Serenity Estates Of Lincolnshire
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincolnshire, Illinois.
- Location
- 150 Jamestown Lane, Lincolnshire, Illinois 60069
- CMS Provider Number
- 146028
- Inspections on file
- 43
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at Serenity Estates Of Lincolnshire during CMS and state inspections, most recent first.
A resident with dementia, psychotic disturbance, and a documented history of fleeing and elopement was assessed as high risk for elopement but was able to leave a locked unit, pass another unit’s nurse station, and exit through a fire door without staff intervention. At the time the exit alarm sounded, assigned staff were occupied on other units, and no staff were present on the unit from which the resident exited. The resident then walked through the courtyard and parking lot, crossed a busy four-lane road, and was later found by staff in a nearby shopping center parking lot after traveling an estimated 1,000 feet, stating she believed she was going home and going to a family birthday party.
The facility failed to schedule sufficient overnight nursing staff to meet its own facility assessment standards, resulting in three nurses covering seven units with nurse-to-resident ratios as high as 1:44 and three CNAs covering four units with approximately 20 residents each. On the reviewed overnight shift, one LPN was assigned to three units totaling 42 residents, one RN to three units totaling 41 residents, and another RN to two units totaling 44 residents, all above the assessment’s maximum ratio of 1:30 for licensed staff. Three CNAs were assigned across four units, each responsible for about 20 residents, exceeding the assessment’s maximum ratio of 1:18 for certified staff, while three other units each had a single CNA with 20 or more residents. A CNA reported that splitting four units among three CNAs was normal practice and noted difficulty monitoring multiple distant units, and the HR Director confirmed the longstanding staffing pattern and acknowledged that one unit could use a full-time nurse on all shifts.
A resident with multiple chronic conditions, including CKD, morbid obesity, gait abnormalities, depression, and anxiety, reported to her insurance case manager and later to staff that a CNA repeatedly called her “big” and “fat,” which she found abusive. She stated she had informed several CNAs and an LPN about these comments. The Administrator and identified staff denied receiving any such report, while another CNA acknowledged that the resident had told her about being called “fat” and feeling abused but admitted she did not report the allegation to anyone. This failure to report occurred despite a facility policy requiring all abuse allegations, regardless of source or severity, to be immediately reported and investigated.
Two residents with multiple chronic conditions, mobility limitations, and cognitive communication deficits reported that a CNA made demeaning comments about a resident’s weight, was rough and aggressive during care, jostled a resident "like a piece of meat," restricted a resident’s access to his remote and meals outside his room, and complained about assisting with leg positioning. The administrator stated she had not received prior reports of verbal abuse or rough care, yet time records showed the accused CNA continued working multiple shifts after these allegations arose, instead of being immediately removed from duty as required by the facility’s abuse policy.
A cognitively impaired, high elopement-risk resident with dementia, altered mental status, and multiple safety risk factors eloped from the facility in a wheelchair after an exit door alarm sounded during the night. Staff turned off the alarm, briefly checked outside, and inconsistently reported whether a full head count was completed or communicated to the nursing supervisor, who stated she was never notified of the alarm and did not perform a head count. The resident, whose wandering risk was documented but whose photo was not included in the facility’s wandering "Walkers" binder, was later found by police about a block away, disoriented, very cold, in urine-soaked clothing, and without appropriate winter gear. EMS documented cold exposure and hypothermia, and the ED later recorded a low rectal temperature before discharge. Interviews and record review showed the facility did not follow its elopement policy, did not effectively respond to the door alarm, and failed to ensure all residents were accounted for, resulting in the resident’s unsupervised exit and cold exposure.
The facility failed to ensure ordered medications were available and administered as prescribed for several residents. One resident repeatedly missed doses of ordered ophthalmic ointment and cough medication because they were not available, and an RN reported the eye ointment had not been on hand for weeks, yet she documented it as given based on a family supply. Another resident, who returned from the ER with a painful tongue injury, did not receive any doses of a prescribed compounded mouthwash, which pharmacy records show was never delivered. A third resident missed multiple bedtime doses of prazosin ordered for dreams, with documentation indicating the drug was still on order. The DON acknowledged that medications should be reordered with 2–3 days’ supply remaining and that residents should not go without ordered medications, as reflected in the facility’s medication administration policy.
Two residents did not receive multiple ordered doses of critical medications when drugs were not available and remained "on order." One resident with a history of pulmonary embolism missed several doses of enoxaparin 100 mg SQ BID, and reported that the facility frequently ran out of her medications. Another resident with a seizure disorder missed several doses of levetiracetam 500 mg (three tablets BID) because the medication was not available. The NP confirmed both medications were prescribed to prevent serious conditions and stated she was not notified of the missed doses, while the DON and facility policy indicated medications should be reordered with 2–3 days’ supply remaining so residents do not go without ordered medications.
A resident with an acute cough had a respiratory viral panel ordered by an NP, who entered the order into the computer and informed nursing staff, but the test was never completed. The DON later confirmed there was no documentation that a specimen was collected, no lab requisition was found, and no evidence the sample was sent to the lab, despite facility policy requiring nursing staff to carry out ordered lab tests and ensure results are obtained.
A resident with an acute cough and a history of chronic bronchitis and pneumonia had a STAT chest x-ray ordered by an NP, who entered the order into the computer and informed nursing staff. The DON reported that the facility’s protocol requires nursing staff to call the x-ray provider for STAT orders, which are typically completed within hours with same-day results, but no documentation or evidence of the x-ray being performed or results received could be found. This failure to carry out the STAT radiology order did not follow the facility’s policy requiring timely provision or procurement of ordered diagnostic services.
A resident with dementia and limited English proficiency, whose records specified Mandarin as the preferred language and a need for an interpreter, experienced a fall and later developed left hip and left elbow fractures. Staff and EMS reported that no formal translation services were used and that staff relied on English and interpreting the resident’s moans, including a repeated word later identified by family as meaning “ouch.” A night LPN found the resident on the floor, documented no pain, gave acetaminophen “just in case,” and moved her, but the fall note was entered more than two days later. The oncoming RN was told only that the resident was in pain, obtained stat X‑rays, and the NP was not informed of a recent fall at the time of consultation. EMS and hospital records documented fractures and noted that staff reported the fall had occurred several days earlier. These actions and omissions, including lack of effective communication, incomplete post‑fall assessment, and delayed documentation, led to the resident experiencing pain and a delay in treatment.
A resident with dementia, prior fracture, osteoarthritis, and spinal conditions experienced two documented falls, including one from bed with head impact and another where the resident was found on the floor and later diagnosed with a left hip and elbow fracture. In both events, nursing staff delayed or failed to notify the resident’s family and the NP, despite facility policy requiring immediate notification of physician and family after any fall. The daughter/POA reported learning of each fall well after the events, and both the DON and NP confirmed that timely notification is expected so they can be aware of changes and make informed decisions.
A resident with multiple serious diagnoses experienced respiratory distress and was unable to reach staff for 45 minutes, ultimately calling 911 for help. Emergency responders found the resident in distress with low oxygen saturation and no staff present for at least 10 minutes after their arrival. Documentation showed no recent vital signs or assessments, and staff interviews confirmed delayed response and lack of awareness of the resident's condition.
Two residents requiring substantial staff assistance for incontinence care and toileting did not receive timely support, resulting in prolonged periods without being changed or toileted. One resident remained in soiled bedding for hours despite repeated requests, while another, cognitively impaired, was left in a wheelchair for an extended period without incontinence care, contrary to facility policy.
A CNA transferred a resident alone using only a gait belt, despite the resident's updated care plan requiring a mechanical lift with two staff due to increased weakness. The CNA was unaware of the change in transfer status after returning from leave, leading to a transfer that did not follow the resident's current safety requirements.
Several residents requiring substantial assistance with ADLs and incontinence care did not receive timely care or medication administration due to insufficient nursing staff. Staff interviews and observations revealed that CNAs and nurses were stretched across multiple units, resulting in delayed incontinence care and late medication passes, contrary to facility policy and care requirements.
Staff failed to administer and document medications as ordered for three residents, including missed doses of an antifungal for a resident with a skin rash and late administration of scheduled medications for two other residents. The DON confirmed that undocumented medications were not given, and facility policy requires timely and accurate medication administration and documentation.
Two residents did not receive their scheduled medications at the ordered times, with doses administered more than one hour late by nursing staff. This resulted in a medication error rate of 20%, surpassing the facility's acceptable threshold, as confirmed by the DON and facility policy.
Two residents with PICC lines did not receive timely dressing changes or proper labeling of IV tubing, as required by facility policy. Staff demonstrated inconsistent knowledge and practices regarding the frequency of dressing and tubing changes, and documentation was lacking for required procedures. These failures resulted in missed dressing changes and unlabeled IV tubing for residents receiving IV antibiotics.
