Aperion Care Oak Lawn
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Lawn, Illinois.
- Location
- 9401 South Ridgeland Avenue, Oak Lawn, Illinois 60453
- CMS Provider Number
- 145197
- Inspections on file
- 52
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Aperion Care Oak Lawn during CMS and state inspections, most recent first.
A resident with dementia, stroke history, seizures, CKD, and a gastrostomy was hospitalized for a brain bleed, during which time her room was changed without prior notification to her legal representative. On return, the family member and POA found the resident’s belongings had been moved without being informed. Interviews with the DON, Social Service Director, and Administrator revealed uncertainty about who is responsible for room change notification, absence of a room change notification policy, and lack of required documentation of such notifications, and records contained no evidence that the resident, guardian, or representative had been notified.
A resident with dementia, stroke, seizures, chronic kidney disease, and gastrostomy status received incontinence care during which a CNA failed to perform required hand hygiene between glove changes. The CNA cleaned the resident’s perineal area after episodes of urinary and fecal incontinence, then handled clean linens, adjusted equipment, and applied clean briefs while wearing soiled gloves, and later donned new gloves without washing hands or using alcohol-based hand rub. In interviews, the CNA admitted forgetting to perform hand hygiene, and the DON confirmed that facility policy requires hand hygiene after contact with body fluids and after glove removal.
Surveyors found that nursing staff failed to remove expired, opened medications from active medication carts, contrary to the facility’s own storage policy. During medication cart audits with two nurses, multiple insulin pens and vials, as well as an ophthalmic solution, were observed with open and expiration dates showing they were beyond the allowable 28–30 day period or otherwise expired. The nurses acknowledged that these medications were open, used, expired, and should not have remained on the carts. The affected medications were associated with residents who had type 2 DM and an eye medication order, while the facility’s policy required all expired medications to be removed from active supply and destroyed, and specified shortened dating for opened multi-dose injectables and ophthalmic products.
Surveyors found multiple failures in food service and sanitation, including lack of hand soap at a handwashing station, use of dirty sanitizing solution at an inadequate quaternary ammonium concentration, and cleaning of food carts with visibly soiled water. In dry storage, flying insects were observed, expired dinner rolls with a green substance were stored alongside non-expired bread, and a black flying insect was found inside a bag of hamburger buns. Dented cans were stored with undamaged cans, with staff expected to ask the Dietary Supervisor before use rather than storing them separately. During a lunch meal service, milk was held in a tub without ice, was not cool to the touch, and was measured at 60°F, despite facility policy and logs requiring milk to be maintained at or below 40–45°F for safe cold holding.
A cognitively intact, bedbound resident reported that after giving a credit card to the Business Office Manager for payment, the card was returned to the overbed table and later found missing, followed by unauthorized charges and a cash withdrawal. The resident notified staff and later spoke with police, identifying who she believed took the card. Facility leadership and staff were aware of the missing card, suspicious transactions, and information suggesting a CNA might be involved, yet no reportable incident was completed despite an abuse prevention policy that defines misappropriation as wrongful use of a resident’s belongings or money without consent.
A resident who was bedridden and cognitively intact reported that after giving a credit card to the Business Office Manager for payment, the card went missing and later showed large unauthorized charges and an ATM withdrawal. The Business Office Manager notified the Administrator, and the Resident Liaison assisted the resident in contacting the bank, which indicated it would investigate and reimburse fraudulent charges. The Social Services Director became involved after some investigation had already occurred but did not verify card possession with the resident’s POA. A police report documented that the Administrator suspected a CNA, previously linked to another stolen debit card and alleged to have discussed a scam, might be responsible. Although facility policy requires immediate reporting of suspected misappropriation of resident property to the state within a defined timeframe, no reportable was submitted for this allegation, resulting in a failure to follow the abuse prevention and reporting policy.
A resident who was bedridden and cognitively intact reported that after giving a credit card to the Business Office Manager for payment, the card went missing and later showed large fraudulent charges, including a florist purchase and an ATM withdrawal. The resident notified staff, the bank, and police, and the bank ultimately reimbursed the fraudulent transactions. The Administrator told police he believed a CNA, previously linked to another stolen debit card and reportedly talking about a scam, was responsible. However, the facility did not follow its abuse prevention policy: it did not initiate or document a thorough internal investigation, did not obtain witness statements, did not formally interview the resident or the alleged staff perpetrator, and did not file a reportable event, despite policy requirements to document and investigate all allegations of exploitation or misappropriation of resident property.
The facility failed to accurately reflect and document advance directives and code status for two residents. For one resident, physician orders and a POLST form identified a DNR/DNAR status, but the comprehensive care plan continued to list the resident as full code with directions to perform CPR and provide intubation and mechanical ventilation. For another resident, no code status was documented on the face sheet or in active physician orders, despite the DON’s statement that code status must be recorded in two locations in the EMR. These lapses occurred despite facility policies requiring comprehensive, person-centered care plans and specific physician orders addressing each advance directive.
The facility failed to prevent resident-to-resident physical abuse when a cognitively intact resident pushed another resident to the floor in a hallway after the second resident went to check on a roommate who had requested help with a cell phone. The resident who was pushed reported falling onto his back, being assisted from the floor by a nurse, and subsequently being evaluated at a hospital, where he was diagnosed with acute midline thoracic pain. The resident stated he wanted to press charges and described a prior incident in which another resident threw coffee on him. The administrator acknowledged being notified that a resident had been pushed and that the aggressor admitted to pushing, but he had not reviewed video surveillance at the time of the survey. An LPN confirmed being told that a resident was pushed, assessed him for back pain, and arranged for hospital evaluation, while facility policy states residents must be free from abuse and defines abuse as willful infliction of injury resulting in physical harm or pain.
Surveyors found that staff did not accurately code MDS assessments for four residents, including incorrectly indicating hospice services for a resident who never received hospice care, failing to document restorative nursing services for two residents who were receiving range-of-motion and mobility programs, and coding PASRR status as negative for a resident with multiple serious mental health diagnoses. The DON, Restorative Nurse, and MDS Coordinator acknowledged that the MDS entries did not accurately reflect the residents’ actual services and conditions.
A resident with moderate cognitive impairment, total urinary incontinence, and a need for substantial/maximal assistance with toileting was not checked and changed in accordance with the facility’s policy requiring incontinence checks at least every two hours and as needed. The resident was observed with wet clothing, a wet wheelchair cushion, a strong urine odor, and a completely saturated brief with urine dripping from the hip, while a CNA reported the last incontinence care had been provided several hours earlier. The resident’s MPOA stated the resident is always left wet, and staff acknowledged that residents should be checked and changed every two hours but did not do so in this case.
A resident with sickle cell disease, COPD, type II diabetes, and major depressive disorder, who had an assessment indicating a need for supervision while smoking, was observed smoking on the patio without staff monitoring after another resident provided and lit a cigarette. The Social Service Director reported that only two residents required supervised smoking and did not initially include this resident, later acknowledging that the assessment showed supervision was required and that residents needing supervision should not hold their own smoking materials or share materials with others. The resident stated she does not keep her own smoking materials and relies on staff or family, and had been informed that residents are not allowed to share smoking materials, in contrast to what was observed.
A deficiency was cited when a resident with an indwelling urinary catheter for neuromuscular bladder dysfunction was observed sitting on the side of the bed eating lunch with the catheter drainage bag resting on the floor and the privacy bag not fully covering the top of the drainage bag. A nurse acknowledged the bag should have been attached to the bed frame, and the DON stated catheter bags should not be on the floor due to infection control concerns. The facility’s urinary catheter care policy required that urinary drainage bags and tubing be positioned so they do not touch the floor, and this policy was not followed.
A resident with dysphagia, muscle wasting, major depressive disorder, and adult failure to thrive experienced a significant one-month weight loss of more than 5%, dropping from approximately 132 lbs to 120 lbs. Despite this documented loss, staff did not obtain a confirmatory reweight within 24 hours as required by facility policy, and no additional weights were recorded until a surveyor requested one, which showed further loss. The Restorative Nurse stated that weights are done monthly and reweights occur with large changes, while the NP indicated she expects reweights when weight changes occur, but the facility’s policy requiring next-day reweights and timely notification of the care team after a ≥5% change was not followed.
A resident dependent on staff for all ADLs and unable to communicate was found with a black eye and facial bruising. Staff did not observe the injury occur, and accounts of the incident were inconsistent and undocumented. The facility failed to report the injury of unknown origin to authorities as required by its abuse policy, and internal documentation was incomplete.
A resident dependent on staff for all ADLs and unable to communicate was found with a black eye and facial bruising. The injury was reported by a family member, but staff did not initiate a timely or thorough investigation, and there was a lack of documentation from both nursing and activity staff. The DON completed risk management documentation days after the incident, and interviews revealed no staff had witnessed the injury, contrary to initial claims. The facility did not follow its abuse policy requiring investigation and documentation of injuries of unknown origin.
