Abbington Vlge Nrsg & Rhb Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Roselle, Illinois.
- Location
- 31 West Central, Roselle, Illinois 60172
- CMS Provider Number
- 146065
- Inspections on file
- 19
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Abbington Vlge Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, malnutrition, immobility, incontinence, and existing heel pressure ulcers was identified as needing frequent repositioning and pressure injury prevention, but the care plan lacked a turning/repositioning program, heel off-loading, positioning devices, and specific nutrition strategies for poor intake. Skin check documentation was incomplete, with bruises and a rash noted without locations or follow-up, and several skin check forms left blank. Later, new sacral pressure ulcers were observed and treated by nursing staff, yet there was no subsequent assessment of these wounds by the wound NP or physician/physician extender, and the DON could not provide documentation of a repositioning schedule or plan to meet the resident’s identified needs.
The facility did not serve meals at the posted scheduled times, resulting in consistent delays of 20 to 60 minutes for all residents receiving oral diets. Multiple residents and staff confirmed the late meal service, which was attributed to reduced food service staffing and increased meal preparation demands. Resident council meeting minutes also documented ongoing concerns about late meal delivery.
Multiple residents, both cognitively intact and impaired, reported that their meals were frequently served late and cold. Resident Council Meeting minutes documented ongoing complaints about cold breakfast meals and delays in meal tray delivery by CNAs. The administrator confirmed the absence of a policy on food palatability or temperature expectations at the point of service.
Three residents with significant medical conditions who were fully dependent on staff for toileting and hygiene experienced prolonged waits for incontinence care, with some waiting over an hour or until the next shift for assistance. Staff did not consistently check or change incontinence briefs every two hours as required by facility policy, and communication lapses between shifts contributed to delays, resulting in residents remaining in soiled briefs for extended periods.
Multiple residents were found without accessible or functioning call lights, including individuals with limited mobility and cognitive impairments. Some had to yell or leave their rooms to seek help, while others had non-working call lights or shared a single device between beds. Facility policy requires call lights to be within reach and promptly repaired, but these procedures were not followed.
The facility did not consistently label or safeguard residents' clothing, leading to multiple reports of missing personal items after switching to an outside laundry service. Staff and resident interviews, as well as documentation, confirmed that laundry bags and clothing were often unlabeled, making it difficult to return items to the correct individuals and resulting in unresolved complaints.
The facility failed to maintain sanitary practices in the kitchen, affecting 57 residents. A dietary aide did not wash hands before handling clean dishes, and the hand sink lacked soap and towels. A sanitizer bucket had a low quaternary ammonia concentration, and food items in the cooler and freezer were improperly stored and labeled. Facility policies from 2017 were not adhered to.
The facility failed to follow its water management plan for Legionella, affecting all 57 residents. There was no documentation of required activities such as chlorine testing, ice machine maintenance, and water temperature checks. Additionally, the facility did not conduct Legionella testing during a prolonged closure of a resident unit, as confirmed by the DON.
The facility failed to maintain a homelike environment, as evidenced by cold rooms, water leakage, and damaged infrastructure affecting multiple residents. Despite reports from residents and visitors, issues such as drafts, peeling paint, and unsecured cords remained unresolved. The maintenance director acknowledged the need for repairs but did not provide immediate solutions.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During a facility tour, it was observed that seven rooms were below ground level. The administrator acknowledged the noncompliance and mentioned a waiver application, but no waiver was provided, and a letter from the Illinois Department of Public Health indicated no waiver had been awarded.
A facility failed to maintain privacy for a resident during wound care. The ADON/Wound Care Nurse left the resident exposed from the waist down while retrieving additional items, contrary to the facility's policy on dignity and privacy. The resident, who was alert and oriented, later expressed that she should have been covered. The staff member acknowledged the importance of ensuring privacy during care.
