later confirmed through interviews and record review, showing that staff did not follow the resident's documented wishes and physician orders regarding resuscitation. Interviews with the resident's power of attorney and physician confirmed that the resident's code status had been changed to full code, with explicit instructions for CPR but no intubation. The physician acknowledged awareness of the full code status and stated that, based on the reported condition of the resident when found, CPR would not have been effective. However, the facility's policy required staff to verify and adhere to each resident's code status, which was not done in this case, resulting in the failure to provide basic life support as ordered.
Failure to Follow Infection Control Practices During Incontinence Care and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence care and the handling of contaminated linens for two residents on contact precautions. For one resident with a history of multidrug-resistant organism (MDRO) infection and an active urinary tract infection, a staff member changed bed linens while wearing gloves, mask, and shoe covers, but did not wear a gown as required by the facility's infection control policy. The staff member later acknowledged that gowns were not available in the PPE bin but admitted that a gown should have been worn during the procedure. The infection preventionist confirmed that contact precautions, including the use of gowns for handling bed linens, were in place for this resident. In another instance, a staff member providing incontinence care to a resident with severe cognitive impairment placed wet wipes directly on the resident's bedside rail without a barrier, contrary to facility policy. Both the infection preventionist and the staff member acknowledged that this practice did not follow the established procedures for infection prevention. The facility's perineal care policy specifies the use of barriers for supplies to prevent infection, which was not adhered to during the observed care.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, affecting all 91 residents. On multiple occasions, residents did not receive timely assistance with activities of daily living, such as bathing and toileting. For instance, one resident, R2, who is cognitively intact and requires extensive assistance with bathing, did not receive a shower for six days. R2 reported that the facility was short-staffed, leading to missed showers and delayed assistance to the bathroom, with one incident involving a two-hour wait for help. Another resident, R3, also cognitively intact, experienced similar issues with delayed assistance. R3 requires partial to moderate assistance for toileting and bathing but did not receive a shower for six days. R3 confirmed the delay in response to her call light, which was not answered for a significant period, causing distress. The CNA responsible for the unit on the night of the incident reported being the only staff member available, with the nurse attending to another unit, leading to prioritization of fall risks over other care needs. Additional residents, such as R12 and R14, also experienced significant delays in receiving showers, with gaps of up to 16 days without bathing assistance. Staff interviews consistently highlighted the issue of insufficient staffing, with CNAs and nurses acknowledging the inability to meet residents' needs timely. The Director of Nurses admitted to staffing challenges and noted that while basic needs were met, tasks like showers were often delayed. Despite these issues, the facility administrator claimed there were no complaints about showers and believed staffing was adequate, although documentation did not support this claim.
Failure to Provide Timely Showers and Toileting Assistance
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living, specifically in ensuring that residents received showers and timely toileting assistance. Four residents, identified as R2, R3, R12, and R14, did not receive showers as per their care plans, with gaps ranging from six to sixteen days without a shower. R2 and R3, who are cognitively intact, reported delays in receiving assistance, with R2 stating that they had to wait two hours for toileting assistance due to staffing shortages. R12, who has severe cognitive impairment, and R14, who is legally blind, also experienced significant delays in receiving showers. The report highlights that the facility was experiencing staffing shortages, which contributed to the inability to meet the residents' needs timely. Interviews with staff members, including CNAs and the Director of Nurses, confirmed that the facility was short-staffed, leading to delays in providing showers and other care. The CNAs reported prioritizing fall risks over toileting and incontinence care, which resulted in extended wait times for residents needing assistance. Despite the facility's policy requiring showers twice a week, the administration acknowledged that showers were sometimes delayed due to staffing issues. The Director of Nurses mentioned hiring new staff, but they had not yet started working. The facility's administrator claimed there were no complaints related to showers, yet the documentation and interviews with residents and staff indicated otherwise. The facility's failure to adhere to its bathing policy and provide timely assistance reflects a deficiency in meeting the residents' basic care needs.