Two residents did not receive scheduled IV antibiotics as ordered because the medication was not available, and staff documented the missed doses and contacted the pharmacy, but the medication was not administered as required by physician orders and facility policy.
A resident's family member filed a grievance regarding care concerns, but the facility failed to maintain the written grievance and did not follow its policy for tracking and resolving grievances. The grievance form was submitted to the receptionist and placed in the DON's mailbox, but was not found in facility records, and staff could not account for its whereabouts. This resulted in a failure to honor the resident's right to voice grievances without discrimination or reprisal.
A dependent resident with severe cognitive impairment and multiple medical conditions was not safely positioned during a meal, resulting in her contracted shins being pressed against the edge of a dining table. This improper positioning led to linear, reddened wounds on both shins, as observed by the wound care nurse. The care plan did not address the skin concerns from the incident, and the facility's policy to provide a safe environment and prevent skin injuries was not adequately followed.
Surveyors found that food items in storage were not properly labeled, dated, or sealed, including opened bags of vegetables, hot dogs, and rice, as well as an improperly closed tub of ice cream. A dietary aide was observed with hair not fully restrained by a hair net, and a sanitation bucket was found to contain soap instead of sanitizer, failing to meet required concentration levels. These actions did not comply with facility policies for food safety and hygiene.
Two residents did not receive proper pressure ulcer prevention interventions as required by their care plans and physician orders. One resident's low air loss mattress was set incorrectly, leading to the development of a new pressure ulcer, while another resident did not have both feet properly offloaded despite multiple wounds and immobility. Staff failed to consistently follow established protocols for pressure ulcer prevention and management.
A resident with multiple medical and psychiatric conditions, including paraplegia and nicotine dependence, was allowed to smoke unsupervised in the courtyard on several occasions, despite requiring substantial assistance for daily activities. The resident kept cigarettes and a lighter accessible in her room and was observed calling for help with shaky hands while smoking, with no staff present to assist. Another resident was able to access her smoking materials, and staff did not respond to her distress, contrary to facility policy and the DON's statements regarding supervision and safety.
A resident with a history of malnutrition and special dietary needs was not served lunch while others at her table were eating. Staff served meals in a random order and failed to notice the omission until another resident brought it to their attention. The resident remained without food for an extended period, despite having a meal ticket indicating her required diet.
Three residents were found with medications left in their possession or self-administering without nurse supervision, including oral pills and topical cream, despite not being assessed or care planned for self-administration. Staff confirmed that no residents on the unit were authorized for self-administration, and a pill was also found unattended in a dining area.
Staff failed to consistently wear required PPE, such as gowns and gloves, when providing direct care to multiple residents on enhanced barrier precautions due to wounds. In several cases, CNAs provided wound care, hygiene, and linen changes without proper PPE, and soiled linens were carried without being bagged, contrary to facility policy and care plans.
A resident with dementia and high fall risk was found on the floor with her arm trapped between a bed rail and mattress, resulting in a comminuted humerus fracture. Staff provided inconsistent supervision and did not individualize fall interventions, and the bed rails were installed with a gap wide enough for entrapment, contrary to facility policy. The resident's care plan relied on reminders to use the call light, despite her cognitive deficits and history of not using it.
A resident with an LVAD did not receive daily sterile wet kit dressing changes as ordered, and staff used inappropriate supplies and monitoring methods, including missed dressing changes and use of an automatic blood pressure machine instead of manual checks. Documentation and staff interviews confirmed multiple lapses in following prescribed LVAD care and monitoring protocols.
A facility failed to assess and monitor a resident's skin integrity and did not obtain a physician's order for wound care. The resident, with a history of multiple health issues, was found with reddened areas and scabs on her forearm, but no documentation or treatment orders were present. The Wound Nurse had not noted any issues in a prior assessment, and the DON emphasized the need for treatment orders and documentation, as per facility policy.
A resident with a hearing impairment was excluded from her care plan meeting, despite being cognitively intact and able to express her needs. The facility's social services staff discussed her care with her daughter without her consent, citing HIPAA concerns. The resident had explicitly requested to be included in all meetings, and the facility's policy mandates resident participation in care planning.
The facility did not provide pressure relieving mattresses for two residents with severe pressure ulcers, despite having orders for such equipment. One resident had a Stage 4 ulcer on the sacrum and a Stage 3 ulcer on the ischial tuberosity, while another had a Stage 3 ulcer on the sacrum. The wound care nurse confirmed the need for low air loss mattresses, which were not supplied, contrary to the facility's policy on pressure ulcer management.
A resident with severe cognitive impairment and a history of wandering fell in the hallway due to inadequate supervision. The resident, who required supervision for walking, was found with a bruise on her forehead after the fall. At the time, only one RN was present on the unit, as other staff were unavailable, leading to insufficient supervision.
A resident with stomach cancer experienced severe pain due to the facility's failure to manage her Norco medication supply. Despite the facility's policy for timely medication refills and access to emergency medication, the resident faced delays and had to seek specific nurses for assistance. The resident's medical records confirmed a gap in receiving Norco, highlighting ongoing issues with medication availability and administration.
A facility failed to administer a resident's prescribed Flonase nasal spray due to it being unavailable. The medication was not given on multiple occasions, and it was incorrectly marked as administered once. An LPN discovered the issue and learned from the pharmacy that the medication was not sent because an over-the-counter form was missing. The DON stated that timely follow-up on unavailable medications is required, as per facility policy.
A facility failed to obtain physician orders for a resident upon admission, despite the presence of wounds. An LPN admitted to not calling a provider for necessary wound care orders, and the DON confirmed that the protocol requires obtaining appropriate orders upon admission. A review showed no active orders for wound care were entered, contrary to the facility's policy.
A resident admitted with wounds did not receive appropriate wound care assessment and treatment. The LPN did not change the resident's dressing upon admission, and the facility failed to follow its wound care protocol. The Wound Nurse was not contacted for recommendations, and no wound care orders were obtained from the physician. The resident's TAR lacked documentation of wound care, and the admission assessment was incomplete.
A resident with severe cognitive impairment and a history of falls was not adequately supervised while ambulating, leading to a fall and serious injuries. Despite the care plan requiring supervision and assistance, the resident was found on the floor after an unwitnessed fall, resulting in a subarachnoid hemorrhage and a subdural hematoma.
The facility failed to conduct quarterly care plan conferences for three residents, leading to a deficiency in care planning. One resident reported never having a conference, and another's son requested one due to dissatisfaction with care. Documentation was delayed or missing, and the facility did not adhere to its policy supporting resident participation in care planning.
A facility failed to implement contact isolation precautions for a resident with scabies, leading to potential cross-contamination. The resident was not isolated, and a communal shower room was not disinfected after use. Housekeeping staff did not wear required PPE when cleaning isolation rooms. The facility lacked a specific scabies prevention policy during a change in ownership.
A resident with dementia and aggressive behaviors attacked another resident, causing a facial fracture. The incident occurred when the aggressive resident was left unsupervised, despite known risks. The injured resident was hospitalized for treatment.
A resident reported an alleged sexual abuse incident to a CNA, who failed to immediately report it to the appropriate authorities as required by the facility's policy. The Director of Nursing confirmed that all abuse allegations should be reported to the Administrator or the DON, but this protocol was not followed, resulting in a delay in reporting and investigation.
A resident left the facility on a community pass without staff awareness or a physician order. The receptionist did not inform the nursing staff, and the resident was reported missing later that evening. The resident was found safe the next day.
The facility failed to ensure medications were administered according to professional standards for two residents. One resident's medications were left on a table while he was asleep, and another resident's medications were left on her bedside table at her request, including a controlled substance and blood pressure medications. The facility's policy requires that medications be administered in a safe and timely manner, which was not followed.
Elopement of High-Risk Resident from Secured Unit and Facility Grounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively impaired resident with a known history of elopement did not elope from the building and grounds. The resident had multiple psychiatric diagnoses, including unspecified dementia with psychotic disturbance, anxiety disorder, major depressive disorder, paranoid personality disorder, and altered mental status. Prior hospital and psychiatric records documented worsening agitation, paranoid delusions, and a behavior of fleeing and escaping from home, including an incident where the resident escaped from home and was missing for several hours until found by police. The facility’s own elopement risk assessment identified the resident as high risk for elopement due to recent wandering outside the room and paranoid delusions, and the care plan noted the resident as an elopement risk with an intervention focused on distraction through activities, food, conversation, and similar diversions. Despite this known risk, the resident was able to leave a locked unit, traverse another unit, and exit the facility through a fire exit door without staff intervention. On the night of the incident, the LPN assigned to the locked unit and other units reported that the resident was initially observed sleeping during rounds and that she then left the locked unit at approximately 3:30 a.m. when the unit door alarm sounded. The resident passed the 400 unit nurse’s station and reached a fire exit door at the end of the hall. At the time the exit door fire alarm went off, the CNA assigned to the 300 unit was providing care to another resident and was not on the 400 unit, and the RN who later responded to the main door alarm was on the 200 unit, not on the 400 unit from which the resident exited. The facility’s nursing schedule for that night showed only one CNA and one RN scheduled to cover the 400 unit, and neither was present on that unit when the resident exited. The fire exit door was equipped with an alarm system that, according to the Maintenance Director, locks for 15 seconds once an attempt is made to open it, with the alarm sounding immediately and remaining on until disarmed. Nonetheless, the resident was able to open this door and leave the building. After exiting, the resident walked through the rear courtyard, through the facility parking lot, and then crossed a busy four-lane road to a nearby shopping center parking lot. Staff later found the resident there, dressed in dark clothing, after an estimated travel distance of approximately 1,000 feet from the fire exit door. The resident expressed to staff that she believed they were taking her home and stated she wanted to go to her granddaughter’s birthday party. The facility Administrator expressed concern about the distance the resident was able to travel, noting that the resident is a strong “power walker.” The Immediate Jeopardy was determined to have begun when the resident exited the secured unit and left the facility unsupervised, traveling off the premises before being located by staff.