A leaking toilet in a shared bathroom, used by four residents, was not effectively repaired, resulting in ongoing water leakage and wall damage. Staff and maintenance confirmed the issue persisted despite previous repair attempts, and surveyors observed water on the floor and makeshift measures to address the leak, indicating the facility did not maintain plumbing fixtures in good repair as required.
The facility did not maintain an effective pest control program, as flying pests were observed in a bathroom shared by two residents and in the dining room. Staff reported seeing bugs and a flying pest on a resident's bed, and a leaking toilet was noted. The Maintenance Director confirmed the presence of gnats and stated pest control visits occur regularly, but there was no documentation of additional pest control notification. Surveyors also observed that interior doors were left open, contrary to facility policy requiring measures to prevent pest entry.
Two residents, both with psychiatric diagnoses and identified risks for aggression and abuse, were involved in a physical altercation in the dining room after one resident backed into the other with a wheelchair. Despite care plans outlining interventions to prevent escalation, staff did not prevent the incident, resulting in minor injuries.
A resident with a history of psychiatric and behavioral issues fell in the dining room and, while attempting to get up, grabbed another resident's arm and bit her, causing a full-thickness wound that required hospital evaluation and antibiotic treatment. The incident was witnessed by staff and other residents, and the biting resident had a documented history of similar behaviors.
A CNA failed to use a mechanical lift for a dependent transfer as required by a resident's care plan, instead performing a stand and pivot transfer at the resident's request. The resident, who had morbid obesity and knee pain, sustained a non-displaced fracture and required hospitalization and surgery. Staff interviews confirmed that the correct transfer method was not followed and that refusals should be reported to nursing leadership.
A resident with Peripheral Vascular Disease and cognitive impairment did not receive proper foot care as required by facility policy. Staff failed to observe or document the resident's toenail condition during routine assessments and bathing, and the resident was not seen by the podiatrist for an extended period. This led to the development of onychomycosis, painful elongated toenails, and other foot complications, which were only addressed after a family complaint.
The facility failed to provide scheduled showers to several residents who were dependent on staff assistance, leading to unmet hygiene needs. Residents expressed dissatisfaction with not receiving showers as per their preferences, and documentation was inconsistent, with missing records for several scheduled days. The DON acknowledged the issue, confirming that showers were not consistently provided according to the schedule.
A resident with significant mobility impairments was injured during a mechanical lift transfer when a CNA attempted the procedure alone, contrary to the facility's policy requiring two staff members. The CNA placed the sling incorrectly, causing the resident to fall. Staff interviews confirmed the policy breach, and the resident's care plan specified the need for two-person assistance.
A resident with multiple health conditions reported giving cash and gifts to a CNA due to financial hardship claims. The CNA admitted to receiving gifts but denied taking cash. The facility's policy prohibits staff from accepting gifts or money from residents, highlighting a deficiency in protecting resident rights and property.
The facility failed to label food items in the walk-in refrigerator, affecting 109 residents on oral diets. Additionally, two residents' personal refrigerators were not maintained, with unlabeled food and thick ice accumulation. Staff interviews revealed confusion over responsibility for refrigerator checks, which were not conducted daily as required by policy.
The facility failed to maintain a safe environment by leaving intravenous medication and hazardous pesticides at residents' bedsides, contrary to safety protocols. Additionally, the facility did not follow physician orders for fall precautions, as residents at risk of falls lacked necessary interventions like floor mats and non-slip materials, and their care plans were not updated after fall incidents.
The facility failed to adhere to infection control practices, with observations of improperly stored nebulizer and CPAP masks, and lapses in hand hygiene by staff. Respiratory equipment was found uncovered and not dated, contrary to facility policy, and staff admitted to forgetting hand hygiene protocols. The Director of Nursing confirmed the expectations for proper storage and hand hygiene to prevent infection.
A resident's call light was ignored by staff, leaving her in distress after a bowel movement. Despite multiple calls to the facility, no assistance was provided promptly. Additionally, two CNAs entered another resident's room without knocking, violating the facility's dignity policy.
The facility failed to ensure call lights were within reach for two residents, leading to unmet needs for assistance. One resident was found yelling for help with a water pitcher spilling, while another was unable to reach their call light or water. Both residents had significant medical conditions requiring assistance, and staff acknowledged the oversight. Facility policy mandates call lights be accessible at all times.
A facility failed to accurately document a resident's advance directive, resulting in a discrepancy between the resident's signed DNR form and their health records, which listed them as full code. This inconsistency was confirmed by the Social Service Director, who found no documentation of any change in the resident's advance directives. The facility's policy requires that advance directives be documented and included in the care plan, which was not followed in this instance.
A resident with a stage 4 pressure ulcer was improperly cared for by using a low air loss (LAL) mattress with multiple layers of linen and a disposable brief, contrary to standard practice. The facility lacked a specific policy for LAL mattress usage, contributing to the improper care. The resident had multiple diagnoses, including a stage 4 sacral pressure ulcer, and was at high risk for developing pressure ulcers.
A facility failed to follow a physician's order for a resident's tube feeding administration. The resident, diagnosed with dysphagia and gastrostomy status, was observed with a disconnected feeding bottle and an off machine, contrary to the order requiring feeding to start at 10 AM. Both a nurse and the DON confirmed the oversight, which violated the facility's policy on medication administration.
A survey found that a medication cart was left open and unattended with keys attached, and pre-poured, unlabeled medications were found inside. Additionally, a medication room refrigerator containing controlled substances was unlocked. The facility's policies require secure storage of medications, which was not adhered to, leading to this deficiency.
A resident at moderate risk for skin breakdown developed three facility-acquired pressure ulcers, and an existing stage 2 ulcer deteriorated due to the facility's failure to provide necessary care. The resident, dependent on staff for all ADLs, did not receive consistent wound assessments or timely treatment orders, and there was a lack of documentation regarding noncompliance with care plans.
Two residents in a LTC facility experienced neglect by a CNA, who failed to provide timely incontinence care, leaving them in soiled briefs for hours. One resident reported severe discomfort and burning sensations due to the neglect, while the other felt unappreciated and ignored. The facility's documentation showed no record of care provided during the shift, and the incident was not initially investigated as neglect despite the facility's zero-tolerance policy.
A malfunction in the call light system affected 26 residents on the North Hall Unit. A resident experienced a delay in response after activating the call light, and staff confirmed the system was down. The Maintenance Director was not informed until the next day, and the issue was linked to older systems affected by power surges. The facility lacked documentation on the outage duration and how residents' needs were managed without the system.
Two residents reported an incident where a CNA failed to respond to a call light, resulting in discomfort due to incontinence. The CNA was described as confrontational and did not return to provide care for the remainder of the shift. The facility's policy requires immediate protection of residents and timely investigation of allegations, which was not followed.
A resident with no cognitive impairment expressed that her request to be put to bed by 8 PM was ignored by a CNA, who instead put her to bed around 9:30 PM. This made the resident feel upset and disrespected. The facility's policy emphasizes respecting residents' preferences, but interviews and Resident Council Minutes suggest that CNAs sometimes ignore such requests.
A resident with a history of chronic pulmonary embolism experienced leg swelling and pain, prompting a nurse to order a stat venous doppler ultrasound. Despite the urgency, the ultrasound was delayed until several days later, revealing a blood clot. The facility's EMR lacked documentation of the physician's notification and the delay, and there was no policy on testing timeframes.
A resident with mobility issues fell during a transfer when a CNA failed to use a gait belt, as required by the care plan. The resident was unsteady and fell while attempting to turn, despite the facility's policy mandating the use of transfer conveyances.
A resident's medications were left unattended at the bedside, contrary to the facility's policy. The LPN responsible for the resident's care incorrectly charted the medications as administered. The resident's care plan did not authorize self-administration, and the DON confirmed that medications should not be left at the bedside.
A resident, who was always incontinent and cognitively intact, did not receive timely incontinence care, resulting in her being soaked with urine and experiencing skin redness. Despite requesting assistance, the resident was ignored by a CNA. The care plan required checks every two hours, but this was not followed, as confirmed by other CNAs. Previous Resident Council Meeting Minutes also noted similar complaints about untimely care.
The facility failed to implement CDC COVID-19 guidelines by not ensuring proper PPE use for residents on isolation. A resident with COVID-19 had their door left open, and another resident visited without wearing a face shield, contrary to the facility's infection control policy.
A facility failed to supervise a high fall risk resident with cognitive impairment, resulting in falls and injuries. Another resident with Alzheimer's and exit-seeking behavior eloped, found a mile away, confused and cold. Staff were unaware of risks, and alarm systems failed, contributing to these incidents.
A resident with vascular dementia and hemiplegia was left cold, wet, and uncomfortable due to the facility's failure to provide timely incontinence care. Despite being dependent on staff for toileting, the resident did not receive care during the day shift, as confirmed by a CNA and the DON. The facility's policy requires care every two to three hours, but records showed the last care was provided early in the morning.