A facility failed to implement a person-centered care plan for a resident with PTSD, despite the resident's history of trauma and multiple diagnoses. The social services staff was unaware of the PTSD diagnosis, and the facility lacked a policy on Trauma-Informed Care, resulting in no care plan to address the resident's needs.
The facility failed to provide adequate hygiene and grooming care for residents requiring assistance with ADLs. One resident was observed with unmet grooming needs over several days, while another expressed a desire for grooming that was not addressed. Additionally, a resident was found wearing double incontinence briefs, with the inner brief soiled, contrary to facility policy. The Assistant Director of Nursing confirmed that these practices were not in line with the facility's standards.
A resident with overgrown toenails was not seen by a podiatrist despite having signed a consent for podiatry services upon admission. The CNA reported the issue to the nurse, but the toenails remained unclipped. The resident expressed a desire for his toenails to be clipped, stating they had not been cut since admission. The resident's MDS indicated he was alert and required assistance for grooming.
Two residents did not receive their prescribed Lidocaine patches for pain management due to a shortage and miscommunication within the facility. Despite being aware of the issue, nursing staff did not notify the physician or provide alternative pain relief, resulting in high pain scores for the residents.
A facility failed to provide trauma-informed care for a resident with PTSD, as critical information about triggers and interventions was missing from the care plan. The resident had a history of sexual abuse and other traumas, but the facility's documentation was incomplete, and staff were unaware of the resident's PTSD diagnosis. The facility also lacked a policy on trauma-informed care for residents with PTSD.
The facility failed to provide proper pureed diets to two residents, serving them granular and lumpy pureed rice and turkey instead of the required smooth consistency. The cook used ground turkey due to a supply issue, and the consultant dietitian confirmed the meals were not safe to serve.
The facility failed to serve planned menu items to all 27 residents due to budget cuts, resulting in inadequate meal substitutions. Essential food items were missing, and the dietitian was not consulted for substitutions, violating facility policy. Residents expressed dissatisfaction with the meals, noting frequent shortages and substitutions that did not meet nutritional needs.
Failure to Plan, Document, and Obtain Physician Assessment for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident admitted with bilateral heel pressure wounds and multiple risk factors, including Alzheimer’s disease, moderate protein-calorie malnutrition, immobility, incontinence, and severe cognitive impairment. On admission, the resident required total assistance with all ADLs and was identified through a tissue tolerance assessment as needing repositioning more often than every two hours. A skin condition assessment documented a right heel pressure ulcer and listed ongoing interventions such as a pressure relief device in the chair, turning and repositioning program, nutrition and hydration interventions, and dressing changes, and directed staff to initiate a care plan. Despite these identified needs and risk factors, the care plan initiated later in December did not include pressure ulcer prevention measures such as a turning and repositioning program, use of positioning devices (e.g., wedges or pillows), a repositioning schedule, or off-loading of the heels while in bed. The nutrition care plan did not outline strategies for feeding the resident or actions to take when the resident refused to eat, even though staff reported the resident often refused to open his mouth at meals. CNAs reported the resident was tall, thin, underweight, did not get out of bed, and required two-person assistance for repositioning due to yelling and swinging at staff, yet there was no documented repositioning schedule or plan to address these needs. Skin monitoring and wound management were also deficient. Daily shower skin check sheets on multiple dates were incomplete or lacked documentation of whether the skin was intact, and when bruises and a rash were noted, no locations or follow-up interventions were documented. On one date in late December, an RN documented new sacral pressure ulcers with reddened skin and two open circular areas on both sides of the sacrum, cleansed the wounds, and applied ointment and foam dressing. However, after these new sacral wounds were identified, there was no documentation that the wound NP or physician/physician extender assessed the sacral wounds from that date through discharge. The DON acknowledged that residents with pressure wounds or at risk should have care plans for prevention and healing and be repositioned every two hours, but was unable to provide documentation that this resident was repositioned as expected or that a plan was in place to meet the resident’s repositioning needs prior to the development of the sacral pressure ulcers.