Overnight Nurse and CNA Staffing Ratios Exceed Facility Assessment Standards
Penalty
Summary
The deficiency involves the facility’s failure to adequately schedule nursing staff on the overnight shift to ensure all seven units were appropriately covered, in accordance with its own facility assessment staffing ratios. Facility records show a census of 128 residents and an established overnight staffing pattern of three nurses and six CNAs for seven units. On a reviewed overnight schedule, one LPN was assigned to the 700 unit, the 100 unit, and half of the 200 unit, covering a total of 42 residents, resulting in a nurse-to-resident ratio of 1:42. Another RN was assigned to the 300 unit, the 400 unit, and the other half of the 200 unit, covering 41 residents at a ratio of 1:41. A third RN was assigned to the 500 and 600 units, covering 44 residents at a ratio of 1:44. These ratios exceeded the facility assessment’s stated maximum overnight licensed staff ratio of 1:30. The same overnight schedule showed that three CNAs were assigned to cover the 100, 200, 300, and 400 units, with each CNA responsible for approximately 20 residents, exceeding the facility assessment’s stated maximum overnight certified staff ratio of 1:18. Each of the 500, 600, and 700 units had one CNA assigned, with unit censuses of 20 or more residents each. In an interview, a CNA stated that it was normal practice to split four units among three CNAs so that each CNA had about 20 residents, and noted that having one CNA per unit would be better due to the distance between units and the inability to see what was happening on another unit while present on one. The Human Resources Director confirmed that the current staffing pattern had been in place for some time and acknowledged that the 400 unit could use a full-time nurse on all shifts, but stated that staffing decisions were not within their authority. The facility assessment, updated earlier in the month, specified that it should be used to determine direct care staffing needs for day-to-day operations, including nights and weekends, using evidence-based, data-driven methods.
Failure to Report Resident’s Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of verbal abuse to the abuse coordinator for one resident. The resident was recently admitted with multiple diagnoses including chronic kidney disease stage 3, gait and mobility abnormalities, depression, anxiety disorder, cognitive communication deficit, morbid obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. A facility assessment showed she was cognitively intact, had no range of motion impairment, used a walker and wheelchair for mobility, and required substantial/maximal assistance with most ADLs. During a visit, the resident’s insurance case manager reported that the resident, who is overweight and sensitive about her weight, stated that a CNA had verbally abused her by calling her “fat” and “big” on several occasions, and that this upset her. In a subsequent interview, the resident stated that on her first day in the facility the CNA told her “You’re so big,” and on days three, four, and five the CNA told her “You’re so fat.” She reported that she told two CNAs and an LPN about these comments but did not recall if she told anyone else. The Administrator stated she had been in communication with the resident since admission and had not received any reports of verbal abuse from the resident or staff. The CNAs and LPN identified by the resident denied that the resident had reported these comments to them. Another CNA later reported that a couple of weeks earlier the resident had told her that the same CNA was calling her “fat,” that the resident felt abused, and that the CNA had not apologized. This CNA acknowledged she did not report the allegation to anyone, despite knowing she should report when someone says they are being abused. The facility’s abuse policy required that all allegations, regardless of source or perceived severity, be immediately reported, thoroughly investigated, and addressed, but this did not occur in this case.
Failure to Immediately Suspend CNA After Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to immediately suspend a CNA who was the subject of abuse allegations, as required by its abuse policy. One resident with multiple chronic conditions, including chronic kidney disease, gait abnormalities, morbid obesity, and cognitive communication deficit, but assessed as cognitively intact, reported to an insurance case manager that a CNA had verbally abused her by calling her “fat” and “big” on several occasions. In a subsequent interview, the resident stated that on her first day in the facility the CNA told her, “You’re so big,” and on days three, four, and five the CNA told her, “You’re so fat.” The resident also reported that some staff, identified by name, complained about their backs when assisting her with lifting and positioning her legs in bed. The administrator stated she had been in communication with this resident since late February but had not received any reports from the resident or staff about the CNA making comments about the resident’s weight or staff complaining about back pain when assisting her. Another resident with Parkinson’s disease, diabetes, unsteadiness on feet, muscle weakness, cognitive communication deficit, anxiety, depression, and other chronic conditions, and who required staff assistance for transfers, toilet hygiene, bathing, and lower body dressing, reported aggressive and rough care by an unidentified female CNA from the midnight shift, described as a large, full-figured African American woman. He stated that when he was incontinent, this CNA would enter and ask, “What do you want,” jostle him around “like a piece of meat,” tell him to go to sleep, and accuse him of abusing call-light privileges. He further alleged that the same CNA who verbally abused the first resident confiscated his remote, restricted him to eating in his room, and was rough when helping him. The administrator reported having no prior reports of verbal abuse or rough care. Despite these allegations, time clock records showed the accused CNA continued to work, including double shifts on two consecutive weekend days and part of a weekday shift, before being suspended, contrary to the facility’s abuse policy that requires immediate separation of the alleged victim and accused staff and placing the accused on administrative leave pending investigation.
Failure to Prevent Elopement and Account for Cognitively Impaired Resident After Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to prevent the elopement of a cognitively impaired resident and to ensure that all residents were accounted for after a door alarm sounded. The resident had multiple diagnoses including dementia, altered mental status, anxiety disorder, unsteadiness on feet, malnutrition, alcohol abuse, pulmonary fibrosis, and a left femur fracture. An elopement risk assessment identified the resident as high risk for elopement, and the Minimum Data Set documented that the resident was not cognitively intact. CNA documentation on two dates in January showed elopement behaviors, and a nurse practitioner documented severe cognitive impairment and disorientation in late January and early February. The resident’s care plan noted cognitive impairment and multiple fall and safety risk factors, including poor safety awareness and dementia. Despite this, the resident’s picture was not included in the facility’s “Walkers” binder used to identify residents who wander. On the night of the incident, staff reported that the resident was last seen in bed asleep between approximately 3:45 AM and 4:00 AM. The RN on duty stated that the main exit door alarm sounded around 3:00–3:20 AM; she turned off the alarm, looked outside, and did not see anyone, but did not notify the nursing supervisor on other units. She reported that a resident head count was performed after the alarm, but this was not communicated consistently, as the nursing supervisor stated she was never notified of an alarm and did not perform a head count on her units. Another CNA gave conflicting statements about whether she recalled an alarm and whether a head count was done, but confirmed that she believed all residents were present at that time. The facility’s policy on elopement and wandering residents states that alarms are not a replacement for necessary supervision, that staff must respond to alarms in a timely manner, and that a systematic approach to monitoring and managing residents at risk for elopement is required. At approximately 5:42–5:43 AM, police responded to a 911 call from a passerby reporting a person in a wheelchair sitting outside in the cold. The police officer found the resident about a block away from the facility, in a wheelchair, wearing only a thin sweater with no winter gear, with a sweater on the ground nearby. The officer observed that the resident was very cold, shivering, had a shaky voice, smelled strongly of urine, and had wet pants in the groin area. The resident was disoriented, did not know where she lived or where she was going, and stated she had been outside all night. EMS arrived and documented cold exposure, chills, confusion, and cold skin, with an impression of hypothermia and emergent acuity. The resident was transported to the emergency department, where she was monitored and later documented to have a rectal temperature of 95.9°F at discharge. The police officer subsequently went to the facility and learned from staff that they had not known the resident had left the building until he informed them. He also reported that staff told him an exit door alarm had gone off around 3:30 AM but they were unable to confirm the cause, and he later observed wheelchair tracks in the snow near an employee exit door with an unshoveled sidewalk, suggesting a potential route of exit. These events demonstrate that the facility did not ensure adequate supervision and monitoring of a known high elopement-risk, cognitively impaired resident and did not effectively account for all residents after a door alarm sounded, resulting in the resident’s elopement and exposure to cold. The Immediate Jeopardy was determined to have begun when the resident was found outside in the cold in her wheelchair by herself and was transferred to the hospital for cold exposure. The administrator was notified of the Immediate Jeopardy several days later. Interviews with nursing staff, the nursing supervisor, the police officer, and the resident, along with review of clinical records, EMS and hospital documentation, and facility policies, confirmed that the facility failed to follow its own elopement and wandering policy, failed to ensure that a high-risk resident was properly identified in the wandering binder, and failed to ensure that all residents were accounted for when an exit door alarm sounded. These failures led directly to the resident’s unsupervised exit from the facility and subsequent cold exposure. The sidewalk route the resident likely used included broken and uneven concrete and led around the facility to a shopping plaza parking lot. The police officer believed the resident left near the employee exit door because the sidewalk there was not shoveled and he observed wheelchair markings in the snow. The resident later told EMS that she had been outside all night and had been living outside for a couple of months, although she had in fact been residing in the facility. When interviewed by the surveyor, the resident could not recall going outside in the cold or speaking with a police officer, and inaccurately reported that she went out the front door to smoke a couple of times a day, despite not having smoked since admission. These observations further illustrate the resident’s cognitive impairment and confusion at the time of the elopement and underscore the facility’s failure to provide adequate supervision and monitoring for a resident known to be at high risk for elopement.