A resident with a seizure diagnosis did not have their Keppra levels monitored weekly as ordered, with only one nontherapeutic level documented. Additionally, nurses crushed the resident's Keppra tablets despite pharmacy recommendations against it, potentially affecting the medication's absorption and efficacy.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to honor a resident’s right to receive appropriate notification before a room change. The resident, an older adult with diagnoses including cerebral infarction (stroke), seizures, chronic kidney disease, dementia, and gastrostomy status, had a cognitive assessment indicating staff were unable to examine cognitive patterns due to dementia and that the resident was rarely or never understood. The resident became lethargic and was sent to the hospital for further evaluation, where she was admitted for a brain bleed and remained hospitalized for four days. During this hospitalization, the facility changed her room. Upon the resident’s return from the hospital, her family member and power of attorney for care reported that the resident’s belongings had been packed and moved to another room without any prior notification to the family. Record review showed no documentation that the resident, her state guardian, or her family member/power of attorney had been notified of the room change. When interviewed, the DON stated uncertainty about who was responsible for informing residents or representatives of room changes and indicated there was no policy for room change notification. The Social Service Director was also unsure of responsibility, and the Administrator acknowledged that any staff performing the room change should notify the resident or representative, but confirmed there was no written policy and that documentation of such notification was not required. No policy on room change notification was provided during the investigation.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The deficiency involves failure to follow the facility’s hand hygiene policy during incontinence care for one resident. The resident has multiple diagnoses including cerebral infarction (stroke), seizures, chronic kidney disease, dementia, and gastrostomy status, and is documented as rarely/never understood due to dementia and memory problems. During an observation, a CNA checked the resident’s disposable brief, found loose stool and urine, and provided incontinence care by cleaning the perineal area and buttocks. While still wearing soiled gloves, the CNA then put a clean fitted sheet and pad on the mattress, applied a clean disposable brief, and adjusted the air loss mattress machine. The CNA subsequently removed the soiled gloves, discarded them, and put on a clean pair of gloves without performing hand hygiene with soap and water or alcohol-based hand sanitizer before donning the new gloves. In a later observation the same day, the CNA again entered the resident’s room, checked the brief, and found the resident wet with urine. The CNA cleaned the resident’s perineal area, removed and discarded the gloves, and again put on a new clean pair of gloves without performing hand hygiene before donning the new gloves. In interviews following these observations, the CNA acknowledged that she should have changed gloves appropriately and performed hand hygiene to prevent the spread of germs, stating she had forgotten. The DON confirmed that CNAs are expected to perform hand hygiene after changing gloves, especially when moving from dirty to clean tasks, in accordance with the facility’s hand hygiene/handwashing policy, which requires hand hygiene after contact with body fluids and after glove removal.
Expired Insulin and Ophthalmic Medications Found on Active Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when expired, opened medications were found on active medication carts during audits with nursing staff. During one cart audit, a nurse (V6) presented an Insulin Glargine Kwik Pen for a resident (R87) and an Insulin Aspart Kwik Pen for another resident (R19), each labeled with open and expiration dates showing they were beyond the 28–30 day usability period after opening. V6 stated that both insulins were opened, used, and expired, and acknowledged that expired medications should not be on the medication cart. R87 had a diagnosis of type 2 diabetes mellitus and a physician order for Insulin Glargine Kwik Pen that was documented as discontinued. R19 also had type 2 diabetes mellitus with an active physician order for Insulin Aspart injection solution to be given per sliding scale. In a separate medication cart audit with another nurse (V7), surveyors observed an insulin lispro product for a resident (R105) and Xalatan ophthalmic solution for another resident (R95), each labeled with open and expiration dates indicating they were expired. V7 stated that these medications were open, used, and expired, and confirmed that expired medications should not be on the medication cart. R105 had type 2 diabetes mellitus and a physician order for insulin lispro solution that was documented as discontinued, while R95 had a physician order for Xalatan ophthalmic solution to be instilled in the right eye in the morning. The facility’s Storage of Medications policy states that all expired medications will be removed from active supply and destroyed in the facility, and that certain opened medications, including ophthalmic solutions and multiple-dose injectable vials, require a shortened expiration date to ensure medication purity and potency. The presence of these expired, opened medications on the active carts demonstrated the facility’s failure to follow its own medication storage policy.
Failure to Maintain Safe Food Storage, Sanitation, and Cold Holding Temperatures
Penalty
Summary
The deficiency involves failure to follow food service and sanitation policies, including improper hand hygiene resources, inadequate sanitizing practices, and improper food storage and handling. During a kitchen tour, surveyors observed that there was no hand soap available at the handwashing area, and the Dietary Supervisor could not provide hand sanitizer when requested. A dietary staff member reported he had notified housekeeping earlier that morning that the soap was out but did not know the staff member’s name. Another dietary staff member was seen cleaning food carts with a white towel repeatedly dipped into a red sanitizing bucket filled with dark, dirty water. Testing of the quaternary ammonium sanitizing solution in that bucket showed a concentration of 100 ppm, while the Dietary Supervisor stated it should be at least 200 ppm for proper sanitizing. In the dry food storage area, surveyors and the Dietary Supervisor observed flying insects, including one landing on a white gallon container stored on a metal shelf. Two large packages of dinner rolls with a “best used by” date that had already passed were found on the bread rack with non-expired bread, and these rolls had a green substance on them. A large package of hamburger buns was also observed with a black flying insect inside the bag. The Dietary Supervisor acknowledged the expired rolls should have been discarded and removed the insect from the bun package. She also stated that dented cans were stored on a shelf with non-dented cans and that staff were expected to ask her before using them. During lunch service, milk was stored in a black tub without ice; both a dietary staff member and the surveyor noted the milk was not cool to the touch. The milk temperature was measured at 60°F, despite facility policy and temperature logs indicating milk should be maintained at or below 40–45°F. The facility has residents who receive tube feedings and do not eat food from the kitchen, but all 118 residents receive food prepared by the facility kitchen.
Failure to Report and Protect Resident From Suspected Misappropriation of Credit Card
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy and protect a resident from staff-to-resident misappropriation of property. A cognitively intact, bedbound resident with a BIMS score of 15/15 and a documented moderate risk for abuse reported that after admission, she gave her credit card to the Business Office Manager to process a payment. The Business Office Manager returned the card and receipt, placing them on the resident’s overbed table. Later, when the resident attempted to put the card back into her zippered pouch, she could not find it and notified the Business Office Manager. The resident subsequently became aware of two unauthorized transactions on her account: a $500 charge to a florist and an $800 cash withdrawal plus a $2.50 fee. The resident stated she was instructed to freeze the card and later spoke with police, to whom she identified who she thought could have taken the card. She reported feeling unnerved and scared that this occurred in the nursing home. Interviews and record reviews showed that facility leadership and staff were aware of the missing credit card and suspicious charges but did not treat the event as a reportable misappropriation under the abuse prevention policy. The Administrator acknowledged that the resident’s credit card was missing and that there were unfamiliar charges, and indicated that the Resident Liaison knew more details. The Resident Liaison reported the missing card to the Social Services Director and contacted the bank with the resident, learning that the bank would investigate and potentially reimburse the charges, but stated she did not know why a reportable was not completed. The Social Services Director stated that by the time she followed up, the bank had already reimbursed the resident and she did not confirm with the resident’s POA that the card was in the POA’s possession. A police report documented that the Administrator told law enforcement he believed a CNA, previously associated with another resident’s stolen debit card and who had spoken about having a “scam system” at the facility, was responsible. Despite this information and the facility’s written policy defining misappropriation of resident property as wrongful use of a resident’s belongings or money without consent, no reportable incident was made by the facility for this event.
Failure to Timely Report Alleged Staff-Related Credit Card Theft
Penalty
Summary
The facility failed to follow its abuse prevention and reporting policy by not reporting an allegation of staff-to-resident theft to the State Survey Agency within the required timeframe. A cognitively intact resident with a BIMS score of 15/15, assessed as at moderate risk for abuse, reported that after admission she provided her credit card to the Business Office Manager to process a payment. The card and receipt were returned and placed on the overbed table, but later, when the resident attempted to put the card back into her zippered pouch, she could not find it. The resident, who is bedridden and does not leave her room, subsequently became aware of unusual activity on her bank account, including a large florist charge and a cash withdrawal with an associated fee, and was instructed to freeze the card. The resident reported the missing card to the Business Office Manager, who stated she informed the Administrator and that the police were notified and a report made. The Administrator acknowledged that the resident’s credit card was missing and that there were unfamiliar charges, and indicated that the Resident Liaison had more information because she had been on the phone with the resident and the bank. The Resident Liaison reported that she contacted the bank with the resident, was told the bank would investigate the pending charges and reimburse the resident if they were fraudulent, and stated she did not know why a reportable was not completed. The Social Services Director stated she was asked to see the resident about the missing card, that the Resident Liaison had already done some of the investigation, and that by the time she followed up, the bank had reimbursed the resident; she did not confirm with the resident’s POA that the POA had the card. A police report documented that the officer spoke with the Administrator, who indicated he believed a CNA assigned to the resident’s room on the day the card was used at an ATM was responsible, and that this CNA had previously been assigned to another resident whose debit card had been stolen and had spoken about having a scam system at the facility. The police contacted the resident’s POA, who was aware of the incident but did not know all the details, and received the resident’s bank statement. The facility’s abuse prevention and reporting policy requires employees to immediately report any incident, allegation, or suspicion of misappropriation of resident property to the Administrator and to inform the Department of Public Health’s regional office by telephone or fax not later than two hours after forming the suspicion, with a complete written report within five working days. Despite these policy requirements and the Administrator’s expressed suspicion of staff involvement, no reportable was made to the State Survey Agency for this event, constituting the deficiency.