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations to the Administrator and the State Survey Agency for two residents. The first incident involved a resident who reported feeling mistreated by an LPN during a medication administration. The resident, who was cognitively intact, claimed the LPN was loud, refused to provide a medication list, and handled him roughly during a blood sugar check. The resident called the police to report the incident, but the facility did not initiate an investigation or report the allegation to the state agency until several days later. The second incident involved a resident with severe cognitive deficits. A Resident Assistant witnessed a CNA being verbally abusive to this resident, telling him to shut up and refusing to assist him out of bed. The Resident Assistant reported the incident to the Business Office Manager, who was the manager on duty at the time. However, the Administrator was not informed until days later, and no investigation was initiated until the surveyor brought it to the facility's attention. In both cases, the facility's failure to promptly report and investigate the allegations of abuse violated their own abuse policy, which requires immediate notification of the Administrator and the Director of Nurses, as well as reporting to the State Survey Agency within 24 hours. The delay in addressing these allegations highlights a significant deficiency in the facility's handling of abuse reports.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and ensure resident protection, as evidenced by incidents involving two residents. The first resident, R1, who is cognitively intact, reported an incident with an LPN, V13, where he felt mistreated during routine care. R1 alleged that V13 was loud, dismissive, and physically rough during a medication pass and blood sugar check. Despite R1's call to the police and his expressed desire to move to another facility, the facility did not conduct a comprehensive investigation or interview other staff or residents about the incident. The second incident involved R13, a resident with severe cognitive deficits, who was reportedly verbally abused by a CNA, V17. A Resident Assistant, V14, witnessed V17 being rude and dismissive to R13, telling him to shut up and refusing to assist him out of bed. This incident was reported to the Business Office Manager, V26, who noted it for discussion but did not follow up with an investigation or check on R13's well-being. The facility's administration, including the Administrator, V1, and the Director of Nurses, V2, did not initiate proper investigations into these allegations. They failed to interview involved parties or other potential witnesses and did not report the incidents as required by their abuse policy. The lack of action and failure to protect residents from potential further abuse highlight significant deficiencies in the facility's handling of abuse allegations.
Improper Transfer Techniques and Incident Reporting Deficiencies
Penalty
Summary
The facility failed to safely transfer four residents, resulting in significant harm to one resident. The first resident, who had severe cognitive impairment and was dependent on staff for mobility, sustained a large hematoma to the chest wall after being transferred using an improper technique. The resident was on Eliquis, a blood thinner, which exacerbated the bruising. The incident was not immediately reported, and the resident was eventually sent to the hospital for evaluation and pain management. The improper transfer method involved lifting the resident under the arms, which is not in accordance with the facility's policy to use a gait belt unless contraindicated. Another resident experienced a fall while being transported in a van, resulting in a bruise to the shoulder. The incident occurred when the wheelchair tipped over due to improper securing in the van. The transport driver failed to report the incident to the nursing staff upon returning to the facility, delaying the resident's assessment and care. The resident later reported shoulder pain, and an x-ray was conducted, revealing no fractures or dislocations. Two other residents were observed being transferred without the use of a gait belt, contrary to the facility's policy. One resident was transferred by two CNAs using a gait belt, while another was transferred by an LPN without a gait belt. The facility's policy mandates the use of a gait belt unless specific contraindications are present, none of which were documented for these residents. The lack of adherence to proper transfer techniques and failure to report incidents contributed to the deficiencies identified in the facility's care practices.
Failure to Notify Family and Physician of Resident Injuries
Penalty
Summary
The facility failed to notify a family member and physician of a change in condition due to injuries for two residents, R1 and R2. R2, who has severe cognitive impairment and is at risk for falls, experienced an incident on 10/3/2024 while being transported back to the facility in a van. The wheelchair tipped over, causing R2 to fall and sustain a bruise on the right shoulder. The transportation aide, V5, did not report the incident to the nursing staff, and the family member, V30, only learned of the incident from R2 during a visit on 10/4/2024. The facility was informed of the incident by V30, leading to an investigation and subsequent notification of the physician and family member on 10/4/2024. R1, who also has severe cognitive impairment and is dependent on staff for mobility, was found to have a large bruise on the left chest/breast area during a shower on 10/3/2024. The registered nurse, V26, assessed the bruise as superficial and attributed it to the resident's use of Eliquis, a blood thinner. V26 did not notify the physician or family until the early morning of 10/4/2024, after observing R1 throughout the night and finding no signs of pain or discomfort. The facility's policy requires immediate notification of the physician and family in the event of an accident, injury, or significant change in condition, which was not adhered to in these cases. The facility's failure to promptly notify the physician and family members of the incidents involving R1 and R2 represents a deficiency in adhering to their policy on accident, injury, and change in condition notifications. The delay in communication could have impacted the timely assessment and management of the residents' conditions. The incidents were only reported after family members became aware, highlighting a lapse in the facility's internal communication and reporting procedures.