Removal Plan
- All residents were reassessed for elopement risk.
- All residents identified as high risk for elopement had care plans reviewed for accuracy.
- Elopement binder reviewed and updated to reflect high risk residents.
- An emergency QAPI was held to review policies/procedures.
- Daily door alarm audits began.
- Door alarm added to interior door leading to staff entrance.
- Second door alarms added to reception door as well as the exit between two units in order to double alarm all exits.
- Additional speakers added so alarms are more audible.
- In-Service/Education was initiated on the facility's door alarm protocol, responding to alarms, and completing head counts.
- R1 was moved to a secured unit.
- The Administrator or designee will perform elopement risk assessment audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
- The Administrator or designee will perform door alarm response audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services and administer medications as ordered for multiple residents when medications were unavailable or not obtained in a timely manner. One resident had an order for Muro 128 ophthalmic ointment to be instilled in the right eye twice daily beginning in early December, but the January and February MARs show multiple missed doses with administration notes stating the medication was not available. A registered nurse reported that during her two weeks at the facility the ointment was never available until recently, that she had called the pharmacy but it never arrived, and that she signed the medication as administered despite not having it because the resident’s mother had a supply. The same resident also had an order for dextromethorphan for cough, with the MAR showing missed doses and notes indicating the medication was not available. Another resident returned from the emergency room with new orders, including a compounded “Magic Mouthwash” for pain control after biting her tongue and having blood in her mouth. The MAR shows that this resident did not receive several ordered doses, and the pharmacy proof of delivery list indicates the mouthwash was never delivered. A nurse practitioner confirmed that the mouthwash was ordered for pain control and did not believe the resident ever received it. A third resident, who was ordered prazosin 2 mg at bedtime for dreams, missed several doses on the January and February MARs, with order-administration notes stating the medication was on order. The DON stated that all medications should be administered as ordered, that medications should be reordered when there is a 2–3 day supply remaining, and that residents should not have to go without their ordered medications, consistent with the facility’s medication administration policy.
Missed Doses of Anticoagulant and Anticonvulsant Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that ordered medications were administered as prescribed, resulting in missed doses of significant medications for two residents. One resident with a history of pulmonary embolism, diagnosed on 11/4/25, had an order for enoxaparin 100 mg subcutaneously twice daily starting 1/2/26 to treat and prevent blood clots. The January MAR shows this resident did not receive the PM dose on 1/2/26, both AM and PM doses on 1/19/26, the PM dose on 1/20/26, and both AM and PM doses on 1/26/26. The administration notes for these dates document that the medication was "on order." The resident reported that the facility was constantly running out of her medications and that she had missed multiple doses, and the nurse practitioner confirmed that the resident was on enoxaparin to prevent additional blood clots and to keep the previous clot from worsening, and that it was important she receive the doses as ordered. Another resident with a seizure disorder had an order for levetiracetam 500 mg, three tablets twice a day as an anticonvulsant. The January MAR shows this resident did not receive either the AM or PM dose on 1/20/26 and did not receive the AM dose on 1/21/26, with administration notes indicating the medication was not available. The nurse practitioner stated that the resident is on levetiracetam to prevent seizures, that it should be given as ordered, and that missing too many doses could result in a seizure. The nurse practitioner also stated that if a medication is not available, staff should call her for direction, and she was not aware that this resident had missed any doses. The DON stated that all medications should be administered as ordered, that medications should be reordered when there is a 2–3 day supply remaining, and that residents should not have to go without their ordered medications. The facility’s Medication Administration Policy, revised 9/1/24, directs staff to reorder medications from the pharmacy when there is a 2–3 day supply remaining.
Failure to Complete Ordered Respiratory Viral Panel
Penalty
Summary
The facility failed to ensure that an ordered respiratory viral panel was performed for one resident. A nurse practitioner documented an acute cough for Resident R4 and entered an order for a respiratory viral panel on 2/5/26, also verbally informing the nurse of the order. During a later interview, the nurse practitioner stated she had not seen any test results and did not know whether the test had been completed. The Director of Nursing explained that when a provider orders a respiratory viral panel, nursing staff are responsible for collecting the specimen, notifying the laboratory for pickup, and completing a lab requisition form, but she was unable to find any evidence that a specimen had been collected or sent. This failure occurred despite a facility policy requiring that laboratory and diagnostic services ordered by authorized providers be obtained to meet residents’ needs and that nurses carry out such orders per facility protocol.
Failure to Obtain Ordered STAT Chest X-Ray
Penalty
Summary
The facility failed to obtain a STAT chest x-ray as ordered for one resident, resulting in noncompliance with its policy to provide or obtain timely diagnostic services. A nurse practitioner documented on 2/5/26 that the resident had an acute cough and, due to a history of chronic bronchitis and pneumonia, ordered a STAT chest x-ray, entering the order into the computer and verbally informing the nurse. The nurse practitioner later stated she had not seen any x-ray results and did not know if the x-ray had been completed. The DON explained that the facility’s process for a STAT x-ray requires the nurse to call the x-ray provider, who typically performs the x-ray within four hours with same-day results, but she was unable to find any evidence that the x-ray had been performed. The facility’s Laboratory and Diagnostic Services and Reporting Policy requires that laboratory and diagnostic services, including radiology, be provided or obtained when ordered and that nurses carry out such orders per facility protocol.
Failure to Assess Post-Fall Injuries and Provide Translation, Resulting in Delayed Fracture Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care, services, and effective translation for a resident after a fall that resulted in hip and arm fractures. The resident had dementia, prior fractures, osteoarthritis, and spinal stenosis, required substantial/maximal assistance for most ADLs, and used a wheelchair. Her MDS documented Mandarin as her preferred language and that she wanted an interpreter to communicate with health care staff, and also showed she had no range of motion limitations prior to the events. Despite this, multiple staff and responding paramedics reported that the facility did not use translation services and instead relied on speaking English and interpreting the resident’s moans and groans, with staff and paramedics unsuccessfully attempting to use phone-based translation on their own. On one date, the resident fell from bed while attempting a self-transfer, landing on her left side and bumping a dresser, with a small bruise to the left forehead documented and no pain or functional change reported at that time. The NP note for that fall described no change in mental status, pain, or ADL function post-event. Over the following weekend, the resident’s daughter and primary nurse reported that the resident was walking, using both arms, and not exhibiting pain. However, the roommate later reported hearing a loud fall on a subsequent night, describing the resident crawling to her side of the room, wedging herself by the door, and moaning and yelling in apparent pain. The roommate stated she activated the call light, staff had difficulty entering due to the resident’s position, and the resident was taken out in a chair and later returned to bed, with the roommate noting that the resident was in pain when moved. The roommate, who was cognitively intact per her MDS, also reported that staff did not use translator services and that she sometimes used Google Translate herself and had learned from the daughter that certain commonly used words meant “pain” and “bathroom.” The night LPN later stated she found the resident on the floor around 12:30 a.m. during rounds, assessed her, and documented no pain or abnormal findings, gave acetaminophen “just in case,” and moved her to a wheelchair near the nurses’ station before she was later returned to bed. This fall note, however, was not entered until more than two days later and after the survey began, and the NP indicated she would not have seen a fall note in the chart at the time she was consulted. The day RN reported being told only that the resident was in pain and pointing to her hip, not that a fall had occurred, and obtained stat X‑ray orders for the left hip and forearm. CNAs reported that on the morning after the undocumented fall the resident remained in bed, ate in her room, and repeatedly said “Iyo” during care, a word they did not understand; the daughter later explained that “Iyo” meant “ouch” or pain. When EMS arrived for transfer after X‑rays showed fractures, paramedics found the resident in bed, noted bruising to the left side of her face and guarding of the left arm, and documented that staff reported a hip and left forearm fracture from a fall five days prior and that the resident only spoke Chinese. Paramedics reported that facility nurses told them they had no translator and that they communicated with the resident in English and interpreted her needs from sounds. Hospital evaluation confirmed a left hip fracture and displaced left elbow fracture, with the orthopedic note stating that staff reported the resident had started moaning the prior night and that X‑rays at the facility showed the fractures. The facility’s own policies required effective communication and language assistance services, as well as thorough assessment, documentation, and post‑fall procedures after any fall or change in condition, but the record and interviews showed gaps in timely fall documentation, incomplete communication of the fall and pain to the NP and oncoming staff, and lack of effective translation services, resulting in the resident experiencing pain and a delay in treatment.