Failure to Investigate Alleged Misappropriation of Resident Credit Card
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and reporting policy in response to an allegation of misappropriation of a resident’s property. A cognitively intact resident with a BIMS score of 15/15, who is bedridden and does not leave her room, reported that after admission she provided her credit card to the Business Office Manager to process a payment. The card was returned and placed on her overbed table, but when the resident later attempted to put it back into her zippered pouch, she could not find it. The resident subsequently became aware of unusual activity on her bank account, including a $500 charge to a florist and an $800 cash withdrawal plus a $2.50 fee, and she was instructed by the bank to freeze the card. The resident reported the missing card to facility staff, including the Business Office Manager, who stated she notified the Administrator and that the police were contacted. The Administrator, Resident Liaison, and Social Services Director each acknowledged awareness of the missing credit card and the fraudulent charges, and the Resident Liaison assisted the resident in contacting the bank. The bank later reimbursed the resident for the fraudulent charges. The resident told surveyors she felt unnerved and scared by the event, especially given that she had been robbed before in the community and did not expect this to occur in a nursing home. The resident also informed police whom she suspected might have taken the card, referencing a CNA who had asked her about how she picked her lucky numbers. A police report documented that the Administrator told law enforcement he believed a CNA assigned to the resident’s room on the day the card was used at an ATM was responsible, and that this CNA had also been assigned to another resident whose debit card had been stolen and had spoken about having a scam system at the facility. Despite this, the facility was unable to provide any documentation that an internal investigation was initiated in accordance with its abuse prevention policy. There was no evidence of an investigation file, no witness statements, no documented interview of the resident, and no interview of the alleged perpetrator. The facility’s written policy requires that all incidents or allegations involving exploitation or misappropriation of resident property be documented and investigated, including interviews with the reporter, the resident, and others with direct knowledge, but these steps were not carried out or documented in this case, and no reportable event was filed by the facility.
Failure to Accurately Reflect and Document Resident Advance Directives and Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident advance directives and code status were accurately reflected and documented in accordance with policy. For one resident, physician orders and a state POLST form indicated a Do Not Resuscitate (DNR/DNAR) status, and the POLST was signed by the resident’s power of attorney/guardian and the provider. However, the resident’s comprehensive care plan for advance directives, initiated and later revised, documented the resident as a full code with instructions to attempt resuscitation, including intubation and mechanical ventilation, and to perform CPR if the resident stopped breathing. The care plan coordinator stated that care plans should be updated quarterly and whenever there is a change, and specifically that advance directive care plans should be updated as soon as a resident or POA changes status from full code to DNR, indicating this had not been done. For another resident, the facility failed to document any code status at all. The resident’s face sheet section for advance directives was left blank, and the active physician orders contained no code status order. The DON stated that a resident’s code status must be visible on the face sheet and in a miscellaneous section, and that code status must be documented in two places in the electronic record, which was not done for this resident. These findings show that the facility did not follow its comprehensive care plan and advance directive policies, which require a written physician order addressing each advance directive and incorporation of resident goals and preferences into the care plan.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Fall and Back Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident physical abuse when one resident pushed another to the floor. One resident, who was cognitively intact with a BIMS score of 15, reported that a male resident came to his room looking for his roommate. He stated that he told the other resident he could not come into the room, got out of bed, and pushed the resident down to the floor while the other resident was standing in the doorway. He further stated that his roommate could not have visitors in the room and that visits should occur in the dining room. The roommate later identified the pushed resident as the one who had come to assist with a cell phone. The resident who was pushed reported that he had been awake late, had gone out to smoke, and was later sitting in the dining room watching videos on his phone when the roommate asked for help with his phone. After the roommate did not return, the resident went to the roommate’s room to check on him and see if he still needed help. While the resident was in the hallway outside the room, the other resident approached him, told him he could not come inside, and pushed him, causing him to fall onto his back in the hallway. The resident stated that a nurse picked him up from the floor, that he had just returned from the hospital, and that he wanted to press charges. He also reported a prior incident in which another resident threw coffee on him and that he felt he was the only one seen on camera in that earlier event. The administrator stated he was informed early in the morning that the resident had fallen after being pushed by another resident but did not recall which nurse notified him. He acknowledged that the resident who pushed had a right to privacy and that the resident who was pushed should not have been visiting other residents in the early morning hours. The administrator stated that the resident who pushed admitted to pushing the other resident, causing him to fall in the hallway outside the room, and that he had not yet reviewed video surveillance. An LPN reported being informed by another nurse that the resident had been pushed to the floor, assessed the resident, noted back pain, and arranged for transfer to the hospital. Emergency room records documented that the resident presented with back pain after being pushed by another resident and falling onto his back, with a diagnosis of acute midline thoracic pain. The facility’s abuse policy affirms residents’ rights to be free from abuse and defines abuse as willful infliction of injury or punishment resulting in physical harm or pain.
Inaccurate MDS Coding for Hospice, Restorative Services, and PASRR Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents, contrary to its practice of accurately reflecting services and conditions. For one resident, the DON stated the resident had been assessed for hospice services but was not eligible and had never received hospice care while at the facility, yet the MDS Section O (Special Services) and K1 for hospice on two separate assessments were coded to show hospice care provided in the facility. Another resident was reported by the Restorative Nurse to be currently receiving restorative programming 15 minutes daily for range of motion to upper and lower extremities and bed mobility, but the resident’s MDS Section O for Restorative Nursing Programs documented zero days of passive range of motion services. A third resident’s face sheet listed diagnoses of bipolar disorder, major depressive disorder, schizoaffective disorder, and anxiety disorder, but the annual MDS Section A1500 (PASRR) was coded “no” for being considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. A fourth resident, admitted with type II diabetes, chronic pain, anxiety disorder, vascular dementia, and schizoaffective disorder, had an MDS dated in October that documented a score of 0 (none) under restorative programs, despite restorative documentation from the prior year describing limited range of motion and participation in assisted range of motion to bilateral upper and lower extremities. The Restorative Nurse stated this resident had been receiving restorative services since 2024 and acknowledged the resident should have been coded for restorative services on the October MDS but was not, and the MDS Coordinator stated staff should ensure MDS coding accurately reflects the care provided for these residents.
Failure to Provide Timely Incontinence Care per Facility Policy
Penalty
Summary
The facility failed to follow its incontinence care policy requiring incontinent residents to be checked at least every two hours and provided perineal and genital care after each episode, resulting in a resident not receiving incontinence care for over two hours. The resident’s MDS documented moderate cognitive impairment, a need for substantial/maximal assistance with toileting, and that the resident was always urinary incontinent. During observation, the resident was seen on a sit-to-stand device with the back of his jogging pants wet, a strong smell of urine, and a wet wheelchair cushion; a CNA who was not the assigned aide stated the resident was soiled and saturated with urine and that she was only taking him to be showered. The resident’s medical power of attorney reported that the resident is always left wet. The resident stated he was last changed at 2:00 a.m., and when the CNA removed the adult brief, it was completely saturated with urine, with liquid dripping from the resident’s left hip. The assigned CNA later reported that she last provided incontinence care between 9:00 a.m. and 10:00 a.m., and acknowledged that residents should be checked and changed every two hours and as needed. These observations and interviews show that staff did not provide incontinence care in accordance with the facility’s policy and the resident’s assessed needs for frequent checks and substantial assistance with toileting and continence care.
Failure to Supervise Resident Requiring Assistance While Smoking
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision of a resident who was assessed as requiring supervision while smoking. The resident was admitted with sickle cell disease, COPD, type II diabetes, and major depressive disorder. A smoking safety risk assessment dated 11/13/25 documented that this resident required supervision while smoking, although no specific safety concerns were checked on the form. On 1/13/26 at 1:34 PM, the resident was first observed in the common dining area, while another resident was observed smoking on the patio. Upon reentering, that other resident assisted the resident in question to the outside patio, provided a cigarette, and lit it. The resident then remained outside to smoke without any staff present on the patio or in the dining room monitoring through the window. During an interview on 1/14/26 at 12:42 PM, the Social Service Director stated that smoking assessments are completed on admission and quarterly, and residents are categorized as either needing supervision or being independent. The Social Service Director initially reported that only two residents required supervision and did not include this resident on that list, and could not recall whether this resident required supervision until shown the assessment indicating that supervision was required. The Social Service Director stated that if a resident requires supervision, they should not hold their own smoking materials and that staff or family would hold them; she reported that the resident’s boyfriend or family hold the resident’s smoking materials and acknowledged that staff should be supervising the resident when smoking and that residents should not share smoking materials. The resident later confirmed that staff had told her residents cannot share smoking materials and that she does not have her own smoking materials, obtaining them instead from staff or family. The facility’s smoking safety policy, revised 10/24/22, states it is intended to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member, and visitor.