Failure to Monitor and Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in a resident, identified as R3, who experienced a 9.5% weight loss in less than one month and a 14% weight loss in less than three months. R3 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, mild protein-calorie malnutrition, and Parkinson's Disease, and required assistance with eating. Despite these conditions, the facility did not implement effective interventions to prevent further weight loss, as evidenced by the lack of regular dietary supplements and the absence of R3 on the list of residents to be seen by the Registered Dietitian over the last three months. The facility's records showed discrepancies in R3's nutritional assessments and weight monitoring. R3's care plan indicated a history of weight loss and a goal to maintain a weight of 154 pounds or more, yet the facility's monitoring and intervention efforts were insufficient. The Registered Dietitian, V15, was unaware of R3's significant weight loss and had not seen R3 in the past three months due to not being included on the dietary manager's list. Additionally, the Director of Nursing acknowledged that the facility's weight management practices were inadequate, partly due to staffing changes, and confirmed that R3's weight loss was significant. Observations revealed that R3 consumed only 25% of the food on their tray, and no dietary supplements were present. The facility's policy on weight loss required notifying the resident's physician and dietitian if certain weight loss thresholds were met, but this protocol was not followed. The facility's failure to monitor and address R3's nutritional needs and weight loss resulted in a deficiency in providing adequate food and fluids to maintain the resident's health.
Inadequate Training and Qualification of Staff for Resident Care
Penalty
Summary
The facility failed to ensure that adequately trained and qualified Certified Nurse Aide (CNA) staff were present to provide routine care and meet the needs of residents, specifically in the case of a resident identified as R2. R2 was admitted with multiple diagnoses, including muscle weakness, lack of coordination, cerebral infarct, and Alzheimer's disease, which contributed to a high risk of falls. The resident's care plan required supervision and assistance with ambulation using a wheeled walker, yet the facility allowed Resident Assistants (RAs), who were not fully trained or qualified, to assist with these tasks. On several occasions, RAs, who were CNA students, were observed performing duties they were not qualified for, such as assisting with ambulation. The RAs had only been checked off on basic skills like hand washing and PPE donning and doffing, and were not trained in more complex tasks like transferring residents or assisting with ambulation. Despite this, RAs were involved in assisting R2, which led to an incident where R2's legs gave out during ambulation, resulting in a fall. The incident was witnessed by an RA who was not qualified to assist with ambulation, highlighting the facility's failure to ensure that only trained staff performed such duties. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that RAs were not qualified to assist residents with ambulation. Despite this, RAs were observed performing tasks beyond their training, such as transferring residents and assisting with ambulation. The lack of a formal checklist of skills for CNA students further contributed to the deficiency, as it allowed unqualified staff to perform duties they were not trained for, compromising resident safety and care quality.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide a safe mechanical lift transfer for a resident, leading to an accident. The resident, who had a history of repeated falls, cerebral infarction, and difficulty walking, was dependent on assistance for transfers. The care plan specified the use of a mechanical lift with the assistance of two staff members for transfers. During an attempted transfer from a chair to a bed, two CNAs were involved. They realized the resident was not properly positioned in the sling, with only two hooks attached to the lift. As a result, the resident slid out of the chair, landing on the footrests and legs of the wheelchair, causing a small scratch on the back of her right thigh. The incident occurred when the CNAs were preparing to use the mechanical lift but had not yet lifted the resident. One CNA, who was only a standby helper due to age restrictions, was unable to operate the lift. The LPN who assessed the resident after the incident noted that the nylon material of the sling might have contributed to the resident sliding out. The facility's policy and procedure for mechanical lifts indicated that the sling should be centered under the resident, with the lower edge behind the knees, which was not adhered to in this case.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to accurately label and maintain the security of medications for four residents. Specifically, insulin pens and eye drops for residents were found in the medication cart without open dates, and one insulin vial was used beyond its expiration date. Licensed Practical Nurse (LPN) verified the absence of open dates and stated that the undated medications would be disposed of and replaced per facility policy. The Director of Nursing (DON) confirmed the expectation that staff should date medications upon opening and dispose of any undated or expired medications. Additionally, during a tour of the medication storage room, an unlocked refrigerator was found containing an unlocked emergency medication box with controlled substances, including injectable Ativan and Ativan oral suspension. The LPN and DON were unaware of the presence of Ativan in the refrigerator and stated that all narcotic medications should be stored under a double locking system as per facility policy. The facility's policies on medication administration and storage were not adhered to, leading to the deficiencies observed. The facility's revised General Medication Administration policy and Medication Storage policy require that medications be dated upon opening and that controlled medications be stored securely under a double locking system. The failure to follow these policies resulted in undated and unsecured medications, compromising the safety and efficacy of the medications administered to the residents.