Failure to Promptly Notify Family and NP After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s family and nurse practitioner after two separate falls. The resident had dementia, a prior pubic fracture, osteoarthritis, a right shoulder bone density disorder, and spinal stenosis. On one occasion, a nurse documented that the resident fell from bed while attempting a self-transfer, landing on her left side and bumping a small dresser, resulting in a small bruise on the left side of the forehead. The nurse later stated she did not notify the resident’s family of this fall until the following day, despite recognizing that the resident must have hit her head due to the mark and bruise. The resident’s daughter/POA confirmed she was not notified of this fall until the next day and stated she expected to be called right away. On another occasion, a nurse documented that during routine rounds around 12:30 a.m., the resident was found lying supine on the floor in her room wearing non-skid socks and gesturing to staff to get her up. Less than 24 hours after this fall, the resident was diagnosed with a fractured left hip and left elbow. The LPN who authored the note stated she did not notify the family or the nurse practitioner after this fall. The resident’s daughter/POA reported she was not informed of this second fall until two days later by the DON. The DON stated that staff are expected to notify the family and provider after a resident falls so they can be aware of changes and make informed decisions, and the nurse practitioner stated she had not been notified of the fall and would have seen the resident if she had known. The facility’s Fall Prevention Program policy, reviewed 9/1/24, requires that after any resident fall, staff assess the resident, complete a post-fall assessment and incident report, notify the physician and family, and document all assessments and actions, which did not occur as required in these instances.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a resident experiencing a change in condition that required medical intervention. The resident, who had diagnoses including esophageal cancer, lung cancer with brain metastasis, anxiety, COPD, and dyspnea, called 911 himself after reportedly attempting to contact nursing staff for 45 minutes without success. Upon arrival, emergency responders found the resident in his bed, alert but in obvious respiratory distress, with an oxygen saturation of 88% on room air and labored respirations. The ambulance crew noted that the resident's abdomen was distended and rigid, and his respiratory effort improved only after oxygen was administered. The paramedics and police reported that no staff were present in the area for at least 10 minutes after their arrival, and the resident was loaded onto the cot before any staff appeared. Documentation in the resident's electronic medical record showed no recorded vital signs or assessments between the evening prior to the incident and the time of transfer to the hospital. The last documented vital signs were from the previous day, and there was no evidence of staff response to the resident's attempts to seek help during his respiratory distress. Interviews with staff indicated that the nurse was occupied on another unit and did not hear calls for assistance, while another resident reported hearing the affected resident yelling for help. The assigned CNA could not be reached for comment prior to the survey exit.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically incontinence care and toileting, for two residents who required substantial staff support. One resident, who was incontinent of urine and stool and required significant help with personal hygiene and toileting, was observed with a call light on for over two hours while requesting to be changed due to being soaked in urine. Despite repeated requests and staff acknowledgment of the need, the resident was not provided incontinence care until nearly ten hours after the last change, resulting in saturated bedding and a wet mattress. Another resident, cognitively impaired due to dementia and also requiring substantial assistance for hygiene and toileting, remained in a wheelchair in a common area for several hours without being toileted or changed. Staff were unable to confirm when incontinence care was last provided, and the assigned CNA reported not having had time to attend to the resident since the start of the shift. Facility policy requires incontinence care at least every two hours, but this standard was not met for either resident.
Unsafe Transfer Performed Without Required Equipment and Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from a wheelchair to bed using only a gait belt and without assistance, despite the resident's care plan requiring a mechanical (hoyer) lift with two staff for all transfers. The resident's transfer status had been updated in May to require the use of a hoyer lift due to declining strength and inability to use a sit-to-stand lift. The CNA, who had recently returned from medical leave, was unaware of the change in the resident's transfer requirements and performed the transfer alone. Interviews with facility staff confirmed that the resident was too weak to be safely transferred by one person with a gait belt.
Failure to Provide Sufficient Nursing Staff for Resident Care and Timely Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of several residents, as evidenced by direct observations, interviews, and record reviews. One resident, who required substantial assistance with personal hygiene and toileting due to incontinence, was left with a call light on for over an hour and a half without receiving incontinence care. The resident reported that their incontinence brief had not been changed since the previous night, and staff confirmed that there was inadequate staffing on the unit, with only one nurse and 1.5 CNAs available for a heavy long-term care unit. The resident's medications were also administered over an hour late due to staffing shortages. Another resident, who was cognitively impaired and required substantial assistance for personal hygiene and toileting, remained in a wheelchair in the dining room for several hours without being changed or toileted. The CNA responsible for this resident was also assigned to another unit and had not yet provided incontinence care, stating that he had been too busy with other residents. Staff interviews confirmed that residents were not being toileted or changed every two hours as required. A third resident did not receive scheduled medications on time, with administration occurring nearly two hours late. The LPN responsible stated she was the only nurse on the unit and was unfamiliar with the residents, working on a PRN basis. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and that the goal was to meet state staffing requirements and resident care needs. The facility's policy requires sufficient staff to ensure resident safety and well-being, but observations and staff statements indicated that staffing levels were inadequate to meet these standards.
Failure to Accurately Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to accurately administer medications as ordered for three residents. For one resident with a skin rash, family reported that staff were not applying an antifungal medication daily as prescribed. Review of the Medication Administration Records (MAR) confirmed that several doses were missed over two months. The Director of Nursing confirmed that if a medication was not documented as given in the MAR, it meant the medication was not administered. For another resident, medications including Lyrica, Rifaximin, Senna, and Sodium Chloride were scheduled to be given at specific times, but were observed being administered outside of the scheduled time. Similarly, a third resident was prescribed Metoprolol Tartrate and Apixaban to be administered via gastrostomy tube at set times, but these were also given late. The DON stated that medications should be administered within one hour of the scheduled time, and the facility's policy requires adherence to the six rights of medication administration, including right time and right documentation.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 20%, which exceeds the acceptable threshold of 5%. Specifically, two residents were observed receiving their scheduled morning medications significantly late. One resident was prescribed Lyrica, Rifaximin, Senna, and Sodium Chloride to be administered at 9:00 AM, but these were given at 10:23 AM. Another resident was prescribed Metoprolol Tartrate and Apixaban for administration at 9:00 AM, but these were given at 10:47 AM. According to the facility's policy and the Director of Nursing, medications are considered late if administered more than one hour after the scheduled time. The survey identified 30 medication administration opportunities with 6 errors, all related to late administration, during the observed medication pass.
Failure to Ensure Timely and Documented PICC Dressing and IV Tubing Changes
Penalty
Summary
The facility failed to ensure proper infection control practices related to dressing changes and intravenous (IV) tubing changes for two residents with peripherally inserted central catheters (PICCs). Observations revealed that one resident's PICC insertion site was dressed but not labeled with a date or time, and the IV tubing was also unlabeled. The resident reported that staff did not change his PICC dressing weekly as required. Another resident had antibiotics infusing via a PICC line with tubing that was not labeled, and reported that his PICC dressing had not been changed for almost two weeks, with IV medication tubing in use for four days instead of the required 24 hours. Interviews with nursing staff revealed inconsistent knowledge and practices regarding the frequency of IV tubing and PICC dressing changes, as well as documentation requirements. Some staff stated that IV tubing should be changed every 24 hours, others said every 72 hours or three days, and there was confusion about labeling and documentation. Review of treatment administration records confirmed that required dressing changes were missed and not documented as completed. Facility policies required IV tubing to be labeled with date, time, and initials, and for PICC dressings to be changed weekly and documented, but these procedures were not consistently followed.
Failure to Administer IV Antibiotics as Ordered Due to Medication Unavailability
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics as ordered by the physician for two residents receiving IV therapy. One resident reported missing an entire day of IV antibiotics because the medication was not ordered, and this was confirmed by nursing staff who noted that the medication was not available and had not been administered. Documentation on the electronic medication administration record (EMAR) and progress notes indicated missed doses, with staff marking codes to indicate the medication was not available and noting communication with the pharmacy regarding the delay in delivery. The medication, Vancomycin, was not available for scheduled doses on multiple occasions, and staff confirmed that the missed doses were not given due to the unavailability of the medication. Nursing staff described their process for handling unavailable medications, which included checking the convenience box, contacting the pharmacy, and documenting the issue in the resident's records. However, there was no evidence that the physician was notified in all instances when the medication could not be obtained, as required by facility policy. The facility's Medication Administration Policy requires medications to be administered as ordered by the physician, and the MAR to be signed after administration, but the records showed that the IV antibiotics were not administered as scheduled for both residents due to medication unavailability.