Failure to Maintain Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
A deficiency occurred when staff failed to follow the facility’s urinary catheter care policy by allowing a resident’s indwelling urinary catheter drainage bag to rest on the floor. The resident had a physician’s order for an indwelling catheter related to neuromuscular dysfunction of the bladder, and the MDS documented the presence of an indwelling catheter. During observation, the resident was seen sitting on the side of the bed eating lunch with the catheter drainage bag on the floor and the privacy bag not fully covering the top portion of the drainage bag. In interviews, a nurse stated the catheter bag should have been attached to the bed frame and not on the floor, and the DON confirmed that indwelling catheter bags should not be on the floor due to infection control concerns. The facility’s written urinary catheter care policy specified that urinary drainage bags and tubing must be positioned so they do not touch the floor directly. This failure to maintain the catheter drainage bag off the floor and properly covered, as required by the facility’s policy and acknowledged by nursing staff and the DON, led to the cited deficiency for not providing appropriate urinary catheter care and not adhering to infection control practices.
Failure to Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility failed to follow its weight assessment and intervention policy by not conducting a required reweight within 24 hours after a significant weight loss was identified for one resident. The resident was admitted with dysphagia, muscle wasting, major depressive disorder, and adult failure to thrive, and had documented weights of 132.5 lbs in October, 132.8 lbs in November, 132 lbs in December, and 120 lbs on January 9, representing a 9.1% loss (12 lbs) from the December 10 comparison weight. Despite this significant unplanned weight loss, no additional weights were documented in the medical record until January 16, when a weight of 118.5 lbs was obtained at the surveyor’s request. The Restorative Nurse reported that weights are taken monthly and reweights are done if there is a large change, but had no other weights for this resident, and the Nurse Practitioner stated she would expect staff to reweigh residents when weight changes occur to confirm accuracy and determine needed interventions. The facility’s undated weight assessment and intervention policy requires that any weight change of 5% or more since the previous assessment be re-taken the next day to confirm and, if verified, that appropriate team members be notified within 24 hours, with a threshold for significant one-month loss defined as 5% or more.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy by not reporting an injury of unknown origin for a resident who was dependent on staff for all Activities of Daily Living (ADLs) and unable to communicate verbally. The resident, who had a history of epilepsy, cerebral palsy, pressure ulcers, falls, and required full staff assistance, was found by a family member to have a black eye and bruising around the left eye. The family member reported the injury to staff, but the administrator stated that staff had witnessed the resident hitting her head on a table, attributing the injury to self-harm. However, the family member disputed this, stating the resident did not exhibit such behaviors. The resident's assessment indicated no documented mood or behavioral issues and a high level of cognitive impairment, making self-reporting impossible. Further investigation revealed inconsistencies in staff accounts. The activity aide who was believed to have witnessed the incident was unsure if the resident had actually hit her head and did not report the incident immediately. The nurse on duty did not document the event or complete the required risk management process, which was only finalized by the DON nearly two weeks later. Multiple staff interviewed could not confirm witnessing the injury or explain its origin. The facility's abuse prevention policy required reporting injuries of unknown source, especially when the source was not observed and the injury was suspicious. Despite this, the injury was not reported to the state agency as required, and internal documentation was incomplete.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy by not initiating and thoroughly investigating an injury of unknown origin for a resident who was dependent on staff for all activities of daily living (ADLs) and unable to communicate verbally. The resident, who had a complex medical history including epilepsy, cerebral palsy, pressure ulcers, a history of falls, and was frequently incontinent, was found by a family member to have a black eye and bruising around the left eye. The family member reported the injury to staff, but the administrator stated that staff had witnessed the resident hitting her head on the table, attributing the injury to self-harm. However, the family member disputed this explanation, stating the resident did not have such behaviors. Further investigation revealed inconsistencies and lack of documentation. The Director of Nursing (DON) indicated that an activity aide reported the incident to a nurse, but the nurse did not document the event or complete a risk management report at the time. The DON later completed the risk management documentation days after the incident. Interviews with staff who worked with the resident around the time of the injury showed that none witnessed the resident hitting her head, and there was no progress note or assessment documenting the injury. The facility's abuse prevention policy required all incidents, including those of unknown origin, to be documented and investigated, but this was not followed in this case.
Failure to Maintain Sanitary and Homelike Environment Due to Unrepaired Leaking Toilet
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment by not effectively repairing a leaking toilet in a shared bathroom used by four residents. A CNA reported observing the leak early in her employment, and the Maintenance Director confirmed that the toilet had been previously repaired but continued to leak, resulting in water damage to the wall extending into the residents' room. During facility tours, surveyors observed a white sheet placed on the floor to absorb water and a puddle of water present in the bathroom, indicating the issue persisted despite reported repairs. Facility records and interviews confirmed that the plumbing fixtures were not maintained in good repair, as required by facility policy and resident rights.
Failure to Maintain Effective Pest Control Program for Flying Pests
Penalty
Summary
The facility failed to maintain an effective pest control program and policy for the treatment of flying pests, specifically affecting two residents. A CNA reported observing bugs in the bathroom shared by two residents and witnessed a flying pest land on one resident's bed while providing care. During a tour of the bathroom with the Maintenance Director, flying pests, identified as gnats, were observed, and a leaking toilet was also noted. The Maintenance Director stated that pest control services the facility twice a month and is available for additional visits if concerns arise, but there was no documentation provided to show that pest control was notified for an as-needed appointment in response to the observed pests. Further observations during lunch revealed the presence of flying pests in the dining room. The facility's entrance consists of automatic doors leading to a foyer and another set of automatic closing doors to the interior. During the survey, the interior doors were observed to be left open, which could allow pests to enter. The facility's pest control policy requires regular and as-needed pest control, as well as environmental measures such as keeping doors closed to prevent pest entry. However, the facility did not adhere to these procedures, as evidenced by the open doors and lack of documentation of pest control notification.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not prevent a resident-to-resident physical altercation involving two residents. One resident, with a diagnosis of schizoaffective disorder and a history of poor impulse control, was identified in the care plan as having the potential to be physically or verbally aggressive, with interventions specified to de-escalate agitation and guide the resident away from sources of distress. The other resident, diagnosed with schizophrenia, was care planned for risk of abuse with interventions to observe the resident when in the company of peers. Despite these care plans, an incident occurred in the dining room where one resident backed into another with a wheelchair, leading to a physical altercation in which both residents struck each other, resulting in minor scratches to one resident's face. Staff were present during the incident and intervened immediately, but the altercation had already escalated to physical contact. Interviews and statements from the residents and staff confirmed that the incident was intentional and not accidental. The facility's abuse prevention policy requires identification of residents at risk for abuse and implementation of interventions to reduce the chances of abuse, as well as ongoing monitoring and updating of care plans. However, the failure to effectively implement these interventions and supervise the residents led to the occurrence of physical abuse between residents.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse by another resident, resulting in a significant incident in the dining room. Early in the morning, a non-verbal resident with a low BIMS score and multiple psychiatric diagnoses, including delusional disorder, schizophrenia, and intellectual disability, stood up from his wheelchair, lost his balance, and fell to the floor. While attempting to get up, he inadvertently grabbed the forearm of another resident who was seated nearby. Startled by the contact, the second resident attempted to pull her arm away, which led to her arm pressing against the first resident's mouth, resulting in a human bite to her right forearm. The incident was witnessed by staff and other residents, who confirmed that the biting occurred quickly as the first resident tried to regain his balance. The injured resident was immediately escorted to the nurse's station, evaluated, and sent to the hospital for further assessment and treatment, which included antibiotics and a tetanus shot. The wound was described as a full-thickness, open area with no signs of infection at the time of evaluation. The biting resident was also assessed and transferred to the hospital for psychiatric evaluation. Prior to the incident, the biting resident had a documented history of physical abuse toward staff and other residents, related to poor impulse control, and his care plan had been revised to reflect these behaviors. The facility's policy affirms the right of residents to be free from abuse and outlines steps for prevention and reporting, including immediate evaluation and separation of residents involved in altercations. Despite these policies and the known behavioral risks, the incident occurred, resulting in physical harm to a resident.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a mechanical lift for a dependent resident transfer, as required by the resident's care plan and facility policy. The resident, who had diagnoses including morbid obesity, right knee pain, and osteoarthritis, requested incontinence care and refused the mechanical lift, insisting on a stand and pivot transfer. The CNA, despite knowing the care plan required a mechanical lift with two staff, complied with the resident's request and performed a stand and pivot transfer alone. After the transfer, the resident complained of right leg pain, which led to the discovery of a non-displaced oblique fracture through the lateral plateau of the right tibia and fibula. The resident was subsequently transferred to the hospital and underwent surgery. Interviews with staff revealed that the CNA was aware of the correct transfer method by referencing the care card and acknowledged that she should have informed the nurse of the resident's refusal and sought assistance. Other staff members confirmed that they follow the care card instructions and notify the charge nurse if a resident refuses the recommended transfer method. The Director of Nursing and Administrator both stated that staff are expected to follow the care plan and report refusals to ensure resident safety. The facility's policy mandates the use of mechanical lifts for residents requiring two-person assistance or who cannot be safely transferred by normal techniques, and staff are trained annually on these procedures.