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve resident meals at the scheduled times as posted in the main dining room, affecting all 60 residents receiving oral diets. Observations showed that lunch trays began to be delivered 20 minutes after the scheduled time and were not fully served until 30 minutes past the scheduled time. Multiple residents reported that meals were consistently late, with some stating delays of 20 to 60 minutes. Staff interviews confirmed that meal service was often delayed, particularly after a reduction in food service aide staffing, which slowed down the tray delivery process. The facility's posted meal schedule and policy required meals to be served at specific times, but these times were not consistently met. Resident council meeting minutes from previous months documented ongoing concerns from residents about the timeliness of meal service, with repeated complaints that lunch was being served later and later. Staff, including a cook and food service workers, acknowledged the delays and attributed them to staffing shortages and the complexity of meal preparation. The facility census indicated that nearly all residents were affected, except for one who did not receive oral diets. The deficiency was identified through observation, resident and staff interviews, and review of facility records and policies.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide palatable food at appropriate temperatures, as evidenced by multiple cognitively intact and impaired residents reporting that their meals were often served late and the hot food was cold. Interviews with four out of five residents reviewed indicated consistent dissatisfaction with food temperature and timeliness. Resident Council Meeting minutes from two separate months documented ongoing complaints about breakfast meals being cold and delays in meal tray delivery by CNAs. Additionally, the facility administrator confirmed that there was no policy in place regarding food palatability or temperature expectations at the point of service to residents.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL), specifically incontinence care, to residents who were dependent on staff. Three residents with significant medical conditions, including multiple sclerosis, obesity, congestive heart failure, neuromuscular dysfunction of the bladder, hemiplegia, hemiparesis, and dementia, were identified as being completely dependent on staff for toileting and personal hygiene. These residents were always incontinent of bowel and bladder and required the use of mechanical lifts for transfers. Observations and interviews revealed that residents waited extended periods for incontinence care. One resident reported waiting from late morning until the next shift for toileting assistance, with staff confirming that the resident's incontinence brief was extremely soiled with urine and bowel movement by the time care was provided. Another resident stated that it took over an hour for staff to arrive to change a soiled brief, and that the same brief had been worn since early morning. A third resident reported routinely waiting about an hour for CNAs to respond to requests for incontinence care on both first and second shifts. Record reviews and staff interviews indicated that staff were expected to check and change incontinence briefs every two hours, regardless of whether residents could verbalize their needs. However, staff did not consistently offer or provide incontinence care at the required frequency, and communication lapses between shifts contributed to delays. Facility policies required residents to be kept dry, comfortable, and odor-free, with incontinence care provided every two hours or more frequently as needed, but these standards were not met for the residents reviewed.
Failure to Provide Accessible and Functioning Call Lights to Residents
Penalty
Summary
The facility failed to ensure that residents had functioning call lights within their reach, as observed in six out of nine residents reviewed for accommodation of needs. In one shared room, only one call light was present and it was positioned closer to one bed, leaving the other resident without access. One resident reported having to pull the call light closer to his bed, while his roommate had no call light and had to yell or leave the room to seek assistance. The Director of Nursing confirmed the absence of a call light for one resident and was unsure why only one was available in the room. Another resident was found asleep in her wheelchair with her call light on the floor behind her bed, out of reach, and the Assistant Director of Nursing acknowledged it should have been clipped to her wheelchair. Additional residents reported non-functioning call lights or a complete lack of access, with one resident stating her call light had not worked since admission and that she had informed multiple staff members without any follow-up. Further observations revealed that some residents' call lights were several feet away and inaccessible, despite their limited mobility and medical conditions such as multiple sclerosis, stroke-related paralysis, dementia, and Alzheimer's disease. The facility's policy requires that call lights be within easy reach of residents in bed or confined to a chair, and that defective call lights be promptly reported to maintenance. However, these procedures were not followed, resulting in multiple residents being unable to summon assistance as needed.