Failure to Conduct Proper Skin Assessment on Admission
Penalty
Summary
The facility failed to assess a resident's skin on admission, leading to the development of pressure ulcers. The resident, admitted with diagnoses including osteomyelitis, a sacral pressure ulcer, and a left lower extremity fracture, was noted to be at very high risk for pressure ulcers according to the Braden Scale. Despite this, the nursing staff did not remove the resident's walking boot during the initial skin assessment or subsequent evaluations, as they believed they were not allowed to do so. This oversight resulted in the discovery of pressure ulcers under the walking boot when the resident was transferred to the hospital a few days later. Interviews with the nursing staff revealed that they were unaware of any wounds on the resident's lower extremity and did not remove the walking boot during their assessments. The Director of Nursing stated that a full head-to-toe skin assessment is expected for every resident upon admission. The facility's Skin Care Management Policy also mandates thorough skin assessments and documentation of any pressure ulcers. However, these procedures were not followed, leading to the resident's pressure ulcers being undetected until the hospital transfer.
Failure to Conduct Smoking Safety Assessments
Penalty
Summary
The facility failed to assess residents for smoking safety, resulting in inadequate supervision to prevent accidents for two residents. Resident R44, diagnosed with Parkinson's disease, epilepsy, and bipolar disorder, was noted to be cognitively intact with a BIMS score of 14. Despite being allowed to smoke unsupervised, there were no smoking assessments in R44's clinical record. R44 confirmed that he does not wear an apron or have supervision while smoking. Similarly, Resident R27, diagnosed with chronic obstructive pulmonary disease, hepatitis C, and fibromyalgia, was also cognitively intact with a BIMS score of 15. R27's care plan allowed unsupervised smoking, but no smoking assessments were found in her clinical record. R27 also confirmed that she smokes without supervision and does not wear an apron. The Director of Nurses (DON) and Social Services staff confirmed the absence of smoking assessments for both residents upon admission and quarterly. The facility's smoking policy requires initial and quarterly smoking assessments to determine if a resident can smoke independently or requires supervision. However, these assessments were not conducted, leading to a failure in ensuring the safety of residents who smoke. The Social Services staff admitted to not performing the required assessments and stated an intention to start doing them quarterly in the future.
Failure to Provide Proper Urinary Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care per current standards of practice for a resident with multiple diagnoses, including hypothyroidism, aphasia, dementia, retention of urine, need for assistance with personal care, and dysphagia. The resident had an order for catheter care every shift and as needed. During an observation, a Certified Nursing Assistant (CNA) performed urinary catheter care for the resident but did not follow proper aseptic techniques. The CNA cleaned the resident's soiled areas without changing gloves or performing hand hygiene before proceeding to clean the urinary catheter. Additionally, the CNA did not perform hand hygiene after doffing gloves and exited the room without washing hands, which is against the facility's policy for preventing infections. The Director of Nursing (DON) confirmed that staff are expected to perform catheter care with aseptic techniques and practice good hand hygiene per the facility policy. The facility's catheter care policy, revised earlier in the year, emphasizes the importance of handwashing as the single most important step in preventing the spread of infection. The policy also outlines specific steps for cleaning the perineum and catheter area, including washing hands and obtaining clean equipment if the resident has had an involuntary bowel movement. The CNA's actions were inconsistent with these guidelines, leading to a failure in providing appropriate catheter care for the resident.