Failure to Provide and Document Required Foot Care for Resident with PVD
Penalty
Summary
The facility failed to follow its nail care policy by not observing or documenting the condition of a resident's toenails during weekly skin assessments and bathing. Despite the resident's care plan specifying daily foot inspections and reporting of changes, there was no documentation of toenail overgrowth or fungal presence in the resident's records from January to April. Shower sheets and weekly nursing skin assessments lacked any mention of the toenail condition, and some assessments were not documented at all. The resident involved had multiple diagnoses, including Peripheral Vascular Disease, Alzheimer's Disease, hypertension, and chronic kidney disease, and was at risk for skin integrity issues. The resident's toenails became overgrown, thickened, yellow, and developed onychomycosis, with associated pain and subungual debris. The podiatrist had not seen the resident for nine months, despite the facility's process for scheduling podiatry visits and the resident's risk factors requiring regular foot care. The omission was only identified after a family grievance prompted an emergency podiatry visit. Interviews with staff revealed that the resident was not included on the podiatrist's list due to an oversight, and there was no documentation of communication with the family regarding concerns about foot care. The facility's own assessment and nail care policy required observation and documentation of nail conditions, especially for residents with PVD, but these procedures were not followed, resulting in the resident developing significant toenail and foot issues.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to residents who were dependent on staff for assistance, according to the facility's protocol and the residents' preferences. This deficiency was observed in eight out of twelve residents reviewed for showers during March 2025. Residents expressed dissatisfaction with not receiving showers as scheduled, leading to feelings of uncleanliness and discomfort. The facility's documentation was inconsistent, with several instances where there was no record of showers being given or refused. Specific cases highlighted include a resident with hemiplegia and hemiparesis who only received one shower during the month, despite being scheduled for two showers per week. Another resident, dependent on two or more helpers, reported not receiving daily showers as preferred, with documentation missing for several scheduled days. A resident with diabetes and difficulty walking reported not receiving any showers during their stay, despite being scheduled for twice-weekly showers. The Director of Nursing (DON) acknowledged the lack of documentation and confirmed that showers were not consistently provided as per the schedule. The facility's policy requires showers to be offered according to residents' preferences and documented if refused. However, the report indicates a failure to adhere to this policy, resulting in unmet hygiene needs for several residents.
Failure to Follow Two-Person Assist Policy During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure resident safety by not adhering to the policy requiring two staff members to be present during a mechanical lift transfer. This deficiency was highlighted when a Certified Nursing Assistant (CNA) attempted to transfer a resident, identified as R4, using a mechanical lift by herself. The CNA placed the sling on backwards, resulting in the resident sliding out of the sling and onto the floor. Interviews with staff members, including the Director of Nursing and Licensed Practical Nurses, confirmed that mechanical lift transfers are supposed to be a two-person assist, which was not followed in this incident. The resident involved, R4, has a medical history that includes conditions such as morbid obesity, cerebral palsy, and paraplegia, making her highly dependent on assistance for mobility and self-care. Her care plan specifically indicates the need for a mechanical lift with two staff members for transfers. The incident report and staff interviews revealed that the CNA did not request assistance, citing insufficient staffing during night shifts as a reason for performing the transfer alone. The facility's policy on transfers and fall prevention program emphasizes the necessity of using mechanical lifts with two caregivers to ensure resident safety, which was not adhered to in this case.
Failure to Prevent Staff from Accepting Gifts from Resident
Penalty
Summary
The facility failed to adhere to its abuse policy and employee handbook by allowing a staff member, identified as a Certified Nursing Assistant (CNA), to accept gifts from a resident. The resident, who has a history of cerebral palsy, paraplegia, epilepsy, neuromuscular dysfunction of the bladder, and bipolar disorder, reported giving the CNA cash and physical gifts over several months. The resident stated that the gifts were given because the CNA mentioned facing financial hardships, and there was an understanding that the money would be repaid, which did not occur. The resident's mental status was assessed as alert and oriented times three. The facility's investigation revealed that the CNA admitted to receiving physical gifts from the resident but denied accepting any cash. The CNA claimed to have immediately reported the gifts to the management and returned them to the administrator. However, the resident insisted that cash was also given, although there were no receipts to substantiate this claim. The facility's policy prohibits staff from accepting any gifts or money from residents, and the CNA was educated on this policy after the incident. Interviews with the resident's family member and facility staff, including the Social Service Director and Director of Nursing, confirmed the resident's tendency to offer gifts and money to staff. The facility's employee handbook and abuse prevention policy clearly state that accepting gifts or money from residents is prohibited and considered a form of abuse or misappropriation of property. Despite the CNA's denial of accepting cash, the facility's failure to prevent the acceptance of gifts from the resident constitutes a deficiency in protecting the resident's rights and property.
Deficiencies in Food Storage and Refrigerator Maintenance
Penalty
Summary
The facility failed to adhere to its Food Storage Policy by not labeling two bowls of gelatin with the date in the walk-in refrigerator, which could potentially affect 109 residents on an oral diet. During an observation, the Dietary Manager acknowledged the oversight and removed the gelatin. The Dietary Director confirmed that the facility's policy requires all food items to be labeled to determine their freshness. This deficiency was identified during a survey, highlighting a lapse in following established food storage protocols. Additionally, the facility did not maintain personal refrigerators for two residents, R42 and R106, as observed during the survey. Both residents' refrigerators contained multiple unlabeled and undated food containers, and the freezers had thick ice accumulation. The temperature logs for these refrigerators had not been updated since October 21st. Interviews with staff revealed confusion over responsibility for checking and maintaining these refrigerators, with the Maintenance Director admitting to checking them only weekly due to time constraints. The facility's policy mandates daily temperature checks and proper labeling of resident food items, which was not followed in these cases.
Failure to Ensure Resident Safety and Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents. Observations revealed that intravenous medication and hazardous pesticides were left at residents' bedsides, which is against the facility's policy. Specifically, a resident was found with intravenous medication on their bedside table, and another resident had a pesticide spray on their bedside table. Both the Assistant Director of Nursing and the Director of Nursing confirmed that these items should not be left at the bedside, indicating a lapse in adherence to safety protocols. Additionally, the facility did not follow physician orders regarding fall precaution measures for residents at risk of falls. One resident, who had a history of falls and was at risk due to multiple health conditions, did not have a floor mat as ordered by the physician, and their fall care plan was not updated after a fall incident. Another resident, also at risk of falls, did not have the required non-slip material in their wheelchair, and their fall care plan was similarly not updated after a fall. These oversights demonstrate a failure to implement necessary interventions and update care plans based on root cause analysis after fall incidents.
Infection Control Deficiencies in Respiratory Equipment Handling and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices in handling oxygen and respiratory equipment, as well as in performing hand hygiene during resident care. Observations revealed that nebulizer masks were improperly stored, with some hanging from drawers without plastic coverings or dates, and nebulizer machines placed on the floor. Staff members, including the Restorative Nurse and Director of Nursing, acknowledged the improper storage and lack of labeling, which is against the facility's policy that requires respiratory equipment to be stored in plastic bags with the date of the last change. Additionally, staff failed to perform hand hygiene as required by the facility's policy. A Certified Nursing Assistant was observed removing gloves and exiting a resident's room without performing hand hygiene, admitting to forgetting the procedure. The Director of Nursing confirmed that all staff are expected to follow hand hygiene protocols, which include washing hands before and after glove use and when entering or exiting a resident's room. Further deficiencies were noted in the handling of CPAP and oxygen equipment. Several residents' CPAP masks were found uncovered and improperly stored, either on the floor or on bedside tables, without being placed in plastic bags as required. The Director of Nursing and other staff members confirmed that CPAP masks should be cleaned and stored in bags to prevent contamination. The lack of proper labeling and storage of oxygen tubing and canisters was also observed, with staff acknowledging the importance of dating these items to track when they need to be changed to prevent bacterial growth.