Failure to Safeguard and Label Resident Clothing Results in Loss of Personal Items
Penalty
Summary
The facility failed to ensure that residents' clothing items were properly labeled and safeguarded from loss, as required by their own policies and procedures. Multiple residents reported missing clothing items, with one resident stating that several pairs of pants had been missing since their laundry was first sent out, and another resident reporting that their clothes did not return from the laundry. A third resident indicated that clothing items went missing upon admission. Observations revealed that laundry bags and clothing were often not labeled, making it difficult for staff to identify ownership. Staff interviews confirmed that complaints about missing clothing had been received, and that there was no consistent process for labeling clothing or laundry bags. The facility had recently switched to an outside laundry service due to broken washing machines, which coincided with an increase in complaints and grievances about missing clothing. Documentation, including resident council concern forms, meeting reports, grievance forms, and email communication between the administrator and the laundry vendor, further substantiated ongoing issues with missing clothing and unreturned laundry bags. The facility's Personal Effects Policy required prompt investigation and resolution of missing property, but the lack of labeling and tracking contributed to the loss of residents' personal items. Staff interviews indicated that while there was an expectation for clothing and bags to be labeled, this was not consistently done, resulting in unidentifiable clothing and unresolved resident complaints.
Sanitary Practices Not Followed in Facility Kitchen
Penalty
Summary
The facility failed to adhere to sanitary practices in the kitchen, affecting 57 residents who received food prepared there. During an inspection, a dietary aide was observed washing dishes on the soiled side of the dish machine and then putting on new gloves without washing her hands before handling clean dishes. Additionally, the hand sink near the dish machine lacked soap and paper towels, and the dietary aide confirmed that housekeeping did not have any supplies available. Furthermore, a red sanitizer bucket in the kitchen was tested and found to have a quaternary ammonia concentration of 0-150 ppm, which is below the recommended range of 150-400 ppm. In the walk-in cooler, a tub of cottage cheese with a broken lid was found, exposing its contents, and the use-by date had already passed. In the walk-in freezer, opened bags of sliced strawberries and blueberries were found exposed to air. The dietary aide mentioned that these were used for a specific resident. The facility's policies from the 2017 manual were not followed, which included proper handwashing procedures, correct sanitizer concentration, and appropriate storage and labeling of food items.
Failure to Implement Water Management Plan for Legionella
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella, impacting all 57 residents. The plan outlined specific measures to manage the risk of Legionella exposure, including quarterly testing of free chlorine levels, monthly maintenance of ice machines, weekly water temperature checks, and monthly monitoring of water heaters. However, the facility lacked documentation to confirm these activities were conducted. Interviews with the Administrator and Maintenance Director revealed that water temperature logs were not maintained, and there was no evidence of ice machine maintenance or free chlorine testing. Additionally, the facility did not implement control measures during the prolonged closure of a resident unit on the second floor, which was closed for several months and reopened without documented Legionella testing. The Director of Nursing confirmed the closure and reopening dates but acknowledged the absence of documentation for control measures or testing during this period. This oversight in maintaining and documenting the water management plan's activities and addressing the prolonged unit closure contributed to the deficiency.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for several residents, as evidenced by multiple deficiencies observed during the survey. One resident, R9, experienced a cold room due to a lack of window coverings and a draft from the window. Despite reporting the issue to staff, the curtain and rod remained unfixed for several days, and a towel was used unsuccessfully to block the draft. Additionally, there was peeling paint and water leakage from the ceiling, which had not been addressed despite being reported by the resident and a visitor. Another resident, R24, faced similar issues with water leakage from the ceiling, which had been ongoing since January. The resident's bed had to be moved due to water dripping onto it, yet the problem persisted in the new location. The maintenance request logs did not reflect the original dates of the requests, and the issues remained unresolved. The maintenance director acknowledged the draft in R9's room but did not provide a resolution. Further deficiencies were noted in other residents' rooms. In R43's room, a television cord was improperly secured, sagging from the ceiling, and there was crumbling drywall. In R45's room, the metal radiator was damaged, with rust and flaking. The maintenance director admitted that there was significant work needed in the building, but no immediate actions were taken to address these concerns.