Failure to Maintain and Track Resident Grievance Documentation
Penalty
Summary
The facility failed to maintain a written record of a grievance and did not follow its own grievance policy for one resident. The resident's daughter filed a grievance after observing her mother in pain, with her legs pressed against the edge of a table, resulting in wounds on her shins. The daughter completed the facility's grievance form and submitted it to the receptionist, who placed it in the DON's mailbox. However, the grievance form was not included in the facility's records when requested by the surveyor, and staff were unable to locate it. Interviews with staff revealed that the receptionist confirmed receiving the grievance form and placing it in the appropriate mailbox, but was unaware of what happened to it afterward. The Social Services Director stated that grievances are typically relayed to the appropriate department and that the Administrator should be aware of all grievances. However, the Social Services Director did not receive the form and only became aware of the concern after speaking with the resident's daughter days later. The Director of Nursing and Administrator also could not account for the missing grievance form. The facility's policy requires that the Administrator oversee the grievance process, track grievances through to their conclusion, and issue written decisions to the resident. The policy also states that staff receiving a grievance must record the specifics on the designated form and that all actions taken to resolve the grievance should be documented. In this case, the facility did not maintain the required documentation or follow the established grievance process, resulting in a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Failure to Safely Position Dependent Resident Results in Skin Injury
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical conditions, including cerebral atherosclerosis, peripheral vascular disease, multiple sclerosis, abnormal posture, dementia, diabetes, and dysphagia, was not safely positioned during a meal. The resident was placed in a reclining wheelchair at a 45-60 degree angle, causing her contracted knees and shins to be elevated above the dining table. Staff parked her diagonally next to the table, resulting in her shins being pressed against the table edge. This positioning led to linear, reddened areas and small wounds on both shins, as observed by the wound care nurse. The resident's daughter reported that during a visit, she found her mother with her shins pressed tightly against the table, causing pain and deep indents. The daughter released the wheelchair brakes and moved her mother away from the table, noting the marks and reporting the incident to staff. The CNA assigned to the resident stated that she had positioned the resident at the table with a nurse and believed the resident's legs were not touching the table when she left. However, it was acknowledged that the table may have been moved by another resident, resulting in the injury. Documentation showed that the resident was dependent on staff for all activities of daily living and had severe cognitive impairment, making her unable to communicate her needs effectively. The care plan did not address the skin concerns resulting from the incident. The facility's policy required interventions to provide a safe environment and prevent skin injuries, but these were not adequately implemented in this case, leading to minor traumatic wounds on the resident's shins.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices. During a kitchen tour, an undated and opened bag of mixed vegetables, an undated and improperly sealed box of frozen hot dogs with visible frost, and an undated, improperly closed tub of chocolate ice cream with ice crystals were found in the walk-in freezer. In the dry storage room, an undated and opened box of parboiled rice was also observed. The Dietary Manager confirmed that all food items should be properly dated and sealed to maintain quality and prevent contamination. Additionally, a dietary aide was seen wearing a hair net that did not contain all of her hair, contrary to facility policy requiring all hair to be restrained for sanitation purposes. Further, a sanitizer test in the kitchen revealed that a sanitation bucket near the dish machine contained soap instead of sanitizer, as indicated by the test strip not changing to the required color for proper sanitizer concentration. The Dietary Manager acknowledged that the sanitizer concentration should be within the appropriate range to prevent bacterial growth. These observations were inconsistent with the facility's policies on food safety, labeling and dating foods, storage of dry goods, and staff hygiene practices.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure appropriate pressure-relieving interventions were in place for two residents at risk for or with a history of pressure ulcers. For one resident with a history of sacral deep tissue injury and a current moderate risk for pressure ulcers, the low air loss mattress was set incorrectly at a setting far above the resident's actual weight. The wound care nurse confirmed that the mattress setting was too high, making it overly firm and increasing the risk of skin breakdown. The resident was found lying on her back, incontinent, and refusing to be repositioned, and a new stage 1 pressure ulcer was identified on her coccyx. The care plan required the mattress to be checked every shift, but this was not done appropriately, and the mattress was adjusted based on the resident's preference rather than clinical guidelines. For another resident with multiple wounds and a care plan requiring offloading of the feet with heel protectors or pillows, staff failed to ensure both feet were properly offloaded. The resident was observed in bed with only one offloading boot in place, while the other boot was not on the resident and was found on the nightstand. The CNA responsible for the resident was unaware of the need for both boots and did not notice the missing boot until it was pointed out. The resident's care plan and physician orders indicated the need for offloading due to immobility and existing wounds, but this intervention was not consistently implemented. Both cases demonstrate a lack of adherence to established care plans and physician orders regarding pressure ulcer prevention and management. Staff failed to ensure that pressure-relieving devices were used correctly and consistently, and did not follow facility policy requiring regular assessment and implementation of interventions to prevent the development or worsening of pressure ulcers.
Failure to Supervise Resident During Smoking Activities
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety of a resident while smoking. The resident, who had multiple diagnoses including anxiety disorder, major depressive disorder, chronic pain syndrome, paraplegia, and nicotine dependence, was assessed as a safe smoker and allowed to keep her cigarettes and lighter in her possession. Observations showed the resident smoking outside in the courtyard on multiple occasions without staff supervision, despite her care plan indicating she was at high risk for falls and required substantial to maximal assistance for activities of daily living. The resident reported that staff did not check on her while she was outside smoking, and she was observed with other residents, with no staff present, for extended periods. During one observation, another resident accessed the first resident's bag and took a cigarette, and the resident was seen crying out for help with shaky hands while holding a lit cigarette. No staff responded to her calls for help, and she remained unsupervised. The facility's policy required residents to be reassessed for safe smoking if there was a decline in condition or cognition and stated that smoking supplies should not be left accessible to other residents. The DON confirmed that residents exhibiting distress or changes in condition while smoking should be reassessed and that smoking materials should not be left out. Despite these policies, the resident was left unsupervised with smoking materials accessible to others, and her distress went unaddressed by staff.
Resident Missed Meal Due to Inadequate Meal Service System
Penalty
Summary
The facility failed to ensure that all residents received their meals as required, resulting in one resident not being served lunch while others at her table were eating. During the lunch service, staff were observed serving meals in a random order, and a resident with a mechanical soft diet and a history of significant weight loss was left without food for an extended period. Despite having a meal ticket indicating her dietary needs, the resident repeatedly stated she had not received her meal and appeared visibly upset and hungry. It was only after another resident alerted staff that the oversight was addressed. The affected resident had multiple medical diagnoses, including moderate protein-calorie malnutrition, heart disease, and dysphagia, and was at risk for fluctuating weights as documented in her care plan. The facility's policy required staff to ensure all components of the meal matched the diet card and resident preferences, but this process was not followed, leading to the resident missing her meal. Staff interviews confirmed the failure to serve the meal and acknowledged the lapse in the meal service system.
Failure to Ensure Safe Medication Administration and Adherence to Self-Administration Policy
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for three residents. One resident with multiple diagnoses, including osteoarthritis and dysphagia, was observed self-administering a cup of assorted pills at lunch without any nurse present. The resident stated that he usually takes his noon medications by himself in the dining room. Another resident with conditions such as rhabdomyolysis, hypothyroidism, and dementia was found with a medication cup containing an orange fluid on his bedside table, which he identified as his blood pressure medication. He reported that the nurse leaves the medication with him, and he takes it when he feels like it. A third resident with a history of cystitis, dementia, diabetes, and kidney transplant was found alone in her room with a tube of topical arthritis pain cream on her bedside table. An LPN acknowledged that the resident was not supposed to have the cream in her possession and that it should be kept in the medication cart. Additionally, an unidentifiable white pill was found on the counter in the group dining room, within easy reach of residents. The Assistant Director of Nurses identified the pill as acetaminophen but was unsure how it ended up there. Interviews with nursing staff and review of records revealed that no residents on the unit were assessed or care planned for self-administration of medications, despite facility policy requiring an interdisciplinary team assessment and care plan documentation before allowing self-administration. The Director of Nurses confirmed the absence of such assessments or care plans for the involved residents.