Failure to Respond to Call Light and Ensure Resident Privacy
Penalty
Summary
The facility failed to respond promptly to an activated call light for a resident, identified as R33, who was observed lying on her bed and had attempted to contact the facility multiple times. R33's call light was within reach, and she activated it at 10:15 AM. Despite eight staff members passing by her room between 10:15 AM and 10:30 AM, none stopped to check on her needs. R33 had called the facility's main line three times, indicating she had a bowel movement and needed assistance. She expressed distress over her situation, stating she felt undignified and preferred death over her current state. The facility's policy requires call lights to be answered promptly, but this was not adhered to in R33's case. Additionally, the facility failed to ensure privacy and dignity for another resident, R50, when two CNAs entered her room without knocking. Both CNAs admitted to not knocking before entering. The Director of Nursing stated that all staff should knock and wait for a response before entering a resident's room. The facility's policy on dignity emphasizes maintaining residents' dignity by protecting their private space, which includes knocking on doors and requesting permission before entering.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, as observed in two cases. On November 7, 2024, a resident identified as R232 was found yelling for help because their call light was on the floor behind the bed, and they were unable to prevent a water pitcher from spilling. The Licensed Practical Nurse confirmed that the call light should have been within reach. The Director of Nursing also stated that all call lights should be accessible to residents. R232 had a diagnosis of dysphagia and required assistance with personal care, with a care plan emphasizing the need for the call light to be within reach and for prompt responses to requests for assistance. Another resident, R10, was observed in a similar situation on the same day. R10 was lying on their right side in bed, unable to reach their call light, which was on the floor, and requested water. The Assistant Director of Nursing acknowledged the oversight and repositioned the call light and water pitcher within reach. R10 had multiple medical conditions, including a transient ischemic attack, cerebral infarction, Parkinson's disease, and an above-the-knee amputation, which contributed to their limited mobility and need for assistance. The facility's policy requires that call lights be accessible to residents at all times, but this was not adhered to in these instances.
Failure to Accurately Document Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive was accurately reflected in their health records. During an observation, it was noted that the resident's name was not on the active DNR list at the South nurse's station, despite having a signed DNR/POLST form indicating Do Not Attempt Resuscitation. A review of the resident's clinical dashboard and physician's orders showed the resident was listed as full code, which contradicted the signed DNR form. The care plan also indicated full code status, including resuscitation and mechanical ventilation, which was inconsistent with the resident's documented wishes. The Social Service Director confirmed the discrepancy during an interview, acknowledging the absence of documentation indicating any change in the resident's advance directives. The resident's admission record and order summary report also reflected full code status, despite the signed DNR form. The facility's policy on advance directives requires that such directives be documented in the resident's medical record and included in the care plan, which was not adhered to in this case. This oversight could lead to staff mistakenly attempting resuscitation against the resident's wishes.
Improper Use of Low Air Loss Mattress for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to adhere to standard care practices for a resident with a stage 4 pressure ulcer by improperly using a low air loss (LAL) mattress. During an observation, the resident was found lying on their right side on an LAL mattress with a flat sheet and cloth pad, while also wearing a disposable brief. This setup contradicts the facility's standard practice, which requires only a flat sheet over the mattress for residents using LAL mattresses. The Assistant Director of Nursing was unaware of the policy regarding the use of multiple layers of linen with LAL mattresses, and the Director of Nursing confirmed that only a flat sheet should be used. The resident involved was admitted with multiple diagnoses, including a stage 4 sacral pressure ulcer, and was under the care of a wound care physician. The resident's care plan included the use of a pressure-reducing mattress and regular skin assessments, indicating a high risk for developing pressure ulcers. Despite these measures, the facility lacked a specific policy for LAL mattress usage, which contributed to the improper care observed. The facility's policy on pressure ulcer prevention, revised in 2028, outlines the use of specialty mattresses for residents with severe wounds but does not provide specific guidance for LAL mattress usage.
Failure to Follow Physician's Order for Tube Feeding
Penalty
Summary
The facility failed to ensure that the physician's order for tube feeding administration was followed for a resident diagnosed with dysphagia and gastrostomy status. During a facility round, it was observed that the resident's tube feeding bottle was hanging on a pole but not connected to the resident, and the feeding machine was off. The resident mentioned that he receives feeding during the day and that staff usually administers it. A registered nurse confirmed that the feeding should have been on according to the physician's order. The Director of Nursing also acknowledged that the physician's order, which specified the feeding should start at 10 AM, was not followed. The order required the administration of enteral feeding via a pump at 70 ml/hr for 20 hours, starting at 10 AM and stopping at 6 AM. The facility's policy mandates that medications, including tube feedings, are administered as prescribed by the physician.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a survey. On one occasion, a medication cart in the East side hallway was found open and unattended with keys attached to the cart lock. A Licensed Practical Nurse (LPN) acknowledged that medication carts should be locked when not in use and that keys should be handed over to another nurse if the nurse on duty takes a break. Additionally, the LPN opened the cart to reveal three medication cups with pre-poured, unlabeled medications, which is against the facility's policy that prohibits pre-filled medication cups being left inside the cart. Further observations revealed that the medication room refrigerator was unlocked, despite containing controlled substances that require refrigeration. The Director of Nursing confirmed that medication cart keys should not be left on the cart and that medication room refrigerators should be locked at all times. The facility's policies clearly state that medications and biologicals must be stored securely and that controlled substances requiring refrigeration should be kept in a locked box within the refrigerator. These lapses in following the facility's policies led to the deficiency noted in the survey.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent a resident, identified as being at moderate risk for skin breakdown and totally dependent on staff for all activities of daily living, from developing three facility-acquired pressure ulcers. The resident, who had a history of quadriplegia, colostomy, and a stage 2 pressure ulcer on the left hip upon admission, developed unstageable pressure ulcers on the coccyx, right hip, and right lateral foot. Additionally, the existing stage 2 pressure ulcer on the left hip deteriorated to an unstageable wound. The facility did not provide the necessary care and services to promote healing of the existing wound upon admission. The Wound Care Nurse (V4) was responsible for assessing residents' skin on admission and implementing preventative measures. However, there was no documentation of weekly skin observations for the resident on certain dates, and the facility's policy for skin assessment and monitoring was not followed. The Wound Care Nurse Practitioner (V5) ordered a CRP level due to a new wound, but was not informed of the elevated result. The Director of Nursing (V2) noted the resident's noncompliance with turning and offloading heels, but there was no documentation of this noncompliance or notification to the resident's power of attorney until a care plan was initiated. The resident's treatment administration records lacked documentation of dressing changes on multiple occasions, and there were no physician orders for wound care treatments for the newly identified wounds until much later. The facility's policy required weekly assessments and documentation of changes, but these were not consistently completed. The facility's failure to adhere to its own policies and procedures contributed to the deterioration of the resident's wounds and the development of new pressure ulcers.
Neglect of Residents by CNA
Penalty
Summary
The facility failed to prevent neglect of two residents, R3 and R4, by a Certified Nursing Assistant (CNA), identified as V4. R3, who is dependent on staff for activities of daily living due to conditions such as osteoarthritis, morbid obesity, and chronic respiratory failure, reported being left in soiled incontinence briefs for multiple hours. This neglect caused severe discomfort and burning sensations in areas of open skin. R3's call for assistance was ignored by V4, prompting R3 to contact the front desk and a family member for help. R3 also reported that V4 was confrontational and rough when care was finally provided, and did not return to the room for the remainder of the shift. R4, the roommate of R3, is also totally dependent on staff for all activities of daily living and is incontinent of bowel and bladder. R4 confirmed witnessing the interaction between R3 and V4 and stated that V4 did not return to provide incontinence care for the entire shift. R4 expressed feelings of neglect and being unappreciated. Documentation reviewed for the date in question showed no record of incontinence care being provided to either resident during the shift in question. The facility's policy on abuse prevention and reporting defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or mental anguish. Despite the facility's zero-tolerance policy for abuse and neglect, the incident was not initially investigated as neglect. The Administrator in Training, V2, was informed of the complaint but did not speak with R4 or other residents to assess if others were experiencing similar neglect. The grievance form filed did not elaborate on the nature of the concern, and no progress note was available in the health record.
Call Light System Malfunction Affects 26 Residents
Penalty
Summary
The facility failed to ensure that the call light system was operational, affecting 26 residents on the North Hall Unit. A resident reported activating the call light from bed and experiencing a delay in response, later being informed by staff that the system was malfunctioning. The call lights were not operational until the following day. The Maintenance Director confirmed that the call light system was down for the entire building and was not notified of the issue until the morning after it occurred. The system's failure was attributed to older systems being affected by storms or power surges, requiring a manual reset. The Wound Care Coordinator and the Administrator in Training were aware of the call light system's malfunction over two days. A work order maintenance binder indicated requests for repairs on both days, but the facility could not provide documentation on the duration of the outage or how staff managed residents' needs without the system. The facility's call light policy requires defects to be reported promptly to the Maintenance Department, with frequent room checks until repairs are completed.