Noncompliance with Room Location Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During an initial tour of the facility, it was observed that seven rooms (101, 102, 103, 104, 105, 106, and 107) were situated below ground level. The facility's Resident Roster confirmed that the affected residents were residing in these below-ground-level rooms. The facility's administrator acknowledged awareness of this noncompliance and mentioned that an application for a waiver had been submitted. However, no waiver was provided, and a letter from the Illinois Department of Public Health indicated that no waiver had been awarded for these rooms.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain resident privacy during wound care for one resident. On February 19, 2025, the Assistant Director of Nursing (ADON) and Wound Care Nurse, identified as V3, provided wound care to a resident with a pressure ulcer on her left buttock. During the dressing change, V3 left the resident's bedroom to retrieve additional items without covering the resident with a blanket or sheet, leaving her exposed from the waist down. The resident, who was alert and oriented according to her Minimum Data Sheet dated January 19, 2025, expressed on February 20, 2025, that the staff should have covered her before leaving. V3 acknowledged that staff must ensure privacy for dignity, aligning with the facility's policy that emphasizes promoting and protecting resident privacy during personal care and treatment procedures.
Failure to Implement PTSD Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident diagnosed with PTSD. The resident, who was admitted with multiple diagnoses including PTSD, major depressive disorder, and anxiety disorder, did not have a care plan addressing her PTSD. The resident's electronic medical record and Minimum Data Set confirmed the PTSD diagnosis, and a progress note highlighted a history of sexual abuse. However, there was no care plan in place to address the resident's PTSD, identify her triggers, or provide interventions for her medical, physical, or mental needs. During an interview, the social services staff member, who had been at the facility for two weeks, was unaware of the resident's PTSD diagnosis. Upon reviewing the resident's electronic medical record, the staff member discovered the resident's history of trauma, including financial abuse, sexual assault, physical assault, and mental abuse, but found no identified triggers. The facility administrator confirmed that there was no policy on Trauma-Informed Care for residents with PTSD, indicating a lack of structured guidance for addressing such cases.
Deficiency in Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide adequate hygiene and grooming care for residents who require assistance with activities of daily living (ADL). Three residents were observed with unmet grooming needs. One resident was noted to have overgrown facial and nasal hair, jagged and discolored fingernails, and uncombed hair over several days, despite being totally dependent on staff for hygiene care. Another resident, who requires substantial assistance for grooming, expressed a desire for her facial hair to be shaved and her fingernails to be clipped, but these needs were not addressed. The Assistant Director of Nursing stated that nail care and shaving should be done during shower days and as needed, while hair care should be done daily. Additionally, a resident requiring substantial assistance for toileting hygiene was found wearing double incontinence briefs, with the inner brief soiled. The staff failed to change the soiled brief immediately, contrary to the facility's policy to keep residents clean, dry, and comfortable. The Assistant Director of Nursing confirmed that it is not the facility's practice to use double incontinence briefs due to the risk of urinary tract infections. The resident's care plan indicated the need for incontinence care as soon as incontinence was noted, which was not adhered to in this instance.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who required foot care was seen by a podiatrist. During an observation on February 19, 2025, a Certified Nursing Assistant (CNA) noticed that the resident had overgrown toenails that curled over the top of each toe. The CNA reported this issue to the nurse, but the toenails had not been clipped. The resident expressed a desire for his toenails to be clipped, stating that they had not been cut since his admission to the facility. The nurse confirmed that during admission, a head-to-toe assessment is conducted, and any issues requiring a physician's attention are referred. The resident had signed a consent for podiatry services upon admission, indicating that he should have been seen by a podiatrist. The resident's Minimum Data Set (MDS) indicated that he was alert and oriented and required substantial assistance for grooming and hygiene.