Failure to Ensure Proper PPE Use and Linen Handling for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff consistently wore appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP) or transmission-based precautions. In one instance, a CNA entered a resident's room, which was marked with an EBP sign, and provided direct care involving wound dressings and offloading boots without wearing a gown or gloves, only a mask. The CNA was unaware of the resident's EBP status, believing the sign was left from a previous room assignment, despite the resident's care plan and physician orders indicating multiple wounds requiring EBP. Another incident involved a CNA providing peri-care and transferring a resident with multiple wounds while only wearing gloves and not a gown, despite an EBP sign posted outside the room. The CNA was unsure of the reason for the precautions, although documentation confirmed the resident was on EBP due to wounds. The care plan specified the need for gown and gloves during high-contact care activities, which was not followed during the observed care. A third case involved two CNAs changing the incontinence brief and bed linens of a resident with a stage 4 sacral pressure injury, both wearing only gloves and not gowns. One CNA carried soiled linens against her body and dropped a sheet in the hallway, and did not use a linen bag as required by facility policy. The Assistant Director of Nursing confirmed that gowns and gloves are required for EBP and that soiled linens should be bagged before removal from the room. Documentation for all three residents indicated the need for EBP due to wounds, and the facility's policy required proper handling of soiled linens to prevent contamination.
Failure to Prevent Accident Hazards and Ensure Safe Bed Rail Installation
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received adequate supervision and individualized fall interventions, and also failed to ensure that bed rails were installed in a manner that would prevent entrapment. The resident, an elderly female with multiple diagnoses including dementia with agitation, atrial fibrillation, diabetes, and hypertension, was assessed as a high fall risk with poor safety awareness and cognitive deficits. Despite her care plan indicating the need for partial to moderate assistance with transfers and toileting, staff reported inconsistent understanding of her needs, with some stating she could transfer independently and others noting she required extensive assistance and supervision. On the day of the incident, the resident was found kneeling on the floor next to her bed, with her right arm trapped between the side rail and the mattress, and her wheelchair positioned behind her. She was unable to explain what had happened and was experiencing significant pain in her right arm. The call light in the room had been activated by her roommate, not the resident herself, as she did not typically use the call light for assistance. Staff interviews revealed that the resident was forgetful, did not remember to use the call light, and would attempt to get up without assistance if left unsupervised. Observations confirmed that there was a gap between the mattress and the side rail wide enough for entrapment, and the bed rails were in the upright position at the time of the incident. Review of facility policies showed that bed rails should only be used after appropriate alternatives have been attempted, with informed consent and a physician's order required. The policy also mandates that installation must prevent gaps that could lead to entrapment. The resident's care plan interventions were not individualized, with repeated instructions to use the call light despite her cognitive deficits and history of non-compliance. The facility's failure to provide adequate supervision, individualized interventions, and safe installation of bed rails resulted in the resident sustaining a comminuted fracture of the right humerus.
Failure to Follow LVAD Care Orders and Monitoring Protocols
Penalty
Summary
The facility failed to consistently implement prescribed treatments and assessments for a resident with a Left Ventricular Assist Device (LVAD). The resident was observed with an undated dressing on the LVAD site, and reported that the dressing was not being changed daily as required, leading to concerns about infection and pain. Staff interviews revealed confusion regarding the frequency and type of dressing changes, with some staff using dry kits instead of the ordered sterile wet kits, and a lack of appropriate supplies on the unit. Documentation showed multiple missed dressing changes and incomplete monitoring of the LVAD and vital signs as ordered by the LVAD clinic. The resident had a history of LVAD infection and required daily sterile wet kit dressing changes to prevent further infection. Upon arrival at the facility, the resident's dressing had not been changed for 11 days, and the correct supplies were not readily available. Additionally, staff used an automatic blood pressure machine, which is not appropriate for LVAD patients, instead of the required manual method. These failures were confirmed through record review, staff interviews, and direct observation, indicating that the facility did not follow the physician's orders or the resident's care plan for LVAD management.
Failure to Document and Obtain Orders for Wound Care
Penalty
Summary
The facility failed to adequately assess and monitor a resident for skin integrity issues and did not obtain a physician's order for wound care. The resident, who has a medical history including anorexia, congestive heart failure, gout, hypertension, dementia, and Parkinson's Disease, was observed with reddened areas, scratch marks, and multiple small scabbed areas on her right forearm. A dressing was also noted on the forearm, which the resident could not recall when or by whom it was applied. There was no documentation in the resident's medical records, including physician orders, care plan, or treatment administration record, regarding the skin issue or treatment for the right forearm. The Wound Nurse reported that during her last assessment of the resident, no skin issues or dressings were present on the upper arms. The Director of Nursing stated that there should be a treatment order in place if a dressing is applied, and treatments should be documented accordingly. The facility's Wound Treatment Management policy requires evidence-based treatments in accordance with physician orders and documentation of treatments. However, the lack of documentation and physician orders for the resident's wound care indicates a failure to adhere to this policy.
Resident Excluded from Care Plan Meeting Due to Hearing Concerns
Penalty
Summary
The facility failed to include a resident, identified as R7, in her care plan meetings, violating her right to participate in her person-centered plan of care. R7, who was admitted with diagnoses including diabetes, a right leg above-the-knee amputation, and wounds, was cognitively intact and able to express her needs despite a hearing impairment. However, the facility conducted a care plan meeting without her presence, instead involving her daughter, despite R7's explicit request to be included and her ability to hear when spoken to directly and clearly. The facility's social services staff, V14, expressed concerns about HIPAA compliance due to R7's hearing difficulties, which led to the decision to exclude her from the meeting. The facility's policy on resident rights mandates that residents be informed and participate in their treatment and care planning. Despite this, R7 was not invited to her care plan meeting, and her financial affairs and prosthetic needs were discussed with her daughter without her consent. The social services staff acknowledged R7's desire to be included in meetings and admitted to not utilizing available communication aids, such as a communication board, to facilitate R7's participation. The facility's administrator confirmed that all residents should be included in their care plan meetings, highlighting a clear breach of the facility's policy and resident rights.
Failure to Provide Pressure Relieving Mattresses for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement necessary interventions to prevent and heal pressure ulcers for two residents. One resident was admitted with a Stage 4 pressure ulcer on the sacrum and a Stage 3 ulcer on the left ischial tuberosity, while another resident had a Stage 3 pressure ulcer on the sacrum. Both residents had orders for pressure relieving mattresses, which were not provided. The wound care nurse confirmed that these residents should have received low air loss mattresses due to the severity of their pressure ulcers, and she had informed maintenance of this requirement. The facility's policy emphasizes the commitment to provide treatment and services to heal pressure ulcers and prevent new ones, yet this was not adhered to in these cases.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, identified as R8, who was at risk for falls due to severe cognitive impairment and a history of wandering. R8, who had diagnoses including dementia, Alzheimer's Disease, recurrent psychosis, and anorexia, required staff supervision for transfers and toileting and was able to walk without an assistive device but with supervision. On the date of the incident, R8 was found to have sustained an unwitnessed fall in the hallway, resulting in swelling and redness on her forehead. Despite being sent to the hospital for evaluation, no injuries were noted from the fall. At the time of the fall, the facility's nursing schedule indicated that only one staff member, V10 RN, was present on the unit, as the other assigned staff members, V11 CNA and V12 CNA, were not on the unit. V10 RN acknowledged seeing R8 walking in the hallway but was occupied with medication administration and unable to supervise R8. The lack of adequate staff presence and supervision contributed to the resident's fall, as V10 RN stated that if a CNA had been present, they could have potentially prevented the fall.
Failure in Pain Management for Resident with Stomach Cancer
Penalty
Summary
The facility failed to ensure proper pain management for a resident with severe stomach pain due to stomach cancer, resulting in the resident experiencing severe pain. The resident, who requires Norco for pain relief, reported frequent issues with obtaining the medication, citing reasons such as the facility running out of Norco, delays in medication delivery, and lack of timely prescription renewals. On one occasion, the resident spent an entire day seeking assistance from nurses to obtain Norco, which was not available, leading to severe pain and distress. The Director of Nursing stated that medication refills should be ordered when there are about three days of medication left, and that pain medications like Norco are available in the emergency medication system. However, a Licensed Practical Nurse (LPN) admitted to not having access to the backup medication supply and not being oriented on how to access it. Another LPN confirmed that the resident had to seek out specific nurses who could access the backup supply to receive her medication. The resident's medical records confirmed a gap in receiving Norco, with the last dose administered on one day and the next dose not given until the following evening. The facility's records, including Resident Council Minutes, indicated ongoing issues with medication availability and delays in receiving pain medication. The resident's care plan highlighted the need for analgesics as ordered, yet the facility's failure to manage the medication supply and ensure timely administration of Norco led to the resident's unmanaged pain. The facility's pain management policy emphasized the importance of recognizing and managing pain, but the execution of this policy was inadequate in this case.