Failure to Investigate Allegation of Abuse and Neglect
Penalty
Summary
The facility failed to investigate an allegation of abuse and neglect involving two residents. One resident, who is dependent on staff for activities of daily living, reported an incident where a CNA failed to respond to their call light, resulting in discomfort due to incontinence. The resident described the CNA as confrontational, rude, and rough with care, and stated that the CNA did not return to provide care for the remainder of the shift. The resident's roommate, who is also dependent on staff, confirmed witnessing the interaction and the lack of care provided by the CNA. The facility's Wound Care Coordinator received a complaint from the resident and reported it to the Administrator in Training, who spoke with the resident but did not interview the roommate or other residents. The Administrator in Training relayed the information to the Administrator, who did not investigate further as the concern of neglect was not communicated. The facility's policy requires immediate protection of residents and timely investigation of allegations, which was not followed in this case.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, was treated with dignity and respect, as evidenced by the resident's unfulfilled request to be put to bed by 8 PM. R5, who has no cognitive impairment, expressed that she was very tired by 8 PM and had repeatedly asked a Certified Nursing Assistant (CNA), identified as V13, to assist her to bed at that time. However, R5 reported that V13 consistently ignored her request and instead put her to bed around 9:30 PM, which made R5 feel upset and disrespected. Interviews with the CNA, V13, revealed that V13 could not recall the exact time R5 was put to bed, despite confirming that R5 was alert and able to verbalize her needs. Another CNA, V10, noted that R5 was particular about her care and that she followed R5's directions regarding her care needs. The Director of Nursing, V2, acknowledged that residents should be treated with dignity and respect, and their preferences should be honored. Additionally, Resident Council Minutes indicated that CNAs were generally good but sometimes ignored residents' requests. The facility's policy on dignity emphasized the importance of maintaining or enhancing each resident's dignity and respecting their individual needs and preferences.
Delayed Ultrasound for Resident with Leg Swelling and Pain
Penalty
Summary
The facility failed to ensure a venous doppler ultrasound was performed in a timely manner for a resident with a history of chronic pulmonary embolism. The resident reported swelling and pain in her legs on a Friday, and a nurse ordered a stat ultrasound on Saturday. However, the ultrasound was not performed until the following Tuesday, despite repeated calls to the ultrasound company. The delay in performing the ultrasound resulted in the resident being sent to the hospital after the test confirmed a blood clot in her leg. The facility's electronic medical record (EMR) lacked documentation of the physician or nurse practitioner being notified of the resident's condition, the order for the ultrasound, or the delay in performing the test. The Director of Nursing acknowledged the absence of a policy on timeframes for specific testing and the lack of documentation in the EMR. The nurse practitioner expected the ultrasound to be done immediately and to be informed if it was not performed within four hours, which did not occur.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident by not using a gait belt, which is a required safety measure according to the resident's care plan. The incident involved a female resident with multiple health issues, including difficulty walking and reduced mobility. During an observation, a Certified Nursing Assistant (CNA) assisted the resident in standing up from the bed without using a gait belt. The resident, who was unsteady and holding onto the bed rail and wheelchair arm, fell to the floor as she attempted to turn. The resident's care plan, dated June 2024, indicated that she was at risk for falls and required substantial assistance for transfers, including the use of a gait belt. The facility's Fall Prevention Program Policy also mandated the use of transfer conveyances in accordance with the care plan. Despite these guidelines, the CNA did not use a gait belt during the transfer, leading to the resident's fall. Interviews with facility staff confirmed that the use of a gait belt was standard procedure for transferring this resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered properly and not left at the bedside, affecting one of the three residents reviewed for medication administration. On September 6, 2024, a medication cup with three pills was found on the bedside table of a resident who was not present in her room. The resident's roommate confirmed that nurses frequently leave medications at the bedside, raising concerns about the potential for others to take the medications. A Certified Nursing Assistant noted that the resident is hard of hearing and forgetful, which may contribute to the issue. A Licensed Practical Nurse, responsible for the resident's care on the day of the incident, admitted to leaving the medications at the bedside and incorrectly charting that they had been administered. The resident's care plan did not indicate that she was capable of self-administering her medications. The Director of Nursing confirmed that medications should not be left at the bedside and that staff should ensure residents take their medications before leaving the room. The facility's Pharmaceutical Services Policy emphasizes the need for assistance with medication administration as needed or requested.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R1, who was cognitively intact and always incontinent. On the day of the incident, R1 was found soaked with urine, with her pants and wheelchair pad saturated, and her skin reddened with indentations from the brief. R1 reported not receiving incontinence care since 6:00 am, despite requesting assistance around noon, which was ignored by the assigned CNA, V19. Both CNAs, V8 and V9, confirmed that R1 should have been changed every two hours and as needed, and R1 had never refused care. The resident's care plan indicated that incontinence checks and changes should occur upon waking, before and after meals, and at bedtime. The Resident Council Meeting Minutes from April and May 2024 also documented complaints about CNAs not changing residents in a timely manner. The Assistant Director of Nurses, V2, stated that staff are expected to check residents every two hours and change linens if they are wet, to maintain dignity and prevent skin breakdown. The facility's incontinence care policy, revised in April 2021, emphasized the importance of regular checks to prevent skin issues and maintain resident dignity.
Failure to Implement CDC COVID-19 PPE Guidelines
Penalty
Summary
The facility failed to implement CDC practices for COVID-19 by not ensuring the appropriate use of personal protective equipment (PPE) for residents on contact/droplet precautions and in isolation. This deficiency affected two residents, R10 and R11, who were reviewed for infection control. R10 was documented as COVID-19 positive and required strict isolation with droplet and contact precautions. However, observations revealed that R10's door, which was supposed to remain closed, was left slightly open. Additionally, R11, who was not wearing the required face shield, was observed visiting R10 in the isolation room, despite the signage indicating that only essential personnel should enter. The Assistant Director of Nursing (ADON) acknowledged that R10's door should have been closed and that R11 should not have been in R10's room. R11 was informed that visiting R10 would require her to be placed in a semi-private room, which she declined, opting to wait until R10 was off isolation. Despite being offered a face shield, R11 refused to wear it. The facility's infection control policy and signage required full PPE, including an N95 mask and eye protection, which were not adhered to in this instance.
Inadequate Supervision Leads to Falls and Elopement
Penalty
Summary
The facility failed to adequately monitor and supervise a resident with cognitive impairment, identified as a high fall risk, resulting in two unwitnessed falls. The resident, diagnosed with Vascular Dementia and Altered Mental Status, had a history of falls and required substantial assistance with transfers. Despite these needs, the resident attempted to self-transfer and fell, resulting in a subdural hematoma and a hematoma on the forehead. Interviews with staff revealed that the resident was forgetful and often attempted to perform tasks without assistance, despite being advised to wait for staff help. Another deficiency involved the facility's failure to prevent a resident with Alzheimer's disease and a history of exit-seeking behaviors from eloping. The resident, who required 24/7 supervision, was found a mile away from the facility, confused and inadequately dressed for the cold weather. The resident's care plan indicated a risk for elopement, but staff were not adequately informed or prepared to monitor and prevent such incidents. The facility's alarm system failed to alert staff, and there was no documentation of monitoring the resident's location or wandering behavior. Interviews with staff highlighted a lack of communication and awareness regarding the resident's elopement risk. The nurse on duty was unfamiliar with the resident's needs, and the social service director was unaware of specific monitoring interventions. The maintenance director confirmed that the door alarms were not functioning as intended, and there was no documentation of daily checks for the week of the incident. These failures in supervision and monitoring contributed to the resident's unauthorized exit from the facility.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to adhere to its incontinence care policy for a resident diagnosed with vascular dementia, hemiplegia, and hemiparesis following a cerebral infarction. The resident, who was assessed as cognitively intact and dependent on staff for toileting hygiene, was found cold, wet, and uncomfortable in urine. The care plan for the resident indicated bowel and bladder incontinence, with instructions to check and change per facility protocol and assist with toileting as needed. On the morning of the incident, the resident reported that the last incontinence care was provided during the night shift, and no care had been given during the day shift. A Certified Nursing Assistant (CNA) admitted to not having provided care yet, citing a usual routine of changing the resident after breakfast and a history of the resident refusing care. However, the resident did not refuse care on that day and typically informs staff when a change is needed. The Director of Nursing confirmed that incontinence care should be provided every two to three hours, but documentation showed care was last provided at 2:47 AM, indicating a lapse in care provision.
Failure to Follow Physician Orders and Pharmacy Recommendations for Keppra Administration
Penalty
Summary
The facility failed to adhere to physician orders and pharmacy recommendations regarding the administration of Keppra for a resident diagnosed with seizures. The resident was admitted with a diagnosis of seizures and had an active physician order for weekly monitoring of Keppra levels. However, the medical record did not document any Keppra levels apart from a nontherapeutic level recorded on 4/19/24. The attending medical doctor confirmed that the Keppra levels were expected to be monitored weekly to ensure therapeutic levels, as subtherapeutic levels could increase the risk of seizures. Additionally, the facility did not follow pharmacy recommendations regarding the administration of Keppra tablets. Despite the pharmacy's advice against crushing the tablets due to potential effects on absorption and potency, nurses were observed crushing all of the resident's medications, including Keppra, and administering them with applesauce. The pharmacist confirmed that crushing the medication could affect its absorption and efficacy. This failure to follow both physician orders and pharmacy recommendations represents a deficiency in the care provided to the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