Failure to Administer Prescribed Pain Patches
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, R19 and R203, who had physician orders for Lidocaine adhesive patches to manage their chronic pain. R19, who has diagnoses including radiculopathy, hemiplegia, and osteoarthritis, reported not receiving his prescribed pain patches for a week, resulting in a pain score of 8/10. Despite being aware of the shortage, the nursing staff did not notify the physician or provide an alternative pain management solution. R19's care plan required the application of Lidocaine patches to multiple sites, but these were not administered as ordered. Similarly, R203, with conditions such as spinal stenosis and arthritis, also did not receive the prescribed Lidocaine patch for several days, leading to a pain score of 7/10. The Director of Nursing confirmed that the patches were house stock and should have been reordered by the central supply staff. However, due to a miscommunication, the patches were not available, and no alternative pain management was provided. The central supply staff was unaware of the shortage until it was reported, highlighting a breakdown in communication and inventory management within the facility.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as evidenced by the lack of identification of triggers and appropriate interventions in the resident's care plan. The resident, who had a history of sexual abuse and other traumas, was admitted with multiple mental health diagnoses, including PTSD. Despite this, the facility's documentation, such as the Admission Trauma-Informed Care Observation, was incomplete, with critical sections regarding triggers and responses left blank. Additionally, the care plan did not include specific behavior monitoring or interventions tailored to the resident's PTSD. Interviews with facility staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis and needs. The social services staff member, who had only been at the facility for two weeks, was unaware of the resident's PTSD and had not reviewed the care plan to address it. Furthermore, the facility lacked a policy on trauma-informed care for residents with PTSD, indicating systemic issues in addressing the needs of residents with trauma histories. The psychiatric care provided focused solely on medication without addressing the resident's trauma-related needs.
Failure to Provide Proper Pureed Diets
Penalty
Summary
The facility failed to provide pureed consistency diets for two residents who had orders for such diets. On February 18, 2025, during a lunch meal, the facility served pureed rice and turkey that appeared granular and lumpy to two residents requiring pureed diets. The cook, V8, mentioned that ground beef did not arrive as ordered, and ground turkey was used instead. The pureed food was observed to be granular and required chewing, which is inconsistent with the facility's policy for pureed diets that should be smooth and pudding-like. The consultant dietitian, V5, confirmed that the consistency was not appropriate for a pureed diet, indicating that the meals were not safe to serve to the residents.
Failure to Serve Planned Menu Items Due to Budget Cuts
Penalty
Summary
The facility failed to serve food items to residents as shown on the facility's planned and approved menu, affecting all 27 residents. During a tour of the kitchen, it was observed that the walk-in cooler and freezer shelves were sparse, lacking essential food items such as eggs, mayonnaise, and ketchup. Residents reported receiving meals that did not match the planned menu, with substitutions made due to budget cuts and lack of ingredients. For instance, on Father's Day, residents were supposed to receive roast beef but were instead served hot dogs without bread or condiments. The Food Service Director (FSD) admitted to making substitutions due to budget constraints, which included replacing roast beef with hot dogs and substituting oatmeal pies for lemon cheese bars. The facility also ran out of bread, ketchup, and mayonnaise, limiting alternative meal options. The dietitian was not consulted regarding these substitutions, which did not meet the same nutritive value as the planned menu items. The facility's policy requires menu changes to be of similar nutritive value and approved by a dietitian, which was not followed. Residents expressed dissatisfaction with the meals, noting frequent shortages of items like yogurt, mustard, and fresh fruit. The FSD acknowledged the inability to serve planned menu items due to budget cuts, resulting in inadequate meal substitutions. The facility's administrator confirmed that the food budget was cut in half, leading to these deficiencies. The facility's policy on menu changes was not adhered to, as changes were not indicated on the posted menu, nor were they of similar nutritive value.
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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