Improper Administration of Extended-Release Medication
Penalty
Summary
The facility failed to administer medication in the form recommended by the pharmacy for one resident (R20). R20, who has diagnoses including unspecified dementia, hypothyroidism, major depressive disorder, and essential hypertension, had a physician's order for nifedipine ER 30 mg to be taken once daily. On 5/28/24, an LPN crushed R20's nifedipine ER tablet and administered it in applesauce, contrary to the pharmacy's recommendation that extended-release tablets should not be crushed. The Director of Nursing confirmed that staff are expected not to crush extended-release medications. The facility's medication administration policy also specifies that extended-release tablets should never be crushed.
Failure to Follow Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care per current standards of practice for three residents, leading to deficiencies in infection prevention and control. For Resident 4, the Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes while treating multiple pressure ulcers on the resident's left foot and ankle. Additionally, the LPN used the same bandage scissors without sanitizing them between uses, further compromising aseptic technique. The Director of Nursing (DON) acknowledged that the staff is expected to follow clean aseptic techniques and good hand hygiene per facility policy to prevent infections. For Resident 55, the LPN also failed to perform hand hygiene between glove changes during the dressing change of two wound sites. The resident was noted to be incontinent of bowel, and pericare was performed, but the LPN did not follow proper hand hygiene protocols before and after glove changes. This lapse in protocol was observed during the dressing change of the right hip and coccyx wounds. Resident 6's wound care was similarly compromised. The LPN did not use a barrier for the dressing supplies and failed to change gloves or perform hand hygiene between different wound sites. The LPN used the same scissors to cut gauze for multiple wounds without sanitizing them. The DON acknowledged that the LPN was nervous during the surveyor's observation but confirmed that the LPN knew the proper procedures. The facility's Skin Care Management Policy emphasizes the importance of clean techniques and good hand hygiene, which were not followed in these instances.
Failure to Offer Pneumococcal Vaccinations and Update Policy
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to two residents, R18 and R12, as per the CDC's most recent recommendations. R18, who has multiple diagnoses including major depressive disorder, hypothyroidism, and dementia, received a Prevnar 13 vaccination in 2017 but did not receive any subsequent pneumococcal vaccinations or document any refusals. Similarly, R12, who has conditions such as hypothyroidism, major depressive disorder, and hemiplegia, received a Prevnar 13 vaccination in 2018 but did not receive any further pneumococcal vaccinations or document any refusals. The facility's Immunization Report for both residents did not document any administration or refusal of the Prevnar 20 vaccine, which is recommended by the CDC for adults aged 65 years or older who have previously received PCV13. Additionally, the facility's Pneumonia Vaccine policy, dated October 2021, did not include the most recent CDC recommendations for administering the series of pneumococcal vaccines. The Infection Preventionist and the Director of Nursing both confirmed that the facility had not offered the Prevnar 15 or Prevnar 20 vaccines to the residents. This oversight in updating the policy and offering the recommended vaccinations has the potential to affect any residents eligible to receive the pneumococcal vaccines.
Failure to Administer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to administer the updated (2023-2024 Formula) COVID-19 vaccine to three residents (R18, R67, and R36) out of a sample of 39 reviewed for immunizations. Resident R18, aged [AGE], with diagnoses including Major Depressive Disorder, Hypothyroidism, Essential Hypertension, Dementia, Pancytopenia, and Alcoholic Cirrhosis of the Liver, had no order or documentation for the updated COVID-19 vaccine in their medical record. Similarly, Resident R36, aged [AGE], with diagnoses including emphysema, atherosclerotic heart disease, chronic obstructive pulmonary disease, and essential hypertension, had no documentation for any COVID-19 vaccinations. Resident R67, aged [AGE], with diagnoses including major depressive disorder, atrial fibrillation, benign prostatic hyperplasia, atherosclerotic heart disease, hyperlipidemia, and dementia, also had no documentation for the updated COVID-19 vaccine in their medical record. The Infection Preventionist/Licensed Practical Nurse (V20) confirmed the absence of consent or refusal documentation for the updated COVID-19 vaccine for these residents. The Director of Nursing (V2) stated that there was a delay in scheduling the COVID-19 vaccinations due to waiting on the Health Department to provide the vaccines. V2 also mentioned that no COVID-19 vaccinations had been administered since the initiation of the use of COVID-19 vaccines and that the facility did not have a specific policy for COVID-19 vaccinations, relying instead on CDC recommendations.
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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