Failure to Administer Prescribed Nasal Spray Due to Pharmacy Communication Lapse
Penalty
Summary
The facility failed to ensure that a resident's prescribed nasal spray, Flonase Allergy Relief, was obtained from the pharmacy and administered as ordered. The Physician Order Summary indicated an active order for the nasal spray to be administered once daily at 9:00 AM, starting on January 18, 2025. However, the Medication Administration Summary revealed that the medication was not administered on January 18, 19, and 21, 2025, due to it being unavailable, and it was incorrectly marked as given on January 20, 2025, despite not being present at the facility. On January 22, 2025, an LPN was unable to administer the Flonase to the resident because it was still unavailable. The LPN acknowledged that they should have followed up with the pharmacy sooner to determine why the medication was not sent. The pharmacy later informed the LPN that the medication was not sent because they had not received an over-the-counter form from the facility. The Director of Nursing stated that it is unacceptable to wait four days to follow up on unavailable medications. The facility's policy requires medications to be ordered or reordered in a timely manner, with any discrepancies reported within 24 hours.
Failure to Obtain Physician Orders Upon Admission
Penalty
Summary
The facility failed to obtain physician orders upon the admission of a resident, identified as R1, who was admitted on 12/3/2024. R1's Admission Record dated 12/16/2024 indicates that the resident was originally admitted on the same date. During an interview on 12/16/2024, a Licensed Practical Nurse (LPN), identified as V10, admitted to not calling a provider to obtain necessary orders for wound care upon R1's admission, despite the presence of wounds. The Director of Nursing (DON), identified as V2, confirmed that the protocol requires the nurse to call the provider to get appropriate orders for the resident's care needs upon admission. A review of R1's Order Summary Report dated 12/16/2024 showed no active orders for wound care were entered during R1's admission on 12/3/2024. The facility's policy, revised on 9/1/2024, states that residents are admitted under the orders of the attending physician.
Failure to Provide Wound Care Assessment and Treatment
Penalty
Summary
The facility failed to assess and provide appropriate wound care for a resident who was admitted with wounds. Upon admission, the resident had wounds on the chest, back, and abdomen, but the Licensed Practical Nurse (LPN) did not change the resident's dressing. The Director of Nursing (DON) stated that an initial assessment should be conducted upon admission, and if wounds are present, the facility's wound protocol should be followed. However, the Wound Nurse LPN confirmed that staff did not contact her for recommendations regarding the resident's wound care, nor did they contact the physician for wound care orders. The resident's Treatment Administration Record (TAR) for December did not document any wound care, and the admission assessment lacked a complete description of the wounds. The facility's Wound Treatment Management policy requires the licensed nurse to notify the physician to obtain treatment orders in the absence of existing orders, but this was not done. The facility's failure to provide a completed admission assessment and to follow wound care protocols resulted in a deficiency in the care provided to the resident.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who was at high risk for falls, resulting in the resident falling and sustaining serious injuries. The resident, who had severe cognitive impairment and a history of falls, was found on the floor after an unwitnessed fall. The resident's care plan required supervision and assistance when ambulating, particularly to and from her room before and after meals. However, on the day of the incident, the resident was seen walking towards her room with a rolling walker without the necessary supervision and assistance, leading to her fall. The resident was later found lying flat on her back with a bump on the back of her head and was subsequently admitted to the ICU with a subarachnoid hemorrhage and a subdural hematoma. The facility's reports indicated that the fall was attributed to the resident suddenly losing her balance while ambulating. The resident's care plan had been updated previously to include specific interventions to prevent falls, but these were not followed, resulting in the resident's fall and subsequent injuries.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for three out of five residents reviewed, leading to a deficiency in care planning. Resident 1 reported never having attended a care plan conference since admission, and there was no documentation in the electronic medical record (EMR) of any conferences or refusals until the Social Service Director (SSD) added information on the day of the survey. Resident 1 was cognitively intact, indicating the ability to participate in care planning. Resident 2's son, who holds power of attorney, stated that they had not had a care plan conference until he requested one due to dissatisfaction with care. The EMR showed a significant delay in documenting a care plan conference, and another conference was missed in August/September. Resident 4 also reported not having a care plan conference for a while, with the last documented conference over a year ago. The SSD added documentation for conferences supposedly held earlier in the year, but these were not recorded until the day of the survey, indicating a delay of several months. Resident 4 was also cognitively intact, suggesting the ability to participate in care planning. The facility's policy supports resident participation in care planning, but the lack of timely documentation and scheduling of conferences indicates a failure to adhere to this policy.
Failure to Implement Contact Isolation Precautions for Scabies Outbreak
Penalty
Summary
The facility failed to implement contact isolation precautions for a resident with a suspected contagious skin rash, leading to a potential risk of cross-contamination among residents. A resident diagnosed with scabies was not isolated from other residents, and the facility did not disinfect and sanitize a communal shower room after the resident used it. Additionally, the resident's personal belongings were not handled in a manner to prevent cross-contamination, as evidenced by a certified nursing assistant transferring a potentially contaminated bag to another resident. The facility's housekeeping staff did not wear the required personal protective equipment when cleaning the room of a resident on contact isolation for a rash. Observations showed that a housekeeper was cleaning a resident's room without wearing a protective gown, despite the resident being on contact isolation due to suspected scabies. The facility's contact isolation policy requires the use of gowns and gloves for all interactions that may involve contact with the patient or the patient's environment. The facility's Assistant Director of Nursing/Infection Preventionist acknowledged that the resident should have been placed on isolation as soon as the rashes were noticed, regardless of the resident's refusal of treatment. The Director of Housekeeping confirmed that staff must notify housekeeping immediately when a shower room needs cleaning after use by a resident with scabies. However, the facility did not have a specific policy or protocol on scabies prevention or treatment at the time of the survey, as they were undergoing a change in ownership and creating new policies.
Resident Injury Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident struck another in the face. This incident involved a female resident with a history of dementia and other medical conditions, who was struck by a male resident with dementia and aggressive behaviors. The altercation occurred when the male resident, who was known to be combative and required supervision, approached the female resident and physically attacked her without provocation. The female resident sustained a closed fracture of the left zygomatic arch and was sent to the hospital for treatment. The incident was reported by various staff members, including CNAs and a nurse supervisor, who noted that the male resident had a history of aggressive behavior and required constant supervision due to his fall risk and unpredictable nature. On the day of the incident, the male resident was left unsupervised momentarily, which allowed him to attack the female resident. The facility's policies on abuse prevention were not effectively implemented, as evidenced by the lack of supervision and the subsequent injury to the resident.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility staff failed to immediately report an allegation of sexual abuse involving a resident. The resident, identified as R1, reported to a Certified Nursing Assistant (CNA) that she believed she was raped by four men and was drugged. The CNA, who worked with R1 on two occasions, recalled the resident telling her the story more than once but could not remember the specific date or to whom she reported the allegation. This lack of immediate reporting to the appropriate authorities, as required by the facility's policy, constitutes a deficiency. The Director of Nursing (DON) confirmed that all allegations of abuse should be reported to the Administrator, who is the designated Abuse Coordinator, or to the DON if the Administrator is unavailable. The facility's policy mandates that suspicions of abuse must be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. The failure to adhere to this policy resulted in a delay in reporting the allegation to the state agency and initiating an investigation.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident (R1) when staff did not recognize that R1 did not return to the facility after being out on a community/day pass. R1, who was admitted for rehabilitation due to a pelvic and hip fracture, left the facility with a friend without staff being aware. The receptionist saw R1 leave but did not inform the nursing staff, and there was no physician order for R1 to leave the building on a pass that day. R1 was reported missing to the local police department later that evening after staff realized she had not returned. The facility's Out on Pass Log showed that R1 left the building at 10:46 AM and returned the next day at 2:11 PM. Nursing staff attempted to locate R1 at 4:04 PM and again at 8:35 PM but were unable to find her. It was only then that they checked the pass log and discovered R1 had left the building earlier that morning. The police were called, and R1 was found safe the next day outside a library in a neighboring town. Interviews with facility staff revealed that the receptionist did not report R1's departure to the nursing staff, assuming it was permissible since R1 had left before. The Nursing Supervisor and DON confirmed that a physician order is required for a resident to leave on a pass and that the receptionist should communicate with nursing staff each time a resident leaves. The Nurse Practitioner emphasized that even though R1 is cognitively intact, she is not physically independent and should not be gone overnight without proper authorization.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards for two residents. One resident reported that a night nurse left his midnight medications on his table while he was asleep in his chair. When he woke up after 1:00 AM, he had to ask the nurse for his medications, which were left on his table. The nurse confirmed that she left the medications on the table because she did not want to wake the resident. The resident's progress note indicated that the nurse left the medications on the table where the resident could easily see them when he woke up. Another resident was found with an empty medication cup on her bedside table. She stated that she likes to go outside in the morning, so the nurses leave her medications on the bedside table for her to take when she returns. The nurse confirmed that he left the medications on the table at the resident's request, including a controlled substance and blood pressure medications. The Medication Administration Record showed that the medications were signed off as given, even though the nurse did not observe the resident taking them. The facility's policy requires that medications be administered in a safe and timely manner and that the nurse should return to administer missed medications, which was not followed in these instances.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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